Acknowledgement

UNIVERSIDAD de MANILA
Acknowledgement
In completing this case study, the members of this group encountered many individuals who helped by offering their time, knowledge, and skills. Before the formal beginning, the group would like to give thanks and acknowledge those Individuals who made this study complete. The group would like to first give thanks to the patient, and his family, in being more than hospitable in providing necessary information in completing the family history and allowing the physical assessment to be done completely. The researchers would like to thank the staff of Justice Jose Abad Santos General Hospital, who helped to clarify many things from the chart and also giving bits of information concerning to the patient and his treatments.
The entire team would also like to give special thanks to their clinical instructors, for giving them pieces of advice based on case studies presented in the previous rotations, so that they may be strengthened somehow. And last but not least, To the God Almighty, Although this case study was made and passed at such a turbulent time, it was through Gods will that it had been completed. It was completed with whole-heart, eagerness and passion. -The Members of Group 1 UDM rotation October 3, 2011
Abstract
Filipinos are known for being matiisin as long as they can handle stuffs and other matters by their own, seeking for medical attention or any kind of help by the medical team or any individual is less needed as long as their concern is manageable by simple over the counter drugs and the BAHALA na practice. From the past to present this has become the main STIGMA by the health care delivery system and the nation itself.
But when the time their case has worsen and is cannot be manage by their own perception and practices , that is the time they need the so called professional treatment . Just like our 21 year old client with a very rare condition hypokalemic periodic paralysis a hereditary condition that causes imbalance with the potassium level in the body that causes an uncontrolled paralysis that can greatly affect his activities of daily living. His condition is never considered easy, acute hypokalemic paralysis is an uncommon cause of acute weakness maybe from stressors and strenuous activity. Morbidity and mortality associated with unrecognized disease include respiratory failure and death. Hence, it is imperative for physicians to be knowledgeable about the causes of hypokalemic paralysis, and consider them diagnostically. The client has done various self-treatments that could lead to positive or negative effect to his condition. Which concerns the medical team especially the nurses because the risk of this practice has no any guarantee of cure but can worsen the condition if not properly oriented. A very challenging case but with a thorough correction management, a series of replacement therapy of potassium and counseling about the onset of disease is genetic and is not much preventable, with briefing and definitely the Holistic care we provide can give a POSITIVE outcome.
Chapter I INTRODUCTION Background of the study
The group chose hypokalemic paralysis as our case to be study in preparation to our grand case presentation at the end of all the rotation. This is our first time to encounter this kind of case and because of that; our group was interested in it. We are willing to do this case to challenge our mind in analyzing the problem and to enhance our hidden knowledge, and also to gain new experiences which would bring new learning for the member of the group. Patient X is a 21 years old male, and was admitted in Justice Jose Abad Santos General Hospital last August 26, 2011 with a chief complaint of muscle weakness and vomiting. He was diagnosed with hypokalemic paralysis.
Significance of the study

This case study will help the group in understanding the disease process of the patient. This would also help the group in identifying the primary needs of the patient with hypokalemic paralysis. By identifying such needs and health problems arise, the group can now formulate an individualize care plan for the patient that would address these needs and problems effectively. Effective management of the problems identified will help the patient recover faster and maintain a holistic sense of wellness even while in the hospital. This case study would also equip the group with knowledge, skills and attitude on how to manage future patients with same or similar disease.
Objectives of the study

