Introduction Homeostasis of fluid and electrolyte balance is important for the body to be able to function. The nursing student will cover the risk, pathology, and signs and symptoms for both fluid deficit and hypokalemia. The nursing student will also apply these findings to the patient specific information from the clinical day February 8, 2011. This will give her the ability to formulate four different nursing diagnosis and evaluations of interventions and outcomes. Review of the patient’s case DS was admitted to the hospital for a ventral hernia repair and a small bowel resection on January 30, 2011.
During recovery from the surgery, DS acquired Clostridium Difficile. She also has a history of hypertension, chronic obstructive pulmonary disease, and has suffered a myocardial infarction. DS smokes a pack of cigarettes daily and states she is guilty of eating poorly. She said she does not take her “heart pill” routinely and deserves all the health issues she has had. A ventral hernia repair is usually caused by a previous surgical incision where the muscle is weak, but can also be caused by a naturally thin place in the muscle wall.
A small portion of the bowels can protrude through this weakness in the muscle wall causing a hernia. In order to correct this issue, a small piece of surgical mesh is surgically inserted to strengthen the muscle wall. The muscle tissue grows into and around the surgical mesh to form a stronger muscle wall. The patient has a Jackson-Pratt drain to draw off excess fluid from the surgery. The nursing student emptied this drain at the end of the clinical day and was able to drain 40 cc.
As stated previously, the patient was having some postoperative complications and through a stool sample was able to find out she had Clostridium Difficile. Clostridium Difficile is a gram-positive spore-forming bacillus. This bacillus can be found in the environment and is not always harmful. It is resistant to the acidity of the stomach and grows in the stomach. The colonization of C. Dif causes mucosal damage and inflammation. It is commonly found in people taking antibiotics or who have been in the hospital for an extended stay. It is also common to find C.
Dif in patients who have recently had an abdominal surgery like DS. C. Dif also increases capillary permeability and stimulates intestinal peristalsis. This is why a common symptom of C. Dif is watery diarrhea and abdominal pain. C. Dif is known to cause dehydration, lacerations in the large intestine, and kidney failure. In order to find out if the patient has C. Dif a stool sample must be sent down to the lab. Antibiotics are used to treat C. Dif (Patho book 933). DS was prescribed many medications she was not taking because she refused to allow intravenous access.
|Medication |Reason Perscribed | |Famotid PO 20 mg daily |To treat and maintain duodenal ulcers | |Gabapentin PO 600 mg every 8 hours |To treat hot flashes or neuropathic pain | |Heparin subcutaneous injections 5,000 units every 8 hours |To prevent deep vein thrombosis, pulmonary embolism, or peripheral | | |embolism | |Metaprolol Tartrate PO 25 mg every 12 hours |To treat hypertension | |Metronidazole PO 500 mg every 8 hours |To prevent postoperative infections | |Nicoderm transdermal patch 14 mg ever 24 hours |To aid the patient in smoking cessation | |Oxycodone 5-Acetemenophen 325 mg PO 1 tablet every 4 hour |.
To treat pain | |Ranolazine ER PO 500 mg every 12 hours |To treat chest pain | |Hydralazine IV push 10 mg every 4 hours PRN |To treat hypertension | |Hydromorphone IV push 0. 5-1 every 3 hours PRN |To treat pain | |Lorazepam PO 0. 5 mg daily |To manage anxiety | |Morphine IV push 2-4 mg every 2 hours PRN |To treat pain | |Ondansetron 4 mg IV push every 6 hours PRN |To treat post operative nausea | Patient’s fluid alteration Add medical interventions The patient, DS, was at risk for fluid volume deficit. This was chosen because the patient has a diagnosis for C. Dif. She has had more than 10 episodes of diarrhea daily. She is also refusing to allow IV access at the time of care.
She was only at risk because she was drinking large amounts of fluid to keep up with the amount of fluid she was losing via diarrhea. Fluid volume deficit is a decrease in fluid of the body. This can be caused by excessive fluid loss, inadequate fluid intake, or failure of the normal homeostasis mechanisms of the body. This often occurs alone, but can also occur with other electrolyte imbalances. Fluid imbalance can occur suddenly, for example in the case of a hemorrhage, or over time. A major issue included with fluid volume deficit is hypovolemia. This is harmful to the body because there is a decrease in the amount of blood circulating through the body. This process stimulates the regulatory mechanism to maintain fluid.
