Instruction
Chief Complaint: 68-year-old man with breathing problems.
History: A 68-year-old man with chronic renal failure was in the hospital in serious condition recovering
from a heart attack. He had just undergone "balloon angioplasty" to re-dilate his left coronary artery,
and was thus on an "NPO" diet (i.e. he was not allowed to have food or drink by mouth). He received
fluid through an intravenous (IV) line. Late one night, a weary nurse who was on the 11th hour of a 12-
hour shift came into the patient's room to replace the man's empty IV bag with a new one. Misreading
the physician's orders, he hooked up a fresh bag of IV fluid that was "twice-normal" saline rather than
"half-normal" saline (in other words, the patient starting receiving a fluid that was four times saltier than
it should have been). This mistake was not noticed until the following morning. At that time, the man
had marked pitting edema around the sacral region and had inspiratory rales ("wet-sounding crackles")
at the bases of the lungs on each side. He complained that it was difficult to breathe as well. Blood was
drawn, revealing the following:
Na+ 157 mEq / liter (Normal = 136-145 mEq / liter)
K+ 4.7 mEq / liter (Normal = 3.5-5.0 mEq / liter)
C1- 101 mEq / liter (Normal = 96-106 mEq / liter).
A chest x-ray revealed interstitial edema in the lungs. Most dissolved substances in the blood plasma can
easily move out of the bloodstream and into the interstitial fluid surrounding the cells.
1. Will the nurse's mistake increase or decrease the "saltiness" of the interstitial fluid? Given your
knowledge of osmosis, will this cause the cells in the body to increase or decrease in size?
2. Why does this patient have pitting edema and inspiratory rales?
3. How would this increase in salt load affect the patient's blood-aldosterone level? In your answer, explain the function of the hormone aldosterone. Can you think of any other normal mechanisms that
the body has to control salt and water balance? How might they react in this situation?
4. What symptoms might result from hypernatremia ("high blood-sodium" level)?
5. How is this patient's interstitial edema in the lungs affected by his already-weakened heart?