Fluid& Electrolyte Imbalance.

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 Case study:
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John Deer is a 62-year-old man brought to the ED via
ambulance following a motor vehicle crash.
Vital signs:
1. BP138/88; HR – 106 regular; respiratory rate – 30; temp –
98.8.
2. Chief complaint: He complains of pain in his abdomen and
leg.
3. PMHx – never seen a doctor, not on any medications.
 What else would you like to know?
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 Past surgical history.
 Nutritional status.
 Suspected spinal cord injury.
 Weight loss.
 Lab results and ABGs.
 Assess the pain characteristics (PQRST).
 Physical exam!
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 Neurological: Awake, alert oriented .
 Cardiovascular: BP138/88; HR – 106 regular; respiratory rate – 30; temp
– 98.8; peripheral pulses strong, palpable; ECG shows ST;
 skin warm/dry& Integumentary: intact .
 Respiratory: lungs clear to auscultation; respirations .
 GI: abdomen distended with diminished bowel sounds – an NG is
inserted and attached to LWS .
 GU: a foley catheter in inserted yielding 400 mls amber urine
What is your analysis of the situation?

 What does the heart rate indicate? What about the BP?
The heart rate indicates response to the stressful situation which is the
accident and the heart beats faster& Increase the blood pressure may be
because your body will release stress hormone into blood stream including
adrenaline which causes initiate the sympathetic nervous system.(Fight or
flight).
 The nurse hung 1000 mls NS. Is this an appropriate solution? Why?
It is appropriate to give 1000 ml of NS to replace the suspected fluid loss
from the trauma and prevent the hypovolemic shock.
 Labs:

 Na+ - 134 mEq/L .
 K+ - 3.7 mEq/L.
 CL – 99 mEq/L .
 CO2 – 24.
 CT – free abdominal fluid .
 X-ray – fx left femur .
 CXR – clear.
 What is your assessment of the
above 
findings?
 The sodium level in slightly decreased for the patient as the normal
range (135-145).
 The patient X-Ray indicate left femur fracture which may cause internal
bleeding.
 Assess the serum potassium level.
 Monitor the patient Urine output.
 ECG.
 2 hours later:
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 Mr. Deer is restless and mildly confused.
 VS: Bp: 84/66; HR – 136; resp rate – 36.
 Skin pale and diaphoretic .
 Urine output 15 mls over the last hour; 20 mls the hour before.
 Cont.

 What are the clinical manifestations that support your analysis?
VS: (BP: 84/66 mm/hg. HR: 136 bpm Respiratory rate: 36 b/min), Skin:
pale and diaphoretic, decrease Urine output 15 mls over the last hour, 20
mls the hour before.
 What compensatory mechanisms do you recognize?
Tachycardia as the heart rate was 136 bpm and tachypnea as the
respiratory rate 36 b/min.
 What interventions do you anticipate?
Maintain the patient oxygenation by administering oxygen , Give the
patient fluid resuscitation for rehydration (IV Isotonic), Assess the patient
CNS changes.
 Assessment:
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 What is your assessment of the situation now?
Assess the signs of dehydration and the patient fluid status, Assess the
patient vital signs (HR, RR, BP, Temp, CSM), CBC, Chest X-Ray, Urine
output, ECG.
 What is the patient fluid status?
The patient has Fluid& electrolyte loss and hypovolemic shock.
 What is the etiology?
The patient had femoral fracture which may cause internal bleeding for the
patient.
 Cont.

 The nurse states that the ED has run out of normal saline, She wants to
hang D5W, Is this an appropriate solution?
This is inappropriate as the D5W may be hypotonic solution and I can’t
give the patient hypotonic solution as the patient dehydration will increase
and hemolysis may occur.
 New labs:
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 Na+: 130 mEq/L
 K+: 5.0 mEq/L
 CL: 94 mEq/L
 CO2: 18
 Blood sugar 166
 BUN: 32 mg/dl.
 ABG’s:
(PH: 7.32, PaCO2: 34 mm Hg, PaO2: 96 mm Hg, HCO3: 19mEq/L).
 Interpret labs and ABG’S!
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 The patient sodium level is decreased (130 mEq/L) as the normal range
(135-145mEq/L).
 CO2: 18 mEq/L is decreased as the normal range (23-29mEq/L) and
indicates Metabolic acidosis which means that your body makes much
acid.
 Blood sugar: 166 mg/dl. Increased because of dehydration as it cause
more concentration of glucose in the blood stream. Normal range (70-
100 mg/dl)
 BUN: 32 mg/dl. Increased as the normal range (5-20 mg/dl). It indicates
that may be kidney injury to the patient.
ABG’S: Metabolic acidosis with partial compensation.
What inter-professional therapeutic
interventions will
 you prepare for?
 Give the patient sodium bicarbonate.
 Assess the patient CSM, pulses and BP.
 Monitor the patient urinary output.
 Prepare the patient for CT, KUB and abdominal laparoscopy.
 What should be included in the
nursing management?

 Assess the patient Hemodynamic status.
 Assess the patient cerebral tissue perfusion.
 Assess the patient fluid status.
 Assess the patient intake and output& fluid status.
 Monitor the patient daily weight.
 What are your concerns?
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 Compensate the patient fluid loss from the bleeding.
 Maintain the metabolic acidosis for the patient by giving HCO3 for the
patient.
 Maintain the patient potassium level to prevent the patient cardiac
arrest.
 Maintain the patient urine output and the intervention if there is any
kidney injury as suspected.
 Hyponatremia:

 It means that the sodium level in the blood is below normal. (135-145
mEq/L).
 Causes: (Excessive sodium loss by “NG drainage”, fluid loss).
 Signs& symptoms: (Confusion, Hypertension, muscle spasms, cold
clammy skin, tachycardia, weak pulses.
 Treatment: Give the patient sodium containing fluids (NS).
 Nursing Management: (I&O, Cardiac monitor, urinary specific gravity,
Monitor respiratory status, confusion, daily weights, Assess the skin for
signs of dehydration.
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