Acid-Base & Fluid Balance Case Studies

A 28-year-old woman has been sick with the flu for the past week, vomiting several times every
day. She is having a difficult time keeping solids and liquids down, and has become severely
dehydrated. After fainting at work, she was taken to the ER where an IV was placed in
anticipation of rehydrating her. Prior to administering fluids, the following ABG results are
obtained:

pH 7.50
pCO2 40 mm Hg
pO2 95 mm Hg
O2 SAT 97%
HCO3 32 mEq / liter

Questions:

1. How would you interpret her acid-base disturbance?

2. What has contributed to this acid-base disturbance? How?

3. What type of IV fluid should the nurse anticipate hanging? Why?

3. How would the kidneys compensate for this acid-base disturbance?

Acid-Base & Fluid Balance Case Studies

A 68-year-old man with a history of chronic renal failure (CRF) is in the hospital recovering
from a heart attack. He is receiving continuous ½ NS IV fluids. Late one night, a weary nurse
changed the man's empty IV bag with a new one. Misreading the physician's orders, he hooked
up a bag of 3%NS saline rather than ½ NS. Just before shift change the following morning, the
nurse assesses the man to have 4+ pitting edema in the sacral region and lower extremities, along
with crackles in the bilateral lung bases. He complained that it was difficult to breathe as well.
Blood was drawn, revealing the following:

Na+ 157 mEq / liter

K+ 4.7 mEq / liter
C1- 101 mEq / liter
A chest x-ray revealed interstitial edema in the lungs (fluid).
Questions:

1a. Will the nurse's mistake increase or decrease the "saltiness" of the interstitial fluid?

1b. Given your knowledge of osmosis, will this cause the cells in the body to increase or
decrease in size? Explain your answer.

2. Why does this patient have pitting edema and inspiratory rales?

4. What ways does the body have to control sodium and water balance? How might they react in
this situation?

BI 233—A&P III
Respiratory Mechanics Case Study

Sean crashed his mountain bike while descending one of the ski runs at Ski Bowl. When the
paramedics found him, Sean complained of a sharp, stabbing pain in his right pectoral and
axillary regions. He also felt out of breath and his heart rate and breathing rate were dramatically
elevated.

Sean was transported to the emergency room. The physician on call listened to Sean's breathing
and ordered a chest X-ray and blood gas test. After viewing the test results, the physician
informed Sean that he had pneumothorax, probably induced by blunt trauma and a broken rib
suffered in the crash.

The doctor told Sean that since his pneumothorax was small, it should heal on its own; however,
Sean should avoid high altitudes, flying in non-pressurized airplanes, and scuba diving.

1. What is pneumothorax and why would it occur?

2. How does pneumothorax relate to the pleural cavity and interpleural pressure? Why?

3. Why would pneumothorax cause Sean's symptoms?

4. What would the blood gas test have revealed and why? What about the chest X-ray?

5. Why was Sean told to avoid high altitudes and non-pressurized airplanes? What about scuba
diving?

1. Mr. Frank is a 60 year-old with pneumonia. He is admitted with dyspnea, decreased lung sounds
bilaterally, fever 103.8F, and chills. His ABG:

pH 7.28
CO2 56
PO2 70
HCO3 25
SaO2 89%

What is your interpretation?

What interventions would be appropriate for Mr. Frank?

2. Ms. Strauss is a 24 year-old college student. She has a history of Crohn's disease and is complaining a
of a four day history of bloody-watery diarrhea. A blood gas is obtained to assess her acid/base balance:
pH 7.28
CO2 43
pO2 88
HCO3 20
SaO2 96%

What is your interpretation?

What interventions would be appropriate for Ms. Strauss?

3. Mr. Karl is a 80 year-old nursing home resident admitted with urosepsis. Over the last two hours he has
developed shortness of breath and is becoming confused. His ABG shows the following results:
pH 7.02
CO2 55
pO2 77
HCO3 14
SaO2 89%

What is your interpretation?

What interventions would be appropriate for Mr. Karl?

4. Mrs. Lauder is a thin, elderly-looking 61 year-old COPD patient. She has an ABG done as part of her
routine care in the pulmonary clinic. The results are as follows:
pH 7.37
CO2 63
pO2 58
HCO3 35
SaO2 89%

What is your interpretation?

What interventions would be appropriate for Mrs. Lauder?

5. Ms. Steele is a 17 year-old with intractable vomiting. She has some electrolyte abnormalities, so a
blood gas is obtained to assess her acid/base balance.
pH 7.50
CO2 36
pO2 92
HCO3 27
SaO2 97%
What is your interpretation?

What interventions would be appropriate for Ms. Steele?

6. Mr. Longo is a 18 year-old comatose, quadriplegic patient who has the following ABG done as part of a
medical workup:
pH 7.48
CO2 22
pO2 96
HCO3 16
SaO2 98%

What is your interpretation?

What interventions would be appropriate for Mr. Longo?

7. Mr. Casper is a 55 year-old with GERD. He takes about 15 TUMS antacid tablets a day. An ABG is
obtained to assess his acid/base balance:
pH 7.46
CO2 42
pO2 86
HCO3 29
SaO2 97%

What is your interpretation?

