Case Study Metro South Orig

8/8/2019 Case Study Metro South Orig

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I. INTRODUCTION

Potassium is the major intracellular electrolyte, 98% of the bodys potassium is inside

the cells. The remaining 2% is in the ECF, and it is this 2% that is important in

neuromuscular function. Potassium influences both skeletal and cardiac muscle activity. The

normal serum potassium concentration ranges from 3.5 to 5.0 mEq/L and even minor

variation are significant. Potassium imbalances are commonly associated with various

diseases, injuries, medications and special treatment, such as parenteral nutrition and

chemotherapy. Alterations in potassium concentration result in electrical signal that interrupt

normal cardiac rhythm, muscle activity and nerve conduction.

Hypokalemia is serum K concentration < 3.5 mEq/L caused by a deficit in total body

K stores or abnormal movement of K into cells. The most common cause is excess losses

from the kidney or GI tract. Most of the bodys potassium is stored inside various cells and

organs, with only a small amount found in the blood. The body maintains a balance of

potassium in the blood by matching the amount of potassium taken in with the amount

excreted (put out) by the kidneys. Hypokalemia occurs when the body releases too much

potassium, such as through severe vomiting, diarrhea, or sweating during intense exercise. It

also can be caused by a disease that affects kidney function the kidneys may excrete too

much potassium, or may not be able to match their output to the bodys potassium intake.

Certain drugs called diuretics increase the bodys urine output, which can also cause

Hypokalemia. Hypokalemia can be caused by overuse of laxatives; by eating disorders such

as bulimia, which involves self-induced vomiting; and by prolonged fasting and starvation.

Symptoms of hypokalemia include irregular heartbeat, which can range from mild to

severe. Severe cases can result in cardiac arrest and paralysis of the lungs. Other symptoms

can include muscle weakness, cramping, or flaccid paralysis (limpness); leg discomfort;

extreme thirst; frequent urination; and confusion. Infants and young children with

gastrointestinal illnesses that cause prolonged vomiting and diarrhea can die from cardiac

arrest when potassium levels become dangerously low.

Hypokalemia is diagnosed by measuring the potassium levels in a blood sample. To

determine the cause of hypokalemia, your doctor may also check potassium levels in a urine

sample. The doctor may also order a test called an electrocardiogram (ECG or EKG), which

measures the electrical activity of the heart.


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Sever hypokalemia is treated in a hospital with intravenous (IV) potassium. In most

cases, however, this condition can be treated by increasing the amounts of potassium-rich

foods in the diet, drinking electrolyte replacement fluids during intense exercise or for severe

vomiting or diarrhea, or by taking a potassium supplement in a dosage recommended by your

doctor. It is important to have the potassium levels in the blood checked regularly if you are

taking diuretics or other medications that affect potassium

II. Patient Profile

Ward: Room 304

Date of Admission: February 05, 2010

Patient Name: Mrs. A

Address: 159 Reyes Street Silang, Cavite

Age: 29 yrs old

Gender: Female

Birth Date: December 08, 1980

Educational Status: College Graduate

Religion: Roman Catholic

Nationality: Filipino

Civil Status: Single

Occupation: Accountant

Health Care Financing: Independent Consultant

Informant: Patient

Reliability: The primary source of data is the patient itself

Admission Data

Chief Complaint: Numbness of both upper and lower extremities

Admitting Diagnosis: t/c hypokalemia periodic paralysis r/o anxiety disorder

Attending Physician: Dr. Antonio Barroso III


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III. Patient History/ Nursing History

History of Present Illness

Prior to admission, the patient was in her office and suddenly she felt numb on her

upper and lower extremities, she was scared so they went to the hospital. Upon admission, the

patient has a chief complaint of numbness of both upper and lower extremities.

Past Medical History

The patient is allergic to any seafood. She had experience numbness before and last

few days before she was admitted to the hospital she had diarrhea.

