CASE STUDY OF HYPOKALEMIA PERIODIC PARALYSIS

PRESENTED BY:
Polvelyn Mae M. Breganza Jisselle Villanueva

Kevin Panganiban

INTRODUCTION:

Hypokalemic periodic paralysis is a condition in which a

person has episodes of muscle weakness and sometimes severe paralysis.

The condition is caused by a defect in the CNA4A gene. It

is congenital, which means it is present from birth. In most cases, it is passed down through families (inherited) as an autosomal dominant disorder that means only one parent needs to pass the gene related to this condition on to person in order to be affected.

Attacks that do not begin until adulthood are rare in

people with hypokalemic periodic paralysis and are usually caused by other disorders.
Unlike other forms of periodic paralysis, persons with
congenital hypokalemic periodic paralysis have normal thyroid function and very low blood levels of potassium during episodes of weakness. This results from potassium moving from the blood into muscle cells in an abnormal way.

Risks include: Having other family members with periodic paralysis. Slightly higher in Asian men who also have thyroid disorders. Disorders that cause intermittent episodes of paralysis as their primary effect are uncommon. Hypokalemic periodic paralysis occurs in approximately

1 out of 100,000 people.

Symptoms:

Some people have attacks every day, while others have them
once a year. Episodes of muscle weakness usually last between a few hours and a day. The weakness or paralysis: Most commonly is located at the shoulders and hips May also affect the arms, legs, muscles of the eyes, and muscles that helps to breathe and swallow

Occurs intermittently
Most commonly occurs on awakening

 Most commonly occurs after sleep or rest Is rare during exercise, but may be triggered by rest after exercise May be triggered by high-carbohydrate, high-salt meals or alcohol consumption Usually lasts 3 - 24 hours Other symptoms may include:

Eyelid myotonia (a condition in which after opening and closing the

eyes, the patient cannot open them for a short time)

Exams and Test

Between attacks, a physical examination shows nothing abnormal. Before an attack, there may be leg stiffness or heaviness in the legs. During an attack of muscle weakness, the blood potassium level is low. This confirms the diagnosis. There is no decrease in total body

potassium, and blood potassium levels are normal between attacks.

During an attack, muscle reflexes may be decreased or absent, and muscles go limp rather than staying stiff. The muscle groups near the body, such as shoulders and hips, are involved more often than the arms and legs.

An ECG or heart tracing may be abnormal during attacks. An EMG or muscle tracing is usually normal between attacks and

abnormal during attacks. A muscle biopsy may show abnormalities.

PATIENTS PROFILE

Name: Patient X Age: 28 years old Address: 445 Torquiza Magcase Ville, San Pablo, City Birthday: February 18, 1985 Sex: Female Religion: Muslim

Chief Complaint: lower extremities weakness Diagnosis: T/C Hypokalemia Periodic Paralysis Attending Physician: Dr. Joel Romero Dr. Joseph Francis Gloria Date and Time of Admission:

November 17, 2013 @ 9:03 PM

Personal and Social History: Patient is negative in Smoking

Patient is negative in Alcohol

History of Present Illness:

Patient was brought for consult due to lower extremities weakness noted and
weak duration progressive associated with numbness. No symptoms like vomiting, fever, trauma, consult at 9 AM.

Physical Assessment
BP: 120/70 Temp: 36 C PR: 62 bpm RR: 20 bpm

General: Weakness Cardiac: regular rhythm and normal rate Gastrointestinal: (+) masses (-) organomegaly

LABORATORY EXAMINATION

Date: November 18, 2013

URINALYSIS
Physical Color Normal Varying degrees of yellow Clear Result Light yellow Chemical Protein Normal Negative Result Negative

Transparency

Slightly turbid Acidic

Sugar

Negative

Positive

Reaction

Usually acidic 1.000- 1.030

Specific Gravity

1.010

Date: November 18, 2013

MICROSOPIC
Test Mucous Threads Bacteria Result few few RBC Puss cells Result 0-2/hpf 1-3/hpf

Epithelial Cells Urates

few few

Hematology
Date: November 17, 2013 Test Reference value (SI Unit) 2.15-7.16 M-59-104 F-45-84 Result Test Reference value (SI Unit) Sodium Potassium 135-145 3.6-5.0 Result

