WESTERNN MINDANAO STATE UNIVERSITY

COLLEGE OF NURSING
ZAMBOANGA CITY

Name : Opina, Vivienne Marie Louise G. Date: October 17, 2020

Activity # 6 Care of Clients with Problems in Fluid and Electrolyte

Imbalances

POST LESSON ACTIVITY

1. Fluid and Electrolyte Balance

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1. Through concept mapping explain the Renin-Angiotensin-Aldosterone

System in the regulation of fluid and electrolyte.
2. Through a pictogram. Explain the Sodium-Potassium Pump System.
 2. Fluid and Electrolyte Imbalances

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INSTRUCTIONS: In all questions apply to this case study. Your responses should be
brief and to the point. When asked to provide several answers, list them in order of
priority or significance. Do not assume information that is not provided. Please print
or write clearly. If your response is not legible, it will be marked as”?”. Utilizing the
Quick Study Guide Tools: Formulate a case study, based on the guide questions.
(Quick study guide tools enclosed).
Case Situation:
43-year-old Rina admitted to the ZCMC medical ward with complaints of dehydration
and fatigue. While taking her history, you discover that she has diabetes mellitus
(DM) and has been insulin-dependent since she was 20. She has undergone
haemodialysis (HD) for the past 2 years.
Your initial assessment of Rina shows a pale, thin, slightly drowsy woman. Her skin
is warm and dry to the touch with poor skin turgor, and dry mucous membranes,
pitting edema ++ both lower extremities. Her vital signs: BP- 140/80, PR-115, RR-18,
T- 37.7° C.
She reports she has been nauseated for 3 days so she has not been eating or drinking
and having severe diarrhea. Serum calcium, phosphate, and magnesium have been
taken but the results are not yet available. Her CBC and blood chemistry results are
back:

CBC Results:
Blood Chem Results:
Sodium 143 mEq/L (normal)
RBC 3.0 million/mm3 (low)
Potassium 7.0 mEq/L (elevated)
Hgb 8.1 g/dL (low)
Chloride 92 mEq/L (normal)
Bicarbonate 27 mEq/L (normal) Hct 24.3% (low)
BUN 49 mg/dL (High) WBC 7,605/mm3 (normal)
Creatinine 5.1 mg/dL (high) Platelets 335,000/mm (normal)
Glucose 240 mg u/L (high)

1. What part of your assessment supports her admitting diagnosis of

dehydration?
She has been nauseated for 3 days so she has not been eating or drinking and
having severe diarrhea. Upon assessment also, she was physically observed for
poor skin turgor and dry mucous membranes.
2. Pinpoint two possible causes for Rina's low-grade fever.
2 possible causes of low-grade fever is dehydration and diarrhea. Diarrhea leads to
fluid loss and dehydration. Dehydration also plays a role. When a person is
dehydrated or losing too much fluid, the body cannot maintain its regular
temperature and may lead to hyperthermia.
3. What is the indication of Rina’s laboratory test results? Show your analysis of
the abnormal results in a table.

Result Normal Value Analysis

Patient History:
Example High.
Indicates compromised kidney
BUN 49 mg/dl 10-20 mg/dl
regulatory mechanism/function,
suggestive of kidney problem.
Creatinine 5.1 mg/dL 0.7–1.4 mg/dL High
Can indicate chronic renal disease
Dehydration
Potassium 7.0 mEq/L 3.5–5 mEq/L High
Kidneys not regulating properly
Glucose 240 mg u/L Fasting: 60–110 mg/dL High
Postprandial (2 h): 65–140 mg/dL body isn't properly using or doesn't
make the hormone insulin
RBC 3.0 million/mm3 Males: 4,600,000– 6,200,000/cu mm Low
Females: 4,200,000– 5,400,000/cu mm It can indicate an internal bleeding,
kidney disease, or caused by
malnutrition
Hgb 8.1 g/dL Males: 13–18 gm/dL Low
Females: 12–16 gm/dL Low RBC count
Hct 24.3% Males: 42%–52% Low
Females: 35%–47% Insufficient supply of RBCs