Nurse Centered: General: To enhance the students skills, comprehension and approach in the practice of nursing and be able to establish knowledge on the risk factors, prognosis nursing management, current trends and incidence of the disease condition that was chosen. Specific: To come up with a comprehensive presentation of the disease condition by means of correct presentation of the data gathered through the use of nursing process. To present the current trends about the disease condition, the reason for choosing such case for presentation, and the importance of the case study.
Patient Centered: General: To enable the client to fully understand and recognize the disease condition, emphasize the importance of making appropriate action and to guide the patient towards recovery. Specific: To understand the importance of a healthy lifestyle. To render proper nursing management and medical regimen needed by the patient. To identify predisposing factors that aggregate the present condition of the patient.
Scope and Limitation of the Study
Every form of paper work, research or just any activities have the so called limits. It said to a guide that could lead to success for it place with the strength of the doer and sense as barracks of our capabilities. It specifies and gives a thorough picture of what to expect in making research The case study was conducted at Jose Abad Santos General Hospital to a 21y/o man with a hypokalemic paralysis: datas and other information was gathered form the reliable source (esp. the client itself) some datas was not that clear and specific for the client wish to keep it for himself for confidentiality reasons. The client was handled by the researchers themselves for three days the nature, causes, sign and symptoms, pathophysiology, medical management and nursing management of the disease are being deliberated in this study. The researchers done various supportive care to the client (eg. Vital signs monitoring I and O medication with a strict and definite supervision of their instructor ); during the interview to the client in is clearly stated that the familial history of specific disease is not well remembered. During the physical examination some procedures were refused by the client to be performed and the researcher respect the decision of the client. The Gordons level of functioning, subtopic sex is quite offensive or too sensitive for the client to handle thats why some data is not definite. The client is not aware on his health history whether or not he is the only one in his family who suffered to that condition. Some laboratory condition is still pending till the day of his discharge. Some procedures in the laboratory were not performed and some results were still not released (TSH, FT4, and ABG). Even so this shortcoming didnt stop the medical team to correct the client for him to achieve the optimum level of functioning. The discharge planning is completely hypothetical and pictured cut the most reliable plan to be done. Over all the study focuses on the onset of any factor that affect and can improve the clients condition in regards to hypokalemic periodic paralysis.
Chapter II NURSING HEALTH HISTORY
Personal data
Name: patient RPB Date of birth: Dec 04, 1989 Birth place: Tondo, Manila Age: 21 years old Status: single Sex: Male Address: 315 CM Recto Tondo Manila barangay 11-zones 2 Educational attainment: High school undergraduate Informant: Patient RPB Date of admission: Aug. 26 2011 Time of admission: 11:45 pm Mode of admission: via stretcher carried by NOD of ER Admitting diagnosis: Hypokalemic paralysis Final diagnosis: hypokalemic periodic paralysis Admitting vital sign: Temperature: 36.5 C Pulse rate: 77 bpm Respiratory rate: 35 cpm Blood pressure: 90/60 Weight: 44 kg Height: 53 BMI: 17.18 Chief complaint: Nanghihina ang buong katawan ko as verbalized by the patient.
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History of present illness Muscle weakness was never been new to the clients condition; it was verbally stated that the client was hospitalized on the 4 th day of May, 1999 at Jose Reyes Memorial Medical Center for almost 4 days, from the year then till 2009, because of extreme muscle weakness. The client is confident that he is finally relieved with his condition that leads him to apply to a very strenuous job, ignoring light muscle weakness thinking that, its only because of his work. Last July 2011 the client was admitted to Justice Jose Abad Santos General Hospital with the admitting diagnosis of Hypokalemic Paralysis with a sense of extreme vomiting and muscle weakness. The client find out with the relative that this is not just any muscle pain, the client has difficulty in moving his extremities with complains of difficulty in breathing. The client was discharged, 2 weeks after the correction but unfortunately he was rushed again to the ER of JASGH, with a newly findings of Hypokalemic Periodic Paralysis last August 26, 2011 at exactly 11:45 PM, with the same complains and reason. Upon receiving from the ER, venocyclysis was already started (D5NM 1L x KVO at the level of 220 cc) with the side drip of PNSS 80cc + 40mEq KCl x 25cc/hr on its 1st cycle to run for 3 cycles. Laborartory exams are requested CBC, Na, K done at ER, to secure for the results. ABG, UA, TSH, and FT4 were requested. At 1:25 am the patient was transferred safely to medicine ward via stretcher carried by NOD of ER.
Past medical history The clients family was said to be conscious to his condition in the past in some ways. Immunizations (BCG, Hep.B, OPV, DPT, and AMV) was completed before he entered grade I; when he is 8 years old (year 1998) the client was hospitalized because of pneumothorax.it took 4 weeks to manage his condition at Jose Reyes memorial Medical Center. He had some wound scars and deep wound on his right eyelid leading him to have stitches at OPD setting at the same hospital. The rest of his wounds cause is unmentioned for he thinks that is confidential. Cough, fever and diarrhea are the common illness experienced by the client that is manageable by over-the-counter drugs like solmux, motilium and biogesic. The client stated that he is not positive any form of allergy in food or drugs.
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Gordons Functional Health Assessment Health perception health management pattern Before hospitalization During hospitalization Prior to hospitalization the client During hospitalization the client stated that he is aware in his stated that he wants to be cure, condition, that there are because he cannot longer something wrong in him. The tolerate his suffering but he felt client does not go to the hospital that it seems like there is no if he felt sick, if he has cough treatment in his condition, that and colds he just took solmux the Doctors doing in him is just a (carbocisteine), if he has fever replacement of potassium that he just took biogesic (antihad been loss in him. But still the pyretics) and if he is suffering client take medication on time from diarrhea he just took as his doctor prescribed with the motilium. Client stated that this help of the nurse. He always illness like cough and colds, follows whatever the nurse and fever and diarrhea does not the doctor says. But he felt that it need special attention. And seems like that there is no cure based on his he can manage for his condition that the doctors this by himself. Client said that he doing in him is just a dont want to take any herbal replacement of potassium that medicine when his sick. Even his has been loss to him. mother insisted because he thought that herbal medicine is not appropriate on his age. Client also verbalized that he was hospitalized several times because of muscle weakness, so he already knew what drug to be take when he experience this at home. Thats why sometimes if he experienced muscle weakness he just took kalium durule as his doctor prescribed to him in his past hospitalization
Interpretation :
Client was knowledgeable about his condition he understands whats happening to him. Because of several times that he was hospitalized in the
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same reason which is muscle weakness he already realized the importance of seeking a doctor when noticing an abnormalities in his body.
Nutritional metabolic pattern Before hospitalization During hospitalization Client stated that he ate thrice a The client was on DAT with high day, breakfast, lunch and potassium diet as ordered by the dinner. In breakfast he often ate doctor, but still the client loss his heavy meal: 2 cups of rice, 1 appetite. Client was hooked on viand like vegetables dish and 1 PNSS 1L regulated at 10gtts/min cup of coffee, at lunch: 3 cups on the left arm, incorporated of rice, 1 viand like fish and lots with 40meqs of KCL. Client BMI is of water 3 to 5 glasses. Then in 17 which is underweight body the dinner: 2 cups of rice, 1 can type of ectomorph. The client is goods like sardines and 3 glasses suffering from vomiting, that also of water. Client stated that if he affects his desire. has extra money he eats snack like bread or pancit. Client was fun of eating foods high in carbohydrates and he drinks a lot of water (8-10 glass a day) of water. Client verbally stated that he doesnt drink any alcoholic beverages and seldom took carbonated drinks. The client doesnt like to eat fruits. Interpretation : Before hospitalization the client has a good eating pattern but because of his muscle weakness that he was experiencing his appetite and eating pattern were affected.
