NURS220 Health and Illness I

Concept 7 Fluid & Electrolyte Balance

Case Study

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 is progressive and involves numerous organ systems of the body. When the
the hearts ability to sustain adequate levels of cardiac output required to meet the metabolic
demands of the bodys tissues and organs are insufficient, compensatory mechanisms are
triggered. The sympathetic nervous system (SNS) is initiated by baroreceptors in the aortic arch
and carotid sinuses when blood pressure falls and stroke volume is lessened. In response, the
SNS, activated by the brain (medulla oblongata), increases heart rate and contractility. This
results in greater cardiac output, as well as vasoconstriction, which raises blood pressure and
increases atrial preload of the heart. The SNS is also responsible for the onset of the renin-
angiotensin-aldosterone cascade (RAAS). The kidneys respond by holding onto sodium and
water improving cardiac output further and reducing volume depletion. However, an overactive
SNS response can lead to ECV excess and high afterload, overworking the left ventricle, which
may also lead to heart failure (Copstead & Banasik, 2013).

Other components of heart failure involve valvular disease, wherein

the valves of the heart are incompetent. Valvular disease causes stenosis,
regurgitation and congestion of cardiac and systemic blood flow (Copstead &
Banasik, 2013).

Inherited or acquired diseases of the heart, called cardiomyopathies,

occur when the heart muscle becomes hypertrophic, dilated, restrictive,
arrhythmogenic or is replaced with scar tissue. Cardiomyopathic conditions
diminish the heart chambers capacity to pump sufficient blood needed to
perfuse the bodies organs requiring the heart to work harder. Eventually, the
heart muscle cannot pump blood effectually and fails (U.S. Department of
Health & Human Services. National Heart, Lung and Blood Institute 2016).

Congenital heart defects are present at birth and refer to cardiac abnormalities of the
heart. The two principal congenital abnormalities of the heart are shunts and obstruction. Shunts
involve abnormal blood flow within the heart that may result in cyanosis, while obstructions
cause increased workload of the heart and risk of heart failure. Another component of heart
failure is cardiac ischemia, which arises when the heart is unable to meet its oxygenated blood
demands. Ischemia is often a result of impaired arterial blood flow, such as in the case of the
narrowing of arteries caused by atherosclerotic plaques (Copstead & Banasik, 2013).

Left-sided heart is the most common form of heart failure and can lead to right-sided
heart failure. Although it is possible to have biventricular failure. Left-sided heart failure
involves failure of the left ventricle and results in both backward and forward effects. The
forward effects of an incompetent left ventricle include a decreased ejection fraction with
increased left ventricular preload, atrial pressure, and pulmonary pressure. The increased
pulmonary pressure leads to right ventricular afterload and pulmonary congestion. The right
ventricle becomes hypertrophic due to higher preload and no longer pumps blood adequately.
The forward effect of left ventricular failure lowers the cardiac output of the heart, which
translates into decreased tissue and organ perfusion. The lowered cardiac output activates the
RAAS causing fluid retention and again left ventricular preload and the cascade of cardiac side
effects leading to left-sided heart failure mentioned above. Right-ventricular failure also has
both backwards and forward effects. Backward effects include reduced ejection fraction,
increased right ventricular preload and right atrial pressure, this leads to systemic congestion.
Forward effects of right ventricular failure decrease output to the left ventricle lowering left
ventricular output. When cardiac output is diminished tissue and organ perfusion is lessened, the
RAAS is started to compensate. This leads to right ventricular preload and eventual systemic
congestion (Copstead & Banasik, 2013).

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.

It is likely Mrs. Malone acquired acute viral gastroenteritis at the elementary school
where she volunteered. Viral gastroenteritis is an infection of the GI tract lining, commonly
referred to as the stomach flu. Several students were sent home after vomiting prior to her
acquiring the infection. Mrs. Malone experienced vomiting and diarrhea that persisted after her
vomiting subsided. Viral gastroenteritis can produce a severe secretory diarrhea leading to
dehydration (Copstead & Banasik, 2013).