During your physical assessment, you noticed that she has an arteriovenous (AV)
fistula in her left arm.
4. What is an AV fistula? What is the purpose for AV fistula and what
precautions should you take when taking care for Rina?
An AV Fistula is type of vascular access for dialysis; created by surgically
connecting an artery to a vein. It’s commonly used by patients undergoing
Dialysis. Avoid applying pressure to the AV fistula to avoid accidents and
complications.
5. Based on the laboratory results. What medical management will you anticipate
Rina will receive?
IV therapy and Blood Transfusion
6. Rina is for haemodialysis. What is a haemodialysis, what is its purpose and
how will you prepare Rina for the procedure?
Haemodialysis is a type of dialysis that uses a machine to filter a patient’s
kidneys. It removes waste products and water from the blood. The nursing
responsibilities are:
• checking the patients' vital signs and talking with them to assess their
condition
• teaching patients about their disease and its treatment and answering any
questions
• overseeing the dialysis treatment from start to finish
• making sure patients are given the correct medications ordered by their
doctors
• evaluating patients' reaction to the dialysis treatment and medications
• reviewing the patients' lab work, home medications and activities and
letting the doctors know about changes in their patients' conditions
• helping patient’s follow-up with their transplant center
• supporting the entire care team in delivering quality care in a considerate,
respectful manner
7. The client was ordered a renal diet with a low potassium diet. What foods
should you include in Rina’s dietary recommendations?
Do not add salt to your food when cooking or eating. Choose fresh or frozen
vegetables instead of canned vegetables. Avoid processed meats like ham,
bacon, sausage and lunch meats. Munch on fresh fruits and vegetables rather
than crackers or other salty snacks. But Rina also has DM, so we should also
look out for foods that can aggravate DM.
8. Rina is to receive packed RBC transfusion. She refuses the blood transfusion
because of her religious conviction. What is your best action in this situation?
We must respect her right to decline and we also offer an advance directive and
denial of care to be signed.
9. Make a drug study of Rina’s medications.
 Furosemide 250 mg in 50ml Calcium 1 cap p.o OD
of 0.9 saline over 1 hour Lantus 100 units SC OD
Captopril 10mg 1tab p.o Bid HS
Losartan 25 mg 1tab. p.o OD Vit B6 5mg 1tab p.o BID
Vit C 100mg 1tab p.o OD