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Elimination pattern Before hospitalization During hospitalization Client verbally stated that he The client I & O is 3960 mL input urinate five times a day, with a and output of 2200 mL. Urine is total of 1000 mL/ day or 200 mL lightly yellow. And slightly turbid for every urination. The urine is without particle and have color light yellow, odorless, clear, aromatic smell. He urinates 7 to 9 no presence of blood or any times for every shift in large particle. The client defecates volume approximately 240 mL once a day every morning. Stool every time he urinates. Client was semi-formed, no other urinates without pain. Client particles. He often experienced defecate once a day in diarrhea, he just thought its between of 2-5pm, stool was because of the foods he ate. He semi-formed and no particles. defecate five times a day, stool was watery and with particles. Interpretation : Client elimination pattern before hospitalization was balance in what he takes in and what he excretes but he often experienced diarrhea that may cause him possible for fluid volume deficits (dehydration). Upon hospitalization client has an unequal input and output. Elimination of stool is within normal range which is within 1-2 times per day.
Activity-exercise pattern Before hospitalization During hospitalization Client stated that swimming is his Upon interviewing the client form of exercised. He does it verbalized that because of thrice a week alternately in muscle weakness he had Dapitan complex together with difficulty in ambulation that he his friends. In their house the need assistance every time he client stated that he do move like going to the household chores like washing of bathroom. Because of that client dish, cleaning the house and always stay on the bed and sometimes cooking. Range of being watch-out by his family to motion is active and able to do avoid injury. his activities of daily living. He is a
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factory worker, strength is required in his field of work because of heavy lifting. He worked five times in a week. Interpretation : If the client is not experiencing muscle weakness he was able to do all his activities of daily living by his own but if muscle weakness occurs he become dependent to other people, everything he used to do was affected specially his work.
Sleep-rest pattern Before hospitalization During hospitalization The client said that his usual The client usually has difficulty in sleeping period is 5 to 6 hours. He sleeping because of often sleeps at around 11pm. For environmental noise like loud him to fall asleep, he listen to the chatting of his roommate. He radio or sometimes texting his was near at the window; he was friends. According to the client destructed by the vehicle noise there are no abnormalities when and the noise coming from the his sleeping. He woke up at 7am village near at the hospital. Also but sometimes if his tired he taking his vital sign interrupts his wake-up almost 9am. sleeping. Interpretation : Client sleeping pattern before hospitalization gives him an adequate rest. And no difficulty in falling asleep. While during hospitalization, environmental noise interrupt
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Cognitive-perceptual pattern Before hospitalization During hospitalization The client stated that he was a Client was conscious and high-school undergraduate, his coherent. Oriented to time, favorite subject then was place, and person. He response mathematics only. He was bored accordingly to every question. listening to his teacher, he much He can recall events that like skilled work subject, like T.L.E. happen to him in the past. He where he can learn answers straight without carpentering and mechanical difficulty. Client can express his work. Client never mentions any thought and emotion. But the problem in his senses. client experiencing numbness sensation in his upper and lower extremities Interpretation : Client mental status was not affected on what he experiencing right now. He was able to answer different questions even it happened in the past. Also his ability to talk is not affected.
Self-perception and self-concept pattern Before hospitalization During hospitalization Client stated that he is not Client stated that he feels so engaged to any formed of vices vulnerable and weak and felt like alcohol, smoking, gambling pity for himself because he cant etc. client see himself as a do anything to help him and simple, quite, shy type person losing hope to live in a normal and a strong man. Client life. verbalized that he want to be a pilot someday but seems that it will be a dream forever because according to him they dont have money to support his study, thats why since high-school his not confident that he may achieve his dream.
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Interpretation : Client has a low self-esteem due to his condition and makes him feel more down. Client seems like he dont have enough strength to go on with his life. That is because of what hes experiencing. Client having difficulty to pursue his dream and continue a normal living.
Role-relationship pattern Before hospitalization During hospitalization The client stated that he was Client stated that his happy with living with his family (mother, his family and best friend, to all father and youngest brother). He their support like financial and described his family as a emotional support. Client is supportive family, they support dependent with his family. And each other even though even though hes not able to sometimes they quarrel they still help their in providing their maintain a good relationship. He needs and in household chores. has lots of friends but theres one person that he treat as a brother, his best friend. They help each other in times of needs. He doesnt belong to any fraternity or affiliation or association. He doesnt participate to any activities in their community and never mingle with his co-worker because he thought they were too old. Interpretation : Client is very much attached to his relationship with his family. Now that the client is ill his family gives their full support and become more understanding that this time their son needs their care.
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Sexuality-reproductive pattern Before hospitalization During hospitalization Client refused to talk about his Client refused to talk about his sexuality-reproductive pattern sexuality-reproductive pattern because he stated that its too because he stated that its too confidential. confidential. Interpretation : Client is too shy to share if he had been in-love or engaged to sex. Client still want to preserve his privacy in this matter.
Coping-stress tolerance pattern Before hospitalization During hospitalization Client verbally stated that if he The client is coping with his had major problem he wants to situation with the help of his be alone and tried to fixed it by family. His getting the strength himself but if he thought that he with his family and best friend. All need the help of her parents he their encouragement and words will go with them but for him , he of wisdom to lighten his feelings. dont want to be a burden in his family. Sometimes he go to his best friend and share what he is going through. Client stated that he is not too tough to face his problem he always need the help of others. Interpretation : With the help of the clients family, he may be able to cope in a short period of time. And client may not be depressed because his family is there in times of need.
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Values-belief pattern Before hospitalization During hospitalization Client is a roman catholic since Client become more prayerful, birth. He believes that theres he paused for a while and God whos watching from talked to God. Even though he is above. Client stated that he is in this situation he never blame not religious because he went to the Lord for what happen to him. the church once a month most He just believed that God wants especially if he have problem. him to learn something. He prays when he goes to the church and confesses his sins. His family thought him to be a Godfearing person and to be humble all the time. He believes that every creature will come to death. Interpretation : Client has faith in God and believes that theres a powerful God. He has a positive attitude in all these. He never gives up in believing to God. And his parents teach him good values that may help him to be a good and better person.