Viral gastroenteritis typically has an incubation period of approximately 24 to 48 hours,

which fits into the timeline between the sick children being sent home and her volunteer date.
Acute gastroenteritis is often caused by a norovirus, the major cause of both sporadic and
epidemic viral gastroenteritis. Norovirus transmission is highly contagious from person-to-
person in close contact, such as in schools and occurs as a waterborne and foodborne illness. The
virus may also be transmitted on objects such as contaminated plates and other eating utensils.
Infection control is best established by frequent hand washing (National Institutes of Health.
Medline Plus 2017). The virus may be caused by fecal oral contamination and young children
may not always wash their hands frequently or effectively causing the spread of viruses. I
believe this was the mode of transmission.
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).

Orthostatic hypotension is also known as postural hypertension. When postural changes

occur, such as going from a supine or seated position, after blood has pooled mostly to the lower
body, the SNS normally responds by rapidly perfusing the brain. When the brain and upper body
are not adequately perfused, a drop-in blood pressure causes orthostatic hypotension. Orthostatic
hypotension is a decrease in systolic blood pressure that transpires very quickly upon assuming
an upright position resulting in dizziness, blurry vision, fainting and injury. The elderly are
particularly at risk for injury as it make take longer for the brain and upper body to be fully
perfused. Orthostatic hypotension may also be an indicator serious health concerns such as
dehydration, circulating volume loss, cardiac arrhythmias and adverse effects of medication.

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.

Mrs. Malone lost a large volume of fluid including potassium and sodium through
vomiting and prolonged diarrhea. She also continued to take her furosemide, a diuretic leading
to additional sodium, potassium and water loss. Mrs. Malone stopped taking her potassium
supplement due to stomach irritation and drank only water, thus she did not replace her
electrolyte loss. Mrs. Malone was experiencing hyponatremia at this time.

5. What electrolyte imbalance was occurring when Mrs. Malone stopped taking her KCL?
Were there other factors contributing to this electrolyte imbalance?

Mrs. Malone developed hypokalemia and extra cellular volume deficit (ECV deficit) due
to vomiting, diarrhea and diuretics. She continued to take her diuretic furosemide, which is a
potassium wasting medication, but discontinued taking her potassium chloride supplement.
Drinking more water did not adequality restore the fluid electrolyte imbalance.

6. Why did the NP recommend Mrs. Malone drink broth with salt and orange juice?

Potassium intake should be increased to balance Mrs. Malones hypokalemia electrolyte

imbalance. Oranges are one of many foods high in potassium, (Pinnacle Health n.d.). Other
potassium rich foods such as tomatoes, green, leafy vegetables, melons and others may contain
too much fiber and exacerbate Mrs. Malones diarrhea. Orange juice is also a common household
food item avoiding a potential trip to the market. A salt broth is easily digested and non-irritating
to the GI system and will increase sodium serum levels depleted by 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)

Chronic heart failure caused the activation of Mrs. Malones RAAS, which in turn led to
sodium and water retention causing ECV excess. The extra sodium in systemic circulation
affected the ratio between the resting membrane potential necessary for communication of nerve
impulses in muscle cells. Mrs. Malone is also hypokalemic, potassium balance is required for
neuromuscular depolarization and repolarization. If potassium levels are too low, the cells cannot
repolarize and are unable to transmit nerve impulses causing muscle weakness. Bilateral
Skeletal muscle weakness that begins in the lower extremities is a symptom of hypokalemia
(Copstead & Banasik, 2013).

Mrs. Malone experienced fatigue, bilateral lower limb muscle weakness, orthostatic
hypotension and hypokalemia, which all may contribute to a patients increased risk for falls.
According to a study including patients with serum potassium levels between 3.0 and 3.5 mEq/l,
patients with mild hypokalemia should be considered a fall risk, hypokalemia increases the risk
of falls by ~ 2.2-fold, and there might be a continuous effect between hypokalemia and the risk
of falling. Therefore, fall prevention measures should be established for patients with even mild
hypokalemia, (Tachi, et al., 2015).

