A patient with a history of hypertension and diabetes presents with hyperkalemia and hyponatremia, and an ECG shows peaked T-waves. Which nursing intervention is most appropriate to prioritize initially?

C) Administer calcium gluconate to stabilize cardiac membranes.

A) Administer sodium polystyrene sulfonate to reduce potassium levels.

B) Establish a low-sodium diet to address the patient's hyponatremia.

C) Administer calcium gluconate to stabilize cardiac membranes.

D) Initiate an increase in fluid intake to correct mild hyponatremia.

A patient with a history of hypertension and diabetes is admitted with hyperkalemia and hyponatremia. The healthcare team administers calcium gluconate and loop diuretics. What is the priority nursing intervention following these treatments?

A) Monitor the patient's urine output and potassium levels

B) Encourage the patient to increase oral fluid intake significantly

C) Advise the patient to avoid foods high in sodium

D) Restrict the patient's activity to prevent fatigue

A patient receiving treatment for hyperkalemia and hyponatremia has a lab result showing a serum sodium level of 130 mEq/L and a serum potassium level of 5.2 mEq/L. The healthcare team is concerned about the risk of central pontine myelinolysis due to the administration of hypertonic saline. Which of the following nursing interventions is most appropriate to prevent this complication?

B) Monitor serum sodium levels every hour during the infusion of hypertonic saline.

A) Administer hypertonic saline rapidly to quickly correct the sodium level.

B) Monitor serum sodium levels every hour during the infusion of hypertonic saline.

C) Increase the dose of loop diuretics to enhance sodium and water excretion.

D) Restrict fluid intake to minimize further sodium dilution.

A patient with acute kidney injury and early-stage chronic kidney disease is receiving loop diuretics for hyperkalemia. The patient develops hyponatremia and reports mild dizziness and fatigue. Which nursing intervention is the priority to address the patient's current condition?

B) Administer hypertonic saline cautiously to correct the sodium imbalance.

A) Increase the rate of loop diuretic infusion to further reduce potassium levels.

B) Administer hypertonic saline cautiously to correct the sodium imbalance.

C) Encourage the patient to drink more water to counteract the effects of diuretics.

D) Educate the patient about reducing NSAID use to prevent further kidney damage.

A patient with a history of chronic kidney disease and acute kidney injury presents with elevated blood pressure, modest improvement in hyponatremia, and new onset of peripheral edema. The healthcare team is considering the introduction of an ACE inhibitor. What is the most important nursing consideration prior to administering this medication?

A) Assess the patient's serum potassium level.

B) Monitor the patient's respiratory rate.

C) Evaluate the patient's urine output.

D) Check the patient's blood glucose level.

A patient with acute kidney injury superimposed on chronic kidney disease is being considered for an ACE inhibitor to manage hypertension. What priority nursing assessment should be performed before initiating this medication?

B) Assess serum potassium levels to check for hyperkalemia.

A) Monitor the patient's blood pressure to ensure it is within normal limits.

B) Assess serum potassium levels to check for hyperkalemia.

C) Evaluate the patient's urine output to assess kidney function.

D) Check the patient's heart rate for signs of bradycardia.

A patient with renal impairment and recent medication adjustments exhibits signs of hyperkalemia, including mild palpitations and muscle weakness. The healthcare team has initiated treatment with intravenous calcium gluconate, insulin, and glucose. Which additional intervention should the nurse prioritize to effectively manage the patient's hyperkalemia?

B) Administer a potassium-binding resin

A) Increase the patient's oral fluid intake

B) Administer a potassium-binding resin

C) Encourage the patient to ambulate frequently

D) Provide a potassium-rich diet

A patient with renal impairment and recent medication adjustments is experiencing hyperkalemia with a serum potassium level of 5.8 mEq/L, palpitations, and muscle weakness. The healthcare team has initiated treatment with intravenous calcium gluconate and insulin with glucose. Which additional nursing intervention is most appropriate to include in the care plan to manage this patient's hyperkalemia and its underlying causes?

B) Encourage increased intake of potassium-rich foods to balance electrolytes.

C) Increase the patient's fluid intake to promote diuresis.

D) Discontinue all antihypertensive medications to prevent further electrolyte imbalance.

A patient with hyperkalemia and hypertension is being managed with insulin, glucose, and loop diuretics. Following intervention, the patient develops mild pulmonary congestion and reports shortness of breath when lying flat. Considering the current clinical presentation, what is the most appropriate nursing intervention?

B) Elevate the head of the bed and continue to monitor respiratory status closely.

A) Increase the frequency of blood pressure monitoring to detect potential hypotension.

B) Elevate the head of the bed and continue to monitor respiratory status closely.

C) Administer an additional dose of insulin to further reduce serum potassium levels.

D) Restrict fluid intake to prevent further fluid overload.

A patient with hyperkalemia and hypertension is experiencing mild pulmonary congestion and fluid overload, as evidenced by crackles at the lung bases and a 1 kg weight gain over 24 hours. The healthcare team has increased the dose of a loop diuretic. Which nursing intervention is most appropriate to prioritize in this situation?

