I. INTRODUCTION

Electrolyte imbalance is present whenever there is an excess or deficit in th plasma level of a specific ion. Terms used to describe the imbalance contain the prefix hyper- for increased or hypo- for decreased, followed by the name of the electrolyte. Electrolyte imbalances can develop by the following mechanisms: excessive ingestion; diminished elimination of an electrolyte; diminished ingestion or excessive elimination of an electrolyte. The most common cause of electrolyte disturbances is renal failure.

Research has been made and proved that the occurrence of electrolyte imbalances is mostly common among pediatric and geriatric patient because children have immature bodily functions that put them to danger while adult’s bodily function are deteriorating that decreases the vital functioning as well. It is also identified that infants, people with lean body mass and females are also risk in developing electrolyte imbalances as they have more water which accompanied by electrolytes content in the body thus, if dehydrated, occurrence of this disease condition is at the utmost peak among the identified individuals (Black and Hawks, 2008; Medical-Surgical Nursing, Clinical Management for Positive Outcomes, 8th edition). The most serious electrolyte disturbances involve abnormalities in the levels of sodium, potassium, and/or calcium. Other electrolyte imbalances are less common, and often occur in conjunction with major electrolyte changes. Chronic laxative abuse or severe diarrhea or vomiting can lead to electrolyte disturbances along with dehydration. People suffering from bulimia or anorexia are at especially high risk for an electrolyte imbalance.

Generally, the symptoms of an electrolyte imbalance can include:

fatigue dizziness nausea weakness

Hyponatremia

A condition wherein the serum sodium level is less than 135 – 145 meq/L. Too little sodium therefore can cause cells to malfunction, and extremes in the blood sodium levels can be fatal.

A decreased concentration of sodium (hyponatremia) occurs whenever there is a relative increase in the amount of body water relative to sodium. This happens with some diseases of the liver and kidney, in patients with congestive heart failure, in burn victims, and in numerous other conditions.

Page 1

Client who is hyponatremic may manifest muscle cramps, weakness, fatigue, anorexia, vomiting, diarrhea, nausea, abdominal cramping (early signs at 125 meq/L); cerebral edema symptoms, headache, depression, personality changes, constipation, lethargy, muscle twitching tremors, further progress to convulsions and coma in severely low levels of sodium(later signs at <120 meq/L).

Hypokalemia

A condition wherein serum potassium levels are below than 3.5 – 5.0 meq/L. Decrease in potassium (hypokalemia) can profoundly affect the nervous system and increases the chance of irregular heartbeats (arrhythmias), which, when extreme, can be fatal.

Hypokalemia, or decreased potassium, can arise due to kidney diseases; excessive loss due to heavy sweating, vomiting, or diarrhea, eating disorders, certain medications, or other causes.

Client with low levels of serum potassium may manifest lethal ventricular arrhythmias (flattened T wave, prominent U wave), anorexia, vomiting, constipation, abdominal distention, paralytic ileus, muscle weakness, paralysis, shallow respiration, fatigue, lethargy, decrease tendon reflexes, confusion, depression, polyuria, decrase serum osmolality, and nocturia.

Metabolic Alkalosis

Because hydrogen is abundant in the upper part of the system (Black and

Hawks, 2008; Medical-Surgical Nursing, Clinical Management for Positive Outcomes,

8th edition) thus, excessive vomiting may cause excessive loss of hydrogen thus, results

to metabolic alkalosis which is defined as the primary increase in HCO3 − with or without

compensatory increase in Pco2; pH may be high or nearly normal. Renal impairment of

HCO3 − excretion must be present to sustain alkalosis. Symptoms and signs in severe

cases include headache, lethargy, and tetany. Diagnosis is clinical and with ABG and

serum electrolyte measurement. The underlying cause is treated; oral or IV

acetazolamide or HCl is sometimes indicated.

Metabolic alkalosis involving loss or excess secretion of Cl is termed Cl-

responsive, because it typically corrects with IV administration of NaCl-containing fluid.

Cl–unresponsive metabolic alkalosis does not, and it typically involves severe Mg or K

deficiency or mineralocorticoid excess. The 2 forms can coexist, eg, in patients with

volume overload made hypokalemic from high-dose diuretics.

Symptoms and signs of mild alkalemia are usually related to the underlying

disorder. More severe alkalemia increases protein binding of ionized Ca++, leading to

hypocalcemia and subsequent headache, lethargy, and neuromuscular excitability,

sometimes with delirium, tetany, and seizures. Alkalemia also lowers threshold for

anginal symptoms and arrhythmias. Concomitant hypokalemia may cause weakness.

Diagnosis

ABG and serum electrolytes Diagnosis of cause usually clinical Sometimes, measurement of urinary Cl− and K+

Page 2

Seizure

"Seizure" is a general term that refers to a sudden malfunction in the brain that causes someone to collapse, convulse, or have another temporary disturbance of normal brain function, often with a loss or change in consciousness. Seizure may be brought by excessive electrolyte imbalances because brain is considered to be the most sensitive part of the body during fluid and electrolyte shifting (Black and Hawks, 2008; Medical-Surgical Nursing, Clinical Management for Positive Outcomes, 8 th edition) thus, alteration of electrolyte and fluid levels may initiate the occurrence of this.

Symptoms may vary depending on the part of the brain involved, but often include unusual sensations, uncontrollable muscle spasms, and loss of consciousness.

When seizures occur more than once or over and over, it may indicate the ongoing condition epilepsy.

