NR 324 Week 1 Altered Fluid and Electrolyte Balance

NR 324 Week 1 Altered Fluid and Electrolyte Balance

Name

Chamberlain University

NR-324 Adult Health I

Prof. Name

Date

Altered Fluid and Electrolyte Balance in Nursing Care

Nursing Care for Altered Fluid Balance

 A client with heart failure was admitted to the emergency room due to shortness of breath. During the initial assessment, several clinical findings were noted, including signs of fluid overload. In this scenario, the appropriate nursing diagnoses for the client include: ineffective coping, ineffective breathing pattern, powerlessness, decreased cardiac output, and fluid volume excess. Each diagnosis reflects the client’s current health status and requires specific interventions. Regarding fluid volume management, medications like furosemide are commonly used to assist in fluid excretion and reduce the risk of further complications associated with fluid overload.

Medication Effects on Fluid Volume 

The management of fluid volume excess often involves the administration of diuretics. Furosemide, in particular, is effective in promoting diuresis, helping to eliminate excess fluids from the body. In this case, medications like tamsulosin, metoprolol, and verapamil are not specifically indicated for fluid removal but may address other aspects of heart failure management. Diagnostic testing is crucial in identifying altered fluid balance. Tests such as the Comprehensive Metabolic Panel (CMP), urine and serum osmolality, and the Complete Blood Count (CBC) can provide insight into the severity of the client’s fluid imbalance.

Diagnostic Testing for Fluid Imbalances 

To monitor the progression or improvement of the client’s fluid imbalance, several diagnostic tests are essential. A CBC, CMP, echocardiogram, and chest X-ray can reveal how well the client is responding to treatment and whether fluid volume is stabilizing. Monitoring signs of fluid volume overload, such as crackles in the lungs, is crucial to preventing further complications. Additionally, vital signs and laboratory results such as potassium levels should be closely observed, as imbalances can exacerbate the client’s condition. For instance, hypokalemia is a common concern when administering diuretics like furosemide.

Table 1: Nursing Care for Altered Fluid Balance

Table 2: Diagnostic Testing for Fluid Imbalance

Table 3: Fluid Volume Overload Indicators

Nursing Management of Fluid Volume Excess and Electrolyte Imbalance

Mechanism of Action and Therapeutic Outcomes

The mechanism of action of albumin is to facilitate fluid movement from the interstitial fluid compartment to the intravascular space. The therapeutic outcomes of albumin administration, along with diuretics, are aimed at increasing urine output and reducing abdominal girth. These interventions help manage fluid volume excess, a condition characterized by an overload of fluids in the body, particularly in conditions such as liver cirrhosis and heart failure. Diuretics like Bumetanide are used to enhance fluid excretion by the kidneys, further alleviating symptoms of excess fluid retention.

Case Scenario: Shortness of Breath and Edema

A client is admitted to the emergency department due to shortness of breath and difficulty walking, caused by edema in the lower extremities. The spouse mentioned that this issue had persisted for the past two weeks. Upon assessment, the client is pale, diaphoretic, and confused, with a history of diabetes mellitus type I, chronic bronchitis, and a recent hospitalization for pneumonia. The vital signs indicate tachycardia, hypertension, tachypnea, and low oxygen saturation at 88% on room air. Immediate nursing interventions should include assessing the client’s level of consciousness, stopping the administration of 3% NaCl IV fluid to prevent further sodium overload, and contacting the healthcare provider for further management.

Appropriate Nursing Actions

In another case, a client with liver cirrhosis presents with increasing abdominal girth and shortness of breath over the past two days. The vital signs indicate respiratory distress, tachycardia, and low oxygen levels. Nursing interventions include administering an albumin IV infusion to shift fluid into the intravascular space, administering Bumetanide 20 mg IV push to promote diuresis, starting oxygen therapy as needed to improve oxygenation, and measuring abdominal girth daily to monitor fluid retention. Additionally, assessing for poor skin turgor is important, as this can indicate dehydration due to fluid imbalance. These interventions aim to manage fluid volume excess effectively, ensuring the client’s condition stabilizes.