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PHYSICAL EXAMINATION
GENERAL APPEARANCE
Vital signs : BP: 90/60 mmHg PR : 79 bpm RR: 20 cpm T : 36.4 C Difficulty in ambulating Muscle weakness on upper and lower extremities Good hygiene and dressed properly for the weather No body odor and breath odor noted MENTAL STATUS Not in distress The client is cooperative and responsive in answering the information needed. The client is conscious and coherent The client speaks clearly
NUTRITIONAL ASSESSMENT
BMI : 17 underweight 53 ft 44 kg The client was in Diet as Tolerated and high potassium No history of allergy in foods
INTEGUMENTARY SYSTEM
INSPECTION : The clients skin color is dark brown No presence of edema Scars are present on the right eyelid and right arm ; no discoloration noted; arranged in a line
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PALPATION : The skin is moist Temperature : 36.4 C Poor skin turgor HAIR INSPECTION : Hair is evenly distributed; black, thick and silky No dandruff or infestation noted
NAIL INSPECTION : Nail plate shape is convex Nail bed color is pink PALPATION : Smooth in texture Blanch test performed and nail bed return to its usual color after 2seconds. HEAD INSPECTION : Clients head is round and proportionate to the body PALPATION: No masses or nodules present FACE INSPECTION : Symmetric facial features ; facial hair is evenly distributed Symmetric facial movement Mole present in the right eyelid
EYE
INSPECTION : Hair in the eyebrows are evenly distributed; skin is intact 20
Eyebrows are symmetrically aligned; movements are equal Eyelashes are evenly distributed; curled and slightly outward Eyelids skin is intact; no discoloration; Lids close symmetrically Conjunctiva is shiny , smooth, and pink in color No edema or tenderness present over the lacrimal gland Sclera is porcelain white in color Pupils are black in color; equally round and react to light and accommodation Both eyes coordinated and moved in unison when six cardinal fields of gaze performed INSPECTION : The external ears are dark brown in color; in bilateral symmetry; the position of aspect of external ear is at the level of the eye. No lesions or nodules noted; PALPATION No swelling or tenderness present on auricles and mastoid areas Pinna recoils after it is folded Mobile when the auricle is pulled upward, downward and backward. Voice tones are audible by following the command Client respond to whispered voice by repeating the nonconsecutive numbers that was whispered on each ear 21
EARS
INSPECTION : The nose is symmetrically aligned and straight; dark brown in color No discharge and nasal flaring noted The nares is pink in color; no discharge and lesions noted Nasal septum is intact and in midline PALPATION: No tenderness or masses present No lesions noted Air moves freely on the nasal cavity when the client breathes through the nose by occluding one nostril. The maxillary and frontal sinuses are not tender when palpated and percussed INSPECTION : The outer and inner lips is pale in color; dryness noted; rough texture ; The client was able to purse lips There is presence of dental carries on the 3rd molar lower mandibular teeth Gums is pink in color; moist and firm texture The clients tongue is in central position Dry and furry tongue No lesions noted The client can move his tongue upward and from side to side No nodules noted The soft palate is smooth and light pink in color The hard palate is lighter pink in color The uvula is positioned in the midline of the soft palate 22
NOSE
MOUTH
The oropharynx is pink in color ; no presence of lesions The tonsils is pink in color ; no discharged noted
NECK
INSPECTION : Neck muscles are equal in size The client cannot move his head using the neck muscles because of muscle weakness Cannot shrug his shoulder The lymph nodes are not palpable Trachea is at the midline of neck No swelling or enlargement noted upon the inspection and palpation of thyroid gland POSTERIOR THORAX INSPECTION : The chest skin is intact and the temperature is uniform The ratio of anteroposterior to transverse diameter is 1:2 PALPATION : No presence of tenderness or masses on area of posterior thorax when palpated The thoracic expansion of the posterior chest is full and symmetric PERCUSSION : Vibration is heard on the posterior chest wall starting from the upper part of the lungs ( at the base of the neck ) to the lower part of the lungs 23
RESPIRATORY SYSTEM
Resonate sound heard from the 1 ICS down to the last Flat sound heard over the scapula
AUSCULTATION: A gentle sighing sound was heard at the base of the lungs during inspiration A blowing sound heard at the upper part of the lungs between the scapula ANTERIOR THORAX INSPECTION : The chest skin is intact The client s respiratory rate is 20 cpm Effortless inspiration noted PALPATION : No presence of tenderness or masses on area of anterior thorax The respiratory excursion is full and symmetric PERCUSSION : Vibration was heard on the anterior chest wall from the upper part of the lungs ( above the clavicle ) to the loer part of the lungs Resonate sound was heard down to the 6th ICS; Dull sounds on areas over the heart AUSCULTATION: Harsh sound heard over the trachea gentle sighing sounds heard on the lower part of the lungs blowing sound was heard on the area between 24
sternum and clavicle INSPECTION : No visible pulsations noted on aortic, pulmonic, tricuspid and apical area of precordium PALPATION: Apical pulsation is felt by palpation AUSCULTATION: Pulsation of heart is heard in four anatomical area but more audible in apical area upon ausculatation Peripheral pulses : - Carotid arteries has a full pulsations - Jugular veins are visible
CARDIOVASCULAR SYSTEM
ABDOMEN
INSPECTION : The clients skin is light brown in color ; no lesions noted Abdominal distention was observed Abdominal movement AUSCULTATION: Hyperactive bowel sounds was heard on the four quadrants of the abdomen PALPATION: Slight tenderness present on the hypogastric area INSPECTION: Muscle size is equal on both sides of the body No tremors present PALPATION : Muscle tone at rest is firm Presence of muscle weakness Muscle strength : LUE 1/5 RUE 1/5 25
MUSCULOSKELETAL SYSTEM
LLE 1/5 RLE 1/5 INTERPRETATION1- 10% of normal strength ; no movement, contraction of muscle is palpable or visible Bones : No deformities noted No tenderness or swelling present Joints : No swelling of joints noted No tenderness or swelling present upon palpation
NEUROLOGIC SYSTEM
LEVEL OF CONSCIOUSNESS: - Conscious and coherent. - Alert and responsive. MOTOR FUNCTION: - The client wasnt able to perform the tests because of the muscle weakness present on the Upper and Lower Extremities SENSORY FUNCTION: - Numbness and tingling sensation felt at the lower leg and feet - The client was able to identify pain sensation - The client reflex responses is hypoactives Glassgow Coma Scale - Eye opening=4 - Verbal= 5 - Motor= 2 - Total of 11
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Patient name: Patient RPB
Date: AUG. 29, 2011
Test: electrolytes Result 139.8 3.80 104.5 Reference range 135-148mmol/L 3.5-5.3mmol/L 98-107mmol/L Analysis Normal Normal Normal
sodium Potassium Chloride
Date: AUG. 28, 2011
Test: electrolytes Result 139.8 2.91 102.3 Reference range 135-148mmol/L 3.5-5.3mmol/L 98-107mmol/L Analysis Normal Below Normal range Normal
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Date: AUG. 27, 2011
Test: Urinalysis (test determines the content of the urine because urine because urine removes toxins and excess liquids from the body it can contain important clues) Physical examination Color = Light yellow Transparency = Slightly Turbid chemical Protein = +1 (plasma) Sugar = negative Specific gravity = 1.010 pH= 6.0 Microscopic WBC = 0-2/huff RBC = 0.2/huff Epithelial cells Mucus threads Amorphous Bacteria Reference Analysis Normal Normal
+ 1.002-1.030 4.5-8.0 0-2/hpf 0.2/hpf +2 +3 (-) 0
Normal Normal Normal Normal Normal Normal Normal Normal Normal normal
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Date: AUG. 26, 2011
Test: electrolytes Result 139 1.64 101.4 Reference range 135-148mmol/L 3.5-5.3mmol/L 98-107mmol/L Analysis Normal Below Normal range Normal
Date: AUG. 26, 2011
Test: Hematology
(The study of the blood, the blood- forming organs and blood disease Component Hemoglobin Hematocrit WBC count Platelet Differential count Neutrophil Lymphocyte Monocyte Eosinophil Stab Result 166g/L 0.46 30.6x109/L 502x109/L Reference 130-180g/L 0.42-0.48 5-10x109/L 150-400x109/L Analysis Within normal range Within normal range Above normal range Above normal range Above normal range Below normal range
0.85 0.15 -
0.36-0.66 0.22-0.40 0.04-0.08 0.01-0.04 0.0-0.01
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Course in the ward