The patient will begin to feel thirsty and the body will release ADH and aldosterone, so that the body retains water and sodium. This is how the body protects itself from cardiovascular collapse (medsurg book 203). Fluid volume deficit can also be commonly caused by a loss of fluid in the gastrointestinal tract. DS was at risk for fluid volume deficit due the watery diarrhea caused by C. Dif. Fluid is drawn from the interstitial space to the vascular space to maintain tissue perfusion and circulation. This causes intracellular dehydration as well. In many cases electrolytes are lost with the fluid causing an isotonic fluid volume deficit (medsurg book 203). There are many typical signs and symptoms that would go along with fluid volume deficit.
Neurologically it can cause an altered mental status, anxiety, and restlessness because of the depleted amount of oxygen reaching the brain. The skin will also be dry and there will be a decrease in skin turgor. The loss of interstitial fluid is what causes a decrease in skin turgor. The skin of the dehydrated patient will remain elevated when pinched. The mucous membranes of a dehydrated patient will be dry and sticky. The urinary output should decrease because the kidney will be retaining fluid and sodium due to the ADH and aldosterone. The patient can experience orthostatic hypotension and tachycardia due to the depleted fluid volume. Also related to the decrease in blood flow the muscles will not be receiving a typical amount of oxygen causing muscle fatigue (medsurg 205).
DS was not expressing every symptom of fluid volume deficit yet because she was drinking a large amount of fluid to protect herself from the deficit. She was expressing some symptoms of deficit though. DS had dry skin. She stated that it was from lying in bed all day and was no used to having dry skin. She also complained of unsteady gait when she would stand. She said she was dizzy for the first few minutes after standing and would like to have someone in the room with her while she was up moving around. She was having difficulty voiding and said that she would feel like she had to go but she would void very little. She also complained of dry mouth.
She had the nursing student fill her ice chips numerous times during her shift. She was positive for fluid intake on her intake and output. She knew she must keep drinking water because she did not want an IV. She had bruising up and down her arms from past IVs. The patient’s vitals were within normal limits. She was alert and oriented to person, place, and time. She was able to hold an extended conversation and was not confused. She was very aware of her pain as well. Nursing theory applied to fluid alteration DS had a risk for activity intolerance related to decreased cardiac output. DS has suffered from an MI in the past and has an increased risk for cardiac complications related to a history of hypertension.
Interventions include observing for symptoms of intolerance such as nausea, pallor, dizziness, visual dimming, and impaired consciousness when getting client out of bed and working with the client to establish mutual goals that increase activity level. These interventions were accurate in the care of DS. The patient was able to get out of bed but was complaining of dizziness upon standing. Once standing she was able to ambulate on her own. Since DS was on contact isolation she was not supposed to leave her room. We were able to increase her activity level by getting out of bed to wash up and walk to the bathroom rather than use the bedside commode a few times a day. We also spent a few minutes walking from the window to the door to stretch out her legs (Ackley 2008).
DS was also at risk for impaired tissue integrity related to fluid deficit. Interventions to protect her skin integrity would be to assess her skin condition frequently and document any changes in color or texture. It is also important to monitor the skin around the incision, the patients skin care practices, and frequency of cleaning. DS’s skin was dry and intact in both the morning and the afternoon. There was no change in color or texture from the morning to the afternoon. DS washed the incision with soap and warm water once a day per doctor’s orders. She was told to leave the drain covered and to allow the nurse to clean the site once a day.
The skin around the incision was pink and the edges were well approximated (Ackley 2008). Patient’s electrolyte imbalance Medical intervention and outcomes DS is exhibiting lab values for Hypokalemia. Low potassium levels are a common side effect of fluid deficit. The normal range of Potassium is between 3. 4-5. 1 mEq/dL. DS’s potassium level was 3. 0 mEq/dL. Potassium is important in the maintenance of cell integrity and acid base balance. It also plays a major role in the ability of the kidney to concentrate urine. Without potassium numerous chemical interactions in the body would not be able to take place. It is responsible for conducting nerve impulses, which lead to the control of muscles.
