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Section 2 :: Chapter 16 :: Patient With Hyponatremia/Fluid Volume Imbalance Case Study

 

Instructions: Read through the overview and objectives of the case study. Answer the case study questions based on the patients’ changing condition below. Provide explanation at the end as to why you choose the answer/answers that you did.
 

Overview

The two fluid compartments in the body are the intracellular space (inside the cells) and extracellular space (outside the cells). Approximately two thirds of the body’s water is located within the cells and is termed intracellular fluid (ICF). The extracellular fluid (ECF) consists of interstitial fluid (lymph and fluid between the cells), intravascular fluid (plasma), and transcellular fluid (a very small amount of fluid located in specialized cavities of the body).

 

Sodium is the main cation of the extracellular fluid and primary determinant of ECF osmolality. Changes in sodium levels will cause a parallel change in serum osmolality and have an impact on the water distribution between the ICF and ECF. Sodium also plays an important role in the generation and transmission of nerve impulses, muscle contractility, and regulation of acid-base balance.

 

Hyponatremia can be caused by a loss of sodium-containing fluids, a water excess in relation to the amount of sodium, or a combination of both. Hyponatremia causes hypoosmolality with a shift of water into the cells, leading to cerebral edema and central nervous system manifestations. Treatment for hyponatremia will vary, depending on the cause. Managing hyponatremia from fluid loss includes replacing fluid using isotonic sodium-containing solutions, encouraging oral intake, and withholding all diuretics.
 

Objectives

Identify relevant assessment data for a patient with hyponatremia and fluid volume deficit.
Evaluate results of diagnostic studies for a patient with fluid and electrolyte imbalances.
Prioritize nursing interventions for a patient with hyponatremia and fluid volume deficit.
Appropriately delegate care for a patient with severe hyponatremia.
Develop a nursing care plan for a patient with hyponatremia and fluid volume deficit.
Describe appropriate interprofessional care of a patient with severe hyponatremia and fluid volume deficit.
Formulate an individualized teaching plan for a patient recovering from hyponatremia and fluid volume deficit.

Case Study

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J.M. is an 83-year-old great-grandmother of five who is admitted to your clinical unit with a diagnosis of hyponatremia and fluid volume deficit. J.M. lives alone since her husband died 3 years ago. Her daughter lives nearby but is very busy working and taking care of her own grandchildren. The daughter found her mother lying on the living room couch very confused and disoriented. There were several empty bottles of water lying on the coffee table. J.M. is unable to state how long she has not been feeling well, but her daughter states that her mother has been complaining of nausea, vomiting, and diarrhea for 1 week.

 

Question: Based on the sketchy history available for J.M., which assumption best identifies the pathophysiologic basis of her fluid and electrolyte imbalance?

J.M. probably suffered a stroke and was unable to regulate her fluid intake appropriately as a result of disorientation and confusion
J.M. lost sodium-rich fluid with vomiting and diarrhea. The water that J.M. drank further diluted the sodium concentration
J.M. lost isotonic fluid with vomiting and diarrhea, but caused a dilutional hyponatremia by drinking too much water afterwards
J.M.’s nausea, vomiting, and diarrhea activated the renin-angiotensin-aldosterone system, cousin the release of aldosterone that further exacerbated J.M.’s fluid deficit

 

Question: You admit J.M., obtain a health history, and perform a physical examination. You pay particular attention to the signs and symptoms that J.M. manifests related to her diagnosis of hyponatremia and fluid volume deficit. Identify the expected manifestations of hyponatremia and fluid volume deficit below. There are *8 correct answers.

Irritability
Confusion
Tachycardia
Weight gain
Postural hypertension
Dry mucous membranes
Polyuria
Bradycardia
Tremors 
Seizures
Hypertension
comma 

 

Question: On physical examination, J.M.’s skin is warm and dry with poor skin turgor. SHe also has dry mucous membranes and dark-colored urine. Which vital signs most likely correspond to these assessment findings? (choose one answer)

BP: 100/62 lying, 104/64 sitting, 110/79 standing; HR: 102 lying, 100 sitting, 94 standing; Resp: 102; Temp: 37.2 degrees C (98.96 F)
BP: 100/62 lying, 85/60 sitting, 80/50 standing; HR: 102 lying, 114 sitting, 130 standing; Resp: 26; Temp: 38 degrees C (100.4 F)
BP: 120/82 lying, 110/64 sitting, 130/88 standing; HR: 80 lying, 70 sitting, 82 standing; Resp: 26; Temp: 37.0 degrees C (98.6 F)

 

Question: You review the results of the laboratory tests ordered for J.M. in the emergency department. Select those findings that you would expect to be present in J.M.’s condition. There are 3* correct answers.

