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Nursing: A Concept-Based Approach to Learning, Volume I, 3rd Edition Solution Manual

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    MODULE 1: THE CONCEPT OF ACID – BASE BALANCE Clinical Examples A – C Clinical Example A (p. 7) Jay James is a 24 - year - old man who was rock climbing with his friends at a national park 25 miles from the nearest hospital when he suddenly lost his footing and slid 20 feet to the ground. Mr. James was alert and oriented when his friends reached him, and he could move all extremities quite easily. He had multiple scrapes over his anterior chest and a large gash over his left thigh (near the groin), which was bleeding profusely. His friends made a makeshift tourniquet, which slowed the bleeding. They immediately contacted the park ranger, who secured a helicopter to evacuate Mr. James to the nearest hospital. Two large - bore IVs were placed in each arm in - flight, and normal saline was administered. The flight medic placed a 100% nonrebreathing mask on Mr. James. Mr. James became disoriented and confused during the flight. Mr. James arrived in the emergency department (ED) 45 minutes after the fall. On arrival in the ED, Mr. James is lethargic but responsive to painful stimuli. He has multiple abrasions over his chin and neck. His pulse oximetry is 99% on the nonrebreather mask, so the ED team replaces the mask with a nasal cannula at 4 L/m. A repeat pulse oximeter reads 95% saturation. Vital signs are as follows: T O 37.3°C ( 99.1°F ) : HR 130 bpm ; R 30/min; and BP 100/60 mmHg. Skin is cool and clammy, nail beds are pale, and mucous membranes are dry. All pulses are palpable but weak and thready. Lungs are clear, heart sounds regular. Output via urinary catheter for the p ast hour is 20 mL. Clinical Reasoning Questions Level I Question 1 What is the most likely cause of Mr. James’s high heart rate and low blood pressure? Answer 1 The most likely cause of the high heart rate and low blood pressure is shock related to loss of blood, which causes compensatory high heart rate and low blood pressure related to volume loss. Question 2 If you were the nurse assigned to Mr. James, what would be your primary concerns at this time? Answer 2 The primary concerns would be loss of blood and unstable vital signs.

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    Clinical Reasoning Questions Level I I Question 3 What is the priority nursing diagnosis for Mr. James at this time? Answer 3 The priority nursing diagnosis is fluid volume deficit related to hypovolemia, and confusion related to decreased blood flow to the brain. Question 4 Wh y is Mr. James exhibiting confusion and di sorientation ? Answer 4 With blood loss there is decreased blood/fluid volume and decreased circulation of oxygenation to the brain , which leads to confusion and disorientation. Question 5 What diagnostic tests would you expect to be ordered for Mr. James? Answer 5 The expected diagnosis tests would be chest x - ray, CT scan, arterial blood gases, and serum labs that include chemistry, blood count, and coagulation. Clinical Example B (p. 11) Anna Zemakis is a 49 - year - old woman admitted to the hospital with severe vomiting and muscle weakness. She fell 2 weeks ago and reports not feeling well since. Four days ago, she developed abdominal discomfort with vomiting. The vomiting has been severe, and she has not been able to eat or drink very much. She says she has lost a significant amount of weight. She has felt very weak, anorexic, and lethargic. She has not had diarrhea or urinary symptoms. There is no significant past medical history, and she reports she is not on any prescribed medications or taking anything over - the - counter. Ms. Zemakis’s vital signs are as follows: T O 37.7°C ( 98.9°F ) : HR 84 bpm; R 18 /min; BP 90/58 mmHg (sitting), BP 110/60 mmHg (lying); pulse oximetry 98% on room air. Her lungs are clear, and her heart sounds normal. You observe she has dry mucous membranes. Initial examination reveals slight abdominal tenderness. Clinical Reasoning Questions Level I Question 1 What is Ms. Zemakis’s primary health problem? Answer 1 The primary health problem is dehydration. Question 2 As the nurse assigned to Ms. Zemakis, what are your concerns at this time?

