Mod 1 CR Path

Peer response 

Response 1

Children are at an especially high risk for fluid and electrolyte imbalances due to their small sizes, high activity level, and fast metabolism. Children are often sick with various illnesses and reduce their fluid intake as a result which puts them at an increased risk for imbalances. According to a study conducted by Naseem et al. (2019), 85% of children hospital admissions are related to fluid and electrolyte imbalances. Of these patients, the length of stay and mortality was also increased due to the added comorbidities (Naseem, 2019). Maintaining an effective and appropriate fluid and electrolyte balance is critical in treating these vulnerable populations. Labs should be taken frequently and adjustments made based on values.

Children with persistent fever, vomiting, and diarrhea are at risk for dehydration, particularly sodium and potassium imbalances (Sawaya & Ravandi, 2016). Providers should use isotonic solutions, in lieu of hypotonic solutions to decreased adverse effects including hyponatremia. Isotonic solutions allow for restoration of electrolytes and even distribution between the interstitial and intravascular spaces. Rehydration with strictly water could result in hyponatremia which results when the body holds only too much water in an attempt to retain what it has left.

Maintenance fluids are given for children experiencing ongoing fluid losses with adjustments made for body surface area to weight ratio which increases for infants, metabolism, and respiratory rate (Sawaya & Ravandi, 2016). Maintenance fluid rate requirements are as follows: 100 mL/kg/d for the first 10 kg (roughly 4 mL/kg/hr), 50 mL/kg/d for the second 10 kg (roughly 2 mL/kg/hr), and 20 mL/kg/d for the rest of the weight of the child (roughly 1 mL/kg/hr) (Sawaya & Ravandi, 2016).

According to Wolfsdorf (2019) with Nicklas Children’s Hospital, clinical manifestations of fluid and electrolyte imbalances care providers will need to watch for include fatigue, headaches, weakness, twitching, seizures, and confusion. Failure to identify and treat fluid losses in a timely manner could result in hypovolemic shock and even death. Because these symptoms are associated with so many other common illnesses, providers will need to document severity and time of onset with each symptom. Parents should also be made aware of signs and symptoms to look for, as well as, advanced progression.

 

References

Naseem, F., Saleem, A., Mahar, I. A., & Arif, F. (2019). Electrolyte imbalance in critically ill pediatric patients. Pakistan journal of medical sciences, 35(4), 1093–1098. 

https://doi.org/10.12669/pjms.35.4.286

Sawaya, R & Ravandi, B. (2016). Fluids and Electrolyte Management. Pediatric Emergency Medicine Reports. 21(3).

Wolfsdorf, J. (2019). Electrolyte Imbalance. Retrieved from

https://www.nicklauschildrens.org/conditions/electrolyte-imbalance

A 92-year-old nursing home patient presenting to the emergency department with a diagnosis of sudden hyperosmolar hyperglycemic nonketotic coma or commonly referred to as (HHNKS) would most likely be a type 2 diabetic with a blood sugar over 600 BGL.  Unlike the more common diabetic ketoacidosis or (DKA) which can occur at a BGL as low as 250 with a wide anion gap and ketones present. DKA is also more prominent with type 1 diabetics or newly on-set diabetics with no known history of diabetes.  

Patient’s signs and symptoms.  

As most patients that are commonly seen in the emergency department, the symptoms might initially mimic those of a DKA with some differences. I would expect this patient to have a BGL of at least 600, possibly altered mental status with extreme lethargy, nausea, and vomiting, polyuria, possibly polydipsia, which according to (Huether, 2020) might not be present due to the age of the patient as the elderly patients’ thirst perception can be impaired. I will also expect the patient to be possibly tachycardic with possible arrhythmia’s secondary to electrolyte imbalance on the cardiac monitor or EKG flattened t-waves if potassium is low, and high peaked t-waves as commonly found if potassium is high which might be unlikely in this case. I expect hypotension secondary to severe dehydration with pure skin turgor and maybe even cracked lips, or pale membranes. possible abdominal cramps secondary to ongoing vomiting, and high risk of seizures.  

Possible causes of this condition 

Due to the age of the patient, and the fact that the patient is a nursing home resident, there can be several possible causes. The patient could be sepsis from possible skin infections or unhealing ulcers which are common from pressure wounds. Due to the patient’s age, the patient might be on certain medications that can also contribute to hyperosmolar hyperglycemic nonketoic coma as well. “Clinical manifestations include severe dehydration; loss of electrolytes especially potassium, and neurological changes.” (Huether et al., 2020). 

Treatments for this patient 

The likely treatment for patients with HNNKS would be admitted to an ICU bed with close monitoring, aggressive fluid (If the patient does not have CHF or kidney failure to prevent fluid overload), and electrolytes replacement. Insulin with especially potassium supplement as we are aware that as the blood sugar level drops, the potassium might also decrease. And most importantly, treat the underlying cause of this episode of hyperosmolar hyperglycemic nonketoic coma.  

 

                                                                                      References 

Huether, SE., McCance, K.L., & Brashers, V.L. (2020). Understanding pathophysiology, Seventh Ed., Elsevier.

            Louis, MO: Elsevier 

Elsevier Inc. (2017). Chapter 5: Fluids and electrolytes. Acids and bases.(PowerPoint slide). Retrieved from

           albanystate.view.usg.edu.  

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