GENERAL BUN Creatinine 1.51 mmol/L 44.20 mmol/L

ELECTROLYTES 126.0 mmol/L 4.6 mmol/L 2.5mmol/L

Calcium

2.15-2.55

Parameters Blood Count

Normal Values

Results

Units

White Blood Cells

Red Blood Cells Hemoglobin Hematocrit Platelet

5-10
M: 4.5-5.0 F: 4.0-4.5 M: 14.0-18.0 F: 12.0-16.0 M: 40-54 F: 37-47 150-400 40-75 20-45

15.8
4.55 13.1 42 420 78.9 12

x 10^9/L
x10^12/L g/L %

Differential Count
Neutrophils Lymphocytes % %

Monocytes

2-6

9.1

PATHOPHYSIOLOGY

Cellular level transport The amount of K in the ECF is so small that changes in the K level can lead to major alterations in membrane excitability in muscle and neural cells, making them less responsive to stimuli. Rapid changes in ECF K cannot be compensated for quickly & can result in profound changes in body function. K moves from the ECF to the ICF (the total body level of K remains unchanged) leading to abnormal distribution of K.

If this decrease is not corrected very quickly, death can occur from cardiac & respiratory arrest.

DRUG STUDY

Drug Name

Classification

Pharmacologic Action of Drug

-Inhibits prostaglandin synthesis, producing peripherally mediated analgesia -Also has antipyretic and antiinflammatory properties. -Therapeutic effect: Decreased pain

Indication and Contraindication

Adverse effect of the Drug

Nursing Responsibilities

Patients teaching

GENERIC NAME: Ketorolac BRAND NAME: Toradol DOSAGE: 1 amp I.V

Non steroidal antiinflammatory agents

Short term management of pain CI: Hypersensitivity - Cross-sensitivity with other NSAIDs may existPre- or perioperative use - Known alcohol intolerance Use cautiously in: 1) History of GI bleeding 2) Renal impairment (dosage reduction may be required) 3)Cardiovascular disease

- CNS: euphoria - RESP: dyspnea - CV: edema - GI: GI Bleeding - GU: renal toxicity

- History of renal impairment, impaired hearing, allegies, hepatic, lactation and pregnacy - Patients who have asthma, aspirininduced allergy, and nasal polyps are at increased risk for developing hypersensitivity reactions. Assess for rhinitis, asthma, and urticaria. - Assess pain (note type, location, and intensity) prior to and 1-2 hr following administration. - Caution patient to avoid concurrent use of alcohol, aspirin, NSAIDs, acetaminophen, or other OTC medications without consulting health care professional.

- Teach patient to recognize and immediately report signs and symptoms of GI bleeding. - Explain that serious GI toxicity, even without any symptoms, can occur. - Advise patient to report persistent or worsening pain. - Explain that drug is intended only for short-term use.

Drug Name

Classification

Pharmacologic Action of Drug Chemical Effect: Inhibits proton pump and binds to hydrogen or potassium adenoxine triphosphate, located at secretory surface of gastric parietal cells. Therapeutic Effect: Decreases gastric acid formation

Indication and Contraindication

- Short-term therapy for active duodenal ulcer. - Maintenance of healed duodenal ulcers. - Helicobacter pylori eradication to reduce riski of duodenal ulcer recurrence. - NSAID gastric ulcer. CI: Contraindicated in patients with known hypersensitivity to any component of the formulation of PREVACID.

Adverse effect of the Drug - CNS:, vertigo, insomnia, anxiety, dream abnormalities -Dermatologic:, urticaria, pruritus, alopecia, acne.

Nursing Responsibilities - Administer before

meals. Caution patient to swallow capsules whole, not to open, chew, or crush. If patient has difficulty swallowing, open capsule and sprinkle granules on apple sauce, - Ensure, yogurt, cottage cheese, or strained pears; for. - WARNING: Ar range for further evaluation of patient after 4 wk of therapy for acute gastroreflux d isorders if symptomatic improvement does not rule out gastric cancer, which did occur in preclinical studies.