08/26/11 Upon admission, patient complains of muscle weakness all over his body. Client was conscious and coherent but his vital signs are unstable, BP: 90/60mmHg, RR: 20bpm, PR: 77bpm, Temp: 36.5 C . Upon receiving the patient from ER, venocyclysis was already started (D5 NM 1L x KVO) with side drip of PNSS 80cc + 40meq KCl x 25cc/hr, on 1st cycle to run for 3 cycles. Patient was on DAT, High K+ diet. Laboratory examination was requested CBC, Na, K it was done at the ER and now waiting for the results. ABG & Urinalysis were requested. At 1:25pm patient was transferred safely to bed. He was conscious and coherent. At 3:00pm, another cycle of KCl drip was administered via soluset with 80cc of PNSS+40mEq KCl. Around 4am, urine specimen was collected and submitted to the laboratory for urinalysis. Input and output noted for continuity of care. August 26, 2011 On the 1st day, the patient was conscious and not in distress. He was received from ER ward via stretcher with ongoing IVF of D5NM 1L x KVO and side dip of PNSS 80cc + 40mEq KCl x 25cc/hr on its right arm 1st cycle, to run for 3 cycles. Vital signs were taken and recorded hourly. The patients vital signs were ranging from BP 90/60mmHg, PR 75-80cpm, RR 20-21bpm and T 36.4-36.6 degree centigrade. The patient was instructed on DAT, high K diet. The CBC, Na, K and UA was done at the ER ward reminded to be
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secured. He was requested for ABG, TSH and FT4. He was encouraged to rest and sleep and was kept safe and comfortable. Due medications were given. Intake and output were noted. His intake for 24 hours was 3960mL IVF and oral. For the patients output he defecated only once between 2-10pm shift and was urinated only a total of 2200mL for 24 hours.
August 27, 2011 On the 2nd day, the patient was received sitting on bed, still conscious and not in distress with ongoing IVF of PNSS 1L + 80mEq KCl to run for 10 hours at the level of 600cc, infusing well at the right arm. Vital signs were taken and recorded hourly. The patients vital signs were ranging from BP 90/60-100/60mmHg, PR 76-90cpm, RR 2022bpm and T 36.2-36.8 degree centigrade. He was seen and examined by Dr. Villegas at around 9am with orders noted and carried out. The patient was still instructed on DAT, high K diet for maintenance. He was still requested for ABG, TSH and FT4 to secure the result of K. The patient was still encouraged to rest and sleep and was kept safe and comfortable. He was also encouraged deep breathing. His BP reached 80/80mmHg and was referred to Dr. Cordova at 12am. The result of K-2.91 was relayed to Dr. Cordova. At 12:15am fast drip of PNSS 200cc was given then the remaining 300cc was incorporated with 40mEq KCl PNSS to run for 10 hours. Due medications were given. Intake and output were noted. His intake for 24 hours was 5450mL IVF and oral. For the patients output, he was urinated only a total of 2600mL for 24 hours.
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August 28, 2011 On the 3rd day, the patient was still conscious and not in distress with ongoing IVF of PNSS 1L + 80mEq KCl at 750cc level to run for 8 hours. Vital signs were taken and recorded every 4 hours. The patients vital signs were ranging from BP 80/50-100/70mmHg, PR 7092cpm, RR 20-22bpm and T 36-36.7 degree centigrade. The patient was still instructed on DAT, high K diet. He was still requested for ABG, TSH and FT4. Due medications were given. The patient was also seen and examined by Dr. De Sagun at 9:10am with orders noted, for report serum K after the 3rd cycle due at 8am. The patient was provided with safety measures. The IVF of PLR was consumed and hooked-up PLR 1L to run for 12 hours. No signs of nausea and vomiting were shown by the patient. The patient was still encouraged to rest and sleep and was kept safe and comfortable. Due medications were given. Intake and output were noted. His intake for 24 hours was 4660mL IVF and oral. For the patients output he defecated twice for this day and urinates for about a total of 2600mL for 24 hours.
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Chapter III CLINICAL DISCUSSION OF THE DISEASE
Description of disease
Hypokalemic periodic paralysis is a disorder related to periodic problems with muscle weakness and, occasionally, mild paralysis. Individuals are generally born with the disorder, although symptoms may not manifest until much later in life. Most cases are inherited, and it only takes one parent with the faulty gene to pass the disorder on to the child. Hypokalemic periodic paralysis is very uncommon, affecting only about one in every 100,000 individuals.
EPIDEMIOLOGY
Hypokalemic periodic paralysis (PP) is the most common of the periodic paralyses, but is still quite rare, with an estimated prevalence of 1 in 100,000. Hypokalemic PP may be familial with autosomal dominant inheritance or may be acquired in patients with thyrotoxicosis .
Clinical penetrance is often incomplete, especially in women [8]. The disorder is three to four times more commonly clinically expressed in men. Approximately one-third of cases represent new mutations.
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Age
The age of onset of the first attack ranges from one to 20 years; the frequency of attacks is highest between ages 15 and 35 and then decreases with age.
Anatomy and physiology
Potassium is present in a fluid form in the body cells and acts as an electrolyte along with other minerals like sodium, chloride, calcium, and magnesium. It is helps in maintaining the heart, brain, kidney, muscles tissues and other organs of the body in a healthy condition. It plays a key role in sending nerve signals and increases the body metabolism to use proteins, fat and carbohydrates for energy.
Benefits of Potassium
The health benefits of potassium to the body are as follows:
It plays a key role in regular contraction and relaxation of the muscles, hence, maintains muscle functions and optimal nerve.It helps in preventing the possibilities of muscle cramps or hypokalemia in the body.Since it functions as an electrolyte, it maintains the electrical conductivity of the brain, and impacts the brain function. It is also plays a vital role in enhancing the higher brain functions like memory and learning.Unlike sodium, potassium helps in balancing normal blood pressure and minimizes the
34
possibilities of heart diseases and hypertension. It is also considered as a best stress and anxiety buster.It plays a significant role in regulating water balance in the human body, and also assists the kidneys to remove the waste products from the body through excretion.Potassium boosts the spirit of nerve reflexes to send messages from one body part to another, which in turn helps in muscle contraction to perform daily activities.
Absorption of potassium from the diet is passive and does not require any specific mechanism. Absorption takes place in the small intestine as long as the concentration in gut contents is higher than that in the blood. If food moves rapidly through the bowel then absorption will not be sufficient.The kidneys are the main regulators of body potassium, maintaining blood levels by controlling excretion, even as intake varies. Some potassium is excreted in sweat. Digestive juices contain significant amounts of potassium but most of this is re-absorbed in the lower gut.
Symptoms of severe potassium deficiency include fatigue, vomiting, abdominal distention, acute muscular weakness, paralysis, pins and needles, loss of appetite, low blood pressure, intense thirst, drowsiness, confusion and eventually coma. Muscle spasms, tetany, heart arrhythmias and muscle weakness can also be caused by increased nerve excitability associated with inadequate intake of potassium.
Causes of potassium deficiency include high sodium diets, surgical operations involving the bowel, extensive burns and injuries,
35
diabetes, Cushing's syndrome, excessive excretion of aldosterone, chronic diarrhea which limits gut re-absorption of potassium, persistent vomiting, influenza, inflammatory bowel disease, anemia, ulcerative colitis, kidney disease, heart disease, chronic respiratory failure, prolonged fasting, therapeutic starvation, bizarre diets, anorexia nervosa, alcoholism and cystic fibrosis. Maximal voluntary exercise followed by rest caused a transient potentiation and then a depression of the action potential and of the twitch tension in the patient and in healthy subjects, but the patient's response was at times quantitatively greater. The deviation from normal tended to be greatest when the patient was weakest. Excessive accumulation of lactic and pyruvic acids in the blood occurred after a standard work load. This may indicate a greater than normal release of these metabolites from muscle or an impaired metabolism by muscle, or both. There appears to be no impairment in glycogenolysis or glycolysis in muscle during exercise. A close relationship was again observed between carbohydrate metabolism and primary hypokalemic periodic paralysis. The present study points to a possible metabolic lesion, or a contributing mechanism, that can be activated by rapidly induced glycolysis.
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Pathophysiology
Hypokalemic periodic paralysis is a condition in which a person has episodes of muscle weakness and sometimes severe paralysis.
The condition is congenital, which means it is present from birth. In most cases, it is passed down through families (inherited) as an autosomal dominant disorder. That means only one parent needs to pass the gene related to this condition onto you in order for you to be affected.
Occasionally, the condition may be the result of a genetic problem that is not inherited.Unlike other forms of periodic paralysis, persons with congenital hypokalemic periodic paralysis have normal thyroid function and very low blood levels of potassium during episodes of weakness. This results from potassium moving from the blood into muscle cells in an abnormal way.Risks include having other family members with periodic paralysis. The risk is slightly higher in Asian men who also have thyroid disorders.
Hypokalemic periodic paralysis causes attacks of muscle weakness or paralysis when the level of potassium in the blood drops. During severe attacks the patient may be unable to move and even appear unconscious. Even during paralysis the patient is awake and completely aware of their surroundings. Abortive attacks become more common in patients as they enter their 40s. Some patients
37
over 40 who had paralysis when younger quit having attacks of paralysis but have abortive attacks instead. Abortive attacks can be more trouble than paralytic attacks, because young patients usually feel strong between attacks of paralysis and patients with abortive attacks rarely feel strong.
Weakness most often affects the muscles of the arms and legs but may cause weakness of the the trunk/back muscles as well. A few patients have trouble breathing and swallowing during severe episodes. The low potassium level during attacks may cause irregular or weak heartbeat. Most patients have good muscle strength between attacks, but in some patients muscle tissue is damaged over time. Some patients have reduced muscle strength by the time they are 50-60 years old.
There are several types of Periodic Paralysis associated with metabolic and electrolyte abnormalities. Of these, Hypokalemic Periodic Paralysis (HPP) is the most common with a prevalence of 1 in 100,000. The clinical features of the syndrome vary somewhat depending on the underlying etiology but the most striking feature is the sudden onset of weakness ranging in severity from mild, transient weakness to severe disability resulting in life-threatening respiratory failure. Attacks may be provoked by stress such as a viral illness or fatigue, or certain medications such as beta-agonists, insulin or steroids. A perturbation of sodium and calcium ion channels results in low potassium levels and muscle dysfunction. As this is primarily a problem with muscle contraction rather than nerve conduction, tendon reflexes may be decreased or absent but