10. Formulate a Nursing Care Plan for Rina with three priority nursing problems
GENERIC NAME: DOSAGE/FREQUENCY/ SIDE EFFECTS/ADVERSE NURSING RESPONSIBILITY
furosemide ROUTE: REACTION
IV Infusion: ADULTS, SIDE EFFECTS BASELINE ASSESSMENT
ELDERLY: Bolus of 20–40 Expected: Increased urinary Check vital signs, esp. B/P, pulse, for
mg, followed by infusion of frequency/volume. Frequent: hypotension before administration. Assess
10–40 mg/hr; may double Nausea, dyspepsia, abdominal baseline serum electrolytes, esp. for
q2h. Maximum: 80– 160 cramps, diarrhea or constipation, hypokalemia. Assess skin turgor, mucous
mg/hr. CHILDREN:0.05 electrolyte disturbances. Occasional:membranes for hydration status; observe
mg/kg/hr; titrate to desired Dizziness, for edema. Assess muscle strength, mental
effect. NEONATES: light-headedness, headache, blurred status. Note skin temperature, moisture.
Initially, 0.2 mg/kg/hr. May vision, paresthesia, photosensitivity,
Obtain baseline weight. Initiate I&O
increase by 0.1 mg/kg/ hr rash, fatigue, bladder spasm, monitoring.
q12–24h. Maximum: 0.4 restlessness, diaphoresis. INTERVENTION/EVALUATION
mg/kg/hr. Rare: Flank pain. Monitor B/P, vital signs, serum
BRAND NAME: INDICATION: electrolytes, I&O, weight. Note extent of
Lasix LASIX is indicated in adults ADVERSE REACTION diuresis. Watch for symptoms of
and pediatric patients for the Vigorous diuresis may lead to electrolyte imbalance: Hypokalemia may
DRUG ILLUSTRATION: treatment of edema profound water loss/electrolyte result in changes in muscle strength,
associated with congestive depletion, resulting in hypokalemia, tremor, muscle cramps, altered mental
heart failure, cirrhosis of the hyponatremia, dehydration. Sudden status, cardiac arrhythmias; hyponatremia
liver, and renal disease, volume depletion may result in may result in confusion, thirst,
including the nephrotic increased risk of thrombosis, cold/clammy skin.
syndrome. LASIX is circulatory collapse, sudden death. PATIENT/FAMILY TEACHING
particularly useful when an Acute hypotensive episodes may • Expect increased frequency, volume of
agent with greater diuretic occur, sometimes several days after urination. • Report palpitations, signs of
potential is desired. beginning therapy. Ototoxicity electrolyte imbalances (noted previously),
CLASSIFICATION: CONTRAINDICATION: (deafness, vertigo, tinnitus) may hearing abnormalities (sense of fullness in
Diuretic LASIX is contraindicated in occur, esp.in pts with severe renal ears, tinnitus). • Eat foods high in
patients with anuria and in impairment. Can exacerbate diabetes potassium such as whole grains (cereals),
MECHANISM OF ACTION: patients with a history of mellitus, systemic lupus legumes, meat, bananas, apricots, orange
Enhances excretion of sodium, chloride, hypersensitivity to erythematosus, gout, pancreatitis. juice, potatoes (white, sweet), raisins.
potassium by direct action at ascending limb furosemide. Blood dyscrasias have been reported • Avoid sunlight, sunlamps.
of loop of Henle. Therapeutic Effect:
Produces diuresis, lowers B/P.
GENERIC NAME: DOSAGE/FREQUENCY/ SIDE NURSING RESPONSIBILITY
captopril ROUTE: EFFECTS/ADVERSE
PO ADULTS, ELDERLY: REACTION
Initially, 12.5– 25 mg 2–3 Frequent (7%–4%): Rash. ● Instruct patient to take captopril as directed at the
times a day. May increase Occasional (4%– =2%): same time each day, even if feeling well. Take
by 12.5–25 mg/dose at 1–2 Pruritus, dysgeusia (altered missed doses as soon as remembered but not if
wk intervals up to 50 mg 3 taste). almost time for next dose. Do not double doses.
times/day. Add diuretic Rare (less than 2%): Warn patient not to discontinue ACE inhibitor
before further increase in Headache, cough, insomnia, therapy unless directed by health care professional.
dose. dizziness, fatigue, ● Caution patient to avoid salt substitutes
BRAND NAME: INDICATION: paresthesia, malaise, nausea, containing potassium or foods containing
Capoten Treatment of hypertension, diarrhea or constipation, dry high levels of potassium or sodium unless directed
HF, diabetic nephropathy, mouth, tachycardia. by health care professional.
DRUG ILLUSTRATION: post-MI for prevention of ● May cause dizziness. Caution patient to avoid
ventricular failure. Hypotension (“first-dose driving and other activities requiring
syncope”) may occur in pts alertness until response to medication is known.
with HF and in those who ● Advise patient to inform health care professional
are severely sodium/volume of medication regimen prior to
depleted. Angioedema treatment or surgery.
(swelling of ● Advise patient that medication may cause
face/tongue/lips), impairment of taste that generally resolves within
CLASSIFICATION: CONTRAINDICATION: hyperkalemia occur rarely. 8– 12 wk, even with continued therapy.
Angiotensin converting History of angioedema Agranulocytosis, ● Advise women of childbearing age to use
enzyme (ACE) inhibitor from previous treatment neutropenia noted in those contraception and notify health care professional
MECHANISM OF ACTION: with ACE inhibitors, with immediately if pregnancy is planned or suspected.
Suppresses renin-angiotensin-aldosterone concomitant use with collagen vascular disease ● Emphasize the importance of follow-up
system (prevents conversion of angiotensin aliskiren in pts with diabetes (scleroderma, systemic examinations to evaluate effectiveness of
I to angiotensin II, a potent vasoconstrictor; mellitus lupus erythematosus), renal medication.
may inhibit angiotensin II at local vascular impairment. ● Hypertension: Encourage patient to comply with
and renal sites). Decreases plasma Nephrotic syndrome noted additional interventions for hypertension (weight
angiotensin II, increases plasma renin in reduction, low sodium diet, discontinuation of
activity, decreases aldosterone secretion. those with history of renal smoking, moderation of alcohol consumption,
Therapeutic Effect:• Reduces disease. regular exercise, and stress management).
peripheral arterial resistance, pulmonary Medication controls but does not cure hypertension.
capillary wedge pressure; improves cardiac
output, exercise tolerance
GENERIC NAME: DOSAGE/FREQUENCY/R SIDE EFFECTS/ADVERSE NURSING RESPONSIBILITY
losartan OUTE: REACTION
Initially, 50 mgnonce daily. SIDE EFFECTS BASELINE ASSESSMENT
Maximum: May be given Frequent (8%): Upper respiratory Obtain B/P, apical pulse immediately
once or twice daily, with total tract infection. Occasional (4%– before each dose, in addition to regular
daily doses ranging from 25– 2%):Dizziness, diarrhea, cough. monitoring (be alert to fluctuations).
100 mg Rare (1% ornless): Insomnia, Question for possibility of pregnancy
dyspepsia, heartburn, back/leg (see Pregnancy/Lactation). Assess
BRAND NAME: INDICATION: pain, muscle cramps, myalgia, medication history (esp. Diuretics).
Cozaar LASIX is indicated in adults nasal congestion, sinusitis, INTERVENTION/EVALUATION
and pediatric patients for the depression. Monitor B/P, vital signs, serum
DRUG ILLUSTRATION: treatment of edema associated electrolytes, I&O, weight. Note extent of
with congestive heart failure, ADVERSE EFFECTS/ diuresis. Watch for symptoms of
cirrhosis of the liver, and TOXIC REACTIONS electrolyte imbalance: Hypokalemia may
renal disease, including the Overdosage may manifest as result in changes in muscle strength,
nephrotic syndrome. LASIX hypotension and tachycardia. tremor, muscle cramps, altered mental
is particularly useful when an Bradycardia occurs less status, cardiac arrhythmias; hyponatremia
agent with greater diuretic often. Institute supportive may result in confusion, thirst,
potential is desired. measures. cold/clammy skin.

