Nursing

These are the disorder to write on

1. Cirrhosis & Liver failure

2. Cholecystitis

3. Acute Pancreatitis

4. Acute Kidney Injury

5.

Pyelonephritis

NSGP 210 Case Studies in

Pathophysiology

– Concept map notes

System: Condition

Basic Concept

Pathophysiology

Risk Factors

Etiology

Pathophysiology (include different types here)

clinical presentation (S&S)

Diagnostic Test/Procedures

Treatment

Complications

Health Conditions

Hypo / hyper kalemia

System Condition: Hypo / hyper kalemia

Basic Concept

Hypokalemia
· Decrease in potassium levels in the blood.
· Ka serum level: < 3.5 mEq/L(3.5 mmol/L) · Ka moderate serum level: 2.5-3.0 mEq/L · Severe: serum level <2.5 mEq/L. Hyperkalemia · increase in potassium levels in the blood. · Ka serum level > 5.0-5.5 mEq/L in adults.
· Serum level: > 7 mEq/L can lead to severe complications such as hemodynamic and neurologic consequences.

Pathophysiology

Hypokalemia
· Potassium is obtained through diet.
· Excretion increased by aldosterone, diuretics, and negatively charged ions deposited into the collecting duct.
· Excretion minimized by low serum and urination flow.
Hyperkalemia
· Triggered by minimal glomerular activity.

Risk Factors

Hypokalemia
· Eating disorders
· AIDS
· Alcoholism
· Bariatric surgery
Hyperkalemia
· ARBs or potassium-sparing diuretics.
· Virilization
· Adrenal gland suppression
· Kidney problems

Etiology

Hypokalemia
· Abnormal losses: medications, gastrointestinal losses, renal losses, hypomagnesemia, dialysis
· Transcellular shift: medications, thyrotoxicosis.
· Pseudo hypokalemia: extreme leukocytosis, delayed sample analysis
· Starvation, dementia.
Hyperkalemia
· Pseudo hyperkalemia
· Decreased renal excretion
· Deficiency in insulin, mineral acidosis, cell injury

Pathophysiology with different types

Hypokalemia
· Low levels of potassium will cause rise in sodium levels therefore causing hypernatremia.
Hyperkalemia
· high levels of potassium will cause drops in levels of sodium hence causing hyponatremia.

Clinical Presentation

Hypokalemia
· Asymptomatic when mild (3-3.5 mmol/L)
· Nonspecific symptoms (general weakness, lassitude, constipation) with more severe hypokalemia
· Serum level of < 2.5 mmol/L leading to muscle necrosis · Serum level of < 2.0 mmol/L leading to ascending paralysis and impairment of respiratory functions. Hyperkalemia · Weakness which at times progresses to flaccid paralysis and hypoventilation. · Metabolic acidosis. · Altered heart electrical activity. Diagnostic Test/Procedures Hypokalemia · Repeated serum potassium measurements. · Measurements for magnesium and glucose. · Measurements for creatine and urine. · Acid-base balance. · If initial work-ups fail, perform thyroid and adrenal work-up. Hyperkalemia · Clinical history · Physical examination · Medications review · Assessment of cardiac functions · Assessment of hydration status · Electrocardiogram · Comprehensive laboratory workup Treatment Hypokalemia · Potassium tablets or infusion. · Increase intake of materials containing potassium. Hyperkalemia · Calcium chloride. · Insulin · Furosemide · Sodium polystyrene · Patiromer Complications Hypokalemia · Increases mortality in CKD or CHF · Symptoms dependent on severity · Severe hypokalemia may result in heart block. Hyperkalemia · Frequently asymptomatic · Can present irregular heart rhythms

