Answer

Nguyen’s Elimination

Laboratory results indicate that Nguyen’s sodium level was 136mEq/L (normal range: 135 – 145mEq/L). His sodium level was within the normal range. However, potassium concentration of 3.0mEq/L (normal range: 3.5 – 5.0mEq/L) was below the normal range. Nguyen should be asked about his dietary choices and practices since it may contribute to decreased potassium levels. In addition, he should be assessed for diarrhea or a history of diarrhea. Other signs and symptoms of hypokalemia that need to be assessed include dysrhythmias, fatigue, confusion, lethargy, nausea and vomiting, thirst, flaccid paralysis, and/or constipation (Huether & McCance, 2017). The patient’s chloride level 96 mEq/L (normal value: 103mEq/L) appears low (Huether & McCance, 2017). However, the normal chloride range is 95 to 105mmol/L (Farinde, 2019). The normal level of bicarbonate is nearly 24mEq/L; therefore, Nguyen’s bicarbonate level (24mEq/L) is equal to the normal value (Huether & McCance, 2017). Besides, the patient’s blood urea nitrogen value of 24mg/dL was within the normal range (8 to 21 mg/dL) (Farinde, 2019). Lastly, but not least, Nguyen’s creatinine value of 0.8mg/dL was at the lowest limit of the normal range (0.8 to 1.3 mg/dL) (Farinde, 2019).

Metformin is the drug of choice for the management of type 2 diabetes mellitus. Adverse events caused by metformin such as nausea, diarrhea, and decreased appetite may have increased loss of potassium in loose stool or decreased intake of potassium in the diet (Burchum & Rosenthal, 2016). Low potassium levels may also be a result of increased urine filtration rate associated with the use of diuretics (Huether & McCance, 2017). Hydrochlorothiazide is a commonly used thiazide that increases renal excretion of sodium, potassium, and chloride. Hydrochlorothiazide can cause adverse events such as hyponatremia, dehydration, hypochloremia, hypokalaemia, hyperuricemia, hyperglycemia, increased excretion of magnesium, and elevated levels of triglycerides, total cholesterol, and low-density lipoproteins (Burchum & Rosenthal, 2016). Hydrochlorothiazide action on the distal convoluted tubules contributes to the loss of potassium in urine (Herman & Bashir, 2020). Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that prevents the formation of angiotensin II, thereby preventing angiotensin II-mediated vasoconstriction as well as aldosterone-mediated volume expansion. Principal adverse effects associated with the use of ACE inhibitors include angioedema, first-dose hypotension, persistent cough, hyperkalemia. It is unlikely that lisinopril has contributed to the lowering of serum potassium levels (Burchum & Rosenthal, 2016).

Nguyen’s education plan includes advice to take adequate quantities of fruits and vegetables as well as to stop alcohol use (if relevant) to improve serum potassium concentrations (Huether & McCance, 2017). The patient should also be advised to adhere to the intake of hydrochlorothiazide in the morning to avoid nocturia (Burchum & Rosenthal, 2016). Moreover, the potential adverse effects of each prescribed drug should be included in the patient education plan. For example, the patient should be informed and educated that the use of hydrochlorothiazide is associated with various adverse effects such as leukopenia, weakness, sialadenitis, jaundice, orthostatic hypotension, pancreatitis, gastric irritation, aplastic anemia, nausea or vomiting, agranulocytosis, hemolytic anemia, thrombocytopenia, abdominal cramping, impotence, headache, and fever. Lastly, he should be informed that the medication can cause photosensitivity, urticaria, pulmonary edema, muscle spasm, vertigo, and restlessness (Herman & Bashir, 2020). 

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