38
sensation is generally intact. Although the serum potassium level is often alarmingly low, other electrolytes are usually normal. Indeed, total body potassium is actually normal with the change in the serum level reflecting a shift of potassium into cells. Electrocardiographic changes are common, but unlike patients who are truly potassium depleted, the changes do not correlate well with the measured serum level . Diagnosis between paralytic episodes is difficult as the patient may have normal strength and potassium levels. Electromyography reveals abnormalities in some patients but is often normal, especially between episodes when no clinically detectable weakness is present.
HPP occurs in several settings and the diagnosis may require an extensive search for the underlying etiology since the treatment varies according to the cause. HPP may occur sporadically in the form of Familial Hypokalmic Paralysis (FHP), a poorly understood disorder which may occur spontaneously or as the result of autosomal dominant inheritance .This form of Periodic Paralysis is felt to be the result of disordered cellular potassium regulation perhaps due to sodium or calcium channel abnormalities. Mutations of the CACNA1S and SCN4A genes have been identified that cause abnormalities in sodium channels resulting in abnormal potassium ion flux. Acute paralytic episodes are treated with potassium replacement and close monitoring of the cardiac rhythm and serum potassium levels. Potassium is essential for many body functions, including muscle and nerve activity. The electrochemical gradient of potassium between the intracellular and extracellular space is essential for
39
nerve function; in particular, potassium is needed to repolarize the cell membrane to a resting state after an action potential has passed. Decreased potassium levels in the extracellular space will cause hyperpolarization of the resting membrane potential. This hyperpolarization is caused by the effect of the altered potassium gradient on resting membran potential as defined by the Goldman equation. As a result, a greater than normal stimulus is required for depolarization of the membrane in order to initiate an action potential. In certain conditions, this will make cells less excitable. However, in the heart, it causes myocytes to become hyperexcitable. Lower membrane potentials in the atrium may cause arrhythmias because of more complete recovery from sodium-channel inactivation, making the triggering of an action potential more likely. In addition, the reduced extracellular potassium (paradoxically) inhibits the activity of the I Kr potassium current and delays ventricular repolarization. This delayed repolarization may promote reentrant arrythmias.
40
41
Drug study
Generic name Brand name: Zantac Classification Histamine H2 antagonist Antiulcer Generic name: Ranitidine Mechanism of action -inhibits the action of histamine at the H2 receptor site located primarily in gastric parietal cells. -inhibits gastric secretion Dosage & route Po: 150mg tablet BID at bed time Indication Contraindication Adverse effect -Prophylaxis & -Hypersensitivity CNS treatment of -Cirrhosis of the Malaise elevated acidity liver insomnia of stomach. -Impaired renal agitation -Treatment of or hepatic somnolence gastroesophageal function Hallucination reflux Side effects -headache -abdominal pain -constipation -diarrhea -N&V Nursing responsibilities 1. do not smoke interferes with healing and drug effectiveness 2. Avoid alcohol aspirincontaining products and beverages that contain caffeine (tea, cola, coffee) these increase stomach acid. 3. Do not drive or operate machinery until drug effects are realized; dizziness or drowsiness may occur.
42
Generic name
Classification
Mode of action -blocks dopamine receptors in chemoreceptor trigger zone of the CNS -Stimulates motility of the upper GI tract and accelerates gastric emptying -decreased nausea and vomiting -decreased symptoms of gastric stasis
Metoclopramide Anti-emetics, GI Stimulants
Dosage & route 150 mg 1amp TIV q 8
Indication -prevention of chemotherapy -induced emesis -treatment of post-surgical and diabetic gastric stasis -facilitation of small bowel intubation in radiographic procedures -treatment and procedures of post-operative nausea and vomiting when nasogastric suctioning is undesirable.
Adverse effects -hypersensitivity CNS -possible GI -restlessness obstruction or -drowsiness hemorrhage -fatigue -history of seizure disorders extrapyramidal Reactions pheochromocytoma -irritability -parkinsons disease -anxiety CV -arrhythmia GI -constipation -diarrhea -nausea -dry mouth ENDO -gynecomastia
Contraindication
Nursing responsibilities IM: for prevention of postoperative nausea and vomiting. Inject near the end of surgery -assess for nausea, and vomiting, abdominal distention, and bowel sounds prior to and following administration -Inject slowly over 1-2min to prevent transient feeling of anxiety.
43
Generic name Brand name: Reglan Reclomide
Classification Antiemetic, GI stimulant
Generic name: Metoclopra mide
Mechanism of action -Blocks dopamine receptors in chemorecept or trigger zone of the CNS -Stimulates motility of the upper GI tract and accelerates gastric emptying. -Decreased nausea and vomiting -Decreased symptoms of gastric static.
Dosage & route 150mg 1 amp TIV q8
Indication -Facilitation of small bowel intubation in radiographic procedures. -Treatment and prevention of postoperative nausea & vomiting when nasogastric suctioning is undesirable.
Contraindication -Gastrointestinal hemorrhage -Obstruction or perforation -History of seizure disorder -Parkinsons disease
Adverse effect CNS -Anxiety -Depression -Irritability CV Hypo/Hypert ension arrhythmias Bradycardia GI -Bowel disturbances
Side effects -Restlessness -Drowsiness -Fatigue -Akathisia -Dizziness -Nausea -Diarrhea
Nursing responsibilities
1. Take as directed; may dilute syrup in water, juice or carbonated beverage just before taking. 2. Teach pt. that drug increases the movements or contractions of the stomach and intestines. 3. Avoid alcohol and CNS depressants. 4. Extrapyramidal effects should be reporter; may be treated w/ parenteral diphenhydramine. 5. Do not operate a car or hazardous machinery until drug effect realized drug has a sedative effect up to 2hr. after dosing.
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Generic name Brand name: Kalium Durule
Classification -Electrolyte (Potassium Supplement)
Mechanism of action -Serve as an activator in many enzymatic reactions and is essential to many processes including: *Gastric Secretion *Transmission of nerve impulses *Carbohydrate metabolism *renal function
Dosage & route PO: 20mg tablet TID
Indication PO: Treatment or prevention of potassium depletion in patient who are unable to ingest adequate dietary potassium.
Contraindication -Severe renal impairment -Untreated Addisons disease -Severe tissue trauma -Hyperkalemic familial periodic paralysis. -Know alcohol intolerance (elixirs)
Adverse effect -GI bleeding CNS -Paresthesia -paralysis -confusion -weakness -restlessness CV -Arrhytmias -ECG changes
Side effects -Nausea & Vomiting -Diarrhea -Flatulence -Abdominal discomfort
Nursing responsibilities
1. Dilute or dissolve PO or soluble powders in cold water, fruit or vegetable juice or other suitable liquid and drink slowly take it w/ plenty of H2O 2. If GI upset occurs products can be taken after meals or with food with a full glass of water. 3. Swallow tablets or capsules; do not chew or dissolve in the mouth. 4. Identify high potassium sources in the diet: spinach, potatoes, collards, tomato juice.
Generic Name: Potassium Chloride
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Name of Drug Brand name: Kalium Durule
Classification
Mode of Action Maintains the following cell characteristics: *acid base balance *Isotonicity
Dosage route
Indication
Contraindication
Side effect GI bleeding GI obstruction
Adverse effect -Fever -Infection at injection site -Venous thrombosis -Phlebitis extending to the injection site
Nursing Responsibilities
Electrolyte ( potassium supplement)
IV: PNSS 1L 80cc + 40 mEqs KCL x 10 hrs
Generic Name: Potassium Chloride
Prophylaxis and treatment of moderate to severe potassium loss when PO therapy is not feasible.
Severe renal function impairment with oliguria.-
Do not administer potassium IV undiluted. Usual method is to administer by slow IV infusion in dextrose solution.
Check site of administration frequently for pain and redness because drug is extremely irritating.
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Name of drug
Classification Mechanism Dosage of action & Route Isotonic solution Electrolyte Maintain body fluid osmolality Help regulate acid-base balance Regulate distribution of body fluids 1L TIV
Indication
Contraindication
Side effect
NSG.RESP.
PNSS 0.9NaCl Na+=154mEq/ L Cl+=154mEq/L Also available with varying concentration of dextrose.
Often to correct an extracellular volume deficit.
Heart failure Pulmonary edema Renal impairment Sodium retention
hypotention Always check IV site for infection Check IV site for blood clotting
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Name of drug D5W No electrolyte 50g of dextrose
Classification Hypotonic solution
Mechanism of action
Dosage & Route
Indication Used mainly to supply water and to correct increase serum osmolality.
Contraindication -head injury -should not be used for fluid resuscitation -should not use solely in treatment of fluid volume deficit. -should not be used in excessive volume in the early postoperative period
Side effect
NSG.RESP. Always check IV site for infection Check IV site for blood clotting
provides 1L TIV needed glucose to patients who are either diabetic or require constant sugar replacement. Dextrose in water also replenishes the body's supply of carbohydrates while facilitating rehydration.
vomiting
ADV.effect: acute hyponatremia
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Medical Management & Surgical Management
Medical Management
Asymptomatic or mild hypokalemia may be treated with enteral potassium supplements in the form of pills. This is the safest and most effective treatment for hypokalemia. Symptomatic or severe hypokalemia should be corrected with a solution of intravenous potassium. For people taking diuretics, potassium supplements are not necessary as long as they eat a balanced diet containing foods rich in potassium. But if hypokalemia has already occurred, use of the high potassium diet alone may not reverse hypokalemia. The treatment of the patients hypokalemia consisted of kalium durule (C: mineral and electrolyte replacement or supplement; A: replaces potassium and maintains potassium level, 2 durules TID per NGT.
Surgical Management
Management is nonsurgical. Medical therapy is aimed at potassium supplementation by the enteral (ie, oral or through feeding tubes) or parenteral route. Potassium supplements restore body potassium storage. Electrolytes are used to correct disturbances in fluid and electrolyte homoeostasis or acid-base balance and to reestablish osmotic equilibrium of specific ion. .
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Chapter IV
Prioritized nursing problem
Ineffective breathing pattern Deficient fluid volume Imbalance nutrition Activity intolerance Risk for injury
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NURSING CARE PLAN