In older clients about 10% or more have standard fainting spells (also called syncope), which is often associated with a brief seizure or seizure-like spell. A person may stiffen or even twitch or convulse a few times. Fortunately, this rarely indicates epilepsy. Most adults recover very quickly (seconds to minutes) and don't require specialized treatment. Currently, 1.5 million elderly people reside in nursing homes, therefore as many as 150,000 elderly patients in nursing homes may be taking AEDs. The widespread prevalence of epilepsy in this population indicates a need to educate the physicians who treat them. Upon completing t his program, physicians will be able to discuss the epidemiology of epilepsy in the elderly, review the means by which seizures are produced and presented in geriatric patients to better understand which treatment is most appropriate, and discuss the special considerations that must be addressed regarding drug interactions in these patients as well as new data regarding the safety and tolerability of pharmacologic and non-pharmacologic treatments in this population. (http://professionals.epilepsy.com/page/cme_seizures_seniors.html)

Types of Seizure:

a. Generalized seizure

Absence seizures are brief episodes of staring. (Although the name looks like a regular English word, your neurologist may pronounce it ab-SAWNTZ.) Another name for them is petit mal (PET-ee mahl). During the seizure, awareness and responsiveness are impaired. People who have

Page 3

them usually don't realize when they've had one. There is no warning before a seizure, and the person is completely alert immediately afterward.

Myoclonic (MY-o-KLON-ik) seizures are brief, shock-like jerks of a muscle or a group of muscles. "Myo" means muscle and "clonus" (KLOH-nus) means rapidly alternating contraction and relaxation—jerking or twitching—of a muscle.

Muscle "tone" is the muscle's normal tension. "Atonic" (a-TON-ik) means "without tone," so in an atonic seizure, muscles suddenly lose strength. The eyelids may droop, the head may nod, and the person may drop things and often falls to the ground. These seizures are also called "drop attacks" or "drop seizures." The person usually remains conscious.

Muscle "tone" is the muscle's normal tension at rest. In a "tonic" seizure, the tone is greatly increased and the body, arms, or legs make sudden stiffening movements. Consciousness is usually preserved. Tonic seizures most often occur during sleep and usually involve all or most of the brain, affecting both sides of the body. If the person is standing when the seizure starts, he or she often will fall.

"Clonus" (KLOH-nus) means rapidly alternating contraction and relaxation of a muscle -- in other words, repeated jerking. The movements cannot be stopped by restraining or repositioning the arms or legs. Clonic (KLON-ik) seizures are rare, however. Much more common are tonic-clonic seizures, in which the jerking is preceded by stiffening (the "tonic" part). Sometimes tonic-clonic seizures start with jerking alone. These are called clonic-tonic-clonic seizures!

Tonic-clonic seizure. This type is what most people think of when they hear the word "seizure." An older term for them is "grand mal." As implied by the name, they combine the characteristics of tonic seizures and clonic seizures. The tonic phase comes first: All the muscles stiffen. Air being forced past the vocal cords causes a cry or groan. The person loses consciousness and falls to the floor. The tongue or cheek may be bitten, so bloody saliva may come from the mouth. The person may turn a bit blue in the face. After the tonic phase comes the clonic phase: The arms and usually the legs begin to jerk rapidly and rhythmically, bending and relaxing at the elbows, hips, and knees. After a few minutes, the jerking slows and stops. Bladder or bowel control sometimes is lost as the body relaxes. Consciousness returns slowly, and the person may be drowsy, confused, agitated, or depressed.

b.) Partial Seizures

Simple partial seizures entails motor, sensory, autoimmune and even psychic malfunctioning.

Complex Partial seizures. These seizures usually start in a small area of the temporal lobe or frontal lobe of the brain. They quickly involve other areas of the brain that affect alertness and awareness. So even though the person's eyes are open and they may make movements that seem to have a purpose, in reality "nobody's home." If the symptoms are subtle, other people may think the person is just daydreaming.

Urinary Tract Infection

A urinary tract infection (UTI) occurs when bacteria enter and multiply in the normally sterile urinary tract. This causes inflammation, which can result in small amounts of blood, pus (white blood cells that fight infection), and bacteria in the urine. This can also cause pain with urination (called dysuria), a sense of needing to urinate frequently, a feeling of urgency, and sometimes cramping in the lower abdomen. The

Page 4

infection can involve the urethra (the short tube from the bladder to the outside of the body), the bladder, sometimes the ureters (longer tubes connecting the bladder and kidneys), and occasionally the kidneys. If the kidneys are involved you may have flank pain, fever, and chills.

Most of these infections-85-95%-are causes by bacteria that are normally present in the intestine. The vaginal area also has certain bacteria present normally. Because women have a short urethra which opens near the vagina, bacteria can enter the bladder relatively easily.

Urine needs to be examined under a microscope for white blood cells, red blood cells, and bacteria. Sometimes with recurrent infections, a culture is grown to determine which organisms are causing the infection. Sensitivity studies determine which antibiotics are effective for those organisms. After treatment, a urinalysis or a colony count is often done to make sure the infection is cleared. This can decrease the possibility of a mild, undetected infection which can lead to an early recurrence of a more severe bladder infection or might spread to the kidneys.

Choosing this case study challenged me to go into a deeper etiology of such occurrences of different disease condition thus, it also allows studying the disease process and how does the existing problems initiate the occurrence of the problem. Furthermore, it awakens my interest to study this specific case for it gives me realization that even in the minute alteration in our bodily function, it would totally affect the system and the rest of the organs thus, taking this case will also give me ample information to know various causative factors, the signs and symptoms that might be manifesting by the client and most importantly for me to be able to manage well these disease condition during attacks and/or occurrence. It also gives me idea on what to relay to my patient and/or the significant others the necessary data to be remembered in order to prevent, reduce and/or completely eliminate the existence of the disease condition.

Page 5

II. CLIENT’S PROFILE

A. Socio-demographic Data

Patient X is a 74-year-old, female, widow, a Roman Catholic from Bayabas,

Cagayan de Oro City. The patient was admitted for the first time at Northern Mindanao

Medical Center last July 27, 2010 around 7:00 pm. She was then diagnosed with

Seizure secondary to electrolyte imbalance secondary to poor intake and vomiting, rule

in complicated Urinary Tract Infection. Information was given by the granddaughter, her

daughter and her son.

