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NURS220 Health and Illness I

Concept 7 Fluid & Electrolyte Balance - Case Study and Worksheets
Chelsea-Nicole K. Poligratis
Kapiolani Community College

NURS220 Health and Illness I - Concept 7 Fluid & Electrolyte Balance

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Case Study and Worksheets

Carefully review the items found below and review current resources to provide your
answers. You will be expected to use your texts purchased for this program as well as online
sources. Using two to five sentences per item, complete the word document and upload to your
Case Study folder found in your drop box on Laulima. Complete a reference page at the end
using correct APA format. A minimum of five resources is required. One current research article
must be included within your document and cited at the end. The deadline for completion is
Sunday, August 30, 2015 by 2359 to your Dropbox. Review the model case study found on page
70 of your Giddens text and answer items.
1. Describe the basic components of heart failure. (Do not use the mechanisms cited in the case
study. Use your own resources that may include nursing or medical web-based sites. Five
sentences is required.)
Heart failure refers to the inability of the heart to maintain sufficient cardiac output to
optimally meet metabolic demands of tissues and organs. If the contracting ability of the heart is
impaired, then blood flow to the systemic circulation will be reduced because left ventricular
failure causes increased fluid pressure back through the lungs and ultimately damaging the right
side of the heart AEB swelling in the legs, ankles, and within the abdomen (ascites). Right-sided
HF is usually caused by left-sided HF. In left-sided HF, the left side of the heart has to work
harder to pump the same amount of blood. When fluid collects in the lungs, this is called
pulmonary edema, and it interferes with breathing, causing shortness of breath. In patients with
HF, these symptoms of fluid overload are described as congestive heart failure. CHF is generally
classified as systolic heart failure (LV loses ability to contract normally so the heart cannot pump
with enough force to push blood to circulation) or diastolic heart failure (LV loses ability to relax

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normally so the heart cannot properly fill with blood during rest between each beat.) The most
common cause of HF is myocardial ischemia from coronary artery disease, followed by
hypertension and dilated cardiomyopathy (Copstead & Banasik, 2013, p. 409-10).
2. What do you think was occurring at the elementary school where she volunteered that resulted
in her vomiting and diarrhea? Cite the mode of transmission.
I think viral gastroenteritis was occurring at the elementary school where Mrs. Malone
volunteered. Centers for Disease Control and Prevention (2014) found Norovirus is a common
viral infection that causes inflammation of the stomach or intestines or both. Its common
symptoms are nausea, vomiting, diarrhea, and stomach pain. Other symptoms are fever,
headache, and body aches. Symptoms of dehydration developed when Mrs. Malone became
light headed when she got out of bed and had difficulty standing up because she had weak legs
and it became significant enough to require medical treatment.
Centers for Disease Control and Prevention (2014) also found the virus can spread
quickly in closed places like the elementary school and can quickly pass from person to person
through shared food or utensils that are contaminated, touching contaminated surfaces, and by
shaking hands or through other close contact like touching the mouth or nose. People who have
a weakened immune system are particularly susceptible to catching norovirus thus this may
have predisposed Mrs. Malone, considering her old age, from getting sick.

3. Using your own words, describe the mechanisms that occur with orthostatic hypotension.
Include effect of the blood pressure and heart rate. (Five sentences is required).
The standard definition of orthostatic hypotension is a decrease in systolic blood pressure
of less than/or equal to 20 mm Hg or a decrease in systolic blood pressure that is lesser than/ or

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equal to 10 mm Hg within 3 minutes of moving in an upright position. Other references state

that an excessive increase in heart rate, by 20 to 30 beats/minute, is also diagnostic. When you
stand up, gravity causes blood to pool in your legs which causes your blood pressure to decrease
because there's less blood circulating back to your heart to pump. Baroreceptors sense the drop
in blood pressure and send signals to your brain to signal the heart to beat faster and pump more
blood in order to stabilize your blood pressure. These special cells in the arteries cause the heart
to beat faster and harder and also cause the small arteries and veins to narrow which increases
resistance to blood flow and increases blood pressure (Copstead & Banasik, 2013, p. 345-356).
4. What electrolyte imbalance was occurring when Mrs. Malone began to drink more water?
Keep in mind that her diarrhea persisted and dietary intake was reduced during this time.
Hyponatremia was occurring when Mrs. Malone began to drink more water. This
electrolyte imbalance was a result of actual decreased sodium due to the increased Na+ loss from
the vomiting and persistent diarrhea. Also, since she decreased her food intake and increased
water intake, her body was ultimately losing electrolytes and was not being replenished of the
salt and potassium being lost.
5. What electrolyte imbalance was occurring when Mrs. Malone stopped taking her KCl? Were
there other factors contributing to this electrolyte imbalance?
When Mrs. Malone stopped taking her KCl, hypokalemia was occurring. She had
stopped the KCl to avoid upsetting her stomach. But in addition, since she was still losing
increased amounts of Na+, water, and K+ due to the vomiting and diarrhea, and her intake was
not increasing appropriately, she ended up developing ECV deficit and hypokalemia (lightheaded
and difficulty standing up after using the toilet because her legs were so weak) (Giddens, 2013,
p. 70)

