Higher Institute of Health Specialties

Post Graduate Diploma in Adult Critical Care

Nursing Program -2024-2025

Case study Framework for

Sub Competency No.2: b. Electrolyte imbalances (Hypernatremia )
Competency No.4: pressure risk assessment
Competency NO 9; arterial blood gas (mixed respiratory and metabolic
alkalosis)

Student Name: SHAHAD SHAMIS ALBATTASHI

I.D Number: HIHS 21581
Academic supervisor: Dr. Asia and Ms. Asma
Introduction:

This case study focuses on three critical clinical competencies: electrolyte imbalances
(hypernatremia), pressure risk assessment, and arterial blood gas (ABG) analysis ( mixed
respiratory and metabolic alkalosis). The case was selected because it presents an opportunity to
integrate these competencies through the interpretation of signs and symptoms, and the accurate
management of patients requiring urgent assistance with altered fluid and electrolyte balance.
Additionally, it emphasizes the importance of interpreting and analyzing Arterial Blood Gases,
assessing pressure risk, and providing appropriate nursing interventions to maintain skin
integrity.

How I Will Achieve the Competencies:

Electrolyte Imbalances (Hypernatremia): I will review the lab results to assess the patient
condition and understand the factors that contributed to the hypernatremia. I will identify the
underlying causes.

Pressure Risk Assessment: To evaluate the risk of pressure ulcers, I will utilize a standardized
tool like the Braden Scale, which assesses key factors including mobility, moisture, nutrition,
activity, and skin condition. This will help me accurately determine the patient's risk level for
developing pressure injuries and guide my prevention strategies.

Arterial Blood Gas Analysis (Mixed Respiratory and Metabolic Alkalosis): I will be
analyzed the ABG results to measure pH, Paco₂, HCO₃⁻, and oxygen levels. In cases of mixed
respiratory and metabolic alkalosis, I will specifically look what was the underlying cases that
lead to this situation. Additionally, I will evaluate the interventions to correct these imbalances
and plan further management accordingly.

Case Details:

 Name of the patient: Miss. F

 Date of admission: 27\09/2024
 Place of admission: KH. ICU
 Date of case taken: 23\10\2024
  Number of day’s student gave care to the patient: Two days
 Diagnosis: sub-arachnoid haemorrhage, left MCA (Middle Cerebral Artery) bifurcation
aneurysms
 Name of the teacher whom the case is reported with: Ms.Sreedivi

Patient History:

Ms. F. 55 years old female patient, on 27\09\2024 brought by EMS. Patient was found in
bathroom by sponsor, semiconscious. Initial GCS 11\15 (E4M5V2), both pupils 1 mm not
reacting.

On 27\9\2024 CT head done shows evidence of diffuse subarachnoid hemorrhage with brain
edema and tonsillar herniation. The intervention was inserted right frontal EVD on 27\9\2024.
Shifting to the ward and after a few days transferred back to ICU due to had convulsion then
LOC with post cardiac arrest and intubated in the ward.

On 08\10\24 DSA + Coilling done for right PVOM and MCA bifurcation Aneurysm.

No Past medical and surgical history

Present History:

At the present, with poor prognosis and weaning started with no improvement of GCS, the
doctors explained to the sponsor regarding the patient conditions and DNR activated on
20\10\2024

(N-O-PQRST): could not assess due to GCS 3\15.

On Assessment:

CNS: GCS E1M1VT, b\l pupils 1 mm and not reacting to the light. Patient have right EVD for
ICP monitoring (ICP: 21 mmHG)

CVS: Hemodynamically was maintained without inotropic support; Vital signs (Temp: 36.2, HR:
90 bpm, RR: 14 bpm, BP: 129\69 mmhg, SPO2: 99 %).