B. Vital Signs

The patient’s vital signs are so important, since it provides a baseline data in

determining what are the alterations in bodily functions. Any change from normal is

considered to be an indication of the person’s state of health and provides clues to the

physiological functioning of the body.

The patient had the following vital signs: blood pressure: 160/100 mmHg, pulse

rate: 80 bpm, respiratory rate: 22 cpm, temperature: 36.2ºC. She currently weighs 43

kilograms from the previous weight of 47 kilograms and she is 5’0 tall.

C. Health Patterns Assessment

1. History of Present Illness

The client was brought to the hospital due to seizure x 1 episode x 30

seconds; (+) poor appetite x 3 days; and (+) vomiting x 5 episodes.

Three days prior to admission (PTA), she was noted to have body malaise

with poor appetite. No consult done. No medication taken. Encouraged by

daughter to eat but only tolerate to eat lugaw (at half of her usual share).

A day prior to admission (PTA) she would only tolerate a few take of

spoonfuls of food with an episode of vomiting and undocumented fever which

was relieved after taking paracetamol 500 mg 1 tablet. She also had 5 episodes

of vomiting more than 1 per episode normally after food intake. Consult done at

City Hospital. Complete Blood Count and Urinalysis done and was told to have

“dugo sa ihi” and was given something for the removal of gastric pain. Urinalysis

and KUB (kidney, ureter, and bladder) was done as requested.

A night prior to admission (PTA), she was noted to be weak and with

increase sleeping time.

July 27, 2010: On her way to St. Ignatius for her Kidney check-up, she

was noted to have “panggahi-pangurog with panghiwi (to the right) for 30

Page 6

seconds. “gahila-hila nag baba”, promptly take the patient to Cagayan de Oro-

Polymedic General Hospital. She was drowsy, documented given with

metoclopramide 1 ampule IVTT; ranitidine 1 ampule IVTT---------- referred to

Northern Mindanao Medical Center.

Client was hospitalized due to Urinary Tract Infection during the year 2006

and did not take any medication and did not take any precautionary measures.

The client was lethargic and restless but able to turn to sides every two hours.

She has no allergic reaction noted and documented on food and/or medications

and she is not taking alcoholic beverages and doesn’t use tobacco but takes 1

cup of coffee daily. There are no illicit drugs taken for her entire life.

2. Nutrition

Upon admission, client was put in Nasogastric feeding for 2 – 3 days.

Patient was then recommended to take general liquids and was permitted to

take soft foods as well. There are no supplements given together with food

intake. The client during general liquid only take 5-6 spoonful of water and

broth soups and during soft diet, only ¼ cup of porridge which indicates poor

appetite. Prior to admission, she has series of episodic vomiting and was then

relieved due to the given medication: metoclopramide 1 ampule IVTT. Patient

has 10 kilogram-weight loss from 50 kg to 40 kg due to poor appetite and

episodic vomiting.

The client has no wounds/drains/dressings and was hooked to an

intravenous fluid PNSS 1L with 40 meq of KCl regulated at 30gtts/minute.

There are no further pertinent data that were collected regarding her

nutritional status.

3. Elimination Pattern

Mrs. X ‘s stool as described by her significant others as brown in color,

formed and defecates everyday with no discomforts. The client defecated last

July 31, 2010 during the day.

Client urinates frequently approximately 8 – 10 times but in small amounts

because of complicated urinary tract infection; in a day with 50-100cc per

urination. Urine is hazy in color with pus and red blood cells and having hard

time controlling urine.

Patient does not have excessive perspiration and does not experience

nocturnal sweats.

Page 7

4. Activity-Exercise Pattern (pre-hospitalization)

The exercise of the client usually associated in her work as a vendor

because she always walk along the Raagas beach resorts to sell foods and

different stuffs and for her, it’s an exercise at the same time leisure time for

her. Client is not attached to any ventilator assistance and O2 supplements.

a. Activity-Exercise Pattern (while confined)

Describe the patient’s functional abilities

a. Feeding: dependent

b. Bathing: dependent

c. Toileting: dependent

d. Bed mobility: dependent and independent (turning to sides)

e. Dressing: dependent

f. Grooming: dependent

g. General mobility: dependent

h. ROM: independent

The patient can do independently Range of Motion but failed to do

feeding, bathing, toileting; diapers are being used, bed to chair mobility,

dressing, grooming and general mobility due to disease condition and client

rather sleeps than doing these things.

5. Cognitive- Perceptual Pattern

The patient can understand & speak Visayan. 2 days after

admission, client manifests forgetfulness to time, place, and person. 4

days after admission patient was able to recall recent and past events

except for the reason of hospitalization and is oriented to time, person and

place. He has the ability to explain things clearly and can make simple

decisions. Patient sometimes failed to follow instructions like not to touch

IV site but still keeps on touching because patient manifest signs of

confusion as well as can perceive pain. Though, pain is not verbalized by

the client. She takes prescribed medicines: paracetamol 500 mg, and do

non-pharmaceutical interventions like sleeping and distraction such as

talking to significant others.

Page 8

6. Sleep and Rest Pattern

She usually sleeps 8 hours every night but mostly exceeds because she’s

practicing “double sleeping” where she takes a sleep during the day and

afternoon. He has no history of sleep disturbances. Prayers as well as singing

lullaby were two of the effective methods to induce her sleeping.

7. Self Perception and Self-concept Pattern (self esteem, body image)

Patient believes she can surpass these problems that she is going through

and she will go in selling stuffs so soon. She can maintain eye contact, able to

talk well, speech was sometimes inaudible due to low volume when speaking.

