An 83-y/o man is brought to the emergency room after a fall while cutting grass. He is
confused, dry all over, extremely lethargy, and shows a heart dysrhythmia on the cardiac
monitor. EMTs have started an IV line and attempted to minimally cool the patient.
1.
Discuss what happens during severe dehydration as well as indicate clinical
manifestations and alterations in laboratory values.
Dehydration is marked by water deficit. Severe dehydration causes loss of ECF,
hypovolemia and increased plasma osmolality. Baroreseptors and osmoreseptors trigger
release of ADH to restore blood volume and reduce osmolality. High ECF osmolality
causes water shift from ICF to ECF and cells shrinkage. Symptoms include tachycardia,
weak pulse, hypotension, hot and dry skin and mucus membranes, decreased urine
output, weakness, hyperreflexia, restlessness, and confusion. If not corrected, severe
dehydration can lead to coma. Laboratory findings include hypernatremia, increased
urine specific gravity, and serum osmolality.
2.
The client’s wife asks the nurse to explain to her what is going on. How would the nurse
respond?
Ma’am, your husband is dehydrated. We are giving him fluids through IV and
monitoring his blood work to make sure there is no damage to his organs. As we age, we
can get dehydrated very easy because our body doesn’t store as much water as it used to,
and we don’t drink as much water as we need to. Some medications can make us prone
to dehydration. Let us go through a list of his medications, and tell me about your
husband’s health problems. It can help us to find the reason for his dehydration faster.
When he will feel better, we will work on a plan how to prevent it from happening in the
future.
You are asked to discuss the following question in a five-minute in-service for your peers
during a staff meeting.
1.
Why is serum creatinine concentration an approximate indication of glomerular filtration
rate (GFR)?
Let us start with a brief anatomy overview. “The nephron is a functional unit of
the kidney” (Huether & McCance, 2008, p. 766). It consists of glomerulus, tubular
apparatus (including loop of Henle) and collecting duct. Glomeruli filters blood.
Approximately 120 ml of plasma is passed through glomelurus per a minute. Part of it is
filtered through and the rate of filtration is known as Glomerular Filtration Rate (GFR).
The fluid filtered by glomeruli contains electrolytes, waste products (including
creatinine), and glucose (Huether & McCance, 2008). Most of them are reabsorbed back
in circulation by the tubular apparatus except creatinine. All creatinine that is filtered out
by glomeruli is excreted in the urine, and is not affected by reabsorption in tubular
apparatus. When GFR decreases, less blood if filtered in glomerulus, and more creatinine
is retained in the blood (Huether & McCance, 2008). Therefore, blood creatinine level is
a good indicator of the GFR.
2.
What physiologic processes are involved in urine formation and excretion, and where do
they occur in the genitourinary system?
Urine formation involves three stages: filtration of blood in glomerulus,
reabsorption in renal tubules, and secretion of urine via collecting tubules, ureter, bladder,
and urethra. The old saying is that a picture is worth of a thousand words. Let us watch a
short video that illustrates urine formation process and excretion (watch the clip from
Penn Medicine web site).
You are visiting your friend at his home. His wife has recently (3 days ago) given birth to a
boy. As you hold the newborn you notice his skin looks ‘tanned’ (? jaundice). Being an
astute nursing student, you ask if they have an appointment for follow-up blood work.
They tell you yes, but they are not going to bother, he is perfectly healthy! Your friend tells
you he has more things to be worried about; his father has just been admitted to the
hospital for “water on his belly”. He asks you to explain how that happens.
1.
How does portal hypertension lead to ascites? Explain this to your friend.
I’m sorry to hear this about your father. “Water in the belly” usually is a sign of
some problem with the liver (Huether & McCance, 2008). Medical people call it ascites.
It means that water leaks out from blood vessels into his abdomen (Huether & McCance,
2008). If you will turn on a facet and step on a hose, water will spray from every little
crack. It will stop leaking if you would lift your foot or turn the facet down. High blood
pressure in veins or obstruction to the blood flow through the liver can do the same thing
inside the belly (Huether & McCance, 2008). Doctors will give your father water pills
and limit his salt in food to help to get rid of this water (Huether & McCance, 2008). If
blood pressure and liver problems get resolved, ascites will go away (Huether &
McCance, 2008). Otherwise, he will need to have the water removed (Huether &
McCance, 2008).
2.
Why is sustained hyperbilirubinemia a toxic condition for newborns, particularly
premature infants? Explain the importance of follow-up blood work and possible
consequences if they choose not to with your friend and his wife.
Jaundice can happen to perfectly normal and healthy babies. It happens because
of a high level of bilirubin in baby’s blood. Before birth, mom’s liver and placenta
helped to remove bilirubin from baby’s blood (Medline Plus, 2011). Now, baby’s liver
has to take over this job. It can take up to two weeks for baby’s liver to filter out
bilirubin (Huether & McCance, 2008). High bilirubin level can be dangerous. It can
cause cerebral palsy, hearing and speech deficit, or brain damage (Huether & McCance,
2008). Bilirubin level is measured in blood work. It can help to find any problems early,
so your son would get help if needed. That is why it is important to follow up with your
son’s blood work.
Your classmate asks you the following questions. Please do not assume you can use
medical verbiage; if you use medical verbiage in (parenthesis) explain, you know your
classmate will clarify you knew it. (Remember: thorough and concise ~150 words each
question).
1. How does cellular hypoxia lead to impairment of cellular function?
2. What three mechanism are abnormal in the systolic form of left heart failure (commonly
called congestive heart failure), and how are they managed?