Hypo / hyper natremia

System Condition: Hypo / hyper natremia

Basic Concept

Hyponatremia
· Na+ serum level < 135 mEq/L · Common imbalance that is mostly seen in isolation · Mild; serum level 130-134 mmol/L · Moderate: serum level 125-129 mmol/L Hypernatremia · Rise in sodium concentration. · Level of concentrations exceeds 145 mmol/L · A water and not sodium problem Pathophysiology Hyponatremia · Water intake depends on thirst mechanism. · Thirst is stimulated by osmolality increase. · Hyponatremia occurs only when some conditions impair normal free water excretion. Hypernatremia · Cells become dehydrated after hypernatremia of any etiology occurs. · Increased sodium reacts and extracts the water. Risk Factors Hyponatremia · Older age >65
· Use of pain medications
· SSRIs for antidepressant therapy
· Diuretics
· Diets poor in sodium
· Hypothyroidism
Hypernatremia
· Older age >65
· Mental and physical disability
· Hospitalization
· Residence in nursing home
· Inadequate nursing care
· Diabetes insipidus
· Diabetes mellitus
· Diuretic therapy

Etiology

Hyponatremia
· Kidney failure
· Congestive heart failure
· Diuretics
· Pain medication
· Severe vomiting or diarrhea
· Excessive thirst

Hypernatremia
· Diabetes insipidus- Central, Nephrogenic
· Diarrhea, emesis
· Burns, excessive sweating
· Premature infants, radiant warmers, phototherapy

Pathophysiology with different types

Hyponatremia
· Low levels of sodium will cause an increase in potassium levels, thus causing hyperkalemia
Hypernatremia
· Subsequently, high levels of sodium will cause a drop in potassium levels causing hypokalemia.

Clinical Presentation

Hyponatremia
· Headaches, seizures, confusion, coma
· Weakness in muscles
· Vomiting, diarrhea, pain in abdomen
Hypernatremia
· 50 % mortality rate due to encephalopathy
· Coma, weakness, neurologic deficits

Diagnostic Test/Procedures

Hyponatremia
· Physical examination
· History examination
· Radiologic imaging
Hypernatremia

· Thorough physical exam inclusive of volume status, mental status and neurologic assessment.

Treatment

Hyponatremia
· Fluid restriction (0.5- 1 liter/day). Encourage water intake
· Demeclocycline (600- 1200 mg/d). inhibits action of adh
· Urea (30mg/d). osmotic diuresis
· Lithium (up to 900mg/d). inhibits action of adh
Hypernatremia

· Reduce intakes rich in sodium.
· Sodium chloride
· Intravenous dextrose

Complications

Hyponatremia
· Fatigue
· Convulsions
· Feeling weak
· Coma
· Low blood pressure
· Confusion
· Short temper
Hypernatremia

· Intense thirst
· Fever
· Nausea or vomiting
· Intense thirst
· Seizures
· Labored respiration
· Focal neurologic deficits

