Patient Case Study: Fluid & Electrolyte Imbalance

Patient Case Study: Fluid & Electrolyte Imbalance

This patient case study report will outline the contributing factors related to a fluid and electrolyte imbalance, whilst assessing the medical and nursing management for the patient. Furthermore, an evaluation of the implemented nursing and medical treatment will also be discussed in this report.

Introduction:

* Patient History:

Mr. Richards presented to accident and emergency on the 7th October 2004, primarily due to the progressive deterioration of end stage motor neuron disease that was diagnosed two years ago. Coupled with a medical history of Alzheimer's disease, renal stones, enlarged prostate, hypertension, and an osophageal rupture, Mr. Richards' health has continued to deteriorate as evidenced by weight decline, diminished appetite, decreased mobility, muscle wasting, poor oral intake and dysphasia. Prior to his admission to hospital, Mr. Richards was cared for at home by his wife, however due to severe cognitive disturbances together with motor neuron features, his wife can no longer care for him at home as she cannot determine his needs or understand his complaints. Mr. Richards and his wife have both accepted his poor prognosis and deterioration as reflected by orders not to resuscitate, intubate or ventilate. His reason for admission is not an acute illness but to determine what palliative measures can relieve discomfort whilst correcting his fluid imbalance.

* Rationale:

A combination of reasons exists as to why Mr. Richards's fluid and electrolyte imbalance has occurred. Firstly, as a result of Mr. Richards growing dysphasia, his difficulty in comprehending language combined with decreased communication has led to an inadequate oral intake (Lewis, 2000). Furthermore, coupled with the chronic, degenerative disease of the brain known as Alzheimer's (Marieb, 2004), a loss of interest in food, diminished appetite and a decreased ability to self-feed have contributed to the development of a fluid and electrolyte imbalance. Ongoing swallowing difficulties following an osophageal rupture ten years ago has compounded this imbalance, as inadequate fluid intake due to discomfort resulting in the refusal to eat or drink, has resulted in dehydration and malnutrition.

Also, a lack of mobility, reduced energy levels, muscle atrophy and fatigue due to end stage motor neuron deterioration, has produced loss of appetite and a bed bound state that has exacerbated Mr. Richards feelings of agitation and an emotional decision to 'give in' to his poor prognosis. These factors have added to rapid weight decline and inadequate daily nutritional and fluid requirements. Both fluid and electrolyte imbalances have therefore developed primarily due to an inadequate fluid intake and poor oral intake of food that has occurred on account of Mr. Richards compounding co-morbid chronic medical conditions.

The Ageing Process:

Mr. Richards' chronic health related problems, when coupled with the natural process of ageing, significantly impact upon the likelihood of developing a fluid and electrolyte imbalance. However, due to the absence of an acute medical condition, the emphasis on the normal age-related changes impacting on Mr. Richards fluid and electrolyte balance will be discussed.

There is good evidence to suggest that, as we age, it becomes harder to maintain homeostatic levels of fluid and electrolytes (Woodrow, 2002). Firstly, specific age-related changes in kidney structure, which regulate homeostasis via their ability to dilute and concentrate urine, can lead to a decreased efficiency of the organ and a gradual decline in the ability to conserve water and concentrate urine. Due to Mr. Richards' inadequate fluid intake and coupled with a decreased efficiency of the kidneys, the inability to conserve and concentrate the little water he consumes has impacted upon his ability to maintain adequate homeostasis which therefore predisposes him to developing a fluid deficit leading to dehydration.

Dehydration, a state of diminished total body water content, has been reported to be the most common fluid and electrolyte imbalance in older people (Woodrow, 2003). Mr. Richard's fluid imbalance is exacerbated by the fact that thirst recognition in the older person becomes blunted, often leading to dehydration if thirst remains disrupted (Grandjean, A., Reimers. K, Buyckx, M. 2003). This is characteristic in the elderly in response to an increase in antidiuretic hormone secretions (ADH) that may develop following an increased plasma serum osmolality or volume concentration and related to a fluid deficit. This may result in decreased extracellular and interstitial fluid volumes, decreased thirst response and taste sensitivity.

In all patients over the age of sixty, some degree of renal impairment should always be suspected (Rose, 2001). A decline in renal mass, a reduction in blood flow to the kidneys and a reduction in certain nephrons that play a key role in concentrating urine, decrease Mr. Richards's ability to filtrate out waste products as they accumulate. This may also account for impaired renal concentration especially when combined with the reduction of thirst and impaired access to water due to his neurologic problems such as Alzheimer's disease and motor neuron disease.

However, the most important functional defect caused by the ageing process that reduces Mr. Richards's excretory capacity and therefore impacts upon fluid balance is a decreased glomerular filtration rate (Kazandjian, M. S. 1997). The glomerular tufts become less lobulated, the number of mesangial cells increase, and the numbers of epithelial cells decrease thus reducing the surface area available for filtration and adversely affecting Mr. Richards ability to concentrate and dilute urine (Edwards, 2001). This decreased filtration rate, coupled with a reduction in bladder capacity and decreased total body fluid associated with the ageing process, places the elderly, like Mr. Richards at risk of developing dehydration due to inadequate water absorption and compounded by an inadequate fluid intake.

Medical Management and Evaluation:

* Rationale and evaluation of medical treatment ordered for fluid imbalance

A non-aggressive palliative approach, coupled with maintaining Mr. Richards comfort, is the main emphasis of the medical treatment ordered to correct his fluid deficit. Therefore, the proposed medical goals