Family Health History

According to the patient, her father was hypertensive. On her father side, her

grandfather was also hypertensive.

Legend:

- Male - Female - deceased

Personal and Social History

The patient is an accountant working on private company. She has to travel a couple

of hours to face different clients everyday. She wasnt able to eat on time due to her work.

+HPN

+HP

N

Mrs.

A

+HP

N


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IV. Gordon's Functional Health Pattern

Level Of Functioning Before Hospitalization During Hospitalization Analysis/Inference

Health Perception/ Health

Management

She was aware that when she felt

numb, she is just hypoventilating

The patient is now aware that she

is hypokalemic

The patient is knowledgeable

about her condition

Nutritional and Metabolic Pattern She wasnt able to eat on time and

most of the time she brought food

on fast-food chain.

DAT and requires to eat at least 1

banana per day

Her eating pattern may caused her

diarrhea

Elimination Pattern Her regular bowel elimination

was 1x a day before bedtime.

Urinates 3 times a day

Past few days before admission

she had diarrhea

(-) Bowel movement

Urination 7x

Her diarrhea may caused her

hypokalemia

Activity - Exercise Pattern Walking is her main exercise. She

also does household chores.

She can't do some exercises, even

walking is limited. Most of the

time, she just sit doing her paper

works with her laptop.

Due to hospitalization her

activity-exercise pattern is limited

Sleep Rest Pattern The patient usually sleeps less The patient cant sleep well. She The patient might be fatigue due


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than 6 hours verbalized hindi ako sanay

matulog sa ibang bahay kaya

hindi ako makatulog ng maayos.

to lack of sleep and she is not used

to the place.

Cognitive Perceptual Pattern She consults the doctor everytime

she felt something wrong with

herself. She is well educated and a

college graduate.

The patient can express her

feelings clearly.

The patient shows security with

herself.

Self perception and Self

concept Pattern

She is concern with regards to her

health.

She is not comfortable due

numbness of her lower extremities

She is conscious that she needs

high potassium diet

Role Relationship Pattern The patient supports the financial

needs of her brother; she is living

on her own.

The patient can still support the

financial needs of her brother.

The patient loves her brother so

she still does her job even at the

hospital.

Sexuality Reproductive Pattern Her menstruation is irregular. She

is single.

Her menstruation is irregular She might feels disturb due to

irregular menstruation.

Coping Stress Tolerance

Pattern

She eats ice cream when she feels

stressed and through the help of

her bestfriends advice she can

cope problems

She is always visited by her

bestfriend to the hospital and able

to express her feeling to her.

When she needs help her

bestfriend is always beside her.

Value Belief Pattern Roman Catholic

Always consulting a doctor

everytime she's not feeling well

Roman Catholic

Always consulting a doctor

everytime she's not feeling well

There will be no problem in terms

of medical assistance due to her

belief


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V. PHYSICAL ASSESSMENT:

AREAS FINDINGS

1. PHYSICAL

1.1 Head Normocephalic, (-) headache, (-) dizziness, (-) head injury

1.2 Eyes Symmetrical, (-)periorbital edema, (-)blurring of vision, (-) discharge,

uses eye glasses1.3 Ears Symmetrical, (-) discharge

1.4 Nose Symmetric and straight, (-) discharge, (-) nosebleeds

1.5 Mouth and Throat (-) dentures, (-) bleeding gums, tongue in central position, tongue

moves freely, (-) halitosis

1.6 Neck Head centered, (-) lumps, (+) stiffness in neck, (-)lesions

1.7 Breast and Auxiliary (-) pain, (-) lumps

1.8 Chest Chest symmetric, skin intact, (-) pain

1.9 Abdomen (-) abdominal pain (-) DOB

1.10 Extremities (-) deformities, (-) joint pain, (-) no swelling, weakness on both lower

extremities

1.11 Skin (-) edema, (+) bruises on IV site

1.12 Hair hair evenly distributed, curly

1.13 Nails short fingernails, smooth texture

1.14 Respiratory (-) cough, (-) asthma, (-) DOB1.15 Cardiovascular BP 100/70, (-) chest pain

1.16 Gastrointestinal Tract (-) bowel movement on day of PE

1.17 Urinary Frequently urinating 7 a day

1.18 Musculoskeletal (+)weakness on lower extremities

1.19 Neurologic Recognizes common object

1.20 Cranial Nerves


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1.20.1 Olfactory Can identify different smell such as alcohol and orange