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6. Why did the NP recommend Mrs. Malone drink broth with salt and orange juice?
The NP recommended Mrs. Malone to drink broth with salt and orange juice to help
increase her intake of Na+, water, and K+ and replenish what was lost from the increased Na+,
water, and K+ output due to the persistent vomiting and diarrhea. In addition, stopping the KCl
caused a decreased intake of potassium which also ultimately contributed to her decreased
potassium levels in combination with the vomiting and diarrhea.
7. What is the relationship between Mrs. Malones electrolyte imbalance and weak legs?
What other recommendations should have been made at this time by the nurse? (Think safety
here)
The relationship between Mrs. Malones electrolyte imbalance and weak legs are that
she developed an increase of K+ output from the vomiting and diarrhea, which caused her to
become hypokalemic. Another recommendation that could have been made is to take an antidiarrheal, to help stop the diarrhea, then if she continued to experience weakness in her legs and
the diarrhea had not stopped in the next hour or so, going to the nearest emergency department
should be required because she may need an IV treatment of fluids to replenish the electrolytes
she has lost since she would have had an increased risk of falling.
According to Giddens (2013), Independent nursing interventions to provide safety and
comfort are foundational for people who have fluid and electrolyte imbalances. For example,
safety is high priority for patients with decreased level of consciousness from osmolality
imbalances of substantial muscle weakness from severe hypokalemia. Comfort measures are
especially important for people who need to restrict fluid or sodium (p. 68).
8. As the nurse consultant, what time frame would you want her electrolytes to be rechecked?
(Be realistic about these outpatient expectations).

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Initially, maybe making sure to check her electrolytes in 2-4 hours after IV therapy or the
last oral dose to assess her response to the treatment. For effective reassessment and evaluation
for Mrs. Malone, I would ask to schedule a blood draw either later during that day or the
following morning.
9. Are there any other health care providers that should be considered in planning care for Mrs.
Malone? Cite a minimum of four and their role in her care. Research and reflect thoroughly
about this collaboration.
The following consultations may be appropriate for Mrs. Malones clinical findings and
planning and managing her care. A renal specialist can help to evaluate unexplained urine K+
losses and appropriately manage her renal function, and a cardiologist to manage her heart
failure. A dietitian would be helpful with her meal preparation and menu planning by educating
her on proper nutrition. A physical therapist can implement certain activity restrictions since she
does have heart failure, and instructing her to discontinue exercise if muscle pain or cramps
develop and making sure she has adequate potassium and fluid available during activities. An
RN can help assist with administering replacement fluids, giving medications, patient education,
monitoring of symptoms of hypokalemia and hyponatremia, and communicating with the
physician. The physician determines and prescribes needed treatments and medications to
address electrolyte imbalances. A home health aid would also be helpful to aid in Mrs. Malones
ADLs, along with a home health nurse for regular assessment to assure that she is not
experiencing FVD or FVE and that treatment plan is met.
10. Describe Medicare and provisions that fund Mrs. Malone in accessing primary care. (Five
sentences are required here)

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Medicare is a health insurance program for people age 65 or older, people under age 65
with certain disabilities, and people of all ages with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or a kidney transplant). If Mrs. Malone meets the required conditions
to get these benefits, Part A Hospital Insurance can help cover inpatient care in hospitals,
including critical access hospitals, and skilled nursing facilities (not custodial or long-term care).
It also helps cover hospice care and some home health care. Part B Medical Insurance would
help Mrs. Malone cover doctors' services and outpatient care. It also covers some other medical
services that Part A doesn't cover, such as some of the services of physical and occupational
therapists, and some home health care. Part B helps pay for these covered services and supplies
when they are medically necessary. There is also a Prescription Drug Coverage that is also
available to Mrs. Malone to help lower prescription drug costs that are covered by private
companies and help protect against higher costs in the future (CMS.gov, Centers for Medicare &
Medicaid Services).
11. If Mrs. Malone were eligible for home care, what five objective data would the RN ask the
health care team to make? (There is an assumption here that the RN will not always be making
the home visit and according to our state Nurse Practice Act, only RNs can assess. Answer this
question as if you were providing instruction to a CNA. )
As an RN, I would ask the CNA to take Mrs. Malones vital signs, specifically her blood
pressure to determine if postural hypotension may be of concern as that is one of the signs of
hypokalemia. The CNA can also assist her with her ADLs, or with transferring since she is at
risk for falls due to her weak legs, thus promoting safety measures such as keeping the bed at its
lowest position with side rails is important. Monitoring I&Os as well as collecting any urine or
stool specimen for further evaluation and testing would be included. Mrs. Malone will also be

