The Case Studies of Anna and George

A significant proportion of the human body weight comprises of water that is functionally divided into the intracellular and the extracellular spaces (40% and 60% of body weight respectively) (Terris & Crean, 2017, p. 1). The extracellular fluid composes of the intravascular and interstitial fluid space. Fluids are essential in the cellular transportation of excretory products, nutrient distribution throughout the body, and regulation of body temperature (El-Sharkawy, Sahota, Maughan, & Lobo, 2014, p. 6). Electrolytes form vital components of body fluids that serve the purpose of chemical balance. Significant electrolytes include magnesium, chloride, phosphorous, calcium, potassium and sodium.

Fluid and electrolyte balance is vital to maintaining normal health conditions. Injury, illness, medication, and surgery are some of the factors that affect the balance (El-Sharkawy et al., 2014, p. 7; Terris & Crean, 2017, p. 2). The following paper examines the case of Anna and George, a paediatric and a geriatric patient respectively by identifying relevant data affiliated to fluid and electrolyte imbalances. The analysis will help determine the goal of care and evaluation of interventional strategy implemented for each case.

Assessment Data from the Case Studies

            Anna is a four-year-old girl who presents with various signs and symptoms that showcase impaired fluid and electrolyte balance. From the assessment, Anna is hypotensive (Blood pressure of 88/50), the heart rate is significantly elevated, and presents with fever. The pain score determined by Anna’s complaints of stomach aches rates six out of ten. Anna is sleepy and lethargic, and she cries when awaken. The patient also does not release tears while crying, the tongue is dry, has pale lips, no urine voided after eight hours, consistent complaints of thirst, and the capillary refill is greater than two seconds.

            George is an 85year-old man who avails to the clinic with a clinical history of gastro-oesophageal reflux disease (GORD) eliciting vital signs and symptoms of fluid and electrolyte imbalance in the body. The objective and subjective assessment data collected reveals that the patient has irregular heart rhythms. Abdominal cramping pain equates to a score of six out of ten. Similar to Anna’s case, George presents with symptoms of no urine output for eight hours, capillary refill greater than two seconds, dry tongue, drowsiness, and pale lips. Notably, the patient reports light-headedness when he stands. The above assessments data collected from both patients are crucial in the diagnosis of the impaired balance of fluids and electrolytes in the body.

            The assessment data collected is interpretable about the underlying pathophysiology of fluid and electrolyte imbalances in the body. Dehydration causes fluid imbalances that result in the loss of plasma instead of whole blood and consequently causes hypovolemia (Pollock, Ryan, Samson, & Brooks, 2014). Roumelioti et al., (2018, p. 8) affirms that impairment of sodium absorption in the small intestines and continued secretion of chloride results in a net fluid secretion that leads to loss of salts and water as watery stools (Seifter & Hsin-Yun Chang, 2017). Also, osmotic imbalances in the digestive tract due to ingestion of isotonic or hypertonic substances (Olalekan, Oluwaseun, Oladele, & Akeem, 2015, p. 1). Hence, dehydration manifests when the patient vomits and diarrhoea due to fluid intolerance. Therefore, the conditions result in reduced blood volume in circulation, decreased venous return, and arterial hypotension.

Anna’s low blood pressure and a capillary refill of greater than two seconds in both patients is a significant symptom of hypovolemia as a result of dehydration. Notably, fluid deficit manifests with dry lips, tongue, and pale eyes (Roumelioti et al., 2018, p. 2). Tachycardia and altered pulse rates occur due to hypovolemia. A decrease in vascular volume activates bioreceptors to signal the anterior pituitary gland to secrete antidiuretic hormone as a compensatory mechanism (Oliveira et al., 2017, p. 1). The hormone increases the rate of sodium and water reabsorption and decreased urine output. Postural hypotension in George’s case is an early sign of fluid deficit.

            There are notable developmental similarities and differences in the manifestation of signs and symptoms of impaired ability of the body to balance fluids and electrolytes. Anna, being a paediatric patient, the condition may manifest due to incomplete development of the kidneys, thus unable to sufficiently concentrate urine. Anna has a high surface to volume ratio that subjects her to higher fluid loss from the skin. According to El-Sharkawy et al., (2014, p. 8), aging kidneys in George’s situation lead to reduced ability to concentrate urine leasing to massive loss of water during impaired mechanisms of fluid and electrolyte maintenance. Also, older adults undergo hormonal changes that affect the homeostasis of electrolytes and fluids. For instance, increased atrial natriuretic peptide activity during high blood pressure in older adults leads to reduced levels of aldosterone and renin in serum (El-Sharkawy et al., 2014, p. 7).

Goal of Care

            The primary goal of care in both scenarios will be to maintain a functional volume of fluid shown by stable vital signs, prompt capillary refill, moist eyes, lips, and tongue, and sufficient urinary output exhibiting a specific gravity within normal ranges within few days. Both Anna and George present with symptoms of the fluid deficit which often occurs due to fistulas, wounds, burns, diarrhoea, gastric intubation, haemorrhage, and vomiting (Chen & Mitchell, 2016, p. 554). Vaideeswar et al., (2016, p. 15) outline that regulatory failure due to systemic infections, diabetes insipidus, diabetic ketoacidosis, and adrenal diseases also cause impairment in the balance of fluids and electrolytes in the body. The above goal of care aims at ensuring that the clients demonstrate behaviours essential in monitoring and correcting fluid and electrolyte deficit and verbalize the understanding of the causative factors of the conditions and the need for therapeutic interventions.