Inspection: The patient in a good condition. Looks clean and dressing well. unconscious.
No cyanosis on lips, equal hair distribution. No edema noted

Palpation: Temporal and carotid pulse felt. Peripheral pules in both extremities felt bilaterally,
patient peripheral extremities are little cold, capillary refill within 2 seconds. Nasal sinus along
with remaining glands including thyroid, maxillary and frontal palpated, no swelling or
tenderness noted

Auscultation: Heart Normal heart beat heard along with clear sound of the chest. Chest:
Bilateral equal and adequate air entry

GIT and bladder: Abdomen inspected looks normal, no distension noted or any masses while
palpation. While percussion, dullness heard over the right upper quadrant and tympanic sound
over the remaining quadrants. Patient with adequate urine output 60-80 ml per hour.

Patient getting 75 ml/hr of ensure feed via feeding pump for 4 hrs and 1 hr for bowel rest and
well tolerated. (ensure contain 1.2 calories)

Skin: all pressure area intact with the Braden scale assessment done (Score 8 patient is high risk
for developed bed sore due to immobility and confined to bed)

Lines: Patient with IV cannula g 20 in the right hand and, no infiltration noted.

Lab investigations:

Arterial Blood Gas (ABG) result 14\10\2024:

Test name Value Normal range

pH 7.55 7.35 -7.45
pCO2 32.20 35 - 45
pO2 88.80 80 - 100
O2 saturation 98 94 – 100
Lactate 1.19 mmol/L <2
Bicarbonate 32 mmol/L 22 - 26
Sodium 152 135-145
Potassium 4.02 3.5-5.1
 RFT (RENAL FUNCTION TEST): 18\10\2024:

Test name Value Unit Normal Range

Urea 4.84 mmol/L 3.2- 8.2
Creatinine 42.06 umol/L 49 - 90
Sodium 142.83 mmol/L 136 - 145
Potassium 3.5 mmol/L 3.5 - 5.1
Chloride in Serum/Plasma 110 mmol/L 98 - 107
eGFR.MDRD >90 mL/min/1.73 90 - 120

Complete Blood Count (CBC): 23\10\24 :

Test name RESULT Unit Normal Range

Red Blood cells 2.92 10*6/uL 4.1 - 5.4
HGB 8.2 g/dL 11 - 14.5
Haematocrit of Blood 25.8 % 34 - 43
Platelet count in Blood 515 10*3/uL 150 - 450
Mean Platelet volume in Blood 9.4 fL 7 - 10.5
WBC 13.08 10*3/uL 2.4 – 9.5

Medication: (Mph, Z. S. (2022))

Drug name Classification Side effect Nursing responsibility

Tab. Valsartan 80 angiotensin II headache Monitor blood pressure before and after
mg OD oral receptor blocker dizziness administration
(ARB) t flu symptoms Regularly check pulse may cause
tiredness bradycardia or tachycardia in some
(abdominal) pain patients.
Valsartan can lead to hyperkalemia
 (high potassium).
Inj. Enoxaparin Anticoagulant Bleeding Monitor for signs of bleeding (e.g.,
sodium 6000 Iu OD Thrombocytopenia bruising, dark urine, unusual bleeding).
Injection site Regularly check platelet counts.
reactions Instruct patients to avoid activities that
may increase the risk of injury.
Ensure proper administration technique
(subcutaneous injection, rotate sites).
Tab. Amlodipine 5 Calcium Peripheral Edema. Measure blood pressure before and after
mg OD Channel Blocker Palpitations or administration
(CCB) Tachycardia Assess for peripheral edema
Fatigue Headache Record daily weights if the patient is at
risk for fluid retention
Inj.Morphine Opioid Sedation Monitor the patient’s vital signs,
sulphate 50 mg Analgesic Respiratory especially respiratory rate and level of
depression consciousness.
Nausea and Assess pain levels regularly and
vomiting evaluate the effectiveness of pain relief.
Hypotension Administer naloxone as an antidote in
case of opioid overdose.
Inj. omeprazole 40 Proton Pump Headache Administer the medication before meals
mg IV OD Inhibitor (PPI) Diarrhea or for optimal effectiveness.
constipation Monitor for gastrointestinal symptoms
Nausea and assess for relief from acid-related
Abdominal pain conditions.
Educate patients about potential side
effects and the importance of taking the
medication as prescribed.
Nursing physical assessment:
Neurological assessment:

 Patient GCS E1M1VT, b\l pupils 1 mm and not reacting to the light.
 Right parietal EVD (External Ventricular Drain) intact for ICP monitoring at level
15 H2O. ICP normal: 21 mmHg.
 Not able to assess for cranial nerves.
 EARS: The size and shape are normal and equal on both sides, no lesions, no
redness, no discharge, no tenderness. Tympanic membrane intact.

Respiratory assessment:

Patient intubated with ETT NO 7 mm, connected to mechanical ventilator on APV-SIMV

mode, PEEP 5, FIO2: 30%, Rate 14 b\min and tidal volume 410 ml. while suctioning
thick yellowish secretion sucked out and Absent cough reflex
 In inspection: could not assess respiratory expansion due patient GCS 3\15, no
mass felt
 In percussion: normal sound present
 In auscultation; chest is clear with the air equally entry in both lungs.

Integumentary assessment:

 Appearance: The color of skin is brown. She has a good skin turgor and skin’s
temperature is cold within normal limit.
 patent is unresponsive and confined to bed. All pressure area is intact.
 Braden scale assessment done, score 8 and patient is high risk to get bedsore.
 Nursing Care Plan:

1\ Ineffective Airway Clearance related to decreased level of consciousness,

impaired cough reflex, and endotracheal intubation.

Assessment Goal/Outcome Nursing Rational Evaluation

intervention

Subjective The patient will 1\ Check vital 1\ To maintain base The patient
data: maintain a signs frequently line condition
patent airway and listen for And auscultation helps improved and
On APV-SIMV with effective abnormal lung assess the goal partially
mode, peep 5, cough and sound effectiveness of airway met: by
fio2: 30% . clearance of clearance. reduced
PS:15 secretions. 2\Perform secretions, and
endotracheal 2\ Suctioning prevents a decrease in
C-Reactive suctioning as airway obstruction the need for
Protein: 85.55 needed to clear caused by secretions suctioning.
Mg\l. secretions, and maintains airway
maintaining patency
Objective data: oxygenation and
Yellow thick ventilation. 3\ To maintain patent
secretion airway
3\ Perform chest
Absent cough tapping 4\ Proper positioning
reflex
helps prevent
4\ Maintain the
patient's head in aspiration and
GCS:3\15 a neutral
facilitates optimal lung
position, with the
Clear lung bed elevated to expansion.
sound 30 degrees,
unless
HR: 90 bpm, contraindicated
RR: 14 bpm,
BP: 129/69
mmhg, SPO2:
99 %).
 2.Ineffective cerebral tissue perfusion related to increased ICP (intracranial
pressure)

Goal/ Nursing intervention Evaluation

Outcome

To enhance Monitor intracranial pressure (ICP) with EVD: to

cerebral prevent further increase in pressure and to reducing the With all this
tissue risk of cerebral ischemia or damage. measures, ICP
perfusion was
Elevate the head of the bed to 30-45 degrees: helps still in higher level.
to promote venous drainage from the brain, reducing
ICP and preventing further compromise to cerebral
perfusion.

Avoid activities that may increase ICP, such as

excessive suctioning or unnecessary movement:
These activities can increase intrathoracic and intra-
cranial pressure.

Monitor for the symptoms of Cushing's triad, which

include bradycardia, elevated pulse pressure, and
tachypanic: Cushing’s triad is an indicator of increased
ICP
3\ Risk for aspiration related to a decreased level of consciousness and

impaired cough reflex.