Hypo / hyper calcemia

System Condition: Hypo / hyper calcemia

Basic Concept

Hypocalcemia
· Ca serum level: <8.8 mg/dL · Hereditary. Hypercalcemia · 90% of hypercalcemia cases caused by hyperparathyroidism. · Mild: Ca 10.5-11.9 mg/dL (2.5-3 mmol/L · Severe: Ca 14-16 mg/dL (3.5-4 mmol/L) Pathophysiology Hypocalcemia · Cased by numerous conditions: hypoparathyroidism, hungry bone syndrome, medications, infusion of phosphate, and kidney and liver diseases. Hypercalcemia · Calcium is crucial in intracellular and extracellular metabolism controlling many processes. · Ca metabolism regulated by hormones affecting entry into the intercellular space and controls its excretion from the kidneys. Risk Factors Hypocalcemia · Medications · Rapid citrated blood transfusion · Infusion of phosphate · Hungry bone syndrome · Altered vitamin D metabolism · hypoparathyroidism Hypercalcemia · Vitamin D intoxication · Vitamin A intoxication · AIDS · Drugs · Lithium · Thiazide diuretics · Mild alkali syndrome · Chronic renal insufficiency Etiology Hypocalcemia · Hypoalbuminemia · Hypomagnesemia · Hyperphosphatemia · Surgical effects · PTH deficiency or resistance · Vitamin D deficiency or resistance · Medication effects Hypercalcemia · Hyperthyroidism · Primary adenoma, hyperplasia, carcinoma · lithium therapy · tertiary hyperparathyroidism · familial hypocalciuric hypercalcemia Pathophysiology with different types Hypocalcemia · low levels of calcium may be caused by low or deficiency of magnesium. · A drop in calcium levels causes an increase in phosphate levels causing hyperphosphatemia Hypercalcemia · Too much calcium in the body will cause a decrease in potassium levels in the blood. Patients with severe hypercalcemia will always be hypokalemic. · An increase in calcium level in the blood will cause a drop in phosphate levels thus causing hypophosphatemia when hypercalcemia is not severe. Clinical Presentation Hypocalcemia · Paranesthesia around mouth, fingers and toes. · Muscle cramps · Tetany · Seizures · Latent hypocalcemia Hypercalcemia · Diabetes insipidus · Acute kidney injury · Hypertension · Nausea · Vomiting · Constipation · Fatigue · Coma Diagnostic Test/Procedures Hypocalcemia · Physical examination · History examination · Measurement of serum intact parathyroid hormone. Hypercalcemia · Blood test for high calcium levels in blood. · Mammogram · Chest x-ray · MRI · CT scan Treatment Hypocalcemia · Magnesium supplements · Intravenous IV calcium gluconate for acute hypocalcemia · Calcium and vitamin D supplements (oral) for chronic hypocalcemia Hypercalcemia · IV hydration with isotonic saline · Salmon calcitonin · Bisphosphonate Complications Hypocalcemia · Respiratory arrest · Cardiac arrest · Tetany · Seizures · Laryngospasm Hypercalcemia · Kidney stones · Kidney failure · Fractures · Hypertension · Pancreatitis · Osteoporosis

Hypo / hyper phosphatemia

System: Condition: Hypo / hyper phosphatemia

Basic Concept

Hypophosphatemia
· Phosphate serum level:< 2.5 mg/dL (0.8 mmol/L) in adults. · Normal ranges of Phos in neonates are 4.8 – 8.2 mg/dL, 3.8 – 6.5 mg/dL in 1week to 3 years old children, 3.7 – 5.5 mg/dL in 3 to 12 year olds, and 2.9 to 5 mg/dL for adolescents to age 19 years. · A serum Phos < 2.5 mg/dL considered hypophosphatemia where < 1.5 is severe. Hyperphosphatemia · Abnormally high serum phosphate levels. · A serum Phos from > 4.5 mg/dL considered hyperphosphatemia.

Pathophysiology

Hypophosphatemia
· Mainly caused by low intake of phosphate into the body, high excretion of phosphate.
Hyperphosphatemia
· Most common cause are decreased kidney function, and massive extracellular fluid phosphate loads.

Risk Factors

Hypophosphatemia
· Severe malnutrition
· Alcoholism
· Severe burns
· Fanconi syndrome
· Chronic diarrhea
· Vitamin D deficiency (in children)
· Inherited conditions such as X-linked familial hypophosphatemia (XLH)
Hyperphosphatemia
· Excessive body fat
· Diabetes mellitus
· Hypercalcemia
· Kidney infections
· High cholesterol levels

Etiology

Hypophosphatemia
· Malnutrition
· Hyperparathyroidism
· Starvation
Hyperphosphatemia
· Renal failure

Pathophysiology with different types

Hypophosphatemia
· A drop in phosphate levels will cause a rise in calcium levels in the blood causing hypercalcemia.
Hyperphosphatemia
· A rise in phosphate levels in the blood will always cause a drop in calcium levels leading to hypocalcemia.