Emotional reaction to present condition: Check only:

Calm: √

Depressed: √

Anxious: √

Angry: ____________

Fearful: √

Irritable: √ (sometimes)

Worried: √

The patient was generally calm and easy to have conversation with but

verbalized that she was worried and fearful because of the recent condition

that she’s experiencing thus, it bothers her a lot every time there is procedure

that is being performed. In addition to that, she was anxious due to financial

constraints as well as she was depressed because with her condition she

cannot do activities of daily living independently.

8. Role and Relationship Pattern

Patient verbalized having good family relationship. She has been a

good mother to her son and daughters. She verbalized having good

relationship with friends in the church.

9. Sexuality – Reproductive Pattern

The client was not engaged in sexual-related activities because she is

already old and her husband is already dead due to prostatic complications.

She did not experience using birth control measures.

Page 9

10.Coping –Stress Tolerance Pattern

Patient was calm but sometimes irritable, anxious, worried and depressed.

She handles stress through sleeping an and praying frequently and satisfied

with the relatives around her. Happiness is around her whenever there are

people taking care of her and takes this as a great help.

11.Values-Belief Pattern

The patient is a Roman Catholic and believes no superstitions. She

together with her family attends mass every Sundays and the client is active

in their church organization and frequently visits divine mercy for healing.

D. Physical Assessment

1. Neurological Assessment

Orientation Fully oriented

Appropriate behavior/communication Responsive and coherent

Level of Consciousness Conscious but sometimes lethargic

Emotional State Anxious (sometimes)

2. Skin

General Color Pallor

Texture rough

Turgor elastic

Temperature Warm

Moisture Dry

3. Head

Facial Movements Symmetrical

Fontanels Closed

Hair Fine

Scalp Clean

Page 10

4. Eyes

Lids Symmetrical

Preorbital Region Intact/full

Conjunctiva Pale

Sclera Anicteric

Reaction to light R- Brisk

L- Brisk

Reaction to accommodation Uniform constriction / Convergence

Visual Acuity Abnormal due to old age

Peripheral Vision normal

5. Nose

Septum Midline

Mucosa Pinkish

Patency Both patent

Gross Smell Normal/symmetrical

Sinuses Non-tender

6. Ears

External Pinnae Normoset; Symmetrical

Tympanic Membrane Intact

Gross Hearing decreased

7. Mouth

Lips Pallor; cracked

Mucosa Pinkish

Tongue Midline

Teeth incomplete

Gums Pinkish

Page 11

8. Neck

Trachea Midline

Thyroids Non-palpable

Others Normal ROM

9. Pharynx

Uvula Midline

Tonsils Not Inflamed

Posterior Pharynx Not Inflamed

Mucosa Pinkish

10.Abdomen

General Normal

Configuration Symmetrical

Bowel Sounds Normoactive

Percussion Tympanitic

11.Back and Extremities

Range of Motion Normal

Muscle tone and strength Fair

Spine Midline

Gait normal

12.Cardiovascular Status

Precordial Area Flat

Point of Maximal Impulse (PMI) 5th ICS, midclavicular line

Heart Sounds Regular

Peripheral Pulses Regular

Capillary Refill 2 seconds

Page 12

13.Respiratory Status

Breathing Pattern regular

Shape of Chest AP:L:2:1

Lung Expansion Symmetrical

Vocal/Tactile Fremitus Symmetrical

Percussion Resonant

Breath Sounds vesicular

Cough Non-productive

Page 13

III. ANATOMY AND PHYSIOLOGY

Nerve Impulses

Neurons send messages electrochemically; this means that chemicals (ions)

cause an electrical impulse. Neurones and muscle cells are electrically excitable cells,

which means that they can transmit electrical nerve impulses. These impulses are due

to events in the cell membrane, so to understand the nerve impulse we need to revise

some properties of cell membranes.

 

The Resting Membrane Potential  [back to top]

When a neurone is not sending a signal, it is at ‘rest’.  The membrane is responsible for

the different events that occur in a neurone.  All animal cell membranes contain a

protein pump called the sodium-potassium pump  (Na+K+ATPase). This uses the energy

from ATP splitting to simultaneously pump 3 sodium ions out of the cell and 2 potassium

ions in. 

The Sodium-Potassium Pump

(Na+K+ATPase)

(Provided by:  Doc Kaiser's Microbiology

Website)

Three sodium ions from inside the cell first

bind to the transport protein. Then a

phosphate group is transferred from ATP to

the transport protein causing it to change

shape and release the sodium ions outside

the cell. Two potassium ions from outside the

cell then bind to the transport protein and as

the phospate is removed, the protein

assumes its original shape and releases the

potassium ions inside the cell.

If the pump was to continue unchecked there would be no sodium or   potassium

ions left to pump, but there are also sodium and potassium ion channels in the

Page 14

membrane. These channels are normally closed, but even when closed, they “leak”,

allowing sodium ions to leak in and potassium ions to leak out, down their respective

concentration gradients.

Concentration of ions inside and outside the neurone at rest:

IonConcentration inside cell/mmol dm-3

Concentration outside cell/mmol dm-3

Why don’t  the ions move down their concentration gradient?

K+ 150.0 2.5 K+ ions do not move out of the neurone down their concentration gradient due to a build up of positive charges outside the membrane.  This repels the movement of any more K+ ions out of the cell.Na+ 15.0 145.0

Cl- 9.0 101.0The chloride ions do not move into the cytoplasm as the negatively charged protein molecules that cannot cross the surface membrane repel them.