I would have included a recommendation for a face-to-face visit by a home health nurse
to accurately access patient safety, reduce fall risk and provide patient education.

8. As the nurse consultant, what time frame would you want her electrolytes to be
rechecked? (Be realistic about these outpatient expectations).

Mrs. Malone is 83 years old, the elderly are fragile and require immediate intervention
and regular monitoring to maintain homeostasis. The patients electrolytes should be rechecked
as soon as possible to determine if serum potassium levels are still too low. Low serum
potassium levels can cause respiratory weakness resulting in decreased organ perfusion. She is
at risk for continued musculoskeletal weakness, which is a major safety risk. The patient has
left- sided heart failure which places her at risk for cardiovascular dysrhythmias, which
potentially may lead to death. The patient has most likely already experienced orthostatic
hypotension, which is another safety risk. Other complications of insufficient potassium are also
possible including decreased peristalsis (Ignatavicius & Workman 2016). The patient should be
educated about the signs and symptoms that lead to a medical emergency related to her
condition. If the patient is unable to obtain a lab appointment on the same day as the initial
telephone call to the NP, a time should be secured in the immediate future and afterwards at
regular intervals. This should be repeated until the patients serum potassium and sodium levels
are stable.
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.

Because Mrs. Malones conditional is multifaceted, she would benefit from

interprofessional care. A cardiologist should be consulted to treat Mrs. Malones chronic heart
failure, hypertension and hyperlipidemia. A nephrologist would be a good choice to care for her
fluid and electrolyte imbalance and monitor kidney function. A respiratory therapist can help
manage perfusion or oxygen issues. A clinical dietician who confers with Mrs. Malones other
physicians to develop a diet reflecting potassium-rich foods and other specialized nutritional
requirements related to her hypertension and hyperlipidemia would be a benefit. Last but
certainly not least, a social worker would be valuable in identifying useful community resources
for Mrs. Malone when self-managing her health (Henry & McMichael 2016).

10. Describe Medicare and provisions that fund Mrs. Malone in accessing primary care.
(Five sentences are required here)

Medicare is the federal health insurance program that provides coverage for persons over
65 years of age, that individuals or their spouses have paid into through employment taxes. Mrs.
Malones hospitalization benefits are included under Medicare Part (A). If a person has
Medicare Part (A) they may purchase Medicare Part (B), which would then cover Mrs. Malones
outpatient care at 80% of the outpatient fees. A Medicare Advantage plan, Medicare Part (C)
may also be added.. Prescription medications prescribed for outpatient primary care are covered
under Medicare Part (D) (Cherry & Jacob 2017).

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.)

Take the patients vital signs and report daily findings. If patient is complaining of pain,
contact the RN or PCP immediately. Assistant patient with ADLs i.e. mobility, bathing and
toileting, providing support as needed and monitor to avoid falls. The patient has recently has
suffered from gastroenteritis, monitor the patient for skin integrity breakdown and measure I &O.
Assist in preparation of meals according dietary specifications set forth the patient. Inform the
RN or PCP of any abnormal findings immediately in addition to regular documentation
protocols.

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 or any resource addressing client rights).
 Autonomy is the patients right of self-determination and provides nursing care based
upon the patients right to decide upon the type of care they wish to receive. This includes the
rights of a patient to refuse treatment, which is to be respected by the medical providers and is
often considered a primary moral principal of patient care. If Mrs. Malone had refused to restart
her KCL she would be within her rights as her decision does not interfere with the autonomous
rights of another, (Cherry & Jacob 2017).

13. Consider and cite two to three cultural implications in caring for an elderly African-
American woman. (Be thorough in your consideration of this culture and the matriarchal
representation for family decisions.)