Goal/ Nursing intervention Evaluation

Outcome

The patient will Position the patient in a semi-Fowler's position; Semi- The patient
Fowler's position helps prevent aspiration by reducing the remains free from
remain free
risk of regurgitation and facilitating drainage from the signs and
from mouth. symptoms of
aspiration.
aspiration.
-Monitor the patient's respiratory status, including
respiratory rate, depth, and oxygen saturation:
Continuous monitoring helps detect signs of respiratory
distress or impending aspiration.

- Elevate the head of the bed to 30-45; To helps prevent

aspiration by reducing the risk of reflux and aspiration of
gastric contents.

-Assist with Feeding: Proper feeding techniques reduce

the risk of aspiration during meals.
 Risk for Impaired Skin Integrity related to immobility, as evidenced by a
Braden Scale score of 8 (high risk for pressure ulcers).

Goal Nursing intervention Evaluation

will maintain Assessing the skin regularly: To reduce pressure in The patient's
intact skin bony prominence area and to prevent pressure sore skin remains
intact, with no
signs of
Reposition the patient every 2 hours: Frequent redness,
repositioning helps to alleviate prolonged pressure on pressure
vulnerable areas. ulcers, or other
skin
Keep the patient’s skin clean and dry: To promote breakdown.
healthy skin integrity

Monitor liver function test: especially albumin level, if

Low albumin may indicate malnutrition.
 Risk for Fluid Volume Deficit related to hypernatremia

Goal/Outcome Nursing intervention Evaluation

The patient Monitor serum sodium levels and other The patient’s serum
will achieve a electrolytes closely: Regular monitoring helps to sodium level returns
serum sodium reducing sodium levels and ensuring electrolyte to the normal range
level within balance. (135-145 mEq/L).
the normal
range (135-145 Monitor intake and output (I&O): Monitoring
mEq/L) fluid balance helps assess dehydration status and
guides fluid replacement.

Administer IV fluids with hypotonic or isotonic

solutions (e.g., 0.45% saline or D5W): Hypotonic
solutions help to gradually reduce sodium levels by
replacing free water, while isotonic fluids restore
overall fluid volume.
Analysis the competency:

NO 4: Demonstrate dexterity to carryout pressure risk assessment and

provide nursing interventions to maintain skin integrity of patients admitted
in critical care areas. (Braden scale)

 My patient is immobility confined to bed, unconscious patient, GCS 3\15, all

pressure areas are intact, Braden Scale score: 8 (indicating high risk for
pressure ulcers) supported on an air mattress to help prevent pressure
injuries, receiving Ensure feed at 1.5 calories per mL, provided continuously
over 24 hours and Albumin level: 40.40 g\l. MI

In critical care, where patients are frequently at high risk for pressure ulcers due to
several risk factors contribute to skin damage in these critically ill patients,
including nutritional deficits, decreased tissue perfusion, long-term use of a
mechanical ventilator, the presence of moisture and circulatory
changes (Mônica etl 2017)

A pressure injury is defined as localized damage to the skin and/or underlying

tissue as a result of pressure. Pressure injury commonly occur over bony
prominences. pressure injury are more commonly associated with a medical device
or object. In addition to pressure, poor blood flow, friction, shear, and tissue
ischemia can all contribute to the develop of a pressure injury. The deep fascia,
subcutaneous fat, skin, bone, and muscle can all be damaged by unrelieved
pressure (Lexie Miller, 2022)

According to Mônica etl (2017) state that “The risk of developing a PU can be
evaluated from measurement scales of pressure ulcer risk factors” also state that
The Braden scale is comprised of six pressure ulcer risk factors. Each factor is
classified by scores. The total final sum of the scores provides the risk
classification for the evaluated patients, as follows: very high risk: 6-9 points, high
risk: 10-12 points, medium risk: 13-14 points and low risk: 15-18 points.

