Eating Disorder-Electrolyte Imbalances UNFOLDING Reasoning Case Study (Mandy White, 16 yea, Exams of Nursing

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UNFOLDING

Reasoning

Case Study

Eating Disorder/Electrolyte Imbalances

UNFOLDING Reasoning Case Study

(Mandy White, 16 years old- Primary Concept

Fluid and Electrolyte Balance)

Eating Disorder/Electrolyte Imbalances

Mandy White, 16 years old

Primary Concept Fluid and Electrolyte Balance Interrelated Concepts (In order of emphasis)

1. Acid-base

2. Nutrition

3. Perfusion

4. Coping

5. Mood and Affect

6. Clinical Judgment

7. Communication

8. Collaboration

9. Patient education

UNFOLDING Reasoning

Case Study

Eating Disorder/Electrolyte Imbalances History of Present Problem: Mandy White is a 16-year-old adolescent who has struggled with anorexia nervosa since the age of 11. She admits to drinking several large glasses of water daily. Mandy has also been recently engaging in self injurious behavior (SIB) of cutting both forearms and thighs with broken glass, causing numerous lacerations and scars. Mandy presents to the emergency department (ED) with increasing weakness, lightheadedness and a near syncopal episode this evening. She admits to inducing vomiting after meals the past three weeks. She is 5’ 5” and weighs 83 lbs/37.7 kg (BMI 13.8). Mandy is reluctantly brought in by her mother and does not want to be treated. As the primary nurse responsible for the care of Mandy, you overhear her say to her mother, “I hate everything about me! I am so tired of living, I wish I were dead!”

Personal/Social History: Mandy was sexually abused by her stepfather from the age of six to twelve. She confided what was taking place to her mother and lives with her mother, who is now divorced. Mandy is sexually active and promiscuous. She uses the Tinder app to meet older men for anonymous sexual encounters when her mother is working.

What data from the histories are RELEVANT and has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance:

• Struggled with anorexia nervosa since age 11, now is 16 (so for 5 years)
• Drinks several large glasses of water daily
• Recently engaging in self harming behavior, she is cutting both forearms and thighs with broken glass (numerous lacerations and scars
• Presents to the ED with increasing weakness, lightheadedness and a near syncopal episode this evening
• admits to inducing vomiting after meals the past three weeks
• She is 5’ 5” and weighs 83 lbs/37.7 kg (BMI 13.8)
• brought in by her mother and does not want to be treated
• overhear her say to her mother, “I hate everything about me! I am so tired of living, I wish I were dead!”
  • It is important to note that the patient has a history of anorexia nervosa because this could mean that she could possibly have more serious side effects because of the length of her ED
  • It is important to note that she drinks water because the patient is at risk for fluid and electrolyte problems. If she is drinking a lot of water she could experience fluid overload which makes her at risk for hyponatremia and seizures
  • The patient is cutting herself, which shows that she is at risk for self-harm and could be a high risk for suicide.
  • The fact that she has increasing weakness, lightheadedness and near syncopal episode shows that she may be experiencing electrolyte imbalances which can be deadly
  • The fact that her BMI is very low shows that she could be experiencing extreme electrolyte imbalances which could lead to organ failure and even death
  • The fact that she was brought in by her mother shows that she has a support system at home and it is important to note that she is resistant to treatment so may need to be hospitalized involuntarily
  • She is stating suicidal thoughts and therefore is a high risk for suicide, suicide ideation RELEVANT Data from Social History: Clinical Significance:
• was sexually abused by her stepfather from the age of six to twelve
• confided what was taking place to her mother and lives with her mother, who is now divorced
• is sexually active and promiscuous
• uses the Tinder app to meet older men for anonymous sexual encounters when her mother is working
• She experienced sexual abuse as a child, which is a major emotional trauma, and these types of trauma can cause the development of eating disorders, anxiety, and depression. She could be using the anorexia nervosa to cope
• The patient has a support system at home, her mother. The nurse may need to include family education as well.
• The patient may be using sexual activities as a coping mechanism for her past sexual abuse

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect.) PMH: Home Meds: Pharm. Classification: Expected Outcome: Anorexia nervosa Citalopram 20 mg PO daily This is an antidepressant and The patient’s depression and

Depression Self-injurious behavior (SIB) Sexually abused as a child

more specifically an SSRI anxiety will reduce, this will hopefully help stop her self harming behavior and improve her ED

What medications treat which conditions? Draw a line to identify what illness is being managed by what medication? Citalopram is helping treat her depression and anxiety, which is correlated to her ED One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in his/her life?