CLASSIFICATION: CONTRAINDICATION:
Angiotensin II receptor antagonist Treatment of hypertension.
MECHANISM OF ACTION: Used alone or in combination
Blocks vasoconstrictor, aldosterone- with other antihypertensives.
secreting effects of angiotensin II, inhibiting Treatment of diabetic
binding of angiotensin II to AT1 receptors nephropathy (in pts with type
2 diabetes and hypertension),
prevention of stroke in pts
with hypertension and left
ventricular hypertrophy
GENERIC NAME: DOSAGE/FREQUENCY/ROUTE: SIDE NURSING
Calcium carbonate IV Infusion: ADULTS, ELDERLY: Bolus of EFFECTS/ADVER RESPONSIBILITY
20–40 mg, followed by infusion of 10–40 SE REACTION
mg/hr; may double q2h. Maximum: 80– 160 SIDE EFFECTS 1. Monitor VS especially
mg/hr. CHILDREN:0.05 mg/kg/hr; titrate to CNS: syncope, BP and PR.
desired effect. NEONATES: Initially, 0.2 tinglingly: 2. Obtain ECG result.
mg/kg/hr. May increase by 0.1 mg/kg/ hr q12– CV: cardiac arrest, 3. Asses for heartburn,
24h. Maximum: 0.4 mg/kg/hr. arrythmias, indigestion, abdominal
bradycardia pain.
BRAND NAME: INDICATION: GI: constipation, 4. Monitor serum calcium
Lasix LASIX is indicated in adults and pediatric nausea, vomiting before treatment.
patients for the treatment of edema associated GU: calculi, 5. Assess for nausea and
DRUG ILLUSTRATION: with congestive heart failure, cirrhosis of the hypercalciuria vomiting, anorexia, thirst,
liver, and renal disease, including the nephrotic Local: phlebitis (IV severe constipation.
syndrome. LASIX is particularly useful when only)
an agent with greater diuretic potential is
desired.