B) Monitor the patient's respiratory status and auscultate lung sounds frequently.

A) Encourage the patient to increase fluid intake to promote diuresis.

B) Monitor the patient's respiratory status and auscultate lung sounds frequently.

C) Advise the patient to avoid foods high in potassium.

D) Increase the patient's dietary sodium to compensate for diuretic therapy.

electrolyte imbalance - Nursing Case Study

Pathophysiology

• Primary mechanism: Renal dysfunction impairs the kidneys' ability to filter and reabsorb electrolytes, leading to imbalances such as hyperkalemia or hyponatremia. This disruption can result from conditions like acute kidney injury or chronic kidney disease, where electrolyte handling is compromised.

• Secondary mechanism: Hormonal imbalances, particularly involving aldosterone and antidiuretic hormone (ADH), can alter electrolyte and fluid balance. For example, excessive ADH in SIADH causes water retention and dilutional hyponatremia, while aldosterone deficiency in Addison's disease can lead to hyperkalemia and hyponatremia.

• Key complication: Electrolyte imbalances can cause significant clinical issues, such as cardiac arrhythmias from hyperkalemia or neurological disturbances from hyponatremia, necessitating prompt identification and correction to prevent severe outcomes.

Patient Profile

Demographics:

45-year-old female, office manager

History:

• Key past medical history: Hypertension, Type 2 Diabetes

• Current medications: Lisinopril, Metformin, Atorvastatin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Persistent fatigue and muscle cramps

• Key symptoms: Nausea, dizziness, palpitations

• Vital signs: Blood pressure 150/95 mmHg, heart rate 110 bpm, respiratory rate 22 breaths per minute, temperature 98.6°F, oxygen saturation 95% on room air

Section 1

As the healthcare team conducts an initial assessment, the focus is on identifying the underlying cause of the patient's symptoms and addressing the potential electrolyte imbalance. Blood tests reveal significant laboratory findings: serum potassium level is elevated at 5.8 mEq/L (normal range: 3.5-5.0 mEq/L), indicating hyperkalemia, while sodium level is slightly low at 133 mEq/L (normal range: 135-145 mEq/L), suggesting hyponatremia. The elevated potassium level is concerning given the patient's history of hypertension and diabetes, as these conditions can exacerbate renal complications and further skew electrolyte balance. An ECG is performed to assess cardiac function, revealing peaked T-waves, a classic sign of hyperkalemia, which correlates with her palpitations and raises the risk for potentially dangerous cardiac arrhythmias.

In light of these findings, the clinical team hypothesizes that the renal dysfunction may be acute, possibly due to a recent, yet undiagnosed, acute kidney injury superimposed on chronic kidney disease. This hypothesis is supported by the patient's persistently elevated blood pressure and ongoing use of medications like lisinopril, which, while effective for hypertension and renal protection, can exacerbate hyperkalemia. The team initiates treatment by administering calcium gluconate to stabilize cardiac membranes, alongside loop diuretics to promote renal excretion of potassium. Simultaneously, fluid management is carefully considered to correct mild hyponatremia without causing fluid overload, especially given her borderline oxygen saturation and elevated respiratory rate.

As the patient responds to initial interventions, her heart rate decreases to 95 bpm, and she reports a slight reduction in muscle cramps and palpitations. However, the team remains vigilant for further complications, such as potential shifts in fluid balance or additional electrolyte disturbances. They plan to continue monitoring her electrolyte levels and renal function closely, while also reevaluating her current medication regimen to minimize further risks. The next step involves a nephrology consultation to explore underlying chronic kidney disease and assess the need for long-term management strategies.

Section 2

As the patient continues to receive treatment, her clinical status is closely monitored. Over the next few hours, repeat laboratory tests are conducted to evaluate the effectiveness of the interventions. The results are mixed; the serum potassium level has decreased to 5.2 mEq/L, indicating a positive response to the loop diuretics. However, her sodium level has dropped further to 130 mEq/L. This unexpected decline in sodium prompts the healthcare team to reassess their fluid management strategy. The patient’s blood pressure remains elevated at 150/90 mmHg, and she reports persistent mild dizziness and fatigue, suggestive of ongoing fluid and electrolyte imbalances.

The team is concerned about the risk of worsening hyponatremia, particularly in light of the patient’s borderline oxygen saturation, which remains at 92%. A repeat ECG shows slight improvement in T-wave morphology, yet the risk of arrhythmias remains due to the residual hyperkalemia and new concerns about hyponatremia. The decision is made to adjust the diuretic regimen and cautiously administer hypertonic saline under close supervision to gently correct the sodium imbalance without precipitating central pontine myelinolysis.

In parallel, the nephrology consultation provides additional insights. The nephrologist identifies signs consistent with acute kidney injury superimposed on early-stage chronic kidney disease, likely exacerbated by recent nonsteroidal anti-inflammatory drug (NSAID) use, which the patient had not initially disclosed. This revelation underscores the importance of a comprehensive medication review and patient education. Moving forward, the clinical team plans to implement a more individualized medication regimen, emphasizing the careful selection of antihypertensive agents and avoidance of nephrotoxic drugs, aiming to stabilize the patient’s renal function and electrolyte balance. This approach sets the stage for a more sustainable long-term management plan to prevent future complications.

