Vomiting Mr. B. is age 81 and has had gastritis with severe 3 days. He has a his

Question

Vomiting Mr. B. is age 81 and has had gastritis with severe 3 days. He has a history of vomiting for feeling heart problems and is presently s dry, dizzy and lethargic. His eyes appear sunken, his mouth he walks unsteadily, and he complains of muscle aching. particularly in the abdomen He is thirsty but isunable to retain food or fluid. A neighbor has brought Mr. KB to the hospital, where examination shows that his blood pressure is low, and s pulse and respirations are rapid. Laboratory tests demon strate elevated hematocrit, hypernatremia, decreased serum bicarbonate, serum pH 7.35, and urine of high specific gravity (highly concentrated) This case study illustrates a combination of fluid, electro e, and acid-base imbalances. Specific laboratory values are not given so as to focus on the basic concepts. For clarity, this case study is discussed in three parts, the early stage, middle stage, and advanced stage of the imbalances. Further informa tion about the specific problems involved is given in each part and is followed by a series of questions

Part A: Day 1 Initially, Mr. K.B. lost water, sodium in the mucus content, and hydrogen and chloride ions in the hydrochloric acid portion of the gastric secretions Alkalosis develops for two reasons, the first being the direct oss of hydrogen ions and the second being the effects of chlo ride ion loss. When chloride ion is lost in the gastric secretions, replaced by chloride from the serum (see Fig. 2-9). To maintain equal numbers of cations and anions in the serum, chloride ion and bicarbonate ion can exchange places when needed. Therefore more bicarbonate ions shift into the serum from storage sites in the erythrocytes to replace the lost chlo ride ions. More bicarbonate ions in the serum raise serum pH and the result is "hypochloremic alkalosis

Part B: Days 2 to 3 As Mr. continues to vomit and is still unable to eat or drink K.B. any significant amounts, loss of the duodenal contents, which include intestinal, pancreatic, and biliary secretions, occurs. No digestion and absorption of any nutrients occurs. Losses at this stage include water, sodium ions, potassium ions, and bicarbonate ions. Also, intake of glucose and other nutrients is minimal. Mr. K.B. shows elevated serum sodium

Part C: Day 3: Admission to the Hospita After a prolonged period of vomiting, metabolic acidosis devel- ops. This change results from a number of factors: Loss of bicarbonate ions in duodenal secretions. Lack of nutrients leading to catabolism of stored fats and protein with production of excessive amounts of ketoacids Dehydration and decreased blood volume leading t decreased excretion of acids by the kidney Decreased blood volume leading to decreased tissu perfusion, less oxygen to cells, and increased anaerobic metabolism with increased lactic acid ncreased muscle activity and stress leading to increased metabolic acid production

Answer the following questions:

1) Predict the serum level of carbon dioxide or carbonic acid in this case.

2) If Mr. K.B. continues to lose body fluid, why might serum Ph decrease below 7.35?

3)If serum drops below 7.35, what signs would be observed in Mr. K.B.?

4) Describe the effects of acidosis on serum potassium levels.

5) Mr. K.B. will be given replacement fluid therapy. Why is it important that sodium and potassium be given as well as water?

Explanation / Answer

Answer:

1) Predict the serum level of carbon dioxide or carbonic acid in this case.

The serum levels of carbon dioxide or carbonic acid will be low in this case due to loss of bicarbonate ions and since the patient is suffering from alkalosis.

2) If Mr. K.B. continues to lose body fluid, why might serum pH decrease below 7.35?

The serum pH decreases below pH 7.35 due to metabolic acidosis. In metabolic acidosis there is a reduction in the serum bicarbonate concentration and pH. The increase in metabolic acids raise the levels of H+ and this causes a decrease in the serum pH. Moreover, heavier breathing leads to a decrease in PCO2

3) If serum drops below 7.35, what signs would be observed in Mr. K.B.?

If serum drops below pH 7.35 the signs and symptoms will be:

4) Describe the effects of acidosis on serum potassium levels.

Metabolic acidosis causes hyperkalemia (increase in concentration of serum potassium levels) due to increase in exchanging of H+ with intracellular K+ by sodium/potassium pumps.

5) Mr. K.B. will be given replacement fluid therapy. Why is it important that sodium and potassium be given as well as water?

Water is given along with sodium and potassium to maintain osmolarity and to prevent dehydration.

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