Adriane Paminiano
11/18/2020 LVN 62
Fluid and Electrolyte Balance
You are a registered nurse working on an acute-care medical-surgical unit. You
... [Show More] receive a
call from the emergency department (ED) that you will be receiving Adele Long, an 82
y.o. woman with a 3-day history of intermittent abdominal pain, abdominal bloating,
nausea, and vomiting. The patient’s medical history includes a colectomy for colon
cancer 6 years ago, ventral hernia repair 2 years ago, and mild arthritis. She has no
history of coronary artery disease, diabetes mellitus, or pulmonary disease. She takes
only Tylenol occasionally for the arthritis. Allergies include shellfish, sulfa drugs, and
meperidine. The admitting diagnosis is gastroenteritis. She is admitted to your unit for
diagnostic work-up. Her VS are BP 92/60, P 90, R 16. She has an I.V. started with a 22
over-the-needle catheter in her right hand, infusing D5/1/2 NS with 20 mEq KCl at 100
mL/hr and has 2 L O2/nc.
1. Based on the information from the ED and presenting picture, what orders would
you anticipate?
Complete Blood count
Urinalysis
Chem 7 labs
NPO
Ultrasound
Stool sample
2. What problems might you anticipate with her I.V. placed in the ED
Phlebitis
Infection
Infiltration
The new orders include the placement of a Foley catheter and the following laboratory
work.
CBC
Blood chemistry profile
Prealbumin
UA
3. What further physical assessments would be important to establish a baseline for
determining fluid and electrolyte balance?
VS
I&O
Assess for edema
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Adriane Paminiano
11/18/2020 LVN 62
Weight
Assess Mucous Membranes
Assess Skin Turgor
Muscle weakness
Spasm
Blood pressure changes
Assess A&O
4. 4. Review laboratory test results in the textbook and identify which laboratory
values indicate possible fluid and electrolyte imbalances. Are any values of concern
to you?
LAB RANGE RESULT
Hgb 12.0 – 16.0 12.5 NORMAL
Hct 37 – 47 47 NORMAL
Potassium 3.5 – 5.5 mEq/L 3 mEq/L ABNORMAL - LOW
Sodium 135 – 145 mEq/L 133 mEq/L ABNORMAL - LOW
Calcium 4.5 – 5.5 mEq/L 9.1 mEq/L ABNORMAL - HIGH
Mag 1.5 – 3.0 mEq/L 1.6 mg/L NORMAL
Chloride 98 – 106 mEq/L 92 mEq/L ABNORMAL - LOW
Serum Osmo 285 - 295 295 NORMAL
BUN 10 – 20 20 mg/dL NORMAL
Creatinine 0.5 – 1.1 0.8 NORMAL
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Adriane Paminiano
11/18/2020 LVN 62
Your physical assessment of the patient includes slightly confused to place and time, BP
115/70 supine and 90/60 standing, P 80 (a bit weak), R 14, weight 110 lb (son reports
that she usually weighs 125), dry mucous membranes, slow capillary refill, and flat neck
veins.
5. What is your conclusion based on the data collected?
Her lab values of K, Na, Ca, Cl are what concerns me because they are abnormal.
Hypokalemia can cause weakness and cardiac arrythmias. Low sodium can cause lethargy and
confusion. Hypercalcemia can create kidney stones, nausea, vomiting and arrythmias. Low
chloride could indicate heart failure, lung diseases and adrenal insufficiency. She does have
orthostatic hypotension which is a risk for fall. Her weight has significantly decreased by 15 lbs.
Her data shows that she is dehydrated. She also needs to be on a continuous EKG because of her
potassium levels.
The Foley catheter is inserted with 100 mL dark amber urine returned.
6. What would be the concerns regarding urinary output? Any concerns regarding the
current administration of I.V. potassium?
- I’m concerned about the color because it does indicate that there is a concentration of
urine and she is dehydrated. Indicates kidney damage and muscle breakdown. Concerning IV
Potassium, she might night to change the site and the gauge of the needle. Because of the large
gauge it could cause infiltration and potassium can burn the skin.
Three hours later, the I.V. site in the right hand appears to be swollen, blanched, and
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Adriane Paminiano
11/18/2020 LVN 62
cool to touch; when questioned, the patient states there is some pain at the site.
7. What further assessments are needed of the site? What nursing actions would you take?
I would take out the IV to prevent tissue damage and find a new IV site. I would also assess for
signs of infection as well.
8. What are your concerns regarding the infiltration of potassium?
The patient was not receiving the potassium as ordered and is still dehydrated. I’m concerned
about the potassium burning her skin as well.
9. Review the INS Standards of Practice scale for infiltration. How would you determine
and rate this infiltration?
Grade 1 Infiltration, Grade one is defined as:
Skin blanched
Edema 1-6 inches in any direction
Cool to touch
With or without pain
10. To initiate a new peripheral-short I.V., what would you consider?
I would consider the size of the vein, also I would consider using IV insertion under ultra-sound
guidance to confirm the placing of the IV.
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Adriane Paminiano
11/18/2020 LVN 62
11. Based on this case, what nursing diagnoses, outcomes, and nursing interventions would
you implement for this patient? Collaborate with other students to develop the top four
priorities for this patient and a care plan.
Nursing Diagnosis Nursing outcome Nursing intervention
Risk for infection r/t to foleycatheter
Pt will not acquire foleycatheter infection during
admission
Assess Foley-catheter every 2
hours, assess for redness
around the site, assess for
fever.
