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Q.1. The Causes and Major Clinical Manifestations Of Abnormal Levels Of Sodium, Potassium, Calcium, Phosphate, and Magnesium

Hyponatremia (low sodium) or hypernatremia (high sodium) is the major cause of abnormal levels of Sodium in the body. Hyponatremia is caused by excess water than sodium content in the body. The clinical manifestation of low sodium levels are irreversible neurological symptoms, such as coma, disorientation, and seizures (McCance & Huether, 2024). In contrast, hypernatremia is caused by excessive intake of sodium, diabetes insipidus, or inadequate fluid intake/dehydration. Clinical manifestations of hypernatremia include hyperreflexia, muscle twitching, seizures, and intracellular dehydration (McCance & Huether, 2024). 

Abnormal levels of potassium are caused by hypokalemia/hyperkalemia. Hypokalemia clinical manifestations include irregular heart rhythms, fatigue, cramping, and muscle weakness, while hyperkalemia clinical presentations are cardiac arrhythmias, palpitations, fatigue, and muscle weakness (McCance & Huether, 2024). In contrast, Hypercalcemia/hypocalcemia is the cause of abnormal calcium levels in the body. The clinical manifestations of hypercalcemia are weakness, constipation, polydipsia, and polyuria. Other clinical manifestations are confusion, anorexia, fatigue, vomiting, nausea, and neuropsychiatric effects (McCance & Huether, 2024). The clinical signs and symptoms of hypocalcemia are muscle cramps, tetany, seizures, Trousseau’s or chvostek’s signs and paresthesia (McCance & Huether, 2024). 

Hyperphosphatemia/ hypophosphatemia are causes of abnormal phosphate levels in the body. The clinical presentation of hypophosphatemia is bone pain, weakness, and fatigue while hyperphosphatemia clinical presentation include tetany, muscle cramps, perioral tingling or numbness. Other symptoms are rash, pruritus, joint and bone pain (McCance & Huether, 2024). Lastly, hypomagnesemia/hypermagnesemia is the causes of abnormal level of magnesium in the body. The clinical presentation of hypomagnesemia are cardiovascular and neurovascular manifestations, including muscular weakness, dysphagia, fatigue, vomiting and nausea. Hypermagnesia clinical presentations are cardiac arrest, respiratory depression, hypotension, and hyporeflexia (McCance & Huether, 2024).

Q.2: The Fluid Imbalance that that the 65-Year-Old Female is Experiencing and Rationale

According to the patient’s laboratory values, the patient experiences multiple fluid imbalances. First, her Serum sodium values are (Na+) 156 mEq/L and serum glucose 412 mg/dl, suggesting hypernatremia. McCance and Huether (2024) define hypernatremia as serum sodium concentrations that exceed 145 mEq/L. The patient’s sodium concentration is 156 mEq/L, indicating dehydration.  Secondly, the patient experiences hyperkalemia because her serum potassium values are (K+) 5.6 mEq/L which are somewhat above the normal range of 5.0-5.5 mEq/L, suggesting  heart failure or chronic kidney disease (McCance & Huether, 2024). Thirdly, the patient has elevated chloride ions” (Cl–) 115 mEq/L”, which suggest hyperchloremia because it has exceeded 106 mEq/L (McCance & Huether, 2024). Thus, the case study patient experiences hypernatremia because of high sodium levels, hyperkalemia because of high potassium levels, and hyperchloremia because of high chloride levels in the blood.

Q.3. Symptoms Expected because of the Patient’s Fluid Imbalance

Hypernatremia expected symptoms include coma, seizures, spasms, muscle twitching, mood changes, confusion, fatigue, and excessive thirst (McCance & Huether, 2024). Hyperkalemia expected symptoms include paresthesias, vomiting/nausea, chest pain, palpitations, dyspnea, and paralysis of frank muscle (McCance & Huether, 2024). Lastly, the expected symptoms of hyperchloremia are breathing difficulties, weakness, dehydration, fatigue, vomiting, and diarrhea (McCance & Huether, 2024).

Q.4. What the Patient’s ABG Results Indicate

The patient’s ABGs results are: pH 7.30; PaCO2 32 mmHg; PaO2 70 mmHg; HCO3– 20 mEq/L. The PH suggests acidemia because the patient’s blood is too acidic, highlighting the critical state of the patient. Additionally, the patient’s HCO3– 20 mEq/L is low. The low HC03 level and a PH< 7.35 suggest metabolic acidosis (McCance & Huether, 2024). The patient’s PaCO2 32 mmHg and PaO2 70 mmHg is below the recommended range, suggesting respiratory alkalosis.  Respiratory alkalosis is attributable to hyperventilation as the patient’s body is trying to compensate for the high acid levels in the blood.

Whether the Patient Has an Onion Gap and What It Indicates

 An anion gap is the difference between the blood’s positively and negatively charged electrolytes. A high onion gap suggests that the blood is acidic while a low onion gap indicates that the blood’s acid level is inadequate (McCance & Huether, 2024).  Nonetheless, both low and high acid levels are indicators of critical disorder requiring immediate medical attention.  Anion gap is calculated using the following equation” (Na+ + K+) – (Cl- + HCO3-) “= Anion Gap

The Anion Gap for the case study patient is: (156 mEq/L +5.6 mEq/L) –(115 mEq/L +20 mEq/L)= 26.6 mEq/L. 

The patient’s anion gap value indicates metabolic acidosis because her kidney cannot excrete NH+4.

Q.5. Isotonic IV Fluid that would be appropriate to be prescribed by the nurse practitioner and why

The case study patient’s condition is attributable to metabolic acidosis. In this case, the most appropriate Isotonic IV fluid for the patient is Ringer’s Lactate (RL) instead of normal saline (NS). NS is not recommended because it will worsen the patient’s acidosis, resulting in hyperchhloremic metabolic acidosis because of the fluid’s high chloride concentration levels (Yan et al., 2023). In this case, Ringer’s Lactate is recommended because it helps resolve diabetic ketoacidosis quickly, leading to improved patient outcomes by counteracting acidosis. The lactate in Ringer’s Lactate fluid is broken down in the liver into bicarbonate to assist in countering acidosis. 

References

McCance, K. L., & Huether, S. E. (2024). McCance and Heuther’s Pathophysiology (9th
ed.). Elsevier.

Yan, J. W., Slim, A., Van Aarsen, K., Choi, Y. H., Byrne, C., Poonai, N., & Clemens, K. K. (2023). Balanced crystalloids (RInger’s lactate) versus normal Saline in adults with diabetic Ketoacidosis in the Emergency Department (BRISK-ED):  A protocol for a pilot randomized controlled trial. Pilot and Feasibility Studies, 9(1), 121. https://doi.org/10.1186/s40814-023-01356-5