CLASSIFICATION: CONTRAINDICATION:
Electrolyte replacement or supplements/ Antacid LASIX is contraindicated in patients with
anuria and in patients with a history of
MECHANISM OF ACTION: hypersensitivity to furosemide.
Essential for nervous, muscular, and skeletal systems. It
is essential for bone formation and blood coagulation. It
is also used a replacement of calcium in deficiency states.
It controls of hyperphosphatemia in end-stage renal
disease without promoting aluminum absorption
GENERIC NAME: DOSAGE/FREQUENCY/ SIDE EFFECTS/ADVERSE NURSING RESPONSIBILITY
Insulin ROUTE: REACTION
Initial dose: 0.5–1 SIDE EFFECTS • Monitor patient response to therapy
unit/kg/day in divided Occasional: Localized redness, (stabilization of blood glucose
doses. Maintenance: 0.5–1.2 swelling, itching (due to improper levels).
units/kg/ day in divided insulin injection technique), allergy • Monitor for adverse effects
doses. to insulin cleansing solution. (hypoglycemia, ketoacidosis,
Infrequent: Somogyi effect (rebound injection-site irritation).
BRAND NAME: INDICATION: hyperglycemia) with chronically • Evaluate patient understanding on
Lantus Treatment of insulin excessive insulin dosages. Systemic drug therapy by asking the patient
dependent type 1 diabetes allergic reaction (rash, angioedema, to name the drug, its indication, and
DRUG ILLUSTRATION: mellitus; non–insulin- anaphylaxis), lipodystrophy adverse effects to watch for.
dependent type 2 diabetes (depression at injection site due to • Monitor patient compliance to drug
mellitus (NIDDM) to breakdown of adipose tissue), lip therapy.
improve glycemic control hypertrophy (accumulation of
subcutaneous tissue at injection site
due to inadequate site rotation).
Rare: Insulin resistance.
ADVERSE EFFECTS/
TOXIC REACTIONS
Severe hypoglycemia (due to
hyperinsulinism) may occur with
insulin overdose, decrease/delay of
food intake, excessive exercise, pts
with brittle diabetes. Diabetic
ketoacidosis may result from stress,
illness, omission of insulin dose,
longterm poor insulin control.
CLASSIFICATION: CONTRAINDICATION:
Diuretic Hypersensitivity,
hypoglycemia.
MECHANISM OF ACTION:
regulate glucose metabolism; lowers the
blood glucose concentration by stimulating
glucose uptake especially by muscle and fat
GENERIC NAME: DOSAGE/FREQUENCY/ SIDE EFFECTS/ADVERSE NURSING RESPONSIBILITY
Pyridoxine (vitamin B6) ROUTE: REACTION
PO/IM/IV: ADULTS, SIDE EFFECTS INTERVENTION/EVALUATION
ELDERLY: 10–20 mg/ Occasional: Stinging at IM injection Observe for improvement of deficiency
day for 3 wks Site symptoms, glossitis. Evaluate for
Rare: Headache, nausea, drowsiness, nutritional
sensory neuropathy (paresthesia, adequacy.
unstable gait, clumsiness of hands) PATIENT/FAMILY TEACHING
BRAND NAME: INDICATION: with high doses. • Discomfort may occur with IM injection.
Vitamin B-6 Prevention/treatment of ADVERSE EFFECTS/ • Consume foods rich in pyridoxine
vitamin B6 deficiency. TOXIC REACTIONS (legumes, soybeans, eggs, sunflower
DRUG ILLUSTRATION: Long-term megadoses (2–6 g for seeds, hazelnuts, organ meats, tuna,
longer than 2 mos) may produce shrimp, carrots, avocados, bananas,
sensory neuropathy (reduced deep wheat germ, bran).
tendon reflexes, profound
impairment of sense of position
in distal limbs, gradual sensory
ataxia). Toxic symptoms subside
when drug is discontinued. Seizures
have occurred after IV megadoses.