What interventions would be appropriate for Mr. Casper?

8. Mrs. Dobins is found pulseless and not breathing this morning. After a couple minutes of CPR she
responds with a pulse and starts breathing on her own. A blood gas is obtained:

pH 6.89
CO2 70
pO2 42
HCO3 13
SaO2 50%

What is your interpretation?

What interventions would be appropriate for Mrs. Dobins?

9. You find Mr. Simmons to be in respiratory distress. He has a history of Type-I diabetes mellitus
(elevated levels of glucose cause an acidic state) and is now febrile. (Wow, what a bad day). RRR 8 and
deep. His ABG shows:

pH 7.00
CO2 59
pO2 86
HCO3 14
SaO2 91%

What is your interpretation?

What interventions would be appropriate for Mr. Simmons?

10. Ms. Berth was admitted to the ER after a motor vehicle accident in which she sustained chest trauma
(hit the steering wheel). She rates her pain as “10” on a scale of 1-10 and vital signs are: RR 40 and
shallow, BP 180/110. ABG:

pH 7.45
CO2 19
pO2 100
HCO3 16
SaO2 98%

What is your interpretation?

What interventions would be appropriate for Ms. Berth?

Answers to the ABG Practice Examples:

1. Mr. Frank has an uncompensated respiratory acidosis with hypoxemia as a result of his
pneumonia. This is due to inadequate ventilation and perfusion. The treatment goals for Mr.
Frank would be to improve both ventilation and oxygenation. Ventilation may improve with the
use of bronchodilators and pulmonary hygiene. If not, Mr. Frank may require CPAP, BiPAP, or
intubation and mechanical ventilation. Oxygen therapy should consist of only the minimal
amount necessary to increase his oxygen saturation to normal (95%). And…what about his
hydration status with that temperature?

2. Ms. Strauss has an uncompensated metabolic acidosis. This is due to excessive bicarbonate
loss from her diarrhea. It is interesting to note that she has no compensation. Normally, the
respiratory center compensates quickly for metabolic disorders. However, in Ms. Strauss' case
she would have to hyperventilate in order to compensate. This may not be possible in her present
condition, and should be evaluated further. Treatment would consist of control of the diarrhea
and bowel rest. It should not be necessary to administer bicarbonate in her present condition.

3. Mr. Karl has a metabolic and respiratory acidosis with hypoxemia. The metabolic acidosis is
caused by his sepsis. The respiratory acidosis is secondary to respiratory failure. This
presentation of sepsis and associated respiratory failure is consistent with ARDS. Treatment
must be aggressive, because his acidosis is severe. His respiratory status needs to be stabilized,
and would probably require mechanical ventilation. If hypotension exists, aggressive fluid and
vasopressor support would be warranted. This patient is at high risk for further complications
and should be managed in an ICU. Bicarbonate should not be administered until the underlying
sepsis and respiratory failure is treated.

4. Mrs. Lauder has a fully-compensated respiratory acidosis with hypoxemia. Full compensation
is evidenced by the normal pH in spite of her acid/base disorder. This is her baseline and doesn't
require treatment.

5. Ms. Steele has an uncompensated metabolic alkalosis. This is due to vomiting that results in
excessive loss of stomach acid. Treatment consists of fluids, anti-emetics, and management of
her electrolyte disorders.

6. As a result of his neurologic condition, Mr. Longo has chronic hyperventilation syndrom. His
blood gas shows a fully-compensated respiratory alkalosis. This is a chronic and stable condition
for him and probably requires no treatment.

7. Mr. Casper has overmedicated himself with TUMS, effectively absorbing too much stomach
acid. His ABG shows a partially-compensated metabolic alkalosis. Treatment consists of better
control of his GERD, possibly with H2-blockers (Pepcid®) or proton-pump inhibitors
(Prilosec®).

8. Mrs. Dobins has a severe metabolic and respiratory acidosis with hypoxemia. The metabolic
component comes from her decreased perfusion (pulseless at first, and remember…the blood is
normally slightly alkaline and hers wasn’t being oxygenated), and the respiratory component
comes from inadequate ventilation (guess so, she had to be coded!) Treatment would consist of
intubation, mechanical ventilation, blood pressure and circulatory support.

9. Wow, Mr. Simmons too! He, like Mrs. Dobbins, has a metabolic and respiratory acidosis with
hypoxemia. However, the cause is different. His respiratory acidosis could be the result of
pneumonia (also causing the fever). His pneumonia has altered his glucose metabolism, causing
hyperglycemia and diabetic ketoacidosis. Treatment should be three-pronged: 1) increase his
oxygenation with oxygen therapy; CPAP, BiPAP, or mechanical ventilation, 2) treat his
pneumonia with antibiotics, antipyretics, and good pulmonary hygiene, and 3) administer insulin
and IV fluids to decrease his blood glucose and treat his DKA.

10. Mrs. Berth is hyperventilating and shows compensated (see the pH?) respiratory alkalosis.
Treatment would consist of slowing her respirations and increasing the depth of the respirations.
Since she has “10” pain, she is likely guarding, which is resulting in the shallow and rapid
respiratory pattern (blowing off CO2).