NSB132 Integrated Nursing Practice 1

Introduction

Developmental and chronological gender, age, support, life experiences, and health status impacts on an individual response to illness. The chosen priority problem for this essay is impaired fluid and electrolyte balance. In relation to impaired fluid and electrolyte balance, the essay will focus on both case studies of Anna, 4years old and Mc Adams, 85 years old.

The essay will identify relevant data in relation to the priority problem and give its interpretation in relation to the underlying pathophysiology of the problem. The paper will highlight the developmental differences and similarities in signs and symptoms expressed by both patients in the cases. The paper will define a goal for care and nursing interventions (nurse-initiated and collaborative) for the chosen priority problem. Lastly, the paper will discuss the evaluation of the implemented nursing interventions in each case highlighting the physical changes that would indicate the effectiveness of the nursing interventions.

Impaired Fluid and Electrolyte Balance

From both case studies, both Anna and Mc Adams had a history of diarrhea and vomiting for two days. They were unable to tolerate any oral fluids given. They both had three episodes of watery bowel motions and vomited up the small amount of water given shortly after consumption. On assessment, Anna’s body temperature is 38.2⁰C, body weight is 16kg, respiratory rate 22, blood pressure is 88/50 mmHg, heart rate is 118. For McAdams, temperature is 38.2⁰C, respiratory rate is 22, blood pressure is 105/60, and heart rate of 108 which is irregular. In both cases, there is nil urine output within 8 hours.

The fluids and electrolyte balance in the body must be in total maintenance to keep the brain, muscles, and nerves in proper function. Fluid and electrolyte imbalance can be due to hypovolemia hypervolemia and normovolemia with poor fluid dissemination. One of the most common causes of hypovolemia is trauma which presents with profuse loss of blood (Noda, & Sakuta, 2013).

Dehydration is another common cause which entails loss of plasma and not whole blood. The end results of hypovolemia constitute of reduction in the volume of blood in circulation, decreased venous blood return into the heart, and arterial hypotension in majority of cases. Failure of heart muscles can result from high myocardial oxygen demand in parallel with the reduced perfusion of the tissues such as the brain which results into the feeling of light headedness as for Mr. George McAdams (El-Sharkawy, Sahota, Maughan, & Lobo, 2014)

Anaerobic respiration takes place which may result into metabolic and respiratory acidosis and, in combination with dysfunction of myocardium may conclude into multi systemic and multi-organ failure. The organs which are susceptible to the extreme effects of hypovolemic shock and hypotension include the splanchnic organs such as the kidneys. Depending on the severity and duration of the effects, they may be irreversible despite the restoration of normal fluid volume through fluid therapy (Balci et al., 2013).

Excessive fluid therapy may result into fluid overload and associated pulmonary function impairment. However, fluid entry into the lungs may be facilitated by increased permeability of blood vessels in some disease condition such as endotoxemia and blood sepsis even in absence of increased hydrostatic pressure. The main aim of fluid management should be to facilitate sufficient delivery of oxygen by balancing oxygenation of blood, the volume in circulation, and the perfusion pressure (El-Sharkawy et al., 2014)

Dehydration, which is attributed to excessive loss of body water through conditions such as sweating, vomiting, urination and diarrhea. It has numerous impacts on the kidney which resuts into urinary concentration due to activation of vasopresssin occurring as a result rising osmolarity of serum due to body water loss (Rhoda, Porter, & Quintini, 2011). Dehydration classically impacts in pre-renal state which is associated with intrarenal vasoconstriction, but there is relative maintenance of the rate of glomerular filtration. In severe volume depletion the glomerular filtration rate reduces close to zero like in these two cases scenarios, though it is reversible with hydration, loss of blood supply results in acute kidney injury (Farthing et al., 2013).  

Water is of critical importance as it helps in getting rid of body waste in urine form as well as keeping the blood vessels open so that blood with nutrients flow freely into the kidney alongside other organs.  Dehydration can result in accumulation of acids and wastes and can block the renal organs with myoglobin which as a result lead to kidney injury. Impaired kidney functioning and reduced glomerular filtration rate results in little or no urine output. For both cases, Anna and McAdams have nil urine output (Dekate, Jayashree, & Singhi, 2013).

The major bodily electrolytes which are involved in homeostasis, and whose imbalance lead to patient deterioration include sodium, potassium, calcium, phosphate and magnesium. The normal sodium ranges are 135-145 meq/L. It plays a significant and primary role in the body fluid balance, nervous system and body muscles. Its abundant in plasma were body water is attracted towards. High levels of this electrolyte, that is hypernatremia, can be due to various conditions namely; dehydration, fever, diabetes insipidus, vomiting, diarrhea, and others. The signs and symptoms include thirst, dry mucous membranes among others. Also, low levels of sodium can be caused by severe diarrhea or vomiting with others (Mount, 2013).

According to the case studies, both patients had a history of diarrhea and vomiting for two days. Diarrhea and vomiting are commonly associated with excessive loss of body electrolytes particularly potassium. Low levels of potassium are termed as hypokalemia. Hypokalemia is associated with dysrhythmias such as tachycardia. Other signs and symptoms of hypokalemia include fatigue, weakness, tiredness, nausea or vomiting and palpitations (Pohl, Wheeler, & Murray, 2013).

Developmental similarities and differences in the signs and symptoms

Based on the pathophysiology of impaired fluid and electrolyte imbalance between adults and children, the manifestations are similar in both age extremities but there could be variations due to the chronological, age and life experiences in the elderly. Aged adults are highly susceptible to electrolyte and dehydration abnormalities whose causes range from physical inability restricting fluid intake access, iatrogenic causes such polypharmacy causes and renal senescence as it applies to the case of McAdams (Gueutin et al., 2013).