The combination of the Na+K+ATPase pump and the leak channels cause a

stable imbalance of Na+ and K+ ions across the membrane.  This imbalance of ions

causes a potential difference (or voltage) between the inside of the neurone and its

surroundings, called the resting membrane potential. The membrane potential is

always negative inside the cell, and varies in size from –20 to –200 mV (milivolt) in

different cells and species (in humans it is –70mV). The Na+K+ATPase is thought to

have evolved as an osmoregulator to keep the internal water potential high and so stop

water entering animal cells and bursting them. Plant cells don’t need this as they have

strong cells walls to prevent bursting.

 

Check Point of The Resting Membrane Potential is always negative (-70mV)

K+ pass easily into the cell

Page 15

Cl- and Na+ have a more difficult time crossing

Negatively charged protein molecules inside the neurone cannot pass the

membrane

The Na+K+ATPase pump uses energy to move 3Na+ out for every 2K+ into

neuron

The imbalance in voltage causes a potential difference across the cell membrane

- called the resting potential

 

The Action Potential  [back to top]

The resting potential tells us about what happens when a neurone is at rest.  An

action potential occurs when a neurone sends information down an axon.  This involves

an explosion of electrical activity, where the nerve and muscle cells resting membrane

potential changes.

In nerve and muscle cells the membranes are electrically excitable, which

means they can change their membrane potential, and this is the basis of the nerve

impulse. The sodium and potassium channels in these cells are voltage-gated, which

means that they can open and close depending on the voltage across the membrane.

The normal membrane potential inside the axon of nerve cells is –70mV, and

since this potential can change in nerve cells it is called the resting potential. When a

stimulus is applied a brief reversal of the membrane potential, lasting about a

millisecond, occurs. This brief reversal is called the action potential:

An action potential has 2 main phases called depolarisation and

repolarisation:

At rest, the inside of the neuron is slightly negative due to a higher concentration of positively charged sodium ions outside the neuron. 

Page 16

When stimulated past threshold (about –30mV in humans), sodium channels open and sodium rushes into the axon, causing a region of positive charge within the axon.  This is called depolarisation 

The region of positive charge causes nearby voltage gated sodium channels to close. Just after the sodium channels close, the potassium channels open wide, and potassium exits the axon, so the charge across the membrane is brought back to its resting potential.  This is called repolarisation. 

This process continues as a chain-reaction along the axon.  The influx of sodium depolarises the axon, and the outflow of potassium repolarises the axon. 

The sodium/potassium pump restores the resting concentrations of sodium and potassium ions 

  

 

Page 17

Page 18

Check Point  of  Action Potential has two main phases:

 Depolarisation. A stimulus can cause the membrane potential to change a little. The voltage-gated ion channels can detect this change, and when the potential reaches –30mV the sodium channels open for 0.5ms. The causes sodium ions to rush in, making the inside of the cell more positive. This phase is referred to as a depolarisation since the normal voltage polarity (negative inside) is reversed (becomes positive inside).

Repolarisation. At a certain point, the depolarisation of the membrane causes the sodium channels to close.  As a result the potassium channels open for 0.5ms, causing potassium ions to rush out, making the inside more negative again. Since this restores the original polarity, it is called repolarisation.  As the polarity becomes restored, there is a slight ‘overshoot’ in the movement of potassium ions (called hyperpolarisation).  The resting membrane potential is restored by the Na+K+ATPase pump.

Page 19

‘All or Nothing’ Law

The action potential only

occurs if the stimulus

causes enough sodium ions

enter the cell to change the

membrane potential to a

certain threshold level.  At

the threshold, sodium gates

open in the membrane and

allow a sudden flood of

sodium ions to enter the

cell.   If the depolarisation is

not great enough to reach

the threshold, then an

action potential (and hence

an impulse) will not be

produced.  This is called

the all or nothing law.

This means that the ion

channels are either open or

closed; there is no half-way

position.  This means that

the action potential always

reaches +40mV as it moves

along an axon, and it is

never attenuated (reduced)

by long axons.   Action

potentials are always the

same size, however the

frequency of the impulse

carrying the information can

determine the intensity of

the stimulus, i.e. strong

stimulus = high frequency.

Page 20

 

How do Nerve Impulses Start?  [back to top]

We and other animals have several types of receptors of mechanical stimuli. Each

initiates nerve impulses in sensory neurons when it is physically deformed by an outside

force such as:

touch

pressure

stretching

sound waves

motion

Mechanoreceptors enable us to

detect touch

monitor the position of our muscles, bones, and joints - the sense of

proprioception

detect sounds and the motion of the body.

E.g. Touch

Light touch is detected by receptors in the skin. These are often found close to a

hair follicle so even if the skin is not touched directly, movement of the hair is detected.

In the mouse, light movement of hair triggers a generator potential in

mechanically-gated sodium channels in a neuron located next to the hair follicle. This

potential opens voltage-gated sodium channels and if it reaches threshold, triggers

an action potential in the neuron.

Touch receptors are not distributed evenly over the body. The fingertips and

tongue may have as many as 100 per cm2; the back of the hand fewer than 10 per

cm2.   This can be demonstrated with the two-point threshold test. With a pair of

dividers like those used in mechanical drawing, determine (in a blindfolded subject) the

minimum separation of the points that produces two separate touch sensations. The

ability to discriminate the two points is far better on the fingertips than on, say, the small

of the back.

The density of touch receptors is also reflected in the amount of somatosensory

cortex in the brain assigned to that region of the body.

Proprioception

Proprioception is our "body sense".

It enables us to unconsciously monitor the position of our body.

Page 21

It depends on receptors in the muscles, tendons, and joints.

If you have ever tried to walk after one of your legs has "gone to sleep", you will

have some appreciation of how difficult coordinated muscular activity would be

without proprioception.

The Pacinian Corpuscle

  Pacinian corpuscles are pressure

receptors. They are located in the skin

and also in various internal organs. Each

is connected to a sensory neuron.  