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    Answer 2 Hypotension, dehydration, and lethargy are the main concerns. Clinical Reasoning Questions Level I I Question 3 What nursing diagnoses are appropriate for Ms. Zemakis at this time? Which takes priority? Answer 3 The nursing diagnosis is Fluid Volume : Defici en t related to hypovolemia. Volume replacement (IV hydration) is the priority. Question 4 What therapies would assist Ms. Zemakis in returning to homeostasis? Answer 4 Fluid replacement with normal saline 0.9% by IV infusion would return the patient to homeostasis. Question 5 Referring to the module on Perfusion: W hat is the significance of the different blood pressure readings in different positions? Answer 5 Postural (orthostatic) hypotension is a significant decrease in BP with a change in body position from supine to sitting/standing or from standing/sitting. Clinical Example C (p. 12) John Quinland is a 60 - year - old man with a 45 - year history of smoking two packs of cigarettes a day. Over the past year, he has become increasingly short of breath. At f i rs t , he noticed this only when exercising, but now he is short of breath even at rest. Over the past year, he has had several infections of the lower respiratory tract that were treated successfully with antibiotics at the local ED . His shortness of breath has not subsided, and he uses his accessory muscles of respiration to assist him in breathing. Mr. Quinland does not have a primary care provider and does not get physical examinations. He had his last physical over 20 years ago to meet a work requirement. Mr. Quinland goes to the nearest hospital when he has a respiratory infection. The ED physician advises Mr. Quinland to find a healthcare provider because he needs routine checkups , b ut Mr. Quinland does not take the advice. Clinical Reasoning Questions Level I Question 1 If you were the nurse taking Mr. Quinland’s health history during his latest trip to the ED ,

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    what would be your primary concerns? Answer 1 The primary concerns would be increasing dyspnea at rest, no follow - up with a primary health provider, and use of the ED for medical care. Question 2 What nursing diagnoses are appropriate for Mr. Quinland at this time? Answer 2 Activity Intolerance related to chronic obstructive pulmonary disease ( COPD ) is the appropriate diagnosis. Question 3 Is Mr. Quinland’s smoking the priority consideration at this time? Why or why not? Answer 3 Smoking is the primary consideration, because it increases the rate of lung function decline and disabling symptoms Clinical Reasoning Questions Level I I Question 4 Refer to the exemplar on COPD in the module on Oxygenation: What signs/symptoms of COPD does Mr. Quinland exhibit? What risk factors does he have? Answer 4 Chronic dyspnea is one of the most common problems of patient s with moderate to severe COPD. Risk factors include smoking, age, and occupational exposure. Question 5 Refer to the exemplar on Nicotine Use in the module on Addiction: Why/how does smoking result in alterations such as chronic hypercapnia and COPD? Answer 5 Patient s with severe COPD with exacerbation are at increased risk for hypoxemia, oxygen desaturation, and hypercapnia. Many patient s have elements of both emphysema and chronic bronchitis, and both diseases have chronic air flow limitations that are not reversible and therefore classified as COPD. Decreased carbon dioxide elimination results in increased carbon dioxide tension in arterial blood (hypercapnia) and leads to respiratory acidosis and chronic respiratory failure. Question 6 What patient teaching would you attempt to provide Mr. Quinland prior to discharge? Answer 6

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    The number one teaching should be smoking cessation. The patient should be encouraged to find a primary care provider and continue with regular visits. A number of tests will be needed, such as a pulmonary function test, to obtain a baseline on this patient.

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    MODULE 1 : THE CONCEPT OF ACID – BASE BALANCE Exemplar 1.A: Metabolic Acidosis Nurs i n g Care P l an (pp. 17 – 18) Question 1 How does a history of laxative and diuretic abuse in the setting of an eating disorder cause metabolic acidosis ? Answer 1 Metabolic acidosis is caused by excess acid or decrease bicarbonate in the body. The use/abuse of laxatives can result in diarrhea which increases the excretion of bicarbonates. Diuretics can lead to decreased fluid volume. Question 2 How do electroly t e and renal dysfunction cause changes in cognition and mental status? Answer 2 The kidneys are responsible for long - term acid – base balance. With renal dysfunction there can be increased excretion of metabolic acids and subsequent increase in bicarb onate excretion and changes in electroly t e status. Electroly t e loss or excess can lead to changes in cognition and mental status with confusion and possibly stupor or coma. Question 3 Normal hematocrit is 3 times the hemoglobin. Why is the hematocrit elevated? Answer 3 With fluid volume deficit , the hematocrit rises artificially and the hemoglobin drops. Note: Fluid volume deficits may be the result of excessive renal loss of water and sodium from diuretic abuse or chronic abuse of laxatives.