It is important to be aware of ones own cultural background and biases, called cultural
awareness. This is to ensure that as nurses, we understand how our belief systems impact our
care of patients. Our understanding of own culture enables us to appreciate variances amongst
cultural differences in our patient population and develop respect for health beliefs and practices
that may differ from our own (Henry & McMichael 2016).

Conventionally African-American elders are revered and treated with deference and
respect within their culture. Regard for ancestors and the belief that elders are closest with their
spiritual family is shared amongst many cultures including peoples of African descent (Watson
and Maxwell, 1977). Older generations are also more traditional; addressing Mrs. Malone by her
title and last name shows respect and begins the process of establishing trust (Dimensions of
Culture 2011).

Many African-American families are matriarchal, including Mrs. Malone in decisions

concerning her health care is consistent with her familiar decision-making role and can lead to
patient compliancy and good communication between healthcare providers and the patient
(Dimensions of Culture 2011).

Many African-Americans have a strong sense of faith and use prayer as part of their
healthcare program. Allowing for the integration of religion or spiritually when treating the
African-American patient is part of the correlation to maintenance of good health (Dimensions of
Culture 2011).

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 learned that fluid and electrolyte imbalances effect multiple, if not all, systems of the
body. Additionally, assessing a patient with fluid and electrolyte imbalances is multifactorial.
Understanding how different systems of the body interact, access to care (Medicare in this case),
along with cultural considerations interface to provide a holistic approach to patient care.

I need to know more about the subtle signs and symptoms of electrolyte imbalances that
can quickly turn into life-threatening situations. Recognizing the signs of an acutely or
chronically ill patient through observation, deteriorating vital signs and proper training in
hydration and fluid management for patients with fluid and electrolyte imbalances is critical
when providing care. Also, further education in medical charting would be advantageous to
providing cohesive and safe care when interfacing with intrapersonal HCPs. In the end,
providing safe, effective and compassionate care, while taking ownership for each patient I care
for and developing new clinical skills is my goal.

References
Copstead, L., & Banasik, J. L. (2012). Pathophysiology (5th ed.). St. Louis, MO: Saunders-

Elsevier.

Dimensions of Culture. Cross Cultural Communications for Healthcare Professionals. (2011).

Healthcare for African-Americans Retrieved from

http://www.dimensionsofculture.com/2011/05/health-care-for-african-american-

patientsfamilies/

Henry, N., McMichael, M., Johnsons, J., DiStasi, A., Ball, B., Holman,(2016). RN Adult

Medical Surgical Nursing (10th ed). Leawood, KS: ATI.

Henry, N., McMichael, M., Johnsons, J., DiStasi, A., Ball, B., Holman,(2016). RN Community

Health Nursing (7th ed). Leawood, KS: ATI.

Ignatavicius, D.D., & Workman, L.M. (2016). Medical-Surgical Nursing:

Patient-Centered Collaborative Care (8th ed.). St. Louis, MO: Elsevier.

National Institutes of Health. Medline Plus. (2017). Viral gastroenteritis

(stomach flu) Retrieved from

https://medlineplus.gov/ency/article/000252.htm

Pinnacle Health. (n.d.). Discharge Instructions for hypokalemia Retrieved from

http://www.pinnaclehealth.org/wellness-library/blog-and-staywell/health-

resources/article/9460

[references continue]

Tachi, T., Yokoi, T., Goto, C., Umeda, M., Noguchi, Y., Yasuda, M., & ... Teramachi, H. (2015).
 Hyponatremia and hypokalemia as risk factors for falls. European Journal of Clinical

Nutrition, 69(2), 205-210. doi:10.1038/ejcn.2014.19

U.S. Department of Health & Services. National Heart, Lung and Blood Institute. (2016). What

is Cardiomyopathy? Retrieved from https://www.nhlbi.nih.gov/health/health-

topics/topics/cm

Watson, W. H., & Maxwell, R. J. (1977). Human aging and dying: A study in sociocultural

gerontology. New York: St. Martins.