The process of ageing comes with physiological alterations in balance of water. The total body water reduces by 10-15% in order adults, leading to the reduced lean body mass as for McAdams. As a result, the ratio of extracellular to intracellular water increases which is accompanied by reduced glomerular filtration rate and reduced ability of urine concentration, predisposing aged people to fluid retention and overload (Piper, & Kaplan, 2012).

  Ageing makes people susceptible to organ dysfunction, such as acute and chronic kidney injury which may end up into electrolyte abnormalities. The abnormalities can also occur without kidney changes, which may be due to structural and functional changes associated with old age. Skin changes associated with ageing make aged people vulnerable to extreme changes in the environmental temperature. There is reduction in the content of water of the stratum corneum and a significantly higher trans-epidermal loss of water from majority of anatomical sites in comparison with young patients (Noda, & Sakuta, 2013).

Goal

Client demonstrates stable fluid volume as evidenced by stable vital signs, balanced intake and output, and ability to tolerate oral fluids.

Nursing interventions

Fluid administration therapy is a collaborative approach which should involve the nurse, the physician and the nutritionist. The physician will prescribe the right and appropriate fluid, and the flow rate in relation to the underlying patient parameters and requirements. He/she she will keep on assessing the fluid status of the patient continuously. Since both Mr. McAdams and Anna are unable to tolerate oral fluids, they need immediate fluid resuscitation owing to their vital signs of hypotension, tachypnea, tachycardia and increased capillary refill on assessment (Hoste et al., 2014).

The nurse will administer the fluids and monitor the patient for fluid overload, urine output, general hydration status, and changes in vital signs to ascertain any abnormalities and to check for normalization. The nutritionist will review the nutritional status and requirements appropriate to the patient needs in relation to age, physical ability, and activity. Upon nutritional review of the patient, the nutritionist should make appropriate dietary prescription. He or she also has a role in enlightening the clients on the importance of adequate fluid intake (Hoste et al., 2014).

Nurse-initiated Approach: The nurse should monitor urine output 8 hourly to ascertain for improvements of the general hydration status. The nurse should assess the patient for edema which could be an indication of fluid overload (Piper, & Kaplan, 2012).

Evaluation

Case 1

The patient should be well hydrated as evidenced by stable vital signs, pink mucous membrane, tears when crying, reduced complains of thirst, and urine output of more than 1 ml/kg/hr (Briefel, 2017).

Case 2

The patient should be well hydrated as evidenced by stable vital signs, less pale lips, moist tongue, reduced or no light headedness on standing up, and urine output of more than 0.5 ml/kg/hr (Briefel, 2017).

Conclusion

Impaired fluid and electrolyte balance is multifactorial. It results from excessive fluid and electrolyte loss from the body due diarrhea, vomiting, urination, diaphoresis. Impaired fluid and electrolyte balance is influenced by developmental and chronological age and life experiences. The collaborative nursing approach for management of impaired fluid and electrolyte balance is fluid administration while the nurse-initiated approach is patient monitoring for hydration status.

References

Balci, A. K., Koksal, O., Kose, A., Armagan, E., Ozdemir, F., Inal, T., & Oner, N. (2013). General characteristics of patients with electrolyte imbalance admitted to emergency department. World journal of emergency medicine, 4(2), 113.

Briefel, G. (2017). Evaluation of renal function, water, electrolytes, and acid-base balance. Henry’s Clinical Diagnosis and Management by Laboratory Methods E-Book, 162.

Dekate, P., Jayashree, M., & Singhi, S. C. (2013). Management of acute diarrhea in emergency room. The Indian Journal of Pediatrics, 80(3), 235-246.

El-Sharkawy, A. M., Sahota, O., Maughan, R. J., & Lobo, D. N. (2014). The pathophysiology of fluid and electrolyte balance in the older adult surgical patient. Clinical Nutrition, 33(1), 6-13.

Farthing, M., Salam, M. A., Lindberg, G., Dite, P., Khalif, I., Salazar-Lindo, E., … & Krabshuis, J. (2013). Acute diarrhea in adults and children: a global perspective. Journal of clinical gastroenterology, 47(1), 12-20.

Gueutin, V., Vallet, M., Jayat, M., Peti-Peterdi, J., Corniere, N., Leviel, F., … & Chambrey, R. (2013). Renal β-intercalated cells maintain body fluid and electrolyte balance. The Journal of clinical investigation, 123(10), 4219-4231.

Hoste, E. A., Maitland, K., Brudney, C. S., Mehta, R., Vincent, J. L., Yates, D., … & Shaw, A. D. (2014). Four phases of intravenous fluid therapy: a conceptual model. British journal of anaesthesia, 113(5), 740-747.

Mount, D. B. (2013). Causes of hypokalemia. In UpToDate. UpToDate, Waltham (MA).

Noda, M., & Sakuta, H. (2013). Central regulation of body-fluid homeostasis. Trends in neurosciences, 36(11), 661-673.

Piper, G. L., & Kaplan, L. J. (2012). Fluid and electrolyte management for the surgical patient. Surgical Clinics, 92(2), 189-205.

Pohl, H. R., Wheeler, J. S., & Murray, H. E. (2013). Sodium and potassium in health and disease. In Interrelations between essential metal ions and human diseases (pp. 29-47). Springer, Dordrecht.

Rhoda, K. M., Porter, M. J., & Quintini, C. (2011). Fluid and electrolyte management: putting a plan in motion. Journal of Parenteral and Enteral Nutrition, 35(6), 675-685.