Table: Nursing Prioritization and Delegation

Clinical Conditions and Expected Findings

Conditions Leading to Fluid Volume Excess

Several conditions can lead to fluid volume excess, including hyperaldosteronism, syndrome of inappropriate antidiuretic hormone (SIADH), and the use of certain medications such as diuretics and IV fluids like hypertonic saline. The nurse must carefully monitor for signs of fluid overload, particularly in clients with a history of heart failure, kidney disease, or liver cirrhosis.

Assessment Findings in Fluid Volume Excess

Clients with fluid volume excess may present with signs such as a bounding pulse, high respiratory rate (e.g., 34 breaths per minute), elevated blood pressure (e.g., 150/80 mm Hg), and reduced urine output (e.g., 50 ml/hour). These findings indicate the need for immediate interventions, such as fluid restriction, administration of diuretics, and monitoring electrolyte levels.

Table: Expected Clinical Conditions and Findings

Reflect: Potassium Imbalances

Delegation

Mary’s potassium level is 5.7 mEq/L. The nurse must prioritize delegation to ensure proper care for Mary. Among the following prescriptions, the tasks that could be delegated to the LPN/LVN assisting with Mary’s care include:

• Administer spironolactone 25 mg orally
• Administer sodium polystyrene sulfonate 15 g orally However, certain tasks such as administering potassium 10 mEq orally and assessing the electrocardiogram (ECG) strip for tall T waves should be performed by a registered nurse due to the critical monitoring needed for potassium levels and cardiac rhythm.

Diet Teaching

As Mary prepares for discharge, she discusses her dietary needs with a registered dietitian. A concerning statement that indicates the need for further education is, “I can still use my salt-substitute while on spironolactone.” This misconception is particularly critical because spironolactone is a potassium-sparing diuretic, and salt substitutes often contain potassium, which could further increase her potassium levels, posing a health risk.

Nursing Diagnosis: Potassium Imbalance

For Arthur, a client experiencing a potassium imbalance, the highest priority nursing diagnosis is risk for decreased cardiac output. This diagnosis is crucial due to the direct impact of potassium levels on cardiac function. Other diagnoses like fatigue or risk for infection are important but are secondary to the immediate concern of cardiac output.

Treatment and Monitoring

Potassium and Digoxin

When caring for a client with hypokalemia who is also on digoxin, the nurse should be alert to manifestations of digoxin toxicity. These include:

• Dysrhythmias
• Bradycardia
• Visual changes These signs warrant prompt attention to prevent further complications.

Nursing Actions

Kyle, a client with a potassium level of 2.9 mEq/L, has been prescribed oral potassium chloride (KCl). The most appropriate nursing action is to administer the KCl supplement orally with sips of water. Crushing the supplement for nasogastric administration should be avoided unless specifically indicated by the healthcare provider.

Appropriate Delegation

The nurse must delegate tasks appropriately on the medical-surgical floor. Tasks that can be delegated to the LPN/LVN and UAP include:

• Roger (LPN/LVN): Reinforce medication teaching to Kyle.
• Heather (UAP): Document Mary’s intake and output.
• Kim (LPN/LVN): Perform Arthur’s admission assessment. Tasks such as discontinuing Kyle’s nasogastric tube should be reserved for the registered nurse (RN).

Reflect: Magnesium Imbalances

Risk Factors and Electrolyte Relationships

Clients with risk factors for magnesium imbalance, such as malabsorption syndrome or inflammatory bowel disease, may develop hypomagnesemia. The nurse should expect to see positive Chvostek’s sign and bradycardia in a client with hypomagnesemia. Additionally, magnesium shares relationships with electrolytes like potassium and calcium, indicating the need for comprehensive electrolyte management.

Plan of Care for Derrick

Derrick’s magnesium level has increased to 3.8 mg/dL, and he now requires potassium chloride supplementation. The nurse’s most appropriate action is to administer the potassium chloride tablet with a full glass of water to promote proper absorption.

