CASE SCENARIO # 2

FLUIDS AND ELECTROLYTES

The Client is a 75 year old woman, retired bank employee from Tayabas Quezon who fell on the
floor when she attempted to get up during intermission while attending a concert with a friend.
When asked whether she takes any drug, she tells you that she has been taking Diuril for 20
years to manage her high blood pressure. The only other drugs she takes are aspirin each day
and multivitamin. She is alert and just a little anxious. Her vital signs are as follows: T- 98.4; P-
102, thready, slight irregular; R- 30 and shallow; BP 98/50; 02 Saturation 95%
Upon admission, she received 40 mEq KCl to be incorporated with 1 L of NaCl regulated at
___________. The physician advised the patient to undergo Electrocardiogram test (ECG Test)
but the patient refused the procedure.

ASSESSMENT:

a. Physical Examination
AREAS NORMAL FINDINGS ABNORMAL FINDINGS

General Looks and body built in accordance Little anxious.

to her age. With signs of acute and mild distress
Clothing appropriate to climate. Sits uncomfortably
Looks clean
Concious and alert
With a little amount of cosmetics
appropriate to age and event
Have a manicure and pedicure

Skin Skin normally warm to touch
Skin sag appropriate to age
Presence of wrinkles
No Lesions Noted.
Color of the skin is brown
Head Hair is black with presence of white
strands.
Head is round in shape
Poor skin turgor for 5 second
Texture is not uniform throughout the
body.
Skin on palms of the hands ans soles
of feet are thicker
Hair not evenly distributed

Eyes Eyes blinking spontaneously from Using eye glasses with a grade.
time to time
Pupils are Equally Round and
Reactive to Light and Accomodation
Ears Presence of small amount of
yellowish – brownish ear wax No Significant Findings
Smooth and warm to touch
Symmetrical
 Weber test: Sound heard equally in
both ears.
No Lateralization.
Rinne Test: Air Conducted sound is
heard twice as long as bone-
conducted sound.
Nose No unecessary discharges No Significant Findings
In the midle of the face above the
lips
Throat Has clear and moderate in sound No Significant Findings
voice
Neck Slightly hyperextended, without No Significant Findings
massess or assymetry.
Trachea is in the midline.
Veins and arteries are flat.
Thyroid gland cannot be visualized.
No presence of mumps noted.

Breast One breast is larger, nearly equal in No Significant Findings

size.
Smooth and the color of neighboring
skin.
Nipples are bilaterally equal, nearly
equal in size.
Respiratory Symmetry and shape of chest Respiratory Rate of 30 breaths per
No masses noted. minute
Presence of shallow breaths
Using accessory muscles while
breathing
Bicarbonate: 34 mEq/L
Venous pH: 7.48 pH
Cardiovascular No mumurs noted. Pulse rate of 102, thready, slight
irregular
K+: 2.8
Cl-: 88
Mg+2: 1.6
Gastrointestinal No Significant Findings No Significant Findings
Urinary No Significant Findings No Significant Findings
Genital No Significant Findings No Significant Findings
Peripheral / Vascular No Significant Findings No Significant Findings
Musculoskeletal No Significant Findings Presence of pain in the buttocks and
back due to fall
Na+: 131
K+: 2.8
Neurologic Concious and alert Slightly anxious
Behave in a manner of concern Mg+2: 1.6
Able to make an eye contact
 Hematologic No Significant Findings Presence of bruises in
Endocrine No Significant Findings Mg+2: 1.6
Psychiatric Concerned about the findings No Significant Findings

b. Health History
The patient reported diarrhea since yesterday, she has no allergies in any medication and food.
She told that both of her parents are hypertensive before while her mother died due to CVA and
her father due to heart attack. She became hypertensive as well at the age of 55 years old. She
said she modifies her diet to low salt diet as prescribed to her. At her age, she stated she doesn’t
experience joint pain, and no problem in balancing. She do mild exercises everyday such as
single limb stance and walking heal to toe to maintain her balance and gait. She has no
immediate family but she have 3 dogs and 1 cat that she treat as her children. She said she tries
to live healthy because she’s worried that no one will take care of her pets if she died.

LABORATORY TESTS and DIAGNOSTIC EXAMINATIONS

LABORATORY R E S UL T S
STUDIES
INTERPRETATION
PATIENT’S NORMAL VALUES
READING

Na+ 131mEq/L 136-145 Abnormal; Decreased

Sodium blood test- The patient’s reading shows
This test measures the that it is below normal level
amount of sodium on
the patient’s body which indicates that the
wherein a sodium is a patient is experiencing
type of electrolytes hyponatremia wherein the
which are electrically
charged minerals that signs and symptoms includes
help maintain fluid altered personality, lethargy
levels and balance of and confusion
chemicals in the body
called acid and bases.
K+ 2.8mEq/L 3.5-5.0 Abnormal; Decreased
The results shows that the
Potassium blood test:
patient’s potassium is too low
This test is used to
monitor or diagnose which is called hypokalemia,
conditions related to in which it can make muscles
abnormal potassium feel weak, cramp, twitch, or
levels. These even become paralyzed, and
conditions include,
kidney disease, high abnormal heart rhythms may
blood pressure, and develop. (RR: 30 bpm)
heart disease.

Cl- 88mEq/L 96-106 Abnormal; Decreased

Chlorine blood test: The patient’s chlorine level is
This test is an too low which indicates that
electrotype in which it
measures the amount of
she is experiencing an
chloride in the blood. electrolyte imbalance called
hypochloremia in which her
body’s metabolism doesn’t
function properly.