ASSESSMENT mediyo Nahihirapan akong huminga as verbalized by the patient Vital signs: Temp: 36.6C RR:30cpm PR:77bpm BP:90/60mmHg DIAGNOSIS Ineffective breathing pattern related to muscle weakness INTERFERENCE Inspiration and expiration doesnt provide adequate cause by muscle weakness PLANNING After 1hour of nursing intervention patient will be able to breathe normally INTERVENTION
-Assess patients breath sound and respiration
RATIONALE
*assessing breathing pattern is a good indication for respiratory distress or accumulation of secretion. *monitoring vital signs will serve as the baseline data for the intervention to the patient Elevating the bed and positioning of the pt. will help better lung expansion *positioning the head of the patient will help the patient open and maintain airway This exercise help patient to breath easily and provide comfort.
EVALUATION After nursing intervention the goal was meet, , patient can now breathe normally.
-monitor vital sign
Elevate the bed of the patient to a high fowlers position
-position patients head appropriate for age
-Encourage deep breathing exercise.
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ASSESSMENT Subjective .madalas akong magsusuka at matubig ang dumi koas verbalized by the patient. Objective Vital signs Temp: 36.5C BP:90/60mmH g RR:35 cpm PR:77bpm -dry oral mucosa -furrowed tongue -cracked lips -poor skin turgor - dry skin
DIAGNOSIS Deficient Fluid Volume related to, vomiting.
INTERFERENCE A decrease in the intravascular, interstials, and/or intracellular fluid due to vomiting and diarrhea that may affect the acid /base balance of the body and may result to a fluid volume deficit.
PLANNING After 6 hours of nursing intervention the patient will be able to maintain electrolyte and acid/base balanced as evidenced by not compromised serum electrolytes and muscle strength.
INTERVENTION -monitor vital signs
RATIONALE -Provides baseline for assessing and evaluating interventions *Potassium is a vital electrolyte for skeletal and smooth muscle Activity.
-Monitor for neurologic and neuromuscular manifestations of hypokalemia (e.g., muscle weakness, lethargy, altered level of consciousness) -Offer the client ice chips followed by clear liquids
EVALUATIO N After 6 hours of nursing intervention the goal was met as evidenced by not compromised serum electrolytes and muscle strength.
-Encouraged fluid intake and monitoring of daily fluid intake and output -Administer medications (antiemetics) if the doctor ordered.
*Fluid electrolyte replacement provides oral replacement therapy *To detect early signs of dehydration *To limit gastric /intestinal losses; to treat bacteria
52
ASSESSMENT nangangayayat na ako kasi wala akong ganang kumain dahil sa pagsusuka ko as verbalized by the patient Desired body weight: 54.18 kg PRESENT: Height: 53 Weight: 44 kg. BMI:17.18 PAST: Height: 53 Weight: 49 kg. BMI:19 Vital signs: Temp:
DIAGNOSIS Imbalalance nutrition less than body requirements related to decrease appetite secondary to vomiting.
INTERFERENCE Due to vomiting there are not sufficient nutrients absorbed and utilize by the body that result to weight loss due to cellular starvation.
PLANNING Short term: After 2 hours of nursing intervention, the client will be able to learn different ways to regain weight appropriately. Long term: After 4 weeks of nursing intervention, the patient will be able to attain its desirable body weight.
INTERVENTION Independent: -determine clients ability to chew, swallow, and taste of food. -assess the tooth for decay.
RATIONALE *this may be a factor of decrease appetite of the patient.
-tooth decay may cause a difficulty to chew thus limiting the intake of foods. *to establish baseline parameter. *help to determine nutritional needs.
EVALUATION Short term: After 2 hours of nursing intervention, the goal was met as manifested by the verbalization of the client as he was able to identify ways to regain weight appropriately. Long term: After 4 weeks of nursing intervention, the goal was partially met, as manifested by a change in its weight from 44 kg to 45.6 kg.
Source: -Brunner, medical surgical nursing pathphysiological concept, vol.1
-assess weight.
-note age, body build, strength and activity/rest level. -provide diet modification, as indicated. -advice to use flavoring agent.
* To enhance food satisfaction
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RR:30 PR:77 BP:90/60 -limit fibrous foods.
to stimulate appetite. *it may lead to early satiety. *may have a negative effect on appetite/eating. *to monitor effectiveness of dietary plan. *intake of nutritious foods may help the client gain weight appropriately and to stay fit and healthy. *to meet these needs it should be with in financial constraints of the client.
-prevent/minimize unpleasant odors/sight.
-weight regularly or graph the results. -emphasize importance of wellbalanced and nutritious intake.
-Provide information regarding individual nutritional needs and ways.
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ASSESSMENT Subjective hindi ko magalaw ang mga kamay at binti koas verbalized by the patient Objective -difficulty in ambulation. LUE=1/5 KUE=1/5 LEE=2/5 RLE=2/5 Potassium level: =1.64 Vital signs Temp: 36.5C BP:90/60mmHg RR:30cpm PR:77bpm.
DIAGNOSIS Activity intolerance related to skeletal muscle weakness secondary to decreased serum potassium level.
INTERFERENCE Due to severe muscle weakness a person will be able to have Insufficient physiological or psychological energy to endure or complete required or desired daily activities
PLANNING INTERVENTION RATIONALE -encourage increase *fluids may aid in After 1week of asses clients actual Assessment of fluid intake. normal digestion. nursing and perceived actual limitations intervention the limitations/degree of can give us a -encourage to thru: *foods high inpicture patient will be action deficits thorough increase intake of potassiumclients able to: a. test for muscle about helps potassium rich to increase for -increase activity resistance capability foods such as potassium level tolerance thru the activity. the - assisting client body. signs expressed tomato, spinach,to - assists client avocado, dried primarily: ADLs till ability to ADLs can help fruits, nuts, dependent oranges, -verbalization becomes improve actual -demonstration of sunflower seeds, to independent tolerance. and potatoes. well tolerated -Simple activities activities (ADL) - assign client simple will be able Dependent:and *to muscles to react lessen activities -administer anti- thevomiting thus continuously add and perceived emetic drugaccording to well from as improving its difficulty prescribe by the of the appetite. the capability weakness physician. session. client per Encourage patient to -potassium will Collaborative: in *to be able to implement eat food high -consult a like interdisciplinary potassium improve skeletal dietitian/nutritionist management and banana and apple and cardiac team, as indicated. Or administer Kaliumto make activity muscle appropriate meal durule as ordered by plan for the the doctor. client.
EVALUATION After 1week of nursing intervention the patient was able to: Meet its goal and can perform his simple ADLs
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Assessment Subjective: Nanghihina ang katawan ko at paa koas verbalized by the client -Fatigue -numbness -Tingling Age: 21y.o. Objective: V/S BP:90/60mmHg T:36.6 PR:79 RR:20 Muscle strength: LUE: - 1/5 RUE: 1/5 LLE: - 2/5 RLE: - 2/5 GCS=
Diagnosis Risk for injury related to muscle weakness.
Interference Due to loss of potassium in the cell, the muscle loses its capability to contract that causes muscle weakness, loss of balance, flexibility and coordination, which can contribute to difficulty in doing its activities of daily living that closely linked to injury and fall. -Bruno, medical surgical nursing with pathophysiological concepts, vol.1
Planning After 4 hours of nursing intervention, the patient will be able to verbalize understanding on what are the ways to reduce/prevent injury to happen with the help of his family and attain muscle strength of: LUE: 4/5 RUE: 4/5 LLE: 5/5 RLE: 5/5
Intervention Independent: -Ascertain knowledge of safety needs/injury prevention and motivation. -Assess clients muscle strength, gross & fine motor coordination. -Assess the level of consciousness
Rationale -To prevent injury to occur in any setting. -To identify risk for falls. -This affects the ability of the clients ability to protect self or others, and influences choice of interventions and teaching. -This will increase the K level to reach normal serum level of K that will result to normalization of body function thus improving muscle strength.
-encourage the client to increase intake of potassium rich foods such as tomato, spinach, avocado, dried fruits, nuts, oranges, sunflower
Evaluation After 4hrs. of Nursing intervention, goal was partially met, as manifested by verbalization on understanding by enumerating to prevent or reduce occurrence of injury and he was able to increase his muscle strength from LUE: - 1/5 RUE: 1/5 LLE: - 2/5 RLE: - 2/5 To: LUE: - 3/5 RUE: 3/5 LLE: - 4/5 RLE: - 4/5
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seeds, and potatoes.
Dependent: -Administer 40mEq KCl intravenously incorporated to 1000cc of PNSS as prescribed by the doctor.
-This will increase the K level to reach normal serum level of K that will result to normalization of body function thus improving muscle strength.
Collaborative: -Assist with identification or treatment for underlying cause. Monitor laboratory studies: *Serum K
- refer to listing of predisposing or contributing factors
-levels should be checked frequently during
57
replacement therapy, especially in the presence of insufficient renal function sudden excess elevation may cause cardiac dysrhythmias *Serum Magnesium. Hypomagnesemia may impair potassium retention.
58
Discharge plan Medication:
-Instruct the client to take his medications on time. Prescribed by the doctor. -Kalium Durule 20mg/tab for 3 days
Exercise :
-Encourage the client to ambulate -Encourage the client to take mild exercise only
Treatment :
-Instruct the client to take Kalium durule and to increase intake of potassium rich foods to increase his serum potassium level.
Health teaching :
: Encourage the client to avoid strenuous activities/exercises. : Encourage to lessen carbohydrate intake and to avoid carbonic & alcoholic beverages. : Encourage to increase intake of potassium rich foods : Encourage to take his medicines on time.
OPD :
Instruct the client to go back to the hospital for his follow up check-up at OPD department on Sept. 6, 2011, 811am.
Diet :
-Instruct the patient to increase potassium intake such as apple, avocado, carrot, kiwi, orange tomatoes, peanut butter, 59
watermelon & milk. -Instruct the patient to lessen intake of carbohydrate rich foods and to avoid carbonic and alcoholic beverages.
Signs and symptoms :
-Advice the patient to go to the clinic or hospital if he experiences any signs and symptoms of hypokalemia such as muscle cramps, frequent vomiting and muscle fatigue or weakness.
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Significance of the study