Nursing Intervention for Magnesium Imbalance

For Mark, a client with hypomagnesemia and related agitation, the nurse’s priority intervention should focus on calming the client while ensuring his safety. The nurse should remind Mark that the heart monitor is for his safety and address his discomfort to promote compliance.

Narrative Report and Nursing Actions

The Unlicensed Assistive Personnel (UAP) provides this report:

S (Situation): While passing by the room, I heard Ms. Smyth calling out for help and trying to remove the immobilizing splint from her leg. She was disoriented, asking where she was and stating that she had to get to work or she would be fired.

B (Background): I had been in the room about 10 minutes ago. At that time, she was resting comfortably in bed, fully alert and oriented to person, place, time, and situation.

A (Assessment): The splint was still in place, but she now reports pain in her leg. Her skin feels warmer than it did earlier. Additionally, her radial pulse has increased to 122 from 94, and her respiratory rate has risen to the 30s, which was the same rate as when she first arrived.

R (Recommendation): I will obtain a full set of vital signs and enter them into the electronic health record (EHR) for your review once complete.

Priority Nursing Actions for Ms. Smyth’s Condition

Given the change in Ms. Smyth’s behavior and physical condition, the nurse must prioritize certain actions to assess her status and gather relevant cues. The three priority actions are as follows:

1. Assess the neurovascular status of the lower extremities – This will help determine whether there is any compromise in blood flow or nerve function due to the splint or her underlying condition.
2. Assess the level of pain – Understanding the severity of her pain will guide appropriate interventions, including medication or further investigation into the cause.
3. Reorient Ms. Smyth to place and time – Due to her confusion, it is essential to re-establish her orientation and assess any cognitive impairment.

Nursing Actions for Respiratory Alkalosis Risk

Respiratory alkalosis can occur in certain clinical scenarios, and identifying clients at risk is crucial. The following individuals are at risk:

• Clients with anxiety or panic disorders.
• Clients experiencing hyperventilation due to pain, trauma, or stress.
• Clients undergoing surgery, such as Ms. Smyth, due to preoperative anxiety or postoperative complications affecting respiration.

The nurse should monitor arterial blood gas (ABG) results to detect imbalances, particularly for those at risk of respiratory alkalosis.

Reflecting on Liam’s Condition

Liam, a 19-year-old male, is experiencing anxiety related to an upcoming speech in his communications class. His roommate has observed increased anxiety, and Liam presents with symptoms such as a headache and sleepiness. The nurse should prioritize obtaining the following assessment data:

• Heart rate
• Respiratory rate
• Oxygen saturation
• Glasgow Coma Scale (GCS)

Based on the arterial blood gas (ABG) results, the nurse diagnoses uncompensated respiratory alkalosis, with a pH of 7.51, CO2 of 27, and HCO3‾ of 20.

The nursing diagnosis for Liam is Anxiety related to the public speaking event as evidenced by rapid breathing, preoccupation with the speech assignment, and an elevated pulse. The discharge teaching for Liam will focus on managing anxiety through slow, controlled breathing, positive self-talk, and imagining success at the task. Exercise and adequate preparation will also be recommended to manage his anxiety levels.

Recognizing Respiratory Acidosis in Damien

Damien, a client with chronic obstructive pulmonary disease (COPD) and pneumonia, shows signs of respiratory acidosis. His arterial blood gas (ABG) results indicate acute respiratory acidosis with the following values:

• pH 7.35
• CO2 58
• HCO3‾ 29
• SaO2 88%

To promote stable acid-base balance and improve respiratory function, the nurse will:

1. Monitor ABG values as prescribed.
2. Encourage deep breathing and coughing exercises.
3. Educate Damien on the use of incentive spirometry.
4. Monitor his respiratory rate and regularity.

Effective nursing care requires a systematic approach to assessing and managing patient conditions. By gathering cues, prioritizing actions, and applying clinical knowledge to identify potential complications, nurses ensure optimal care for clients like Ms. Smyth, Liam, and Damien.