Nursing Interventions and care are essential to prevent and treat impaired skin
integrity: Implement wound care protocols as prescribed. Position the patient
comfortably. Ensure adequate skin perfusion. Determine the patient’s
continence and skin moisture. Promote proper nutrition and fluids. Protect
the skin from further injury. Coordinate with a wound/ostomy specialist.
Avoid irritation.
Summary of Article:

Tite: Braden Scale in pressure ulcer risk assessment

Author: Jansen RCS etl year 2020

The article highlights the importance of using validated risk assessment scales, such as
the Braden Scale, and considering additional risk factors, including age, comorbidities,
and medical device use, to accurately assess a patient's risk of developing a PrI.

The key findings of the text are the importance of comprehensive PrI risk assessment,
the need for care plans and prevention strategies, and the importance of following
guidelines and policies for PrI assessment and treatment.

Braden Scale or Braden Scale II According to Dr Hester of Health Sense Ai/HD Nursing,
Clinicians should use the Braden Scale version that their provider is currently licensed
for and has approval to use in their electronic health record (EHR)

When a patient is determined to be at risk, implement care plans and prevention

strategies to avoid a Pressure injury (PrI) from occurring if possible, or prevent
a PrI from deteriorating

Objectives: The objective of the article is to discuss the importance of pressure injury
risk assessment and the use of validated risk assessment scales, as well as to highlight
additional risk factors that should be considered.

Methods: The article does not describe a specific study or methodology, but it provides
an overview of pressure injury risk assessment and the use of validated risk
assessment scales.

Results: The article does not present specific results, but it discusses the importance of
using validated risk assessment scales and considering additional risk factors to
accurately assess a patient's risk of developing a PrI.

Conclusions: The article concludes that pressure injury risk assessment is a

multifaceted process that requires the use of validated risk assessment scales, such as
the Braden Scale, and consideration of additional risk factors, including age,
comorbidities, and medical device use. The conclusions of the text are that
comprehensive PrI risk assessment and prevention are crucial, and that clinicians
should follow guidelines and policies for PrI assessment and treatment.

Implication:

The Braden Scale evaluation tool is a commonly used technique in hospitals throughout
Oman to determine a patient's risk of getting pressure ulcers (bedsores). Each patient's
Braden Scale score is assessed daily by the nursing staff, who pay particular attention
to sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The
patient's risk status is updated and care plans are modified as necessary with the use of
this evaluation. Additionally, the nurse assigned for that patient reviews the Braden
Scale results from the previous week and records an updated score every Friday at
Khoula Hospital. This makes it easier to record any long-term alterations in a patient's
health that could raise or lower their risk of developing a pressure ulcer.

Second Competency:

NO 2: Demonstrate skill in monitoring hemodynamic status, interpretation of

signs and symptoms and management of patients who needs urgent assistance
with altered fluid and electrolyte balance accurately following the
management protocol of the concerned hospital.

b. Electrolyte imbalances (Hypernatremia)

 Patient X was diagnosed with a subarachnoid haemorrhage and left MCA

(Middle Cerebral Artery) bifurcation aneurysms. An external ventricular drain
(EVD) was inserted to monitor intracranial pressure (ICP). A CT scan of the head
revealed brain edema, and 3% saline was initiated to reduce the swelling.
However, after a few days, the patient's sodium level increased to 155 mEq/L. As
 a result, the 3% saline was discontinued, and management for hypernatremia
was initiated.

The most common electrolytes in the human body (in tissues and fluids such as blood,
urine and sweat) are sodium, potassium, calcium, phosphate and magnesium.
Electrolytes play vital roles in nerve conduction, muscle contraction, hormone secretion
and enzyme activity. Some bodily functions rely on several electrolytes being within a
specified range (e.g. muscle contraction is affected by sodium, potassium, calcium and
magnesium concentrations) ( Gareth N & Ben H, 2022).

Hypernatremia is defined as increased serum sodium concentration.145mmol/L. It is a

hyperosmolar state in which there a deficit in total body volume in comparison to total
body electrolytes (Kinsuk, C, 2019).

causes: Dehydration, High sodium intake and Diabetes insipidus.

 According to my patient, not have any of this causes.