3. What is the relationship between myocardial ischemia, angina, and diabetes mellitus?
Cells use oxygen to produce energy for all their functions. Blood carries oxygen
and nutrients to all cells in a body. When cells don’t get enough oxygen they become
hypoxic (Huether & McCance, 2008). It can happen to someone who has anemia,
breathing problems, or narrowing of blood vessels. Cells have a special mechanism in
their membrane that is called an ion pump. This pump uses energy from oxygen to move
ions and water across the membrane (Huether & McCance, 2008). Without enough
oxygen and energy, the ion pump stops working. As a result, cells swell. Hypoxic cells
try to produce energy without oxygen. It cases a buildup of lactic acid and pH imbalance
(Edwards, 2003). Swelling, acid build-up and lack of energy causes cells to malfunction
(Edwards, 2003; Huether & McCance, 2008). If hypoxia last for a long time it can lead
to a cellular destruction.
Heart failure is a condition when heart cannot pump enough blood to supply
body’s needs (Mayo Clinic, 2011, Heart failure). Efficiency of heart’s pump depends on
three factors. The first is contractility or how much blood the heart can eject during a
contraction (Huether & McCance, 2008). The second is the volume of blood in the heart
chamber before the contraction-preload (Huether & McCance, 2008). The last on is
afterload or the resistance to the heart’s pumping action (Huether & McCance, 2008). If
heart’s contractility is low, blood accumulates in a heart chamber. Eventually, it will
cause the heart muscles to overstretch, make them stiff, and unable to pump the blood out
(Mayo Clinic, 2011, Heart failure). High blood pressure causes increase of afterload.
Medications such as Digoxin can improve heart’s contractility. Beta-blockers and ACEinhibitors can lower blood pressure, and make it easier for heart to pump. Diuretics, also
known as water pills, can help to lower preload too. Depending on what part of pumping
action is not working properly, a doctor will prescribe one these medications or a
combination of them.
Myocardial ischemia develops when heart muscles don’t receive as much oxygen
as they need. It can happen because of low blood flow to the heart muscles or low
oxygen level in the blood (Huether & McCance, 2008). A plaque can form inside an
artery and cause its narrowing. High blood sugar in diabetic patients causes plaques to
grow faster (Mayo Clinic, 2011, Angina). Plaques limit blood flow to heart muscles.
Limited blood flow causes cardiac muscle to become ischemic. Usually, there is enough
blood flow even if a half of the artery is closed by the plaque (Huether & McCance,
2008). Exercise, high blood pressure, fast heartbeat, or other heart diseases increase need
for oxygen (Huether & McCance, 2008). Blocked arteries cannot supply enough blood
and oxygen to muscles. You will feel it as chest pain. Doctors and nurses call it angina
(Huether & McCance, 2008; Mayo Clinic, 2011, Angina).
A friend calls and tells you she just came from the doctor’s office. She sounds upset. She
tells you she has a red itchy rash on her face that is hideous. She tells you the doctor called
it “top der-mites” or something like that. She wants to know how to get rid of these bugs
and if she is going to look like a freak all her life.
1.
What stimulates the inflammatory response in atopic dermatitis?
2.
What do you plan to tell your friend about atopic dermatitis (“top der-mites”)?
“Top der-mites” is atopic dermatitis. It is not an infection or parasites. It is a skin
inflammation (Mayo Clinic, 2011). We don’t know what causes it (Huether & McCance,
2008). Some say our immune system produces antibodies called immunoglobulin E
when skin contacts irritants (Huether & McCance, 2008). That causes inflammation of
skin. Young people have it mostly on the face, scalp, arms, and legs (Huether &
McCance, 2008). Fortunately, the rash can go away with good skin care. It is very
important not to scratch the skin. Scratching and rubbing can cause skin break down and
make the rash even more itchy (Mayo Clinic, 2011). Skin cracks can get infected (Mayo
Clinic, 23011). Things like stress, sweating, dry skin, some foods, soaps, and perfumes
can cause flare-ups (Mayo Clinic, 2011). If you notice something causes skin redness
and itchiness stop using it (American Academy of Dermatology, 2011). Use calamine
lotion to sooth the skin (Mayo Clinic, 2011). You can put an anti-itch cream to help with
itchiness (Mayo Clinic, 2011). Keep your skin clean and moisturized (American
Academy of Dermatology, 2011; Mayo Clinic, 2011). Most important, don’t panic. Tell
me, did you change recently laundry soap, any facial products, makeup, or eat something
new?
American Academy of Dermatology. (2011). Atopic dermatitis. Retrieved from
http://www.aad.org/skin-conditions/dermatology-a-to-z/atopic-dermatitis/atopicdermatitis
Edwards, S. (2003, July 1). Cellular pathophysiology. Part 2: Responses following hypoxia.
Nursing Times. Retrieved from http://www.nursingtimes.net/nursing-practice-clinicalresearch/cellular-pathophysiology-part-2-responses-following-hypoxia/200091.article
Huether, S. E., & McCance, K. L. (2008). Understanding pathophysiology (4th ed.). St. Louis,
MO: Mosby.
Mayo Clinic (2011). Angina. Retrieved from
http://www.mayoclinic.com/health/angina/DS00994
Mayo Clinic. (2011). Atopic dermatitis (eczema). Retrieved from
http://www.mayoclinic.com/health/eczema/DS00986
Mayo Clinic (2011). Heart failure. Retrieved from http://www.mayoclinic.com/health/heartfailure/DS00061
Medline Plus. (2011). Newborn jaundice. Retrieved from
http://www.nlm.nih.gov/medlineplus/ency/article/001559.htm
Penn Medicine. (2011). Medical animation library. Urination. Retrieved from
http://www.pennmedicine.org/encyclopedia/em_DisplayAnimation.aspx?gcid=000136&
ptid=17