1.20.2 Optic Uses reading eyeglasses

1.20.3 Occulomotor Eyes can move freely

1.20.4 Trochlear Eyes can move freely. Can look upward and downward

1.20.5 Trigeminal Patient was able to clench her teeth and determine different sensation

applied on her face

1.20.6 Abducen Eyes can move laterally

1.20.7 Facial Can smile, lift eyebrows, close eyes

1.20.8 Auditory She was able to repeat words accurately, able to hear

1.20.9 Glosopharyngeal Able to swallow, gag reflex present

1.20.10 Vagus Able to swallow

1.20.11 Accesory Can rotate the head

1.20.12 Hypoglossal Able to move her tongue

Glasgow coma Test

Eye Opening Response Verbal Response Motor Response

Score

4- Open spontaneously 5-oriented & converses 6- obey verbal command


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VI. ANATOMY & PHYSIOLOGY

Nephron

o The nephron is the structural and functional unit of the kidney. It consists of a specialized

tubular structure and closely associated blood vessels. Responsible for the formation of urine.

o Each kidney contains 1,000,000 nephrons that filter the blood and form urine. About 99%

of the initial filtrate from the glomerulus is reabsorbed by the nephron and returned to the

blood in the peritubular capillaries.

o Glomerulus each nephron contains one of these clumps of capillaries. These capillaries

are highly porous and allow large amounts of solute-rich, virtually protein-free fluid

FILTRATE to pass from the blood into the glomerular capsule.

Afferent arterioles feed into the glomerular capillary bed. Has a larger diameterthan the efferent arteriole (this is one of the reasons that blood pressure is so high in


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the glomerulus. The elevated blood pressure is needed to force fluid out of the

bloodstream and into the nephron).

Efferent arterioles carry the newly filtered blood away from the glomerulus.

Narrower diameter than the afferent vessels keeps glomerular pressure high.

o Glomerular capsule/ Bowmans capsule a cup-shaped structure (a blind pouch) thatencloses the glomerulus. It is the first portion of the nephron pathway that moves fluid out of

the body.

o Proximal convoluted tubule (PCT) extends off of Bowmans capsule, it is formed by a

single layer of cuboidal epithelium. These actively absorb substances (glucose, amino acids,

65% of the sodium, Cl-, and water) from the filtrate and dump them into the peritubular

capillaries. These cells also secrete substances back into it (nitrogenous wastes, ammonium

ions). The cells have what is known as a brush borderof microvilli that greatly increases theabsorptive surface area that they have to work with. Filtrate has been reduced by 65% once it

leaves the PCT.

o Nephron loop (of Henle) the proximal partion that is connected to the proximal tubule

contains the same types of cells in its walls. The rest of the descending limb is thinner (the

thin segment) and is made of simple squamous epithelium that are freely permeable to

water (salt cannot permeate the cells of this portion of the tubule, so, it becomes more

concentrated in the filtrate). After we enter the ascending limb which becomes thicken with

cuboidal/low columnar cells and is known as the thick segment. The ascending limb is

permeable to salt and Cl-(and K+) and impermeable to water. Therefore, since water is left

behind and solutes are being removed, the filtrate is now dilute.

o Distal convoluted tubule (DCT) the next segment of the nephron after the ascending

loop of Henle, it contains cubiodal epithelial cells in its walls, but, unlike the proximal tubule,

they rarely contain microvilli. This hints at the tubes function: secretion of solutes back into

the filtrate as opposed to a lot absorption (some sodium and Cl- are reabsorbed here). Further

down the distal tubule, the walls contain intercalated cells (with villi) that play a role in pH

balance andprincipal cells that help maintain the bodys sodium/water balance (they lackvilli).

o Collecting duct collects urine from several nephrons distal tubules and carries it through

the medulla pyramids to the minor calyces. Some reabsorbtion and secretion does happen.