Signs and the symptoms: Thirst, Restlessness, confusion, Muscle twitching and
Elevated blood pressure

 According to my patient, GCS 3\15, unconscious and the blood pressure

increased up to 160\77, management with tablet amlodipine and valsartan.

Management of hypernatremia: Provide free water intake if able, administer hypotonic

fluids (e.g., 0.45% saline) and reduce sodium intake.

 Due to my patient have brain edema and they involve using 3% saline as
hypertonic solution to reduce it. However, when my patient sodium level
rose up to 155 mEq\L, they manged with free water via NGT and IV fluid
0.45% saline until sodium reach to normal level.

Electrolyte Imbalance Causes Signs & Symptoms Management

- Restrict water intake
- Excessive water
- Nausea, vomiting - Administer saline IV
intake
- Headache (e.g., 0.9% or
Hyponatremia - Diuretics
- Confusion, seizures hypertonic saline if
- Heart, liver, or kidney
- Muscle weakness severe)
failure
- Monitor sodium levels
Hypokalemia - Diuretics Muscle weakness, - Increase dietary
- Vomiting/diarrhea cramps potassium
- Inadequate - Irregular heartbeat - Administer oral/IV
Electrolyte Imbalance Causes Signs & Symptoms Management
(arrhythmias) potassium (monitor
potassium intake - Fatigue closely)
- Constipation - Monitor ECG
- Limit potassium intake
- Kidney failure - Muscle weakness
- Administer calcium
- Excess potassium - Abnormal heart
gluconate (for heart
Hyperkalemia intake rhythms
protection)
- Tissue damage (e.g., - Tingling/numbness
- Use diuretics or
trauma) - Shortness of breath
dialysis
- Muscle spasms,
cramps Administer calcium
Vitamin D deficiency
- Numbness/tingling in supplements (oral or IV)
- Hypoparathyroidism
Hypocalcemia fingers - Increase vitamin D
- Chronic kidney
- Seizures intake
disease
- Positive Chvostek's - Monitor calcium levels
and Trousseau's signs
- Hydration (oral/IV
fluids)
Hyperparathyroidism Nausea, vomiting
- Administer diuretics
- Excessive vitamin - Bone pain
Hypercalcemia (e.g., furosemide)
D/calcium - Constipation
- Use bisphosphonates
- Cancer - Mental confusion
(for cancer-related
cases)

Summary of article:

Title: Rate of Correction of Hypernatremia and Health Outcomes in Critically Ill

Patients

Author: Kinsuk C etal year: 2019

Hypernatremia is defined as increases serum sodium

concentration.145mmol/L .is a hyperosmolar state in which there is a deficit
in total body volume in comparison to total body electrolytes. The incidence
of hypernatremia is reported to be up to 3%in hospitalized patients
and9%inpatientsadmittedto the intensive care unit (ICU) (Acute
hypernatremia in ICU patients may have an independent association with
higher mortality and length of stay, although the higher risk of mortality may
reflect severity of related illness and comorbid conditions.

The study found no significant difference in in-hospital 30-day mortality

proportion between rapid (≥0.5 mmol/L per hour) and slower (<0.5 mmol/L
per hour) correction rates in patients with hypernatremia on admission or
hospital-acquired hypernatremia. Additionally, there was no association
between rapid correction and neurologic complications such as cerebral
edema, seizures, and alteration of consciousness.

Rapid correction of hypernatremia was not associated with a higher risk of

mortality, seizure, alteration of consciousness, and/or cerebral edema in
critically ill adult patients.

The objective of the study was to determine the association between the
rate of correction of hypernatremia and health outcomes in critically ill
patients, including mortality and neurologic complications.

Methods: The study used a retrospective cohort design, extracting data

from the MIMIC-III database. Patients with severe hypernatremia were
identified, and their correction rates were calculated using serum
sodium values after the peak level. The association between correction
rates and outcomes was examined using logistic regression analysis.