Interventions

            Achieving the goal of care mentioned above, it is imperative for the nurse to initiate appropriate interventions. One of the nurse-led intervention will be to administer oral fluids such as water or juice. In consideration that the patient is vomiting and exhibiting diarrhoea, it is imperative that the nurse administer these fluids in small volumes at a time to enable the patient’s body maintain normal osmotic pressure, retain fluids in the body, while concentrating urine (Terris & Crean, 2017). As the nurse administer the fluids, they should conduct a consistent evaluation after every specified period of time by monitoring vital parameters, capillary refill, and urine output. According to El-Sharkawy et al., (2014, p. 10), monitoring vital signs enables the nurse to note the degree of change in postural blood pressure and monitor fever occurrences. McClelland (2014) indicates that fluids and electrolytes deficits in the body elicit varying degrees of hypotension and an accompanying tachycardia. Wolf (2013) also notes that monitoring sudden elevations in the dyspnoea, restlessness, and blood pressure is vital because rapid correction of the deficit in fluids and electrolytes may compromise the cardiopulmonary system due to fluid shifts resultant from a change in osmotic pressure.

            The intervention will aid in the restoration of capillary refill time that is notable by palpation of peripheral pulses and noting the colour of the skin (Terris & Crean, 2017). Making such observations is crucial because some conditions that contribute to fluid and electrolyte imbalance in the extracellular space can cause inadequacy of organ perfusion, a state that potentiates circulatory shock or collapse (McClelland, 2014). Inadequate urine output is elemental in the determination of hypovolemic, polyuria, and insufficient renal perfusion. Therefore, oral fluids administration intervention helps in assessing the amount of fluid replacement required based on the current deficit (Wolf, 2013).

            The other intervention to accomplish the goal of care in these patients is collaborative. Here, the response will assist in identifying and treating the underlying causes of fluid and electrolyte balance impairment through the administration of intravenous medication consisting of isotonic solutions, and monitoring the laboratory studies (McClelland, 2014). The nurse should refer to the listings of the factors that predisposed or contributed to the patient’s condition so that they can develop an appropriate treatment plan to accomplish the care goal.

Laboratory studies following the administration of drug solutions check for coagulation, pH, partial pressure of carbon IV oxide in the blood, glucose concentration, and the level of electrolytes in the body. Fluid loss adopts different avenues, such as diarrhoea and vomiting, thus, result in differing imbalances in metabolic activity and electrolyte homeostasis (Diacon & Bell, 2014, p. 55). Hence, these problems require adequate correction through the collaborative interventions. Intravenous solutions such as 0.45% sodium chloride are crucial in the excretion of metabolic wastes by providing electrolytes and free water needed to facilitate the process (Hamel, 2018).

            Owing to the developmental differences, modifying the interventions can meet the unique the unique needs of each patient. One of the strategies is to alter the intravenous doses undertaken by both Anna and George. Notably, children tend to experience adverse effects to drugs. Hence, there is a need to modify the doses administered to Anna to ascertain good response and alleviate the existing condition (Kear, 2017). Older adults tend to elicit blunted thirst response which reduces fluid intake whereas children tend to drink much water, which adequately compensates fluid lost (El-Sharkawy et al., 2014). Therefore, meeting interventional goal requires modification of the procedures used in replacement therapy to ensure the corrective measure is sufficient.

Evaluating the Implemented Care

            Evaluation of the implemented care interventions is essential in the determination of their effectiveness. In alignment to the goal formulated, administering the intervention to both Anna and George should have restored homeostasis, freed the patients from complication, ensured that they both understood the condition and treatment needs, and formulated a discharge plan to meet the requirements of care identified following the assessment. Physical signs of recovery will include moistened lips, eyes, and tongue for both patients. Also, Singh et al., (2015, p. 370) note that drowsiness and the feeling of thirst will alleviate as there will be an adequate balance of osmotic pressure, and equal absorption of water and salts in the small intestines. Therefore, future assessments should focus on identifying the underlying conditions to the impairment of fluid and electrolyte balance to ensure the formulation of more accurate and efficient interventions (McLafferty, Johnstone, Hendry, & Farley, 2014, p. 42).

Conclusion

            Impaired fluid and electrolyte balance is a condition that emanates from homeostatic anomalies leading to low retention of water in the body. The case studies presented reveal two patients, Anna, and George, who present with signs and symptoms that explain the above condition. The assessment data that correlates with fluid and electrolyte balance impairment identified from the patients included dry lips, tongue, and eyes, abdominal pains, vomiting, diarrhoea, hypotension, fever, irregular heart rate, and drowsiness. All the above characteristics explain the pathophysiology of the conditions. The goal of care would be to restore fluid volume and electrolyte balance by observing normal vitals and homeostasis. Interventions would include continuous monitoring of aspects such as vital measures and urine output. Evaluating the effectiveness of the intervention will consist of checking whether the parameters of the set goals were accomplished. Modifying the dose and replacement therapy will suit the recovery needs of both Anna and George.

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