Patients Teaching

GENERIC NAME: Lansoprazole BRAND NAME: Prevacid Dosage: 30mg IV OD

Proton pump inhibitors

- Take the drug before

meals. Swallow the capsules wholedo not chew, open, or crush. If you are unable to swallow capsule, open and sprinkle granules on apple sauce, or use granules, which can be added to 30 mL water, stirred, and drunk immediately. - Arrange to have regular medical follow-up care while you are taking this drug. - You may experience these side effects: Dizziness (avoid driving a car or performing hazardous tasks); headache (medications may be available to help); nausea, vomiting, diarrhea (proper nutrition is important, consult with your dietitian to maintain nutrition); symptoms of URI, cough (reversible; do not self-medicate, consult with your health care provider if this becomes uncomfortable).

- GI: Diarrhea, abdominal pain,, constipation,

-Respiratory: URI symptoms, epistaxis

Drug Name

Classification

Pharmacologic Action of Drug

Indication and Contraindication

Adverse effect of the Drug

Nursing Responsibilities

Patients Teaching

Lactulose Brand name: Dulphalac Dosage: 1tbsp.BID

Laxative

Chemical Effect: Produces osmotic effect in colon. Resulting distention promotes peristalsis. Decreases blood ammonia buildup that causes hepatic encephalopathy, probably as result of bacterial degradation, which lowes Ph of colon contents therapeutic effect: Therapeutic Effect: Relieves constipation decreases blood ammonia concentration.

- Constipation -To prevent and treat haptic encephalopathy, including hepatic precoma and coma in patient with severe hepatic disease. -To induce bowel evacuation in geriatric patient with colonic retention of barium and severe constipation after a barium meal examination. - To restore bowel movements after hemorrhoidectomy

CI: Contraindicated in patients with: galactosaemia gastro-intestinal obstruction Hypersensitivity to the active substance or any of the ingredients.

-Precaution: Lactulose intolerance diabetes. -Adverse reaction: Abdominal discomfort associated with flatulence and intestinal cramps. Nause, vomiting diarrhea on prolonged use.

-To minimize sweet taste, dilute with food. - Monitor mental status and potassium level when giving to patient with hepatic encephalopa thy

- Inform patient about adverse reactions and tell him to notify prescriber if reactions become bothersome or if diarrhea . - Instruct patient not to take other laxatives during lactulose therapy.

Drug Name

Classification

Pharmacologic Action of Drug The Patient was given dexamethasone 1.8 mg through IV every 6 hours to decreases inflammation, mainly by stabilizing leukocyte lysosomal membranes; suppresses immune response; stimulates bone marrow ; and influences protein, fat and carbohydrate metabolism.

Indication and Contraindication

Specific -Adjunctive treatment in bacterial meningitis, General -Cerebral edema -Allergic and inflammatory conditions -Shock -Tuberculosis meningitis

Adverse effect of the Drug

Nursing Responsibilities
- Determine whether patient is sensitive to other corticosteriods. - Most adverse reaction to corticosteroids are dose or durationdependent. - For better result and less toxicity, give once daily dose in morning. - Give oral dose with food when possible. Patient may need drugs to prevent irritation - Give I.M injection deeply into gluteal muscle .Rotate injection sites to prevent muscle atrophy. Avoid subcutaneous

Patients Teaching

Generic Name: Dexamethasone Brand Name: Decadron

Antiinflammato ry Glucocortic oid

Dosage: 1.8 mg IV q6

CI: Depending
on the indication and the general condition, peptic ulcers, osteoporosis, psychoses, infectious diseases (e.g. herpes simplex, keratitis), diabetes and hypertension can be considered contraindications

-CNS: insomnia, pschotic behavior , pseudotumor, cerebri, depression. - CV: hypertension, arrythmias, thromboembolis m - EENT: cataracts, glaucoma. - GI: peptic ulceration, pancreatitis -GU: increase urine glucose, and calcium levels - Metabolic: hypokalemia, hyperglycemia -Musculoskeletal: muscle weakness - Skin: delayed wound healing

- Tell patient not to stop drug abruptly or without prescribers consent. - Instruct patient to take drug with food or milk - Teach patient signs and symptoms of adrenalin insufficiency; fatigue, muscle weakness, join pain, fever,anorexia - Warn patient onlong term therapy about cushingoideffects( moon face, buffalo hump) - Warn patient about easy bruising.