Acid-Base Disorders and Metabolic Alkalosis

The arterial blood gas (ABG) results provided—pH 7.35, PaCO2 72 mmHg, and HCO3 38 mEq/L—indicate a fully compensated respiratory acidosis. Fully compensated respiratory acidosis occurs when the body compensates for elevated PaCO2 levels by increasing bicarbonate (HCO3) to maintain a relatively normal pH. Other potential diagnoses such as metabolic alkalosis, respiratory alkalosis, or uncompensated respiratory acidosis do not align with the provided ABG values.

Case Study: Metabolic Alkalosis

Assessment Findings and Hypothesis

Carole Jeanne presents to the emergency department with complaints of weakness, fatigue, palpitations, and muscle cramping. She denies a history of diabetes, respiratory illnesses, or significant cardiac history other than hypertension, which is controlled with antihypertensive and diuretic medications. During her physical assessment, Carole’s vital signs reveal a temperature of 98.4°F, heart rate of 108 beats per minute (irregularly irregular), respiratory rate of 14 breaths per minute, and blood pressure of 110/66 mmHg. Carole admits to taking double the prescribed dose of her diuretic for the past two weeks in an attempt to lose weight before her daughter’s wedding.

Based on this assessment, the nurse hypothesizes that Carole’s symptoms may be due to hypokalemia. Hypokalemia, a common side effect of diuretic overuse, can cause cardiac dysrhythmias, muscle cramps, and fatigue. Other possible causes of her symptoms, such as anxiety or hypoventilation, are less likely given the clinical data and patient history.

ABG Interpretation and Nursing Actions

Carole’s arterial blood gas (ABG) test reveals the following results: pH 7.51, PaO2 99 mmHg on room air, PaCO2 40 mmHg, HCO3‾ 36 mEq/L, and SaO2 99%. These values suggest uncompensated metabolic alkalosis, as the pH is elevated and HCO3‾ is significantly increased without a compensatory rise in PaCO2. Metabolic alkalosis occurs when there is a loss of acid or a gain of bicarbonate in the body, often due to factors such as excessive diuretic use or vomiting.

Based on the ABG results, the nurse should promptly notify the healthcare provider of Carole’s condition. Treatment may include electrolyte replacement, especially potassium, and adjustments to her medication regimen to correct the alkalosis and prevent further complications.

Contributing Conditions to Metabolic Alkalosis

Several factors can contribute to the development of metabolic alkalosis. These include:

1. Hypokalemia: Often associated with diuretic use.
2. Mineralocorticoid use: Can increase renal excretion of hydrogen ions.
3. Excessive use of antacids: May lead to an increase in bicarbonate levels.
4. Diuretic therapy: Can result in the loss of hydrogen and potassium ions, contributing to alkalosis.
5. Vomiting: Leads to a loss of stomach acid (hydrochloric acid), causing a rise in bicarbonate levels.
6. Nasogastric suctioning: Removes stomach acid, leading to a similar effect as vomiting.

Rheumatoid arthritis, alcohol intoxication, and ketosis are not typically associated with metabolic alkalosis and are less likely to contribute to its development.

Prioritizing Nursing Actions

In Carole’s case, the healthcare provider has written several orders. The nurse should prioritize addressing the underlying cause of her symptoms—overuse of diuretics leading to hypokalemia and metabolic alkalosis. The two priority actions are:

1. Administer potassium supplementation: Correcting her hypokalemia is critical to resolving her symptoms and preventing complications such as cardiac arrhythmias.
2. Monitor electrolyte levels and ABG values: Ongoing monitoring is necessary to assess the effectiveness of treatment and ensure that her acid-base balance and electrolyte levels return to normal.

References

American Association of Critical-Care Nurses (AACN). (2020). Arterial blood gas (ABG) analysis for critical care nurses.
American Heart Association (AHA). (2021). Metabolic alkalosis: Causes, symptoms, diagnosis, and treatment.

NR 324 Week 1 Altered Fluid and Electrolyte Balance

Smith, J. & Johnson, L. (2022). Understanding acid-base imbalances: A clinical guide. Nursing Journal, 36(2), 23-29.