Results: The study found no significant difference in mortality or neurologic

complications between patients with rapid and slower correction rates
of hypernatremia. Also, The mortality rates were consistently lower in
patients with rapid correction of hypernatremia, but the difference was not
statistically significant.
Conclusions: The study concludes that rapid correction
of hypernatremia is not associated with a higher risk of mortality, seizure,
alteration of consciousness, and/or cerebral edema in critically ill adult
patients with either admission or hospital-acquired hypernatremia. The
study suggests that clinicians should consider correcting the serum
sodium level with free-water administration to shorten the length of stay in
this vulnerable patient population.

Implantation:

In general, in each hospital there are a protocol how to manage the electrolytes
imbalance, such as in khoula hospital the protocol is:

 The management of surgical patient with electrolyte imbalance should

include the following:

1 The doctor should put a request in the electronic patient record (Al Shifa system),
It applies to patient who fulfill the following criteria: A. Serum creatinine < 150
μmol/L. B. Adult > 13 years old. C. Urine output > 0.5 ml/kg/hr for 2 consecutive
hours. D. Patient not at risk of fluid overload (e.g. dialysis, heart failure). E. No
arrhythmia. F. Patient no known renal or endocrine disease as etiology of
electrolytes imbalance e.g. adrenal insufficiency.

2. Electrolytes abnormalities are based on serum lab values (not only ABG
sample).

3. Patients with symptomatic electrolyte imbalance and those with ECG changes
will need medical team referral after initiating the replacement by the surgeon to be
followed up.
Third competency: Demonstrate the ability to interpret and analyses the
following Arterial Blood Gases.

An ABG test was performed for Patient X, showing the following values:

 pH: 7.55 (indicating alkalosis)

 PCO₂: 32.2 mmHg (lower than normal, suggesting respiratory alkalosis)

 Bicarbonate (HCO₃⁻): 32 mEq/L (higher than normal, suggesting metabolic alkalosis)

These results indicate mixed respiratory and metabolic alkalosis.

Metabolic alkalosis is a condition that occurs when the body’s chemistry becomes too
alkaline. The pH above 7 being alkaline. This type of alkalosis occurs due to a loss of fluids
from vomiting, diarrhea, or excessive urination.

Cause: Loss of stomach acids, Excessive bicarbonate intake, Diuretics and

Hypokalemia:

Signs and Symptoms: Muscle cramps, twitching, or spasms, Nausea and vomiting, Tingling
in fingers or toe and Mental confusion or dizziness

Management: Electrolyte replacement: Especially potassium and sometimes chloride to

correct deficits. Monitor ABG levels: Regular checks help assess the effectiveness of
interventions

Respiratory Alkalosis: occurs when there is an increase in blood pH due to a decrease in

carbon dioxide (CO₂) levels, usually because of excessive breathing (hyperventilation).

 Causes: Hyperventilation, Mechanical ventilation, Fever or infection and Hypoxia:

 Signs and Symptoms: Lightheadedness or dizziness, Numbness or tingling, particularly

around the mouth or in extremities, Muscle cramps or spasms and Palpitations or
shortness of breath

 Management: Reduce breathing rate: For ventilated patients, adjusting the ventilator
settings to a lower rate or tidal volume. Breathing techniques: For conscious patients,
controlled breathing techniques or breathing into a paper bag can help retain CO₂
 Summary of articles:

Title: Metabolic alkalosis and mixed acid base disturbance in an aesthesia and critical care

Author: M Park and D. Sidebotham year: 2023

Metabolic alkalosis is common in critically ill patients and often occurs in the context of a
mixed acid-base disturbance. It can be caused by bicarbonate excess or hydrogen
ion deficit (traditional approach) or by a relative deficit of chloride, a relative excess of
sodium, or a reduction in the total weak acids in plasma (physiochemical approach).

 The key findings of the article are:

The strong ion difference (SID) is a useful concept in understanding metabolic alkalosis.

Changes in sodium and chloride concentrations can affect the SID and lead to
metabolic alkalosis.