Sodium 124 mEq/L (124 mmol/L)
Chloride 106 mEq/L (106 mmol/L)
Hgb 10 g/dL
Hct 54%
BUN 35 mg/dL
Potassium 4.8 mEq/L

 

Question: After completing J.M.’s assessment, you develop an individualized plan of care based on nursing diagnoses appropriate to her assessment findings. You would give the highest priority to which nursing diagnosis?

Risk for injury related to altered sensorium
Impaired verbal communication related to decreased LOC
Risk for impaired skin integrity related to poor skin turgor
Decreased cardiac output related to excessive ECF losses
 

Question: Select all of the appropriate nursing interventions that you would plan to implement during care of J.M. There are 8* correct answers.

Assess intake and output every 8 hours
Change patient position slowly
Administer oxygen to main O2 saturation greater than 95%
Hourly neuro checks for sodium levels of <120 mg/dL Weigh pt daily Turn patient every 2 hours Assess skin turgor in the lower extremities Perform frequent skin care using soap to remove oil  Administer IV normal saline as ordered Ensure that sodium levels do not rise more than 0.5 mg/dL per hour Offer patient 100 mL of tap water hourly Provide oral care every 4 hours and prn   Scenario: At 3:00 AM, J.M.'s blood pressure drops to 74/40. The graduate nurse calls the resident on call and receives an order from the sleepy physician to administer an IV of D5W at the rate of 200 mL/hr to treat J.M.'s hypovolemia. The graduate nurse immediately follows these instructions.   Question: At 7:00 AM, the graduate nurse and you enter J.M.'s room for bedside report. You find J.M. nonresponsive and displaying generalized seizure activity. Which statement most accurately describes the cause of J.M.'s present condition? Hypovolemia causes decreased cerebral perfusion resulting in seizure activity J.M. is displaying symptoms of septic shock related to her week-long viral activity Inappropriate administration of sodium-free water causes cerebral cellular swelling Fluid volume deficit causes shrinkage of cerebral cells and neuronal hyperexcitability   Question: Based on J.M.'s change in condition, which nursing diagnosis is now the priority in planning care for J.M.? Risk for injury related to seizures secondary to abnormal CNS function Impaired social interaction related to impaired sensorium and seizure activity Impaired vocal communication related to decreased LOC and seizure activity Disturbed body image related to altered body appearance secondary to seizure activity   Question: In order to best provide emergent care to J.M., which activity would be most appropriate for you to delegate to unlicensed assistive personnel (UAP) at this time? Position J.M. on her side to prevent aspiration of secretions during seizure activity Call J.M.'s family to explain what is happening and ask if they want a DNR order Notify the health care provider of J.M.'s status while you stay in the room with J.M. Reassess J.M.'s neurologic status every 15 minutes while you consult with the health care provider   Question: Select all the appropriate diagnostic tests and collaborative interventions you may expect the health care provider to order for J.M. at this time. There are 8* correct answers. Assess neuro status every hour. Diazepam 5 mg IV push stat Phenytoin level in AM Serum electrolytes now and every 6 hours Furosemide 40 mg IV stat Fluid restriction—no free water Fosphenytoin 150 mg PE IV push now and every 8 hours Morphine sulfate 4 mg IV push stat 500 mL NaCl 3% IV to infuse over 10 hours 1000 mL normal saline to infuse at 75 mL/hr Vasopressin 5 units IV stat   Scenario: J.M.'s hypovolemia and hyponatremia begin to resolve with IV fluid replacement therapy and oral fluid restrictions. You decide to teach J.M. and her daughter measures to prevent a further recurrence.   Question: If you develop nausea, vomiting, or diarrhea in the future, it is important to replace fluids with ______ drinks such as Gatorade and to consult your health care provider for medications to control the nausea, vomiting, and diarrhea. Drinking only _______  to replace fluid lost as a result of vomiting and diarrhea can lead to a very serious drop in serum ______ , leading to the symptoms of  ______ and ______ that you demonstrated on admission.   Options to fill in blanks: Bradycardia Calorie rich Confusion Disorientation Electrolyte rich Hypertension Potassium Sodium  Water SCIENCE HEALTH SCIENCE NURSING NURSING MISC

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