Clinical Presentation

Hypophosphatemia
· Weakness in muscles.
· Seizures
· Blood issues
· Getting numb
· Alteration of mental state
· Weakening of bones
Hyperphosphatemia
· Rashes
· Soft bones thus weak
· Pain in joints
· Spasms
· Numbness in the mouth

Diagnostic Test/Procedures

Hypophosphatemia
· Measurement of blood phosphate.
· Additional tests may also be done to determine underlying cause of disorder
Hyperphosphatemia
· Measurement of blood phosphate
· Other tests to check to reason behind rise of phosphate.

Treatment

Hypophosphatemia
· Phosphate supplements, orally.
· Active vitamin D
· Treatment for related disorders: cinacalcet, calcitonin, or dipyridamole, but in future.
Hyperphosphatemia
· Reduction of phosphate in diet.
· Removal of extra phosphate with dialysis.
· Lower amount of phosphate intestines absorbs using medication

Complications

Hypophosphatemia
· Acute hypocalcemia
· Tetany
· Renal failure
Hyperphosphatemia
· Cardiac arrest
· Valve calcification (heart)
· Elevated PO4 due to lack of adequate binders.
· Elevation of PO4 can still be caused by diets high in phosphorus.

Hypo / hyper magnesemia

System: Condition: Hypo / hyper magnesemia

Basic Concept

Hypomagnesemia
· An electrolyte disturbance caused by low levels of serum magnesium.
· While in low levels:< 1.46 mg/dL in the blood Hypermagnesemia · Serum concentration: Mg >2.6 mg/dL (> 1.05 mmol/L)

Pathophysiology

Hypomagnesemia
· Magnesium is essential for biochemical reactions.
· Affects sodium, calcium and potassium, mostly while is in low levels.
· Magnesium homeostasis involves the kidney.
· Hypomagnesemia occurs when something changes or interferes with magnesium homeostasis.
· Deficiency in magnesium can cause other conditions such as hypocalcemia.
Hypermagnesemia
· Occurs mostly due to chronic kidney disease

Risk Factors

Hypomagnesemia
· Diabetes mellitus
· Poor nutrition
· Heart failure
· Potassium deficiency
· Calcium deficiency
Hypermagnesemia
· Decreased renal function
· Lithium therapy
· Low thyroid activity
· Diseases such as Addison’s
· Syndromes such as milk-alkali
· Drugs containing magnesium
· Familial hypocalciuric hypercalcemia

Etiology

Hypomagnesemia
· Mainly caused by starvation, alcoholism, and critical illness.
· Can be secondary to medications such as proton pump inhibitors, digitalis, chemotherapeutic drugs, amphotericin, aminoglycoside antibiotics, loop and thiazide diuretics.
Hypermagnesemia
· Renal failure.
· Low renal excretion caused by depletion of salt.
· Drug abuse (antacids and laxatives)
· Rhabdomyolysis
· Endocrinopathies

Pathophysiology with different types

Hypomagnesemia
· When magnesium levels in the blood are low (hypomagnesemia) the patient will suffer from hypocalcemia and hypokalemia.
Hypermagnesemia
· Having too much magnesium in the blood is uncommon.

Clinical Presentation

Hypomagnesemia
· Hypocalcemia, prolonged QT and QU interval, tremors, weakness in muscles.
Hypermagnesemia
· Confusion, weakness in muscles, paralysis in the bladder, lethargy

Diagnostic/Test Procedures

Hypomagnesemia
· Physical exam
· Symptoms
· Medical history
· Blood test
Hypermagnesemia
· Blood test

Treatment

Hypomagnesemia
· Supplements for magnesium (oral)
· Increased intake of foods containing magnesium
· Magnesium intravenously for severe cases
Hypermagnesemia
· First identify and stop the production of extra magnesium.
· To reduce symptoms, administer intravenous (IV) calcium.
· Diuretics
· Water pills
· Dialysis for patients with kidney failure or if other medications are failing.

Complications

Hypomagnesemia
· Seizures
· Sudden death
· Cardiac arrhythmias
· Coronary artery vasospasm
Hypermagnesemia
· Hypotension
· Cardiac arrhythmia
· Confusion
· Lethargy
· Coma
· Cardiac arrest