1 Case Study: Fluid & Electrolytes Summer A. Hill Christine E. Lynn College of Nursing: Florida Atlantic University NUR4716L: Acute Care in Nursing Situations with Adults and Aging Populations Mary Ann Leavitt, PhD, RN, CCRN-K, CHFN May 19, 2022 2 Case Study: Fluid & Electrolytes Electrolyte Imbalance Patient Profile E.G. is a 73-year-old woman whose daughter brings her to see the health care provider because she has had a case of the “stomach flu,” with vomiting and diarrhea for the past three to four days and is now experiencing occasional light-headedness and dizziness. Her past medical history includes hypertension, hypercholesterolemia, and mild heart failure. She is taking: Digoxin (Lanoxin) 0.125 mg po daily. Captopril (Capoten) 25 mg po BID. – hypertension treatment. ACE inhibitor. Furosemide (Lasix) 40 mg po daily. Potassium chloride (K-tab) 20 mEq po daily. Simvastatin (Zocor) 20 mg po at bedtime. Subjective Data Has been following a low sodium diet States her abdomen feels bloated and she has been constipated since the onset of the “flu” Has been taking her medications except for the potassium chloride pill because it upsets her stomach. Occasionally takes an extra “water pill” when her ankles are swollen Objective Data Physical Examination Temperature 98.2° F, pulse 88, respirations 20, BP 138/86 Lungs clear to auscultation, breathing regular and unlabored +1 edema bilaterally in ankles Muscle strength in upper extremities normal and equal and in lower extremities weak Sensation to all extremities normal Abdomen distended with hypoactive bowel sounds Diagnostic Studies Lab values Sodium 139.0 mEq/L 3 Potassium 3.0 mEq/L – LOW. Normal range (3.6-5.2) HCO3- 25.4 mEq/L Chloride 99.5 mEq/L Discussion Questions: 1. What is a possible pathophysiologic cause of E.G.’s muscle weakness and dizziness? What other symptom does E.G. have that may be related to this problem? A possible pathophysiologic cause of E.G.’s muscle weakness and dizziness could be related to hypokalemia. This is evidenced by the indicated low potassium level of 3.0 mEq/L. Additionally, patients taking diuretics should be monitored for electrolyte imbalance, with particular attention to potassium since this is often excreted in the urine at higher levels. If E.G. is also not keeping up with her K-tab to maintain adequate potassium levels this could result in muscle weakness and dizziness; however, it is possible that another cause of her weakness and/or dizziness is due to her hypertension which appears to be slightly elevated and for which she takes a combination of medications. 2. What factors contributed to the development of this electrolyte imbalance? Electrolyte imbalance tends to be more common in patients taking diuretics such as Furosemide. This is due to increased excretion and the ability of potassium to be absorbed easily by the cells and excreted. In E.G.’s case, the nausea and vomiting can also contribute to the electrolyte imbalance. E.G. also had not kept up with her medication regimen in order to replenish her decreasing potassium levels. 3. What should you be on an alert for in a patient who is on furosemide and digoxin and why? 4 Patients who take digoxin along with loop diuretics such as furosemide should be monitored for electrolyte imbalance and digoxin toxicity, particularly because Furosemide is a Postassium-wasting diuretic. The Furosemide also affects aldosterone which in turn causes the body to reabsorb sodium but excrete potassium and hydrogen ions. E.G. should then also be monitored for metabolic alkalosis. 4. What additional signs and symptoms should you assess E.G. for? In addition to signs of digoxin toxicity, which can include confusion, loss of appetite, nausea, vomiting, diarrhea, or vision problems (Digoxin (Oral Route), n.d.), E.G. should also be monitored for signs and symptoms of gout. This is due to the fact that loop diuretics are known to increase uric acid levels. Patients therefore should be monitored for symptoms of gout which are often characterized by sudden, severe attacks of pain, swelling, redness and tenderness in one or more joints, most often in the big toe (Gout - Symptoms and Causes - Mayo Clinic, n.d.). E.G.’s fluid status should also be continuously assessed. Continuous monitoring of daily weight, intake and output ratios, amount and location of edema, lung sounds, skin turgor, and mucous membranes would also be necessary. Additional signs of electrolyte imbalance might also include anorexia, muscle weakness, numbness, tingling, parasthesia, confusion and excessive thirst. In these cases a provider should be notified (Diuretics, n.d.). 5. What diagnostic test is indicated and why? Lab Test indications would include blood glucose (checking for signs of hypoglycemia), BUN (to check kidney function with patients on loop diuretics), and serum uric acid levels (checking electrolyte balance) before and periodically throughout course of therapy (Diuretics, n.d.). 5 6. What instructions should you give E.G. regarding the signs and symptoms of this electrolyte imbalance and how to prevent it? I would advise E.G. to continue to monitor herself for the aforementioned signs and symptoms of electrolyte imbalance and digoxin toxicity and report any findings to her provider immediately. Also, since Furosemide is potassium-wasting it will be important for EG to take her medications and K-tabs as prescribed. She can discuss with her provider about changes to her diet that might include potassium rich foods if she is having GI issues with the K-tabs. Patient teaching regarding EG’s list of medications is extremely important, especially given the drugdrug interaction between digoxin and loop diuretics. 6 References Digoxin (oral route). (n.d.). https://www.mayoclinic.org/drugs-supplements/digoxin-oralroute/precautions/drg20072646#:~:text=Some%20early%20warning%20signs%20of,the%20chest)%2C%20or %20fainting. Diuretics. (n.d.). https://www.drugguide.com/ddo/view/Davis-Drug-Guide/50939/all/diuretics Gout - symptoms and causes - mayo clinic. (n.d.). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/gout/symptoms-causes/syc20372897#:~:text=It's%20characterized%20by%20sudden%2C%20severe,big%20toe%2 0is%20on%20fire.