Pacinian corpuscles are fast-conducting,

bulb-shaped receptors located deep in

the dermis.  They consist of the ending of

a single neurone surrounded by

lamellae. They are the largest of the

skin's receptors and are believed to

provide instant information about how

and where we move. They are also

sensitive to vibration. Pacinian

corpuscles are also located in joints and tendons and in tissue that lines organs and

blood vessels. 

  Pressure on the skin changed the shape of the Pacinian corpuscle.  This

changes the shape of the pressure sensitive sodium channels in the membrane,

making them open.  Sodium ions diffuse in through the channels leading to

depolarisation called a generator potential.  The greater the pressure the more sodium

channels open and the larger the generator potential.  If a threshold value is reached,

an action potential occurs and nerve impulses travel along the sensory neurone.  The

frequency of the impulse is related to the intensity of the stimulus.

Adaptation

When pressure is first applied to the corpuscle, it initiates a volley of impulses in

its sensory neuron. However, with continuous pressure, the frequency of action

potentials decreases quickly and soon stops. This is the phenomenon of adaptation.

Adaptation occurs in most sense receptors. It is useful because it prevents the nervous

system from being bombarded with information about insignificant matters like the touch

and pressure of our clothing.

Page 22

Stimuli represent changes in the environment. If there is no change, the sense

receptors soon adapt. But note that if we quickly remove the pressure from an adapted

Pacinian corpuscle, a fresh volley of impulses will be generated.

The speed of adaptation varies among different kinds of receptors. Receptors

involved in proprioception - such as spindle fibres - adapt slowly if at all.

Na+/K+ (Sodium/Potassium) Pump

The Na+/K+ pump is found in the membranes of many types of cells. In particular, it plays a very important role in nerve cell membranes. Notice that 3 positive ions (Na+) are pumped out of the cell (towards ECF) for every 2 positive ions (K+) pumped into the cell (towards ICF). This means that there is more positive charges leaving the cell than entering it. As a result, positive charge builds up outside the cell compared to inside the cell. The difference in charge between the outside and inside of the cell allows nerve cells to generate electrical impulses which lead to nerve impulses.

The Na+/K+ pump illustrates "active transport" since it moves Na+ and K+ against their concentration gradients. That is because there is already a high concentration of Na+ outside the cell and a high concentration of K+ inside the cell. In order to move the ions (Na+ and K+) againts their gradients, energy is required. This energy is supplied by ATP (adenosine triphosphate). An ATP molecule floating inside the cell, binds to the pump transferring some energy to it. As the energy is used, the ATP falls off and having lost its energy it is converted into ADP (adenosine diphosphate).

Notice in the diagram that there are 3 binding sites for the 3 Na+ ions on the inner surface of the pump and 2 binding sites for the 2 K+ ions on the outer surface of the pump. The shape of these binding sites ensures that only Na+ and K+ can bind and be transported.

Page 23

Since the pump requires an ATP every time it works, ATP must be constantly supplied to the cell. ATP is created during the processes called "cellular respiration" which occur inside the cell (in the ICF). Part of cellular respiration happens in the cytoplasm and part happens in the mitochondrion. Since these organelles are part of the nerve cell, as the ATP is made, it floats up to the pump and provides its energy. More ATP is made and the pump continues to do its job. If something interferes with the production of ATP, the pump will stop working and the nerve cell will also stop working. This can cause serious loss of nerve function and even death. Since cellular respiration requires oxygen, if you were to stop breathing, ATP could not be produced and you would die. Of course ATP is needed by many processes in the body so it is not only the Na+/K+ pump that would stop.

There are poisons or toxins that also interfere with the pump. One is called "oubain", an arrow poison. Oubain works by attaching to the pump and blocking its action. A branch of science called "pharmacology" deals with how drugs affect the body. Pharmacologists have designed drugs that, if administered fast enough, can travel to the cells and attach to the oubain removing it from the Na+/K+ pumps allowing them to function properly.

This is just one example of active transport in which ATP is used to pump materials against a concentration gradient. Your body stores glucose (a sugar) in your liver and muscles. In order to stockpile the glucose for when you might need it, the glucose must be pumped into cells building up a high concentration there. Even though it uses up ATP to do this, every glucose molecule can be broken down by cellular respiration to produce 38 ATP's! So it's a worthwhile process.

Female Urological System:

In both sexes, the bladder is a hollow organ located within the pelvis (unless it is full and distended.)  It consists primarily of smooth muscle protected on the interior surface by a two flexible stretchy layers, the submucous, and the mucous coats - which serve to protect the muscle layer from the acids, salts, and toxins in urine. 

The outside of the bladder is encased in and supported by a layer of connective tissue called fascia.

Page 24

The ureters are thin, stretchy tubes which lead from the bladder to the kidneys, and the urethra is a much shorter tube which leads from the bottom of the bladder, to the external opening known as the urethral orifice.  The urethra contains mucous glands which secrete protective mucous into the urethral canal.  In females, this tube is fairly short, about 4 cm. (or slightly less than 2 inches) long.

The urethral orifice (external opening) is located anteriorly above the vaginal opening, but can vary a little from person to person, based on anatomical differences.  The urethra in females is designed to carry only urine and mucous secretions.  At the point where the bladder empties into the urethra (the bladder neck) there is an internal urethral sphincter, or a ring of muscular tissue.

The process of voiding is quite complicated, even in normal, non-dysfunctional circumstances.  The important detrusor muscle, the perineal muscles (bottom of the pelvic floor), the muscles of the abdominal wall, the muscles of the urethral sphincters, and even the diaphragm are involved in the process of building pressure within the bladder and then relaxing once the nerves have succeeded in transmitting the urge to void.