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on bed rest until better, so I would also ask the CNA to assist and perform range-of-motion
exercises in order to prevent contractors. Since she is temporarily immobile, it would also be
important for the CNA to monitor for skin breakdown and reposition q2hr.
12. If Mrs. Malone had refused to restart her KCl, what ethical principle would she be asserting?
Does Mrs. Malone have the right to refuse this treatment? (This information may be found in
your Cherry text, chap. 9 or any resource addressing client rights).
According to American Cancer Society (2015), when taking part in treatment decisions
You have the right to be informed about your treatment options and take part in decisions about
your care. You have the right to ask about the pros and cons of any treatment, including no
treatment at all. As long as you are able to make sound decisions, you have the right to refuse
any test or treatment, even if it means you might have a bad health outcome as a result. You can
also legally choose someone who can speak for you if you cannot make your own decisions.
13. Consider and cite two to three cultural implications in caring for an elderly AfricanAmerican woman.
When caring for an elderly African-American some cultural aspects that we can take into
courtesy and consideration include their communication, social roles, food preferences, and
health risks. In regard to communication, nonverbal communication may be important so to be
mindful of things like head nodding does not always mean agreement or prolonged eye contact
may be interpreted as rudeness or aggressive behavior. Personal questions asked on initial
contact may also be viewed as intrusive. Their social roles commonly see the importance of
large extended family networks with older adults being respected, many households may be
headed by a single-parent woman, and religious beliefs and church affiliation as sources of
strength. When providing education on diet, food preferences to keep in mind include fried

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foods, chicken, pork, greens, and rice; some pregnant women engage in pica as well. African
Americans are at increased risk for sickle cell anemia, hypertension, heart disease, cancer,
lactose intolerance, diabetes mellitus, and obesity. Overall, I think it is most important to assess
the meaning of the clients verbal and nonverbal behaviors, be flexible, and encourage family
involvement (Saunders, 2016, p. 35).
14. What have you learned completing this case study? Equally as important, what do you think
you need to know more about to be a competent nurse managing Na+ and K+ imbalances?
I have learned that fluid and electrolyte imbalances on an elderly client can be much
more detrimental to their health than to a young, healthy adult, and that it can cause a chain
reaction of repercussions when having medical conditions such as CHF. Risk factors such as
age, cultural factors like religious values and dietary customs, and financial and living situations
all impact a clients health. It is so essential to be able to really connect the dots when assessing
and determining an appropriate plan of care for the client by considering all resources and health
care providers possible.
Although a great accomplishment, as a recent LPN graduate, there is still much more I
need to learn and practice to become a competent nurse. I may know the basics like signs and
symptoms of hypokalemia and hyponatremia and what it is, but now it is about being able to
assess the situation and determining the right plan of care and treatments while at the same time
taking into consideration other factors. Timing and prioritizing is key when being a competent
nurse. Mrs. Malone could have had serious sequela if her electrolyte imbalances were not
corrected in a timely manner. Also just as important, being able to provide good client teaching
involves therapeutic communication to the client and their family members; explanations on

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causes, diagnoses, and treatments they can understand; and providing helpful resources to them.
I do know time and experience will help get me there.

References
About norovirus: Transmission. (2014, June 3). Retrieved August 30, 2015, from
http://www.cdc.gov/norovirus/about/transmission.html
Copstead, L., & Banasik, J. (2013). Pathophysiology (5th ed., pp. 345-346, 409-410). St. Louis,
Missouri: Elsevier.
Giddens, J. (2013). Concepts for nursing practice. St. Louis, Missouri: Elsevier. VitalBook file.
Medicare program - general information. (2014, July 25). Retrieved August 30, 2015, from
https://www.cms.gov/medicare/medicare.html
Patients Bill of Rights. (2014, January 6). Retrieved August 30, 2015, from
http://www.cancer.org/treatment/findingandpayingfortreatment/understandingfinancialan
dlegalmatters/patients-bill-of-rights

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Silvestri, L. (2016). Cultural awareness and health practices. In Saunders comprehensive review
for the NCLEX-PN examination (6th ed., p. 35). St. Louis, Missouri: Elsevier.