Objectives of the study

INSPECTION : Hair in the eyebrows are evenly distributed; skin is intact 20

Date: AUG. 29, 2011

sodium Potassium Chloride

Patient name: Patient RPB

Date: AUG. 28, 2011

sodium Potassium Chloride

Date: AUG. 27, 2011

+ 1.002-1.030 4.5-8.0 0-2/hpf 0.2/hpf +2 +3 (-) 0

Date: AUG. 26, 2011

sodium Potassium Chloride

Patient name: Patient RPB

Date: AUG. 26, 2011

0.36-0.66 0.22-0.40 0.04-0.08 0.01-0.04 0.0-0.01

Course in the ward

Anatomy and physiology

The health benefits of potassium to the body are as follows:

Metoclopramide Anti-emetics, GI Stimulants

Dosage & route 150 mg 1amp TIV q 8

Generic name Brand name: Reglan Reclomide

Classification Antiemetic, GI stimulant

Generic name: Metoclopra mide

Dosage & route 150mg 1 amp TIV q8

Side effects -Restlessness -Drowsiness -Fatigue -Akathisia -Dizziness -Nausea -Diarrhea

Generic name Brand name: Kalium Durule

Classification -Electrolyte (Potassium Supplement)

Dosage & route PO: 20mg tablet TID

Side effects -Nausea & Vomiting -Diarrhea -Flatulence -Abdominal discomfort

Generic Name: Potassium Chloride

Name of Drug Brand name: Kalium Durule

Side effect GI bleeding GI obstruction

Electrolyte ( potassium supplement)

IV: PNSS 1L 80cc + 40 mEqs KCL x 10 hrs

Generic Name: Potassium Chloride

Severe renal function impairment with oliguria.-

Often to correct an extracellular volume deficit.

Heart failure Pulmonary edema Renal impairment Sodium retention

Name of drug D5W No electrolyte 50g of dextrose

Classification Hypotonic solution

Dosage & Route

ADV.effect: acute hyponatremia

Prioritized nursing problem

NURSING CARE PLAN

-monitor vital sign

Elevate the bed of the patient to a high fowlers position

-position patients head appropriate for age

-Encourage deep breathing exercise.

DIAGNOSIS Deficient Fluid Volume related to, vomiting.

INTERVENTION -monitor vital signs

RATIONALE *this may be a factor of decrease appetite of the patient.

Source: -Brunner, medical surgical nursing pathphysiological concept, vol.1

* To enhance food satisfaction

RR:30 PR:77 BP:90/60 -limit fibrous foods.

-prevent/minimize unpleasant odors/sight.

-Provide information regarding individual nutritional needs and ways.

Diagnosis Risk for injury related to muscle weakness.

seeds, and potatoes.

- refer to listing of predisposing or contributing factors

-levels should be checked frequently during

Signs and symptoms :