electrollyte - Nursing Case Study

Pathophysiology

• Primary mechanism: Electrolytes, such as sodium, potassium, and calcium, help regulate numerous body functions. Imbalances occur when the body either has too much or too little of these ions. This can be due to issues like dehydration, medications, diseases (kidney or heart failure), or treatment (chemotherapy).

• Secondary mechanism: Electrolyte imbalances affect the ability of our cells to generate energy, maintain the stability of their walls, and function effectively. For example, a potassium imbalance can disrupt cardiac cell function, leading to arrhythmias.

• Key complication: Severe electrolyte imbalances can lead to systemic complications like seizures, abnormal heart rhythms, or potentially life-threatening issues like cardiac arrest. Regular monitoring of electrolyte levels is thus crucial in clinical settings.

Patient Profile

Demographics:

47-year-old female, elementary school teacher

History:

• Key past medical history: Diagnosed with chronic kidney disease stage 3, hypertension

• Current medications: Lisinopril, Amlodipine, Furosemide

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Feeling very weak and fatigued for the past week, difficulty concentrating, irregular heartbeat

• Key symptoms: Extreme fatigue, muscle weakness, irregular heartbeat, feeling thirsty all the time, frequent urination, confusion

• Vital signs: Blood pressure 155/90 mmHg, pulse 110 bpm irregular, respiratory rate 18 breaths per minute, temperature 98.6°F, oxygen saturation 96% on room air

Section 1

Change in Patient Status:

Over the next couple of days, the patient's condition continues to deteriorate. She complains of severe muscle cramps and her confusion seems to be worsening. Her pulse is now irregular and rapid at 120 bpm, and her blood pressure has significantly increased to 175/100 mmHg. The patient also reports experiencing shortness of breath, even while at rest.

Despite adequate fluid intake, her extreme thirst and frequent urination persist. Her latest lab results show a serum potassium level of 6.5 mEq/L, well above the normal range of 3.5-5.0 mEq/L, and a serum sodium level of 150 mEq/L, exceeding the normal range of 135-145 mEq/L. These findings suggest that the patient is experiencing hyperkalemia and hypernatremia, which are likely contributing to her worsening symptoms. The physician also notes decreased urine output, which, given her chronic kidney disease, suggests a potential progression to acute kidney injury.

Section 2

Change in Patient Status:

Unfortunately, the patient's condition continues to worsen in the days following these findings. She becomes increasingly lethargic and her confusion escalates to the point of disorientation. Her pulse continues to be irregular, now clocking in at an alarming 135 bpm, and her blood pressure has spiked further to 190/110 mmHg. The patient's shortness of breath also exacerbates, now becoming severe even while at rest, and she begins experiencing episodes of chest pain. The patient's persistent thirst and frequent urination remain constant, despite increased fluid intake.

New Diagnostic Results:

Given the rapid escalation of the patient's symptoms, the physician orders new lab tests, an ECG, and a chest x-ray. The ECG reveals a pattern consistent with hyperkalemia, including tall peaked T waves and a widened QRS complex. The chest x-ray shows evidence of pulmonary edema, likely contributing to the patient's severe shortness of breath. Her serum potassium level has risen to 7.0 mEq/L, and her serum sodium level has climbed further to 155 mEq/L. The patient's urine output remains decreased, and her latest BUN and creatinine levels are significantly elevated at 45 mg/dL and 3.5 mg/dL respectively, indicating worsening kidney function.

This progression of symptoms and lab results suggest the patient's hyperkalemia and hypernatremia are now severe. In conjunction with her escalating hypertension, irregular heart rate, and evidence of pulmonary edema, the patient appears to be progressing towards cardiac instability and acute kidney injury. Prompt intervention is required to prevent further deterioration and potentially life-threatening complications.

Section 3

Response to Interventions:

In response to the worsening condition of the patient, the medical team administered intravenous fluids to address the dehydration, along with sodium bicarbonate and calcium gluconate to counteract the hyperkalemia. A loop diuretic was also given to reduce the pulmonary edema and manage her hypertension. In addition, the patient was placed on a ventilator to assist with her breathing. A renal consult was requested given the patient's declining kidney function, and dialysis was considered as a possible next step.

Unfortunately, despite these interventions, the patient's condition continued to deteriorate. Her blood pressure remained elevated at 180/105 mmHg and her pulse continued to be tachycardic at 130 bpm. She was still notably disoriented and lethargic. Her serum potassium and sodium levels showed little change, remaining at 6.8 mEq/L and 155 mEq/L respectively. The patient's BUN and creatinine levels continued to rise, now at 50 mg/dL and 4.0 mg/dL respectively, indicating further decline in renal function.

The patient's lack of response to the interventions suggests the possibility of an underlying issue that has not yet been identified. Further diagnostic testing and consultation with specialists may be needed to elucidate the cause of her deteriorating condition. This situation requires the application of clinical reasoning skills to identify potential causes, formulate a plan of care, and evaluate the effectiveness of interventions.

Section 4

New Diagnostic Results:

The medical team decided to conduct further diagnostic tests to identify the underlying cause of the patient's deteriorating condition. An abdominal ultrasound revealed the presence of multiple cysts in both kidneys, suggesting a diagnosis of polycystic kidney disease (PKD). Her glomerular filtration rate (GFR) was measured at 19 mL/min/1.73m^2, further confirming the advanced stage of renal impairment. Moreover, a chest X-ray showed signs of congestive heart failure, which explained her elevated blood pressure and pulmonary edema.

The discovery of PKD in combination with the congestive heart failure provides a clearer picture of the patient's health status. It also presents a complex clinical situation requiring careful management of multiple conditions, along with a need for patient and family education about the implications of these diagnoses. The team will need to devise a comprehensive plan of care, considering both immediate management of the patient's current symptoms and long-term strategies to manage her chronic conditions.

Section 5

Change in Patient Status:

Over the next several days, the patient's status began to deteriorate. Her blood pressure continued to rise, measuring at 170/95 mmHg, despite the initiation of antihypertensive therapy. Her respiratory rate was noted to be 26 breaths per minute, indicating an increased effort to breathe, and her oxygen saturation level was wavering between 88-92%, even with supplemental oxygen. The patient reported increased fatigue, shortness of breath, and loss of appetite, all of which are symptoms suggesting the worsening of her congestive heart failure and renal disease.

Additionally, her lab results showed a potassium level of 6.0 mEq/L and a serum creatinine level of 3.5 mg/dL, both of which are higher than the normal range. This could possibly indicate the development of hyperkalemia and worsening renal function, respectively, which are common complications in advanced stages of PKD. This change in status necessitates a reevaluation of her treatment plan, as her condition appears to be refractory to the current interventions. The medical team will need to consider additional or alternative therapies to manage her symptoms and address the progression of her diseases.