Risk for infection of R hand
IV r/t Infiltration evidenced
by Cold and blanched skin
Patient will not have infection
due to IV.
Apply cold compress, elevate
site, assess pain and site
every 2 hours
Risk for fall r/t to fluid
electrolyte imbalance
Patient will be free from falls
through discharge
Assess level of consciousness
every 3 hours
Risk for seizure r/t electrolyte
imbalance
Pt will not experience seizure
trauma during admission
Monitor level of
consciousness, reduce visual
stimulus.
List the adult normal values for the following
electrolytes:
Hypermagnesemia
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Adriane Paminiano
11/18/2020 LVN 62
1. Sodium (Na+) = 135 – 145 mEq/L
2. Potassium (K+) = 3.5 – 5.5 mEq/L
3. Chloride (Cl−) = 99 – 109 mEq/L
4. Calcium (Ca++) = 4.5 – 5.5 mEq/L
5. Phosphate (PO4−) = 1.2 – 3.0 mEq/L
6. Magnesium (Mg++) = 1.7 – 2.2 mEq/L
Case Study: A 36-year-old client was admitted with gastroenteritis. He has been vomiting and
having severe diarrhea for 2 days. He is very weak. The current laboratory results are Na+ 128
mEq/L, K+ 2.8 mEq/L, Cl− 90 mEq/L. The physician orders IV of 0.9% normal saline solution
at 100 mL/hr, NPO, and I & O.
Pertinent Terminology: Define these terms
Sodium (Na+) – Hyponatermia, Most abundant electrolyte. Major role in regulating Body fluid
volumes, muscular activity, nerve impulse conduction and acid-case balance.
Potassium (K+) – Hypokalemia, Major intracellular cation. Maintains fluid osmolarity and
volume within a cell. Essential for normal membrane excitability, transmits nerve impulses,
needed for protein synthesis and to breakdown glycogen. Also maintains plasma acid-base
balance.
Chloride (Cl−) – Hypochloremia, Usually bonds with sodium or potassium. Regulates osmotic
pressure between fluid compartments and regulates acid-base balance.
Calcium (Ca++) – Usually combines with phosphorus to form mineral salts of bones and teeth.
Works with phosphorus in a reciprocal relationship.
Hypokalemia
Hypochloremia
Hyponatremia
Hypercalcemia
Hyperphosphatemia
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Adriane Paminiano
11/18/2020 LVN 62
Phosphate (PO4−) – Helps build and repair bones and teeth. For nerve function and muscle
contraction.
Magnesium (Mg++) – Metabolism of carbohydrates and proteins and stores intracellular energy
and neural transmission. Important for the function of heart, nerves and muscles.
Third space syndrome – When too much fluid moves from intravascular space into the
interstitial space (the nonfunctional area) between cells. Can cause edema, reduced cardiac
output and hypotension.
Edema – Swelling caused by fluid, excess water in the extracellular space.
Pitting edema – Caused by excess fluid in the body. Indicated by pressing on swollen areas
which leaves an indentation or “pit” in the body.
From the case study, identify the abnormal laboratory results. List the major clinical signs or
symptoms that you would assess with each abnormal value:
Na+ 128 mEq/L = Nausea, Vomiting, Muscle weakness, lethargy, hypotension, upper abdominal
pain, headache, confusion, coma, seizures, muscle twitching, vision changes,
K+ 2.8 mEq/L = Muscle cramps and weakness, Arrythmias, kidney problems, drowsiness,
arrythmias, irregular heartbeat, tachycardia.
Cl− 90 mEq/L = Diarrhea, weakness, difficulty breathing, hypotension, tachycardia, convulsions,
strider.
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Adriane Paminiano
11/18/2020 LVN 62
Follow-up case study: The client's vomiting and diarrhea has begun to subside in the evening and
the MD has ordered a clear liquid diet. The client's 24-hour I & O for the day is charted below:
24-Hour Intake/Output Record
On the basis of the case study and Intake and Output Record, select the most appropriate
NANDA nursing diagnoses for the client:
_____ Excess fluid volume
X - Deficient fluid volume
X - Diarrhea
_____ Impaired skin integrity
X - Imbalanced nutrition: Less than body requirements
X - Risk for injury
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Adriane Paminiano
11/18/2020 LVN 62
Interactive Activity: With a partner, read the case study below and write a rationale for each of
the nursing interventions listed:
CASE STUDY NURSING INTERVENTION RATIONALE
Ms. M was admitted with
heart failure. The nursing
diagnosis of “Fluid volume
excess r/t noncompliance to
dietary Na+ restriction” is
listed in her NCP/ Digoxin
0.25 mg qAM po,
furosemide 40 mg qAM po
and K-dur 10 mEq po tid
are her medications
Weigh Daily Determine if pt has edema if she is
retaining water, change in body weight,
Monitor I&O Determines if a pt is retaining liquid
which could lead to edema. Determines
therapeutic response of Furosemide.
Monitor dehydration, monitor sodium
and potassium levels
Take Apical Pulse Determines arrythmias & bounding pulse
due to the heart working harder due to
excess liquid in the blood stream. Assess
for tachycardia and elevated BP.
Determines therapeutic response of
Digoxin.
Assess Skin Assess for edema and skin turgor and
proper hydration. Assess if skin is pale,
cold.
Assess Lungs Hyperkalemia manifests in respiration
difficulties. Assess if you can hear
pulmonary edema.
Neck Veins Assess if JVD is present.
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