Section 3

As the clinical team implements the revised treatment plan, they monitor the patient closely for any changes in her status. Four hours after the administration of hypertonic saline, the patient's sodium level improves modestly to 134 mEq/L, reflecting a cautious yet effective correction of her hyponatremia. Her oxygen saturation rises slightly to 94%, suggesting some stabilization in her respiratory function. However, the patient's blood pressure remains elevated at 148/88 mmHg, indicating the need for further adjustment of antihypertensive therapy. Her dizziness persists, though it is less pronounced, and she now reports a new onset of mild peripheral edema, particularly in her lower extremities.

The team orders additional diagnostic tests, including a repeat renal panel and a urinalysis. The renal panel reveals a serum creatinine level of 2.1 mg/dL, consistent with acute kidney injury, while the blood urea nitrogen (BUN) has increased to 45 mg/dL. The urinalysis shows mild proteinuria and hyaline casts, supporting the nephrologist's earlier assessment of acute injury superimposed on chronic kidney disease. These findings prompt the team to re-evaluate the patient's fluid management and consider the introduction of a renal-protective antihypertensive, such as an angiotensin-converting enzyme (ACE) inhibitor, while ensuring careful monitoring of serum potassium levels given her recent hyperkalemia.

Recognizing the complexities of the patient's condition, the healthcare team emphasizes the importance of a multidisciplinary approach. They engage in discussions with the patient and her family, providing education on the potential impact of NSAIDs on kidney function and the importance of adherence to the new medication regimen. With the patient's condition showing both improvements and new challenges, the team remains vigilant, ready to adjust the management plan as needed to optimize her recovery and prevent further complications. This proactive and collaborative approach is crucial to ensuring the patient's long-term health and stability.

Section 4

As the healthcare team continues to monitor the patient, they observe a change in her status that requires immediate attention. Despite the improvement in her sodium levels, the patient begins to exhibit signs of electrolyte imbalance, specifically hyperkalemia, which is a known risk given her renal impairment and recent adjustment in medications. Her latest lab results reveal a serum potassium level of 5.8 mEq/L, an increase from the previous reading. The team notes that she is experiencing new symptoms, including mild palpitations and muscle weakness, which are consistent with elevated potassium levels.

In response to these findings, the clinical team convenes to reassess her medication regimen. They decide to temporarily hold the ACE inhibitor to prevent further increases in potassium levels while they address the acute hyperkalemia. The team initiates treatment with intravenous calcium gluconate to stabilize the cardiac membrane, along with insulin and glucose to facilitate the intracellular shift of potassium. Additionally, they consider the use of a potassium-binding resin as a longer-term strategy to manage her potassium levels.

The patient's blood pressure remains a concern, with readings averaging 150/90 mmHg despite adjustments in her antihypertensive therapy. This persistent hypertension, in combination with her acute kidney injury, necessitates careful balancing of her fluid status. With the risk of fluid overload contributing to her peripheral edema, the team opts for a cautious diuretic approach, using low-dose loop diuretics to enhance renal excretion of potassium and address her volume status. Throughout this process, the team continues to educate the patient and her family, reinforcing the importance of dietary modifications and medication adherence to manage her complex condition. As they work to stabilize her electrolytes and blood pressure, they remain vigilant for any further complications, ready to adjust the treatment plan as necessary.

Section 5

As the healthcare team manages the patient's hyperkalemia and hypertension, they note her blood pressure has stabilized slightly, now averaging around 145/88 mmHg, but remains elevated. In response to the interventions, particularly the insulin and glucose administration, her serum potassium level decreases to 5.2 mEq/L. While this is an improvement, it remains above the desired range. The patient reports a reduction in palpitations, yet continues to experience mild muscle weakness, suggesting that further action may be needed to optimize her electrolyte balance.

During the follow-up assessment, the team observes a subtle change in the patient's respiratory status. She has developed a mild cough and reports occasional shortness of breath, particularly when lying flat. On auscultation, they detect faint crackles at the lung bases, which may suggest early fluid overload. Her weight has increased by 1 kg over the past 24 hours, further indicating possible fluid retention. These findings prompt the team to consider the delicate balance required in managing her fluid status and the potential need to adjust diuretic therapy.

To further investigate these changes, the team orders a chest X-ray, which reveals mild pulmonary congestion. This finding, coupled with her clinical presentation, highlights the necessity to carefully titrate her diuretic therapy to relieve her symptoms without compromising her renal function. The team decides to cautiously increase the loop diuretic dose while closely monitoring her renal parameters and electrolytes. They emphasize the importance of ongoing monitoring and reassessment, recognizing the potential for further complications if her fluid status is not effectively managed. This careful balancing act will be crucial in guiding the next steps in her treatment plan, ensuring both her cardiac and renal systems remain stable.