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    MODULE 1 : THE CONCEPT OF ACID – BASE BALANCE Exemplar 1.A: Metabolic Acidosis Reflect Reread Clinical Example A on page 7. Mr. James’s arterial blood gas values were pH 7.28 ; PaCO 2 31 mmHg ; PaO 2 95 mmHg ; and HCO 3 15 mEq/L. CVP ( c entral venous pressure) or right atrial pressure (RAP) ranged from 1 to 3 cm H 2 O pressure. ECG revealed sinus tachycardia with ST depression in most leads. Two units of packed red blood cells were ordered and rapidly transfused into the patient. His hemoglobin was 10 g/dl and his hematocrit was 40% before the transfusion. Question 1 What is the priority nursing diagnosis for Mr. James at this time? Why? Answer 1 Fluid Volume, Deficient is the primary diagnosis because of the low reading of the right atrial pressure, which reflects fluid volume. Normal RAP is 2 – 8 mmHg , and higher RAP is needed to ensure adequate volume. Question 2 What is the interpretation of the ABG ( arterial blood gas ) results? Answer 2 ABG results indicate metabolic acidosis. Question 3 How is the patient compensating for the acidosis? Answer 3 The body attempts to compensate in various ways. Hyperventilation is one means of compensation for metabolic acidosis. Question 4 Refer to the module on Perfusion: Why was the CVP catheter placed in this patient? What are normal CVP values? Answer 4 Normal CVP can be measured in two ways: s ternum: 0 – 14 cm H 2 O ; m idaxillary line: 8 – 15 cm H 2 O . Question 5 Why is the hematocrit falsely elevated? Answer 5

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    In severe dehydration, the volume of fluid drops and the number of RBCs per volume of fluid rises. This is the most common cause of a high hematocrit . With adequate fluid intake, the hematocrit returns to normal. Question 6 What safety precautions should be implemented for Mr. James at this time? Answer 6 Safety is the number one priority at all times. Safely monitor all activity levels for the patient. When the patient is critically ill, he will be on bedrest. It is important to turn the patient and to provide oral care and good hygiene.

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    MODULE 1 : THE CONCEPT OF ACID – BASE BALANCE Exemplar 1.A: Metabolic Acidosis Relate The ambulance arrives with a patient who presents with Kussmaul respirations and a history of diabetes mellitus. Linking the exemplar of metabolic acidosis with the concept of metabolism: Question 1 Based on the patient’ s history, what impact does the nurse expect to find on acid – base balance? Answer 1 This patient will likely have decreased plasma pH, decreased PaCO 2 , normal or decreased HCO 3 , and compensated increased urine pH. He is likely in diabetic ketoacidosis. Question 2 When the nurse is assessing this patient, what symptoms would be directly related to alterations in pH? Answer 2 This patient will have ketones in his urine. The metabolic acidosis is compensated for by CO 2 excretion by the lungs. This is the Kussmaul breathing. Linking the exemplar of metabolic acidosis with the concept of fluids and electrolytes: Question 3 When assessing the patient, what electrolyte imbalances should the nurse monitor in acidosis ? Answer 3 In respiratory acidosis, potassium imbalance such as hyperkalemia may occur. In metabolic acidosis, potassium imbalance such as hypokalemia may occur. Question 4 What signs of dehydration will the nurse observe in a patient in acute metabolic acidosis? Answer 4 Signs and symptoms of metabolic acidosis vary with the severity of the acidosis. Fluid replacement with potassium supplementation is required in the acute diabetic state. Linking the exemplar of metabolic acidosis with the concept of safety

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    Question 5 What precautions sh ould the nurse implement for the patient with metabolic acidosis to prevent potential injury? Answer 5 This patient may need to be restrained secondary to confusion for his safety. Make sure side rails are up because of drowsiness and confusion. Patient may need to be turned on side to prevent aspiration if there is nausea or vomiting. Question 6 The patient with metabolic acidosis becomes confused and disoriented. What nursing care should the nurse provide to this patient to maintain safety? Answer 6 This patient may need to be restrained, the side rails up, or 1:1 care to prevent fall or injury.

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    Module 1 : MODULE 1: THE CONCEPT OF ACID – BASE BALANCE Exemplar 1.B : Metabolic Alkalosis Reflect Reread Clinical Example B on page 11 . Ms. Zemakis’s initial labs reveal Na 130, K 2.0, Cl 103, Mg 1.4, blood urea nitrogen ( BUN 10 ) , and creatinine 1.2 mmol/ L . Arterial blood gas ( ABG ) values are pH 7.47, PaCO 2 26 mmHg, Pa O 2 88 mmHg, HCO 3 29 mEq/L. Ms. Zemakis is transferred to the intensive care step - down unit for fluid and electrolyte replacement with electrocardiogram ( ECG ) monitoring. Question 1 What are the priority nursing interventions for Ms. Zemakis at this time? Answer 1 Treatment of the underlying cause is the intervention. Electrolyte replacement with volume replacement is the priority. Question 2 What is the interpretation of the ABG results? Answer 2 ABG results indicate metabolic a lkalosis. Question 3 What is the cause of her muscle weakness? Answer 3 Hyponatremia, hypokalemia, and hypomag n es em ia cause her muscle weakness. Question 4 Why is ECG monitoring necessary? Answer 4 Severe electrolyte disturbances cause cardiac irritation. ECG would display “U” waves because of low serum potassium. Question 5 Why does this patient need closer monitoring in the intensive care step - down unit? Answer 5 Intensive care is required for a patient who is critically unstable.