Page 25

IV. PATHOPHYSIOLOGY

Legend:

Disease Process

Signs and Symptoms

PREDISPOSING FACTORS:

Age (High Risk)(74 years old) Gender: female

PR ECIPITATING FACTORS:

Excessive vomiting x 5 days

Excessive excretion of sodium and potassium within the serum

Low serum sodium and serum potassium levels

Serum sodium and potassium levels are insufficient in the brain.

Further decrease of serum sodium and serum

Poor intake x 3days

Weakness

PeripheralBody malaise

Muscle cramps

Alteration in the integrity of neuronal cell

Alteration in the integrity of neuronal cell

CNS

lethargic

Memory changes

drowsiness

Increase frequency and

Intensity of the discharges reaches the

Page 26

Neuronal firing spreads to the adjacent neurons

Unconsciousness

CNS depression

Uncontrolled general involuntary movement x 30

seconds

Slowing of neuronal firing ion the cortex by the anterior

Exhaustion of the epileptogenic

Involuntary movements

Page 27

PREDISPOSING FACTORS:

Age (High Risk)(74 years old) Gender: femaleHabitual intake of carbonated drinksImproper perineal flushingLimited water

PR ECIPITATING FACTORS:

Changes in voiding habits

Waste products (urine) are not excreted

Accumulation of waste

Increase BUN of 25.5

Increase creatinine of

2.94Invasion of

Occurrence of infection in the bladder

Ascending infection occurs

Epigastric pain

fever

Hematuria

Pus in the urine

Page 28

VIII. DISCHARGE PLANNING/ HEALTH TEACHINGS

M – edicationa.) Electrolyte imbalance

Most physicians don’t require maintenance when there is electrolyte imbalance because it might overcorrect the underlying disease bringing it to a more severe complications.

b.) Seizure Never stop taking any seizure medicines without talking with your

doctor. (People with uncontrolled seizures should NOT drive.) Do not stop taking your seizure drugs just because your seizures have stopped.

Do not skip a dose. Get your refills a week before you run out. Keep seizure medicines in a safe place, away from children. Store medicines in a dry place, in the bottle that they came in.

Throw away all old bottles. Take medications daily as prescribed to keep the blood-drug level

constant to preventseizures. Medication should never be discontinued by the patient, even when there is noseizure activity.

Keep a “drug and seizure chart,” noting when medications are taken and any seizure

If you miss a dose:

Take it as soon as you remember. If it is within a few hours of your next dose, skip the dose that you

forgot and take your next dose. It is OK to take it a little early. After that, go back to the schedule. Do not take a double dose.

If you miss more than one dose, talk with your doctor or nurse. Since mistakes are unavoidable and you may miss several doses at some point, it may be useful to have this discussion ahead of time rather than when it happens.

c.) Urinary Tract Infection Urinary tract infections are treated with antibiotics. Take your medication exactly as directed. Don’t skip doses.

Continue taking your antibiotics as directed until they are all gone—even if you start to feel better. This will prevent the UTI from coming back.

Take the entire course of any prescribed medications. After a patient’s temperature returns to normal, medication must be continued according to the doctor’s instructions, otherwise the infection may recur. Relapses can be far more serious than the first attack.

Page 29

E – xercisea.) Electrolyte imbalance

Client may do such activities like the usual activities of daily living. Report if there are any feelings of shortness of breath, headache

and or changes in the level of consciousness.b.) Seizure

The patient may continue the activity she used to be doing specifically selling goods along the seashore but with precaution.

Avoid over exhaustion and stress because it initiates and triggers the occurrence of seizure.

c.) Urinary Tract Infection An ample exercise may be done and instruct client to allow urinates

when she feels to urinate because depriving in doing so may encourage the multiplication of bacteria.

If the exercise of the client interferes with the usual or habitual urinary pattern of the client, the activity may be reduced, controlled or completely eliminated.

T – reatmenta.) Electrolyte imbalance

During excessive sweating, client may drink fluids rich in electrolytes to replace the loss fluid and electrolytes.

b.) Seizure In the occurrence of episodic seizures, the client may be given

anticonvulsants parenterally. If there is maintenance mentioned, it should be taken regularly

even in the absence of seizure activities.c.) Urinary Tract Infection

Cranberry juice, plums, or apricot juice can help by creating a more acid environment in which bacteria cannot grow as easily. NOTE: This is not a substitute for treatment with antibiotics.

H – ealth Teachinga.) Electrolyte imbalance

Regularly drink fluid with electrolytes whenever undergoing strenuous activities to avoid electrolyte imbalances.

b.) Seizure

You should get plenty of sleep and stick to as regular of a schedule as possible. Try to avoid too much stress.

Keep your bathroom and bedroom doors unlocked. Keep these doors from being blocked.

Take showers only. Do not take baths because of the risk of drowning during a seizure.

Replace all glass doors either with safety glass or plastic. Do not take your seizure drugs when you drink alcohol. Using alcohol or illegal drugs will change the way your seizure

medicines work in your body. If you drink alcohol, drink small amounts, and do not drink too often. DO NOT restrain (try to hold down) the person.

Page 30

DO NOT place anything between the person's teeth during a seizure (including your fingers).

DO NOT move the person unless they are in danger or near something hazardous.

DO NOT try to make the person stop convulsing. They have no control over the seizure and are not aware of what is happening at the time.

DO NOT give the person anything by mouth until the convulsions have stopped and the person is fully awake and alert.

DO NOT start CPR unless the seizure has clearly stopped and the person is not breathing or has no pulse.