Drug Name

Classification

Pharmacologic Action of Drug

Indication and Contra -indication -Treatment of partial seizures with and without secondary generalizations in clients 12 years and older. - Adjunct to treat partial seizures in children 3 to 12 years of age. - In adults, management of post of herpetic neuralgia or in the area affected by herpes zoster after treating the disease. CI: Patients who are allergic to gabapentin or other ingredients should not take gabapentin.

Adverse effect of the Drug -Most common dizziness Somnolence Peripheral Edema Ataxia Nystagmus Tremors

Nursing Responsibilities -Do not allow 12 hours to pass between the 2 doses using the 3 times per day daily regimen. -If discontinued or alternate anticonvulsant added to regimen, dose gradually over 1 week period. -The 1st dose on day one maybe taken at bedtime to minimize somnolence, dizziness, fatigue, and ataxia.

Patients Teaching

Generic Name: Gabapentin Brand name: Neurontin

Anticonvulsant

Anticonvulsant and analgesic mechanisms are not known. Is related to chemically GABA but does not interact with GABA receptors Pharmacokinetics Food has no effect on the rate and extent of absorption; however, as the dose increases, the bioavailability decreases.

-Maybe taken with or without food. Do not chew or crush. -Do not take antacids at anytime while taking gabapentin. -If having trouble swallowing , may open capsule and mix with juice. - Report any increase in seizures, visual changes, unusual bruising, or bleeding, emotional availability, Restlessness or hyperactivity. -Report worsening depressions signs and symptoms.

Nursing Care Plan

Assessment
Subjective: Hindi ko maigalaw ang mga binti ko at paa as verbalized by the patient Objective: - slowed movement - difficulty in turning - inability to ambulate - irritability

Diagnosis
Impaired mobility related to hypokalemia periodic paralysis as evidenced by lower extremities muscle weakness

Planning
Short term: -Verbalize understading of situation or risk factors and individual therapeutic regimen and safety measures - Demonstrate techniques/ behaviors that will enable safe repositioning Long term: - The patient will be able to maintain position of function and skin integrity of the patient

Implementation
- Determine diagnosis that contribute to immobility - Use suggested functional level classification scale - Assess skin intergrity. Check for signs of redness and tissue ischemia like sacrum, hips, ankle and toes - Monitor input and output record and nutritional pattern

Rationale
- To identify causative/contributing factors - To determine degree of immobility in relation - Regular examination of the skin will allow for prevention or early recognition and treatment of pressure sores. - Pressure sores develop more quickly in patients with a nutritional deficit. Proper nutrition also provides needed energy for participating in an exercise or rehabilitative program. - Feelings of frustration and powerlessness may impede attainment of goals

Evaluation
Short term: -Patient shall have verbalized understanding of situation or risk factors and individual therapeutic regimen and safety measures. -Patient shall have demonstrated techniques/ behaviors that will enable safe repositioning. Long term: - Patient shall have maintained position of function and the integrity of the patient.

- Assess emotional/ behavioral responses to problems of immobility

Assessment

Diagnosis

Planning

Implementation
- Encourage and facilitate early ambulation and ADls when possible - Facilitate transfer training by teaching or using appropriate techniques or devices when transferring patients to bed, chair or stretcher. - Provide positive reinforcement during activity.

Rationale
- The sooner the patient becomes mobile the less chance that debilitation will occur. - This allows the patient to see or use information immediately, thus enhancing retention. - Patient reluctant to move or initiate new activity due to a fear of falling. A positive approach allows the learner to feel good about learning accomplishments. - This promote a safe environment - Turning patients optimizes circulation to all tissues and relieves pressure. - Maintaining proper alignment of extremities prevents contracture such as footdrop and/or excessive plantar flexion or tightness.

Evaluation

- Keep side rails up and bed in low position - Turn and position the patient every 2 hours or as needed.

- Maintain limbs in functional alignment (e.g with pillows). Support feet in dorsiflexed position.

Assessment

Diagnosis

Planning

Implementation
- Perform passive or active assistive ROM exercise to the lower extremities - Teach energy-saving techniques. - Assist the patient in accepting limitations. Emphasize abilites

Rationale
- Exercise promotes increased venous return, prevent stiffness and maintain muscle strength and endurance . - These optimize the patients limited reserves. - Quality of life is influenced by a variety of factors that extend beyond only physical function.

Evaluation

THE END