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    MODULE 1 : THE CONCEPT OF ACID – BASE BALANCE Exemplar 1.B: Metabolic A lkal osis Relate Linking the exemplar of metabolic alkalosis with the concept of fluids and electrolytes: Question 1 What pathophysiologic process is involved with metabolic alkalosis that leads to a decrease in mental function? Answer 1 There is a loss of acid, possibly from prolonged vomiting. With this patient there will also be a loss of potassium and sodium, as well as excess calcium and magnesium, which will cause mental confusion. There would also be a loss of fluid volume that would decrease cerebral perfusion and lead to mental confusion. Question 2 What changes in serum electrolyte levels could indicate a risk for metabolic alkalosis? Answer 2 Changes in serum electrolytes that would indicate a risk for metabolic alkalosis are decreased potassium, decreased sodium, increased magnesium, and increased calcium. There might also be a compensatory mechanism, which is a decreased respiratory rate , to increase plasma CO 2 . Linking the exemplar of metabolic alkalosis with the concept of tissue integrity: Question 3 What caring interventions might be implemented (independently by the nurse or collaboratively by the healthcare team) to prevent metabolic alkalosis? Answer 3 Health personnel can prevent vomiting, refrain from suctioning, provide a potassium supplement, and refrain from diuretic therapy to prevent the metabolic alkalosis. Linking the exemplar of metabolic alkalosis with the concept of communication: Question 4 What information about the patient with metabolic alkalosis should the nurse include in the end - of - shift report? Answer 4 Bedside report would include ongoing treatment to correct this condition. Treatment includes volume restoration and electrolyte repletion.

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    Question 5 The patient with metabolic alkalosis becomes confused and disoriented. What strategies will help promote communication with this patient ? Answer 5 Confusion may be related to dehydration, electrolyte disturbances, and cardiac arrhythmias. The nurse should address the underlying factors and ensure patient safety. Interventions to promote orientation to the environment should be initiated , including call ing the patient by name, introducing yourself, and telling the patient what you are doing.

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    MODULE 1: THE CONCEPT OF ACID – BASE BALANCE Exemplar 1.C: Respiratory Acidosis Reflect Reread Clinical Example C on page 12. Mr. Quinland’s vitals were as follows: T O 38.4 ° C ( 101.1°F ) ; HR 125 bpm; R 32/min; BP 150/90 mmHg. ABGs ( a rterial blood gases) were immediately drawn by the respiratory therapist. ABG values were pH 7.32 ; PaCO 2 50 mmHg ; PaO 2 78 mmHg ; HCO 3 45 mEq/L. The nurse auscul t ated decreased breath sounds with scattered rhonchi in the right upper and middle lobes. The patient was placed on a 2 - L nasal cannula, and pulse oximetry was 90%. The respiratory therapist administered a nebulizer treatment, and a chest x - ray was performed. The hospital admitted Mr. Quinland overnight. The chest x - ray revealed hyperinflation with flattened diaphragm and right lobular bacterial pneumonia. He was started on antibiotics and remained on low - flow oxygen. A pulmonologist consult was ordered, and Mr . Quinland was discharged after seeing the pulmonary physician. He was scheduled for pulmonary function studies after the pneumonia cleared. The discharge medications were antibiotics, respiratory inhalers, and oxygen. Discharge teaching included informati on on smoking cessation. Unfortunately, Mr. Quinland was not able to wean to room air, and he was discharged on a 2 - L nasal cannula with oximetry of 91%. Home care services have been arranged for Mr. Quinland. Question 1 What is the interpretation of the ABG results? Answer 1 ABG results indicate r espiratory a cidosis. Question 2 How is the patient compensating for the acidosis? Answer 2 Compensation for respiratory acidosis occurs through renal retention of bicarbonate. Question 3 How can you determine if this is a chronic problem? Answer 3 Chronic obstructive pulmonary disease ( COPD ) patients hold onto bicarbonate to compensate for acidosis. Question 4 Mr. Quinland’s pO 2 is clearly below the normal range. An instinct might be to give 100% oxygen. Why would this be dangerous for him?

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    Answer 4 If CO 2 is chronically higher than 50 mmHg, the respiratory center becomes insensitive to pCO 2 as a respiratory stimulant, leaving hypoxemia as the drive for respiration. Oxygen at higher flow levels may remove the stimulus of hypoxemia , and the patient would then develop carbon dioxide narcosis. He will stop breathing with extremely high CO 2 levels. Question 5 Why is it important for the patient to follow up with the pulmonologist? Answer 5 C OPD is a progressive disease ; therefore , it is necessary to follow up with the healthcare provider to monitor the disease and improve quality of life.

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