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Regulation of Kidney Function (Extrinsic Mechanisms)

Kidney function is subject to a number of regulatory influences from both extrinsic (outside

the kidney) and intrinsic (within the kidney) sources. Those mechanisms acting from outside

the kidney include:

(1) Systemic blood pressure

(2) Aldosterone

(3) Antidiuretic Hormone (ADH)

1. The role ofsystemic blood pressure in controlling kidney function is obvious. The

glomerular capillaries are located between the afferent and efferent arterioles. Any

change in the diameter of these will affect hydrostatic pressure. Since the rate of

glomerular filtration is directly related to the hydrostatic blood pressure in glomerular

capillaries, any increase in blood pressure results in a corresponding increase infiltration rate and urine output. Since this process ultimately decreases blood volume,

the kidneys are a powerful means of controlling long term blood pressure.

Conversely, drops in blood pressure have the opposite effect. This mechanism is

important because it illustrates how circulatory and renal systems interact as blood

pressure changes affect kidney function and vice versa.

2. The steroid hormone, aldosterone, released from the adrenal cortex in response to

elevated levels of potassium, causes nephrons to secrete potassium into the urine. But,

since potassium and sodium share the same transport carrier, as potassium is excreted

the sodium is retained (reabsorbed). Chloride ions and water follow the retained

sodium to cause an increase in fluid retention and expansion of blood volume with

corresponding increases in blood pressure. Fluid retention is a common side effect ofsteroid hormone activity.


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3. The posterior pituitary hormone, antidiuretic hormone (ADH), is produced by the

hypothalamus and released from the posterior pituitary when the osmotic pressure of

blood and body fluids increases. The increased in osmotic pressure correlates directly

with solute concentration, indicating that water retention and/or intake is required to

correct the situation. Distal convoluted tubules and the proximal collecting ducts are

the targets for ADH action. Membrane pores for water transport increase (increasedthe water permeability) in these target cells under ADH influence. Because of the high

sodium ion concentration in the kidney interstitial fluids, increasing the number of

these pores increases the rate of water reabsorption from the urine back into blood in

this distal region of the nephron. It is important to notice that only water is reabsorbed

from filtrate under ADH influence allowing this mechanism to fine tune the

osmolarity of body fluids and blood while concentrating or diluting the urine output.


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Renal tubular site of potassium reabsorption and secretion. Potassium is reabsorbed in

the proximal tubule and in the ascending loop of Henle, so that only about 8% of the filtered

load is delivered to the distal tubule. Secretion of the potassium into the late distal tubules

and collecting ducts adds to the amount delivered, so that the daily excretion is about 12% of

the potassium filtered at the glomerular capillaries. The percentages indicate how much of

filtered load is reabsorbed or secreted into different tubular segments.


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VII. PATHOPHYSIOLOGY

Diarrhea/Polyuria

Anxiety

Hypokalemia

Clinical Manifestation

Muscle weakness,

Paresthesia at both upper

and lower extremities

Potassium

(Fluid loss)