If possible, assist patient to floor Protect head Loosen any constrictive clothing Move furniture – to prevent injury If in bed, raise side rails and remove pillows Never attempt to open jaws that are clenched shut If at all possible, place patient on side with head flexed so that the

tongue will fall forward Keep patient on side after seizure to prevent aspiration. Assure

patient airway – Possible short period apnea Apneic and confused state may follow generalized seizure – reorient

AFTER THE SEIZURE Keep the patient on one side to prevent aspiration. Make sure the airway

is patent

There is usually a period of confusion after a grand mal seizure A short apneic period may occur during or immediately after a

generalized seizure The patient, on awakening, should be reoriented to the environment If the patient experiences severe excitement after a seizure, use

calm persuasion and gentle restraint

c.) Urinary Tract Infection Hot baths can alleviate discomfort. Rest helps conserve energy for healing the infection. Drink plenty of liquids to keep the urinary tract flushed.

Concentrated, stagnant urine can allow bacteria to multiply. Always urinate when you feel the need. Overfilling the bladder can

cause irritation and microscopic tears in the bladder wall,which lead to infection.

Wash your hands before you urinate, as well as after. To avoid spreading bacteria, wipe from front to back after urination or bowel movements.

Urinate before and after sexual intercourse to flush bacteria away. Keeping the vaginal area dry will make it harder for bacteria to

grow. Wearing cotton underwear and avoid confining clothes can help keep the area dry. Providepri vacy for patient

Page 31

O – utpatient

When a seizure starts, family members or caregivers should try to keep you from falling. They should help you to the ground, in a safe area. They should clear the area of furniture or other sharp objects.

Cushion your head. Loosen tight clothing, especially around your neck. Turn you on your side. If vomiting occurs, turning you on your side

helps make sure you do not inhale vomit into your lungs. Stay with you until you recover, or professional medical help

arrives. Meanwhile, caregivers should monitor your pulse and rate of breathing (vital signs).

Get plenty of rest. Adequate rest is important to maintain progress

toward full recovery and to avoid relapse.

Call your doctor if you have:

Seizures that have been happening more often. Side effects from medications. Unusual behavior that was not present before. Weakness, problems with seeing, or balance problems that are

new. Keep all of follow-up appointments. Even though the patient feels

better, his lungs may still be infected. It’s important to have the

doctor monitor his progress.

D – ieta.) Electrolyte imbalance

Instruct client and/or significant others to frequently eat fruits nad vegetables containing sodium and potassium. A banana per meal may be helpful.

Replace fluid losses with electrolytes.b.) Seizure

The client may eat anything but in small amounts so that in the occurrence of seizure, it will be easily removed from the mouth to avoid obstruction of airways.

c.) Urinary Tract Infection Avoid caffeine (common in coffee, tea, and cola drinks), because it

irritates the bladder thus, encourage invasion of microorganism.

Page 32

IX. RELATED LEARNING EXPERIENCE

In our duty experience in Reverse Isolation Ward at Northern Mindanao Medical

Center (NMMC) we’ve encounter so many kind of things, which are often unexpected

and were full of lessons that must be inculcated in our hearts and minds like giving

medication to our patients specially via IVTT it was the first time for us, having a

bedside care, regulating the IVF every 1 hour, monitoring the patients vital signs, and

other relevant procedures that were done during the whole period of the 2nd rotation.

In our first duty in Reverse Isolation ward we committed so many kinds of errors

and we are all guilty for that but for that errors we’ve learn a lot and gradually we are

learning to improve our work in order to follow the mission of the nursing profession,

which is to give care to the patient. We’ve learn that not at all the times we will be

perfect on what we will be doing, we’ve learn that the patients admitted in the Reverse

Isolation are so sensitive and immunocomprised thus, they need more attention and we

need to be more careful in the provision of the care they needed. Ideally, I must have

refer the patient to registered advisers so that there will be a comprehensive advise to

the client and to the significant others as well but because due to the institutional

policies and time constraints, I failed to do it as well and have done modification through

giving here ample information.

In our skills, we’ve improve and we’ve got a new knowledge for what we are

doing like calculating the drops of the IVF either it is micro drops or macro drops that is

being administered in our patients and also monitoring the intake and output to our

patients, monitoring patient during blood transfusion and doing correctly administration

of medication via IVTT.

In making this case study, it strengthens me and really proves that in everything

that we do, learning is always there for us, waiting to be grasped and well-digested. I

know for the fact that this study requires a lot of sacrifices and fortunately I survived all

the things we have done. My great felicitation and commemoration to my Clinical

Instructor, Ryan Manuel Nasol, RN, who gave us the motivation to be serious in the

clinical area in order to promote the proper and appropriate care towards our patient.

We extend our thanks to my PCI, Ms. Judee Mae Saree Cabanag, who taught and gave

us the inspiration to do things well. She just not do things to comply with the

requirements but has done it with passion and whole heartedly.

And last we learn the real value of being a student nurse that we should control

our temper, our emotion while we are on our patients side, we have to adjust the in

environment where we belong it is because we didn’t know the feelings of the watchers

and more importantly our patient. Patient must not be only a patient but he/she should

be “my/our” patient. Thank you…………

Page 33

X. SOURCES:

WEB:

http://en.wikipedia.org/wiki/Water-electrolyte_imbalance

http://www.breastcancer.org/treatment/side_effects/electrolyte.jsp

http://www.medicinenet.com/electrolytes/discussion-382.htm

http://www.biologymad.com/NervousSystem/nerveimpulses.htm

http://www.uoregon.edu/~uoshc/patientinfo/uti.htm

http://www.scribd.com/doc/23193426/SEIZURES

http://www.epilepsy.com/epilepsy/types_seizures

BOOKS:

Nurse’s Pocket Guide 11th edition (Diagnoses, Prioritized interventions, and

Rationales)

By: Marilyn E. Doenges, Mary Frances Moorhouse and Alice C. Murr

Nursing 2003 Drug Handbook 23rd edition

By: Springhouse Lippincott Williams and Wilkins

Medical-Surgical Nursing (Clinical Management for Positive Outcomes) 8th edition

By: Joyce Black and Jane Hokanson Hawks

Page 34