Bicarbonate 34mEq/L 25 Abnormal; Increased

Metabolic alkalosis; The
Bicarbonate blood
patient’s bicarbonate is
test: This measures the
amount of bicarbonate, elevated which indicates that
a form of carbon he is experiencing metabolic
dioxide, in the patient’s alkalosis, in which there is
blood. too much bicarbonate in her
blood that makes her feel
signs and symptoms of
confusion, hand tremor,
lightheadedness, or nausea
and vomiting.

Mg+2 1.6mEq/L 1.8-2.5 Abnormal; Decreased

Magnesium blood The patient is experiencing
test: This test helps to hypomagnesemia in which
evaluate the level of
magnesium in the her magnesium level is low
blood and to help that she is experiencing signs
determine the cause of of weakness in her bones.
abnormal levels.

Venous pH 7.48 pH 7.31-7.41 Abnormal; Increased

The test reveals that her
Venous pH: This is a
venous is above normal
point-of-care test
routinely used to assess which indicates that the
acid-base status along patient’s blood is more basic
with adequacy of and has a higher bicarbonate
ventilation and
oxygenation among
level
predominantly
critically/acutely ill
patients.

PATHOPHYSIOLOGY Electrolyte Imbalance

Non-Modifiable Modifiable

Age 75 years Diuril

old (Diuretics)

Decrease
production of
aldosterone

Increase Urination Excessive

sweating

Hypokalemia Hyponatremia

Decreased
Alteration of
depolarization ECF volume
heartbeat

Loss of acids
Weak muscle
Tready and contractions
irregular pulse

P= 102 bpm
Decreased of Increased
Muscle Weakness
Dehydration chlorode (Cl = 88) HCO2 (34)
and magnesium
Increased pH
(Mg = 1.6)
(7.48)
Fall
Metabolic
Alkalosis
 DRUG STUDY

GENERIC BRAN CLASSIFICATIO MECHANISM INDICATION SIDE EFFECTS NURSING

NAME D N OF ACTION IMPLICATION
NAME S

Acetylsalicyli Aspiri Anti-platelet Inhibit - -Ulcer -Instruct

c acid n drugs prostaglandi Hypertensio -Abdominal patient to take
n H synthase n pain the medication
in platelets -Nausea after meal to
and blocks -Gastritis limit the
the - gastrointestinal
formation of Gastrointestinal irritation.
thromboxane bleeding -Educate
A2 -Headache patient to
-Diarrhea or report tinnitus.
constipation -Monitor the
-Increased liver function
bleeding and monitor
-Easy bruising for ototoxicity
-Hepatotoxicity -Instruct the
-Ototoxicity patient to
increase fluid
intake.
-Assess the
patient for
signs of
bleeding.
Chlorothiazid Diuril Thiazide Interfere - -Dizziness -Monitor
e Diuretics with the Hypertensio - electrolyte
renal tubular n Lightheadednes laboratory
electrolyte s results.
reabsorption. -Stomach upset -Monitor the
It increases -Nausea patient’s blood
the excretion -Diarrhea or pressure.
of sodium constipation -Monitor
and chloride, -Hypokalemia intake and
potassium -Hypochloremia output of the
and -Hyponatremia patient.
bicarbonate. -Monitor signs
and symptoms
of
hypokalemia,
hypochloremia
and
hyponatremia.
(Vomiting,
Diarrhea,
Muscle
weakness,
Confusion,
Fatigue, Leg
cramps, dry
skin,
dehydration.)
-Increase fluid
intake.
NURSING CARE PLAN

NURSING DIAGNOSIS PLAN OF CARE NURSING INTERVENTION RATIONALE EVALUATION

Fluid volume deficit related to
fluid loss secondary to diarrhea
Subjective:
The patient reports being weak
and anxious.
Objective:
-Irregular heartbeat
-Restlessness
-Muscle weakness
-Shallow breathing
-Diarrhea
-Low sodium level
-Low potassium level
-Low chlorine level
-Low magnesium level
After 2 hours of nursing intervention,
the patient will be able to exhibit
signs of improvement in hydration
status.
1. Monitor and document Decrease in circulating blood After 2 hours of nursing intervention,
vital signs especially volume can cause hypotension the patient will be able to exhibit signs
BP and HR. and tachycardia. Alteration in of improvement in hydration status.
HR is a compensatory
mechanism to maintain cardiac
output. Usually, the pulse is
weak and may be irregular if
electrolyte imbalance also
occurs. Hypotension is evident
in hypovolemia.
2. Assess skin turgor and Signs of dehydration are also
oral mucous detected through the skin. Skin
membranes for signs of of elderly patients losses
dehydration. elasticity, hence skin turgor
should be assessed over the
sternum or on the inner thighs.
Longitudinal furrows may be
noted along the tongue.

A common manifestation of
3. Monitor BP for fluid loss is postural
orthostatic changes hypotension. It is manifested
(changes seen when by a 20-mm Hg drop in
changing from supine systolic BP and a 10 mm Hg
to standing position). drop in diastolic BP. The
Monitor HR for incidence increases with age.
orthostatic changes.
Oral fluid replacement is
 indicated for mild fluid deficit
4. Encourage the client to and is a cost-effective method
increase fluid intake. for replacement treatment.

Excessive fluid loss through

regulatory mechanisms failure
5. Monitor I & O and IV may result in severe
fluids. dehydration.

Fluid deficit can cause a dry,

6. Emphasize importance
of oral hygiene.
sticky mouth. Attention to
mouth care promotes interest
in drinking and reduces
discomfort of dry mucous
membranes.

Dehydrated patients may be

7. Aid the patient if he or weak and unable to meet
she is unable to eat prescribed intake
without assistance, and independently.
encourage the family or
SO to assist with
feedings, as necessary.

To reduce stress and anxiety.

8. Keep a quiet
environment and calm
activities.