Causes of hypokalemia can be from inadequate intake of potassium, excessive gastrointestinal, renal, and skin loss, or redistribution between intracellular fluid and extracellular fluid. Potassium intake must be at least 40-50 mEq/day. The kidney excretes 80-90% of the potassium lost by the body. Non-potassium sparing diuretics are the most common cause of hypokalemia. Potassium is also lost through the skin. Potassium is lost when the body sweats to keep cool, as well as when the skin is burnt. Hypokalemia can also occur for diabetics during the treatment of diabetic ketoacidosis (PATHO BOOK). DS was loosing the most potassium through gastrointestinal loss.
This occurs with increased vomiting, diarrhea, or gastric suction. DS has had days in diarrhea, so that is where she is losing the majority of her potassium. C. Dif makes the capillaries in the gut more permeable so fluid and electrolytes are lost due to the infection. There are many typical signs and symptoms expressed by patients suffering hypokalemia.
Hypokalemia interferes with the body’s ability to concentrate urine. This typically causes the patient to have complaints of polyuria, nocturia, and increased thirst. Patients with hypokalemia often experience anorexia, nausea, vomiting, abdominal distention, and paralytic ileus. The problem with gastrointestinal issues is that the symptoms hinder with the body’s ability to intake more potassium.
This can also cause muscular weakness, muscle fatigue, and muscle cramping. This is because potassium plays a major role in the nerve firing and action potential. The most serious symptoms are cardiovascular symptoms. Postural hypotension, sinus bradycardia, and ventricular arrythmias can all occur due to hypokalemia. DS did not exhibit all the symptoms of hypokalemia. Patient had increased thirst. She had no complaints of nausea or vomiting and she was not experiencing any paralyzation of her intestines. She had a minimum of 10 episodes of diarrhea daily. She was experiencing postural hypotension upon standing but was able to adjust after standing for a minute. She was suffering from muscle weakness and fatigue.
(MEDSURGE BOOK) Nursing theory applied to electrolyte status DS is experiencing fatigue related to low serum potassium levels as evidence by patient complaints. One intervention used was to evaluate sleep patterns, to encourage the patient to avoid napping in the late afternoon and evening, and to use a routine sleep/wake cycle. The patient complained about having no sleep prior to the nursing students day of clinical. She stated that it was been impossible to get any sleep during her stay in the hospital. Her sleep/wake cycle however was effected because she was sleeping the majority of the day making it difficult for her to fall asleep at night.
Another intervention used was to encourage the patient to express feelings of fatigue. Also, it is important to help the patient establish short-term goals and identify energy management techniques. During the clinical day the nursing student was not able to establish short-term goals but the nursing student would have encouraged her to be more involved in physical activity each day. The nursing student would have also suggested a limit be put on the time spent napping during the day. Energy saving techniques discussed included having everything she needed to get ready for the day all in one place before she got out of bed, so that once she was up she would not be wasting energy searching for different items (Ackley 2008).
Diarrhea related to infectious processes as evidence by numerous episodes of watery stool each day. This is important to her electrolyte imbalance because if she continues to have diarrhea she will continue to become more and more hypokalemic. One intervention used was for the patient to keep a stool diary to keep track of the time of defecation, amount of stool, consistency of stool and frequency of defecation. This worked well for DS. She was able to participate in her treatment plan because she was responsible for writing each episode down. Another intervention was to inspect, auscultate, palpate, and percuss the patient’s abdomen. The nursing student did this in the assessment of DS.
Upon inspection the nursing student found the abdomen was slightly distended with a vertical incision down the center of the abdomen and a Jackson-Pratt drain. Bowel sounds were hyperactive in all four quadrants. The abdomen was tender to palpation and percussion was not done (Ackley 2008). Conclusion Fluid and electrolyte imbalances are very detrimental to the patient’s health. Fluid volume deficit can cause so many other health issues. Realizing the importance of homeostasis of fluid balance in all the body systems puts a new perspective on “drink your water”. Citations Patho book Medsurg book Ackley, B. & Ladwig, G. (2008). Nursing diagnosis handbook: An evidence based guide to planning care (8th ed. ). St. Louis: Mosby.