CLASSIFICATION: CONTRAINDICATION:
Coenzyme None
MECHANISM OF ACTION:
Enzyme cofactor for amino acid
metabolism, essential for erythrocyte
production, Hgb synthesis
GENERIC NAME: DOSAGE/FREQUENCY/ SIDE EFFECTS/ADVERSE NURSING RESPONSIBILITY
Ascorbic Acid (Vitamin C) ROUTE: REACTION
PO: ADULTS, ELDERLY: SIDE EFFECTS INTERVENTION/EVALUATION
50–200 mg/day. Rare: Abdominal cramps, nausea, Assess for clinical improvement (improved
vomiting, diarrhea, increased sense of well-being and sleep
urination with doses exceeding 1 g. patterns). Observe for reversal of
Parenteral: Flushing, deficiency symptoms (improving
headache, dizziness, sleepiness or gingivitis, bleeding gums, poor wound
BRAND NAME: INDICATION: insomnia, soreness at injection site. healing, digestive difficulties, joint pain).
Vita-C Prevention and treatment of PATIENT/FAMILY TEACHING
scurvy, acidification ADVERSE EFFECTS/ • Larger doses may cause diarrhea,
DRUG ILLUSTRATION: of urine, dietary supplement TOXIC REACTIONS nausea, abdominal cramping. • Foods
May acidify urine, leading to rich in vitamin C include rose hips,
crystalluria. Large doses of IV guava, black currant jelly, Brussels
ascorbic acid may lead sprouts, green peppers, spinach, watercress,
to deep vein thrombosis. Prolonged strawberries, citrus fruits.
use of large doses may produce
rebound ascorbic acid deficiency
when dosage is reduced to normal

CLASSIFICATION: CONTRAINDICATION:
Vitamin Large doses during
pregnancy
MECHANISM OF ACTION:
Assists in collagen formation, tissue repair,
and is involved in oxidation reduction
reactions, other metabolic reactions
 Nursing Responsibilities Justification
Decreased Cardiac Output Based on the patient’s lab, she has low RBC, Hct, and Hgb
Fluid Volume Deficit When the patient first came in, she has been nauseated for 3 days so she has
not been eating or drinking and having severe diarrhea
Excess Fluid Volume Rina was assessed for pitting edema

ASSESSMENT NURSING OBJECTIVE INTERVENTION RATIONALE IMPLEMENTATION EVALUATION

DIAGNOSIS OUTCOMES
Subjective: Excess Fluid The patient will
dehydration and Volume be having lessen • Instruct Family, • Information and
fatigue related to or free from other members of knowledge about
Pitting edema the health care team condition are
edema on to manage fluid vital to patients • Communicating
Objective: lower The patient will intake who will be co- with the family
Pitting edema extremities verbalize that she • Monitor laboratory managing fluids and the health The patient’s
BP- 140/80 is comfortable or studies, such as • Continuous care team edema has
PR-115 is in less pain or sodium, potassium, monitoring is decreased
RR-18 uneasiness from BUN, and arterial vital for baseline
T- 37.7° C her condition. blood gasses date and Patient verbalizes
(ABGs), as comparison in that she feels a bit
indicated. the future better compared to
• Assist in giving • Diuretics aids in • Cooperate with earlier
medications such as the excretion of the pharmacy
diuretics and IV excess body
Therapy fluids.
• Elevate edematous • Elevation
extremities, and increases venous
handle with care. return to the
• Place the patient in a heart and, in • Carefully elevate
semi-Fowler’s or turn, decreases patient and avoid
high-Fowler’s edema. from falls or
position Edematous skin accidents
• Reposition every 2 is more
hours susceptible to
• Aid with injury.
repositioning every • Raising the head
2 hours if the patient of bed provides
 is not mobile. comfort in
breathing.

References: https://nurseslabs.com/fluid-electrolyte-imbalances-nursing-care-plans/ https://nurseslabs.com/excess-fluid-volume/