Question

Mrs. Malone, age 83, lives in an apartment with her cat. She has hypertension, hyperlipidemia, and chronic left-sided heart failure, which are managed with the diuretic furosemide, KCl, several other medications, and dietary Na+ restriction. Mrs. Malone volunteers at a nearby elementary school, where earlier in the week several students were sent home sick after vomiting. Mrs. Malone developed vomiting and diarrhea. Although the vomiting stopped, the diarrhea persisted. She drank more water than usual, ate rice and dry toast, and stopped taking her KCl to avoid upsetting her stomach. After 2 days of diarrhea, Mrs. Malone became lightheaded when she got out of bed and had difficulty standing up after using the toilet because her legs were so weak. She telephoned her nurse practitioner (NP), who advised her to drink some broth with salt in it as well as some orange juice. Mrs. Malone needed considerable teaching regarding the importance of Na+ intake to replace her increased Na+ output in diarrhea, but eventually she did agree to try the rehydration schedule her NP advised. After checking back by telephone later in the day and learning that Mrs. Malone was no longer lightheaded but still had “weak legs,” the NP advised Mrs. Malone to restart her KCl, continue drinking orange juice, and make an appointment to have her plasma K+ concentration checked.

Case Analysis

Mrs. Malone had chronic heart failure. Her reduced cardiac output and other mechanisms of heart failure increased activation of her renin–angiotensin–aldosterone system, causing more renal retention of Na+ and water and creating chronic ECV excess. To counteract her decreased Na+ and water output, she used the prescribed furosemide, a K+-wasting diuretic that increases Na+ and water output. Because this diuretic also increases K+ output, Mrs. Malone also took KCl to increase her K+ intake. She adhered to her Na+-restricted diet because she had learned that Na+ kept water in her body and “made her ankles swell more” (her understanding of ECV excess). When Mrs. Malone developed increased Na+, water, and K+ output from vomiting and diarrhea, her intake did not increase appropriately, so she developed ECV deficit (lightheaded upon standing) and hypokalemia (bilateral quadriceps weakness). Learning about the vomiting and diarrhea, her NP asked appropriate assessment questions over the telephone to elicit these symptoms and planned appropriate fluid and electrolyte replacement therapy. The NP taught Mrs. Malone the reason for the temporarily increased Na+ intake, even though she usually followed a Na+-restricted diet, and asked Mrs. Malone to make a follow-up appointment.

Question 1.

Why did the NP instruct Mrs. Malone to drink orange juice?

Question 2.

Why is it important that Mrs. Malone drink orange juice and resume taking her oral KCl right away?

Answer 1

Answer: The NP instructor Mrs. Malone to drink orange juice because she was suffering from diarrhea. In this case there is imbalance in the ions occurs. The diarrhea causes weakness and fatigue too. Hence orange juice is beneficial in the case of diarrhea as it is rich in vitamin A, C. It is a good source of fibre, contains potassium, thiamine, copper, magnesium as well as flavonoids. This will balance the electrolyte in the patient and provides energy.

For the drug absorption, Fluid intake is essential. The potassium chloride absorption requires more fluid and to balance the electrolyte. Hence with the fluid intake the KCl will lead to more absorption and helps in balancing the electrolyte loss.