MODULE 1: THE CONCEPT OF ACID BASE BALANCE

Nursing: A Concept-Based Approach to Learning, 4e Copyright © 2023 by Pearson Education, Inc. All rights reserved.

MODULE 1: THE CONCEPT OF ACID –BASE BALANCE

Clinical Examples A–C Clinical Example A 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: TO 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 past hour is 20 mL.Clinical Reasoning Questions Level I Question 1 The nursing assessment should focus on which system initially?Answer 1 The nursing assessment should initially focus on the cardiovascular system since 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 You take note that Mr. James has cool, clammy skin and a thready pulse, what is your priority nursing intervention?Answer 2 A priority nursing intervention is to monitor his vital signs and oxygen saturation levels.(Clinical Nursing Skills A Concept-Based Approach, (Volume 1, 2, 3) 4e By Pearson) (Solution Manual, For Complete File, Download link at the end of this File) 1 / 3

Nursing: A Concept-Based Approach to Learning, 4e Copyright © 2023 by Pearson Education, Inc. All rights reserved.Clinical Reasoning Questions Level II Question 3 What are the nursing priorities for Mr. James at this time?Answer 3 The nursing priorities are fluid volume deficiency related to hypovolemia, and confusion related to decreased blood flow to the brain.Question 4 Why is Mr. James exhibiting confusion and disorientation?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 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: TO 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 assessment do you want to perform first on Ms. Zemakis and why?Answer 1 ABCs are the first to assess in every patient. We will focus on C for circulation because Ms.Zemakis is orthostatic hypotensive. Decreased fluid volume can decrease renal perfusion and 2 / 3

Nursing: A Concept-Based Approach to Learning, 4e Copyright © 2023 by Pearson Education, Inc. All rights reserved.cause confusion Question 2 As the nurse assigned to Ms. Zemakis, what questions would you ask about her fall?Answer 2 There are many factors that can increase fall risk. Assessing fall risk should include at a

minimum:

• History of accidental falls • Impaired gait or mobility • Visual impairment or dizziness • Chronic medical conditions such as osteoporosis, arthritis.• Orthostatic hypotension related to volume loss • Altered mental status or cognitive limitations Orthostatic hypotension could be the reason for MS Zemakis’s fall Clinical Reasoning Questions Level II Question 3 What nursing priorities are appropriate for Ms. Zemakis at this time? Which is most important?Answer 3 There is deficient fluid volume 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 Module 16 Perfusion: What 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.

• / 3