PERIODICPARALYSIS


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VIII. Diagnostic/Laboratory

HEMATOLOGY

TEST RESULT NORMAL VALUES ANALYSIS

WBC ct. 6.6 4.5 5.5 x 10 12/L

Hematocrit 0.38 0.37 0.47 Normal

Hemoglobin 122 110 150 G/L Normal

Thrombocyte Count adequate

Differential Count

Segmenters 0.65 0.50 0.70 Normal

Lymphocytes 0.35 0.20 0.40 Normal

BLOOD CHEMISTRY

TEST RESULT NORMAL VALUES

Sodium 144.6 mEq/L 135-145

Potassium 2.84 mEq/L 3.5-5.3


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URINALYSIS

Macroscopic Examination Microscopic Examination

Color dark yellow RBC - 35 40 / hpF

Transparency turbid Pus Cells - 10 15 / hpF

Reaction (PH) 7.5 Epithelial Cells - few

Specific Gravity 1.02 Mucus Threads -

Protein Trace A. urates / Phosphates - few

Glucose - Negative Bacteria moderate

HGT- 91 mg/dl


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X . NURSING CARE PLAN

Actual Problem

CUES DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

S: parang tinutusok ng

karayom ang mga

kamay at binti ko as

verbalized by the patient

O: -Paresthesia

-frequent urination

-weak pulse

-confusion

-irritability

-Facial grimace

Potassium level deficit

as manifested by

Paresthesia

Within the shift, the

patient will elevate

potassium level and

decrease discomfort

from its clinical

manifestation

-Monitor patients V/S

-Assess level of

consciousness and

neuromuscular function

-Encourage intake of foods

high in potassium

-Maintain accurate record

of urinary and gastric

losses

-Instruct not to use

potassium-wasting diuretics

-Discuss preventable

causes of condition

-Monitor laboratory studies

-administer I.V potassium

as ordered

-to obtain baseline data

- drowsiness, irritability,

paresthesia and coma

may occur

-potassium loss maybe

replace or maintain

through diet

-guide for potassium

replacement needs

-Provides opportunity

for patient to prevent

recurrence

After shift, the

patient was able to

increase potassium

level and decreased

discomfort


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S: "Hirap akong

matulog" as

verbalized by the

patient.

O: BP 100/70

T 37.2

P 70

R 22

(+) sleep

disturbance

(+) decreased

performance

-Haggard looking

-Restlessness

Sleep pattern

disturbance related to

environmental changes

Within 8 hours of

nursing intervention,

patient will:

-report improved

sense of energy

-in feeling rested

Monitor Patients V/S

-maintain environment

conducive to sleep rest

-instructed not to take

foods and beverages

containing caffeine

-provide soporifics such as

milks

-discourage pattern of

daytime nap

-Limit fluid before bedtime

-to obtain baseline data

-to promote Relaxation

-caffeine may delay

patient sleep

-to help promote sleep

-napping can disrupt

normal sleep pattern

-to reduce voiding

during night

After 8 hours of

nursing

intervention, patient

was able to:

-reported improved

sense of energy

-feel rested


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S: nanghihina itong

mga binti ko as


O: -weakness in lower

extremities

-Minimized

movements

-Stays in bed most of

the time

Activity intolerance

related to

neuromuscular

impairment

Within 8 hours of

nursing intervention,

the patient will

regain strength

-Establish rapport

-Provided assistance for

range of motion exercise.

-Kept necessary utensils

within reach of the patient.

-Encouraged patient to do

self care activities such as

oral care, walking exercise.

-keeps side rails up

- To gain the patient

trust and cooperation

during the entire

procedure.

-Maintains mobility and

functions of joints

alignment of extremities

and reduces venous

stasis.

-Keeping all in reach,

can greatly reduce the

risk of accident to the

patient.

-This is to enable the

patient to regain muscle

strength and keeping

himself clean, and will

gain independence.