Hypoalbuminemia, diuretic use, and vomiting can cause metabolic alkalosis due to
relative chloride deficit.

Methods:

The article uses a combination of traditional and physiochemical approaches to explain

metabolic alkalosis, including the use of equations and formulas to quantify the
variables influencing plasma pH. The study used a physiochemical approach to
understand acid-base disturbances, and a simplified approach was proposed for
diagnosing mixed acid-base disturbances.

Results:

The article provides a comprehensive overview of metabolic alkalosis, including its

causes, mechanisms, and diagnosis using both traditional and physiochemical
approaches. The article does not present specific results, but rather provides a
comprehensive review of the concept of strong ion difference and its application in
understanding and managing metabolic alkalosis. The results showed that Ringers'
lactate solution causes a small increase in serum lactate concentration, and that the in
vivo SID of a fluid determines its acid-base effect.
Conclusions

Metabolic alkalosis is a common and complex acid-base disturbance that requires a

thorough understanding of its causes and mechanisms to diagnose and treat effectively.
The conclusions of the article are: The strong ion difference (SID) is a useful concept in
understanding metabolic alkalosis. Metabolic alkalosis can be caused by a variety of
factors, including hypoalbuminemia, diuretic use, vomiting, and activation of the RAAS.
A stepwise approach can be used to identify and manage metabolic alkalosis in critically
ill patients. The conclusions are that the in vivo SID of intravenous fluids affects their
acid-base impact, and that understanding this concept is crucial for managing acid-base
disturbances in critically ill patients.

Implication:

In general, in all hospital in Oman especially in critical care area they perform arterial blood gas
(ABG) analysis to monitor patients' respiratory and metabolic state, because ABG provides
critical insights into oxygenation, ventilation, and acid-base balance. Also, this proactive
approach is crucial in an ICU setting, where patients are often critically ill and require precise,
real-time monitoring to ensure optimal outcomes.
References:

Ccm, M. W. B. R. (2024, January 28). Impaired Skin Integrity Nursing Diagnosis & Care Plans |
NurseTogether. NurseTogether. https://www.nursetogether.com/impaired-skin-integrity-
nursing-diagnosis-care-plan/

Chauhan, K., Pattharanitima, P., Patel, N., Duffy, A., Saha, A., Chaudhary, K., Debnath, N., Van
Vleck, T., Chan, L., Nadkarni, G. N., & Coca, S. G. (2019). Rate of Correction of
Hypernatremia and Health Outcomes in Critically Ill Patients. Clinical Journal of the
American Society of Nephrology, 14(5), 656–663. https://doi.org/10.2215/cjn.10640918

De Azevedo Macena, M. S., Da Costa Silva, R. S., Da Conceição Dias Fernandes, M. I., De
Almeida Medeiros, A. B., Lúcio, K. D. B., & De Carvalho Lira, A. L. B. (2017). Pressure
Ulcer Risk Evaluation in Critical Patients: Clinical and Social Characteristics. The Open
Nursing Journal, 11(1), 91–97. https://doi.org/10.2174/1874434601711010091

Electrolyte disturbances: causes and management - The Pharmaceutical Journal. (2023, May 9).
The Pharmaceutical Journal. https://pharmaceutical-journal.com/article/ld/electrolyte-
disturbances-causes-and-management

Mph, Z. S. (2022, September 21). Metabolic alkalosis: Causes and treatment.

https://www.medicalnewstoday.com/articles/metabolic-alkalosis#causes

Nursing guidelines : Pressure injury prevention and management. (n.d.).

https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pressure_Injury_Preven
tion_and_Management/#Introduction
Phn, A. C. R. B. (2024, October 16). Amlodipine Nursing Considerations. NurseStudy.Net.
https://nursestudy.net/amlodipine-nursing-considerations/

Themes, U. (2016, July 18). Fluid and electrolyte imbalances. Musculoskeletal Key.
https://musculoskeletalkey.com/fluid-and-electrolyte-imbalances-2/