Name: Queenie B.

Gallego

Section: BSN 3-A

NCM 112 CLINICAL (Fluid and Electrolytes)

Case Scenario 2

SCENARIO:

Patient Profile:

F.B, a 78 years old that lives alone, is admitted to the hospital because of weakness and
confusion. She has a history atrial fibrillation and chronic heart failure (HF). On admission it is
noted that her at home medications include Digoxin (Lanoxin), Furosemide (Lasix), Metoprolol,
Diltiazem and Levothyroxine.

Objective Data:
Neurologic: Confused; slow to questioning; generalized weakness; states she has trouble
focusing his vision- people look green with halo’s
Cardiovascular: BP 100/59; HR 55 irregular; peripheral pulses weak; ECG indicates Atrial
fibrillation with controlled ventricular response
Pulmonary: Respirations at 12/min; shallow
Skin: decreased turgor; dry mucous membranes

Laboratory Results
Electrolytes Hematology ABGs Serum Digoxin

Na+ 134 mEq/L RBC 5 x 106/uL pH 7.55 Digoxin level 1.0

K+ 2.5 mEq/L WBC 7,000/uL PaO2 88 mm/Hg ng/ml
Mg+ 1.2 mEq/L Hemoglobin 14 g/dL PaCO2 45 mm/Hg
Cl- 88 mEq/L Hematocrit 50% HCO3- 42 mEq/L
BUN 42 mg/dL Platelets 250,000/uL
Creatinine 0.9 mg/dL
Glucose 122 mg/dL
(random)
CO2 31 mEq/L
Critical thinking questions:

1. Evaluate Frances’ fluid volume and electrolyte status. Which physiological

assessment findings support your analysis? Which lab results support your
analysis? What is the most likely the etiology of these imbalances?
 Patient P.B has a fluid volume deficit when they have lost a significant amount of
fluid from their body. This can happen due to dehydration, sweating, bleeding, or
other causes. The patient appears dehydrated, with dry skin and dry mucous
membranes. They also have an irregular heart rate and low blood pressure.

The physical assessment of patient PB with hypokalemia reveals decreased skin

turgor, dry mucous membranes, weak pulses, low blood pressure, and confusion.
Lab findings shows elevated levels of BUN, hematocrit, and decreased levels of
Na+ and Cl-.

The patient's physical assessment reveals weakness, confusion, and an irregular

heartbeat. Their laboratory findings show that their sodium, chloride, potassium,
and magnesium levels are all low. They have not been ordered potassium with
their furosemide.

The patient's diuretic therapy may be causing them to urinate excessively, and
they may not be able to take care of themselves properly. Additionally, they may
be experiencing toxicity from digoxin, a medication used to treat heart conditions.

2. Explain the reasons for Frances’ ECG changes?

 The changes in her ECG are associated with low levels of potassium and
magnesium in her blood. This can cause symptoms like muscle weakness,
irregular heartbeat, and difficulty breathing.

3. Analyze the ABG results. What is the etiology of the primary imbalance? Is the
body compensating for this imbalance?
 Metabolic alkalosis is a condition in which the body's pH level becomes too
alkaline. This can happen if the patient have too much bicarbonate in their blood.
Bicarbonate is a substance that helps regulate the body's pH level. Metabolic
alkalosis can also occur if the body loses too much acid, such as through
vomiting or diarrhea. Metabolic alkalosis is usually not serious and can be treated
with fluids and electrolytes.

The etiology of diuretic-induced hypokalemia is due to the use of diuretics.

Diuretics are medications that increase urine output, and as a result, can cause
potassium levels to drop. Hypokalemia is a condition characterized by low
potassium levels in the blood.
 Complete compensation for diuretic-induced hypokalemia does not always occur.
Some patients may require additional potassium supplementation even when
taking a diuretic.

4. What has Frances’ advanced age placed her at risk for fluid imbalance?
 As people age, their bodies contain less fluid. In older people, only 45% of body
weight is fluid, compared with 60% in younger people. Some older people may
have physical problems that make it difficult for them to get something to drink
when they are thirsty. Others may have dementia, which can prevent them from
realizing they are thirsty or from being able to communicate this to others.

5. Discuss the role of aldosterone in the regulation of fluid and electrolyte balance.
How will changes in aldosterone affect Frances’ fluid and electrolyte imbalances?
 Aldosterone is a hormone that helps regulate blood pressure and fluid levels in
the body. In response to a high level of potassium in the blood (hyperkalemia),
the body secretes aldosterone to help reduce potassium levels. In this case,
however, the patient's low blood pressure and lack of fluids in the body
(extracellular fluid deficit) would stimulate the release of aldosterone, which
would cause the body to retain more sodium and water, but also lead to even
more potassium loss.