To promote safe

environment

After 8 hours of nursing

intervention, the patient

was able to regain

strength


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Potential Problem


S: mayat maya ihi

ako ng ihi as


O: BP 100/70

T 37.2

P 70

R 22

-frequent urination

-dry lips and dry mouth

-restlessness

-weakness

Risk for Fluid volume

deficit related to active

fluid loss

Within 8 hours of

nursing intervention, the

patient will prevent

dehydration andnormalize elimination

pattern

-Monitor patients V/S

-Encouraged patient to

increase fluid intake

-Instructed to provide oral

hygiene

-Monitor I&O, being

aware of altered intake &

output

-Limit fluids that tend to

exert a diuretic effect

-Promote intake of High-

water content foods and

electrolyte replacement

replacement drinks

-To obtain baseline data

-to avoid dehydration

-to maintain fluid

electrolyte in the body

-To ensure accurate

picture of fluid status

After 8 hours of nursing

intervention, the patient

prevented dehydration

and normalizedelimination of pattern


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XI. DRUG STUDY


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Name of

Drug

Classification Dosage and

Frequency

Course of

Action

Contra-

indication

Adverse

Reaction

Nursing

Responsibilites

ENERIC

FLOXACI

RAND

NOLON

Anti Infective/

Fluoroquinolone

40 mg BID DNA gyrase

inhibitor,

ofloxacin

interferes

with converse

ofintermediate

DNA

fragments

into high

molecular

weight DNA

in bacteria.

hypersensitivit

y to drug or

other

fluoroquinolon

es

> increased

intracranial

pressure,

seizures,

dizziness,

headache,insomia, acute

psychoses,

confusion,

tremors,

hallucination

> pseudomem-

branous colitis,

nausea, diarrhea

> leucopenia,

eosonophilia

>tendonitis,

tendon rupture,joint pain, back

pain

>steven Johnson

syndrome

> anaphylaxis

> patient should be

monitored for allergic

reactions

> encouraged patient to

maintain fluid intake ofat least 1,500 ml daily to

prevent crystalluria

> tell patient to

immediately report

fever and diarrhea

specially if the stool

contains blood, pus or

mucus. Caution him not

to treatdiarrhea without

consulting the

prescribers.

> instruct the patient to

immediately report rash

or tendon pain or

inflammation.

Name of

Drug

Classification Dosage and

Frequency

Course of

Action

Contra-

indication

Adverse

Reaction

Nursing

ResponsibilitesENERIC

ECOBAL

MINE

RAND

ETHYL

OBAL

Nootropics and

Neurotronics

500 mg 1 tab

TID

Tab:

treatment of

peripheral

neuropathies.

Inj:

megaloblastic

anemia due to

vit B12

deficiency,

peripheral

neuropaties

Patients whose

occupation

requires the

handling of

mercury or

mercury

compounds.

In frequently:

anorexia,

nausea,

vomiting,

diarrhea, pain

and indurations

at IM injection

site

Rarely: skin,

rash, headache,

sweating or hotsensation

Obtain patients history

of medical condition

before starting the

therapy.

Inform the patient about

the adverse reaction.


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IX. Course in the ward

Prognosis of the Patient

The patient was admitted at the hospital with a chief complain of numbness of both

upper and lower extremities. She is conscious and responsive in every interaction. The next

day, her feeling of numbness on upper extremities relieved and she feels weak on lower

extremities.

New Medications

PNSS 1L + 40mEq of KCl

Ofloxacin

New Order

Continue meds. On DAT and have to eat at least 1 banana per day

Reasons for New Meds. And Orders

To increase her potassium intake.


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XII. DISCHARGE PLANNING

MEDICATION Instruct the patient that diuretics can cause

hypokalemia.

DIETInstructed on diet to take foods rich in

potassium such as avocado, potato, banana,

meat, squash, carrots and beans.

EXERCISE Exercises are mostly appropriate to promote

proper circulation of the blood in the body.

ACTIVITY / LIFESTYLE CHANGES

Patient should continue to live a healthy

lifestyle and to be able to rest more to gain

her strength.

.

FOLLOW-UP Emphasized the importance of follow-up

check-up to monitor his condition


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Case Study Metro South Orig

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