Hyponatremia and Gas Exchange Overview

Hyponatremia

• Decreased sodium levels (hyponatremia) cause mental status changes and generalized weakness.
• Fluid and electrolyte excess leads to increased blood pressure, strong peripheral pulses, distended jugular veins, peripheral edema, and fluid shifting to interstitial spaces.
• Hyperkalemia or hypercalcemia can cause cardiac dysrhythmias and skeletal muscle spasms.
• Assessment includes health history, nausea/vomiting/diarrhea history, medication history, vital signs (BP, PR), weight changes, and lab tests (electrolytes, BUN, serum osmolality).
• Interventions for fluid deficit involve fluid replacement (oral or parenteral). Fluid overload is treated with fluid restriction and diuretics (note: diuretics can cause hyponatremia and hypokalemia). Elevate legs to improve venous return for lower extremity edema. Electrolyte deficits are treated with IV fluids.

Gas Exchange

• Oxygen transport to cells and carbon dioxide removal occur through ventilation and diffusion.
• Ventilation is triggered by brain neurons sensing gas exchange needs, stimulating skeletal muscle contractions to expand the chest cavity for oxygen inhalation.
• Oxygen binds to hemoglobin in red blood cells and is transported to tissues for cellular metabolism. Carbon dioxide diffuses into blood and red blood cells.
• Adequate ventilation requires a functioning brain, spinal cord, neurons, diaphragm, skeletal muscles, and chest thorax.
• Decreased gas exchange leads to insufficient oxygen transport, CO2 retention (ischemia, cell death), and acidosis.
• Assessment involves respiratory assessment, lung disease/trauma history, breathing effort/rate/O2/cap refill/thoracic expansion/lung sounds, cough/SOB/dizziness/chest pain/cyanosis/adventitious lung sounds, and lab results (arterial blood gases, complete blood count). Chest x-ray, CT, or V/Q scan may be needed.
• Patient education includes infection control, smoking risks, and immunizations.
• Interventions focus on identifying and treating the underlying cause with drug therapy (antihistamines, decongestants, glucocorticoids, bronchodilators, mucolytics, and antimicrobials). Sitting or semi-Fowler's positions improve chest expansion.

Inflammation

• Normal response to cellular injury, allergy, or pathogen invasion.
• Classified as acute (e.g., cholecystitis, appendicitis) or chronic (e.g., inflammatory bowel disease, rheumatoid arthritis).
• Consequences include redness, warmth, swelling, pain, and potentially organ inflammation.
• Assessment involves signs/symptoms of organ dysfunction, WBC count with differential, C-reactive protein, erythrocyte sedimentation rate (ESR), and possibly endoscopy.
• Treatment often includes rest, ice, compression, elevation (RICE) and local/systemic treatment.

Mobility

• Ability to perform purposeful physical movement.
• Patients with musculoskeletal or nervous system dysfunction are at high risk for decreased mobility/immobility. Prolonged bed rest increases risk.

Nutrition

• Process of ingesting and utilizing food/fluid for growth, repair, and optimal body function.
• Malnutrition can be generalized or involve specific nutrient deficiencies (vitamin D, iron, protein).

Pain

• Unpleasant sensory and emotional experience.
• Acute pain is short-lived and localized.

Perfusion

• Nursing assessment of perfusion includes monitoring for changes in peripheral and central perfusion.

Sensory Perception

• Visual and hearing impairments are common, often correctable with devices, drug therapy, or surgery.

Sexuality

• Changes in sexuality can result from menopause, aging, erectile dysfunction, chronic disease, and medications.

Tissue Integrity

• Management of tissue integrity problems involves drug therapy, wound debridement, and wound vacuum devices. Interprofessional collaboration is key.

Trauma Response Factors

• Comorbidities (affect recovery).
• Substance abuse (drug interactions, symptoms).
• Pregnancy (anatomic and hemodynamic changes).
• Advancing age.

Blunt vs. Penetrating Trauma

• Blunt trauma: less obvious, object doesn't break the skin.
• Penetrating trauma: sharp objects and projectiles (shearing, acceleration/deceleration).

Primary Survey (Trauma)

• Alertness: AVPU (alert, verbal, pain, unresponsive).
• Airway: Assess for bony deformity, burns, edema, fluids, foreign objects, inhalation injury, loose teeth, sounds, tongue obstruction, vocalization. Cervical spine stabilization is crucial. Interventions include jaw thrust, OPA, NPA, ETT. Normal capnography: 35-45 mmHg.
• Breathing: Assess breath sounds, depth, pattern, rate, work of breathing, dyspnea, open wounds, skin color, spontaneous breathing, subcutaneous emphysema, and symmetrical chest rise and fall. Remove backboard as appropriate. Continuous reevaluation using the VIPP (Vitals, Injuries, Primary Survey, Pain) model.

Trauma Injuries

• Chest: Rib fracture, flail chest, pulmonary contusions, tension pneumothorax, open pneumothorax, massive hemothorax.
• Cardiac: Cardiac tamponade, vascular trauma, blunt cardiac injury.
• Abdominal: Spleen injury, liver injury. Hemostasis and contamination prevention are vital.
• Head: Direct impact, acceleration-deceleration, shock wave injury.
• Pelvic: Symptoms include perineal ecchymosis, pain on palpation of iliac crests, hematuria, and lower extremity rotation. Diagnosis via CT scan. Initial management focuses on hemorrhage control and stabilization.

Trauma Triad of Death (Lethal Triad)

• Hypothermia: Often present (blood loss, shock, weather). Target temperature: 36.5-37.5°C.
• Coagulopathy: Initially hypercoagulation, then depletion of clotting factors due to acidosis and decreased perfusion, leading to increased bleeding.
• Acidosis: pH < 7. Causes decreased coagulation, increased lactic acid, and decreased heart performance. Assessment includes labs (INR, PTT), neurologic changes, blood pressure, and medication history (aspirin, heparin). Bleeding manifestations include cyanosis, bruising, increased respiratory rate, and bleeding from various sites. Treatment involves platelets, clotting factors, and blood transfusions.

Primary Survey Interventions (Life-Threatening Injury)

• Airway management (jaw thrust, OPA, NPA, ETT)
• Cervical spine immobilization
• Breathing support (oxygen, ventilation)
• Hemorrhage control.