6. What are the primary daily assessments that the nurse will complete?
 Encourage and assist with oral fluid intake
 Provide skin care
 Advise the limit of using soap
 Assist with changing of position
 Asses vital signs every 4 hours
 Asses input and output for abnormalities
 Assess cardiac monitoring until the electrolytes and acid-base are normal
 Assess the type and rate of IV fluid and electrolyte replacement.
 Assess lung sounds for signs of fluid overload in cardiac compromised
patients
 Assess daily serum electrolytes and blood gas levels

7. What would be the top 3 priority nursing problems?

 Fluid volume deficit related to decreased fluid intake
 Risk for injury related to confusion, muscle weakness
 Risk for impaired skin integrity related to dehydration

8. Complete a comprehensive Nursing Care Plan and a nurse’s notes (1 FDAR

Charting, 1 NCP).
 ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective cues: Fluid volume deficit After 6-8 hours of Independent Independent After 6-8 hours of
related to proper nursing proper nursing
States that she has
decreased fluid intervention, the intervention, the
trouble focusing her
intake as patient will be able >Assess vital signs >To obtain baseline patient:
vision- people look
evidenced by to: data
green with halo’s >Maintained fluid
decreased skin
>Maintain fluid > These signs volume at a
turgor, dry mucous >Note changes in
volume at a indicate sufficient functional level as
membrane, usual mentation,
Objective cues: functional level as dehydration to evidenced by
elevated BUN, and behaviour, or
evidenced by cause poor stable vital signs,
(-) skin turgor electrolyte functional abilities
stable vital signs, cerebral perfusion moist mucous
imbalance (confusion, loss of
(+) dry mucous moist mucous and or electrolyte membrane, good
membrane, good ability to carry out skin turgor, stable
membranes imbalance.
skin turgor, stable usual activities) mental status
(+) confusion Scientific > To maintain skin
mental status >Bath infrequently,
Rationale: integrity and >Verbalized
(+) slow to >Verbalize using mild soap, understanding of
prevent excessive
questioning Dehydration and provide optimal
understanding of dryness. causative factors
happens when skin care with
causative factors and purpose of
(+) generalized someone don’t suitable emollients
and purpose of individual
weakness drink enough
individual >Change position > To reduce therapeutic
water. When the
(+) weak peripheral therapeutic frequently pressure on fragile, interventions and
body's water
pulses interventions and dehydrated skin medications
content is too low,
medications and tissues.
(+) kidney failure it causes damage >Demonstrated
quickly. Factors >Demonstrate behaviours to
that greatly affects behaviours to monitor and correct
>Provide frequent
Vital signs taken as geriatric patient monitor and correct > To prevent injury deficit at indicated
oral as well as eye
follow: includes decreased deficit at indicated from dryness.
care -GOAL MET-
thirst sensation,
BP- 100/59 mmHg > if the patient may
kidney malfunction, >Offer fluids on a
not sense/or be
and cognitive regular basis
HR- 55 cpm able to report thirst,
impairment.
> Review client's
RR- 12 bpm (Brennan, MD, medications, > To identify
2021) including medications that
prescription, over- can alter fluid and
the counter (OTC) electrolyte balance.
drugs, herbs, and These may include
nutritional diuretics,
supplements vasodilators, beta
blockers,
aldosterone
inhibitors,
angiotensin-
converting enzyme
(ACE) blockers,
and medications
that can cause
syndrome of
inappropriate
secretion of
antidiuretic
hormone (e.g.,
phenothiazides,
vasopressin, some
antineo plastic
drugs).
>Emphasize the
need for reporting > This facilitates
suspected drug timely intervention
interactions/side to prevent or
effects to reduce
healthcare provider complications.

>Discuss factors >To reduce risk of

related to
occurrence of fluid recurrence
deficit (improper
use of diuretics)
>Discuss signs and
symptoms >To promote timely
indicating need for intervention
emergent of further
evaluation and
follow-up

(Nurses Pocket (Nurses Pocket

Guide: 14th Edition, Guide: 14th Edition,
2016) 2016)

Collaborative
Coordinate with > To evaluate the
other health care body's response to
personnel for fluid loss and to
Laboratory results determine
as follows: replacement needs.

>Serum electrolytes > Electrolytes are

electrically charged
minerals that help
control the amount
of fluids and the
balance of acids
and bases in the
 bod
>Blood, urea, > measures how
Nitrogen much of the waste
product is in the
blood and assess
the function of the
kidney
>Creatinine level
> blood test that
measures how well
the kidneys work

>Blood Glucose >blood test that

level screens for
diabetes by
measuring the level
of glucose (sugar)
in a person’s blood
>CO2 test
> The kidneys and
lungs maintain the
concentration of
CO2 in the blood
and CO2 test can
help diagnose
kidney and
respiratory
problems.

Nursing Notes/ FDAR Charting

Date and time: September 13, 2022, 7:00 am

F Fluid volume deficit related to decreased fluid intake as evidenced by decreased skin turgor, dry mucous membrane,
elevated BUN, and electrolyte imbalance

D (-) skin turgor

(+) dry mucous membranes
(+) confusion
(+) slow to questioning
(+) generalized weakness
(+) weak peripheral pulses
(+) kidney failure

A >Assessed vital signs

>Noted changes in usual mentation, behaviour, or functional abilities (confusion, loss of ability to carry out usual activities)
>Bathed infrequently, using mild soap, and provide optimal skin care with suitable emollients
>Changed position frequently
>Provided frequent oral as well as eye care
>Offered fluids on a regular basis
> Reviewed client's medications, including prescription, over-the counter (OTC) drugs, herbs, and nutritional supplements
>Emphasized the need for reporting suspected drug interactions/side effects to healthcare provider
>Discussed factors related to occurrence of fluid deficit (improper use of diuretics)
>Discussed signs and symptoms indicating need for emergent of further evaluation and follow-up
 >Collaborated with other health care personnel for laboratory test, as follows: Serum Electrolytes test, BUN, Serum
Creatinine, Blood Glucose level, and CO2 test.

R >Maintained fluid volume at a functional level as evidenced by stable vital signs, moist mucous membrane, good skin
turgor, stable mental status
>Verbalized understanding of causative factors and purpose of individual therapeutic interventions and medications
>Demonstrated behaviours to monitor and correct deficit at indicated
-GOAL MET-