- Circle what PMH problem likely started FIRST. - Underline what PMH problem(s) FOLLOWED as domino(s).

Patient Care Begins:

Current VS: P-Q-R-S-T Pain Assessment (5th VS):

T: 96.2 F/35.7 C (oral) P rovoking/Palliative: Denies

P: 50 ( regular) Q uality:

R: 16 (regular) R egion/Radiation:

BP: 86/44 MAP: 58 S everity:

O2 sat: 99% room air T iming:

Orthostatic BP’s Position: HR: BP: Lying 50 86/ Standing 78 72/

What VS data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: T: 96.2 - She has a low body temperature which may mean she is not getting the amount of blood that P: 50 she needs and therefore her body temperature is lowering BP 86/44 - Her pulse is low which shows bradycardia. She is having difficulty pumping blood and MAP 58 circulating blood and the heart is not working at full capacity. Orthostatic BPs Lying HR - She has a low BP because she is not getting enough blood circulation and the low MAP shows 50 and BP 86/44 that blood may not be getting to the bodies organs Standing HR 78 and BP - Orthostatic hypotension is indicative of electrolyte imbalances and extreme complications 72/40 related to anorexia. This could be why she is experiencing the lightheadedness and weaknes

Current PHYSICAL Assessment:

RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort

CARDIAC: Pale-pink, cool and dry, 2+ bilateral pitting edema of feet and ankles, heart sounds

regular with no abnormal beats, pulses weak, equal with palpation at

radial/pedal/post-tibial landmarks, cap refill <3 seconds

GI: Abdomen scaphoid, several 1 cm open ulcers present on oral mucosa that are also dry and

tacky, soft and tender to gentle palpation in epigastrium, bowel sounds hypoactive

and audible per auscultation in all four quadrants

GU: Voiding without difficulty, urine clear/dark amber, she has not had her menses the

past 6 months

SKIN: Numerous vertical old scars from SIB present on both forearms, has several recent

vertical lacerations that are partial thickness on her left forearm, hair on head is

thinning, skin is dry with lanugo body hair apparent on both arms.

What PHYSICAL assessment data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance:

• Skin is pale-pink, cool and dry
• 2+ bilateral pitting edema of feet and

ankles

• pulses weak
• Abdomen scaphoid
  • several 1 cm open ulcers present on oral mucosa that are also dry and tacky
  • The patient may be experiencing the dry and cool skin because of dehydration and her heart may not be pumping efficiently due to the malnutrition and the electrolyte imbalances. This is also why the patients pulses may be weak
  • The patient is experiencing pitting edema which could be due to electrolyte imbalances with sodium. She could be experiencing hyponatremia. Her pulses may also be weak because she has a low HR and she has been drinking increased fluid and therefore could have fluid retention which can also cause edema
  • The patient may have a scaphoid abdomen and ulcers in oral mucosa due to

• soft and tender to gentle

palpation in epigastrium

• • bowel sounds hypoactive
• urine clear/dark amber, she has not

had her menses the past 6 months

• Numerous vertical old scars from

SIB present on both forearms. , has

several recent vertical lacerations that

are partial thickness on her left

forearm

• hair on head is thinning, skin is dry with lanugo body hair apparent on both arms.

her vomiting and anorexia. She does not have anything in her stomach and therefore it may look sunken. She may have the ulcers because the acid from vomiting is causing ulcers in her mouth. Her bowel sounds are hypoactive because she has not been eating and her stomach is not digesting anything

• The urine could be dark amber due to dehydration and her menstrual cycle is affected due to malnutrition
• The fact that her hair is thinning means she could be lacking vitamins and she is experiencing malnutrition from the anorexia
• The lacerations on her forearms show she is self harming and is a suicide risk

Mental Status Examination:

APPEARANCE: Wearing oversized baggy shirt. Emaciated appearance with little subcutaneous body fat, breasts atrophied MOTOR BEHAVIOR: Generalized weakness SPEECH: Soft, quiet MOOD/AFFECT: Flat affect, appears depressed, does not maintain eye contact THOUGHT PROCESS: Is logical and goal directed THOUGHT CONTENT: No^ overt^ delusions,^ but^ does^ indicate^ possible^ distorted^ body^ image^ stating,^ “I^ am^ just^ a little overweight” despite emaciated appearance SUICIDAL/HOMICIDAL: Denies homicidal ideation. Suicidal ideation is present. Stated, “I am so tired of living, I wish I were dead!” Admits to cutting as a way to relieve frustration. PERCEPTION: Denies auditory/visual hallucinations INSIGHT/JUDGMENT: Poor insight as evidenced by ongoing physical decline related to anorexia nervosa. Poor judgment is indicated by her desire to exercise excessively and wanting to go for a long walk despite her current weakness

COGNITION: Alert and oriented to person, place, time, and situation (x4). States that she has

difficulty concentrating in school.

INTERACTIONAL

ABILITY:

No apparent problem

What MSE assessment data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Assessment Data: Clinical Significance:

• Wearing oversized baggy shirt. Emaciated appearance with little subcutaneous body fat, breasts atrophied
• Generalized weakness
• Speech is soft, quiet Indicate possible distorted body image stating, “I am just a little overweight” despite emaciated appearance
• Suicidal ideation is present. Stated, “I am so tired of living, I wish I were dead!” Admits to cutting as a way to relieve frustration
• Poor insight as evidenced by ongoing physical decline related to anorexia nervosa. Poor judgment is indicated by her desire to exercise excessively and wanting to go for a long walk despite her current weakness
• States that she has

difficulty concentrating in school.

• The fact that she is wearing an oversized baggy shirt is a symptom of anorexia because she thinks she is bigger than she is and has to cover up with a baggy shirt
• Her weakness and soft and quiet speech could be due to her depression
• She has body image issues which is seen with people who are anorexic
• She is suicidal which means that she needs psychiatric help and put on suicidal precautions
• Difficulty concentration in school is a side effect of ED and depression

Cardiac Telemetry Strip:

Rhythm Interpretation: The heart rhythm looks slow, sinus bradycardia

Clinical Significance: Electrolyte imbalances, especially with potassium, can affect the heart. She could experience heart failure.

Lab Results:

Complete Blood Count (CBC:) Current: High/Low/WNL? Previous: WBC (4.5–11.0 mm 3) 4.0 5. Hgb (12– 16 g/dL) 9.8 10. Platelets (150- 450 x10 3 /μl) 85 125 Neutrophil % (42–72) 60 68

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Lab(s): Clinical Significance: TREND:

Improve/Worsening/Stable:

• Low WBC - A low WBC means that the bodies immune system is weak All lab values are worsening
• Low Hgb and this could be due to vitamin deficiencies and malnutrition
• Low Platelets - A low Hgb could indicate that the patient’s red blood cells
• Neutrophils WNL but are are not carrying enough oxygen to the heart and other vital decreasing organs
  • The low platelets means she could be have problems with clotting and she is at risk for hemorrhage and strokes

Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Previous: Sodium (135– 145 mEq/L) 132 LOW 135 Potassium (3.5–5.0 mEq/L) 1.9 LOW/RED FLAG! 3. Chloride (95– 105 mEq/L) 88 LOW 92 CO2 (Bicarb) (21– 31 mmol/L) 16 LOW 25 Anion Gap (AG) (7– 16 mEq/l) 8 WNL 10 Glucose (70– 110 mg/dL) 60 LOW 70 Calcium (8.4–10.2 mg/dL) 8.5 WNL 8. BUN (7– 25 mg/dl) 35 HIGH 14 Creatinine (0.6–1.2 mg/dL) 1.5 HIGH/RED FLAG! 0.

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Lab(s): Clinical Significance: TREND:

Improve/Worsening/Stable: Low sodium - Low sodium levels could be due to an electrolyte imbalance All lab values are worsening

• Low potassium (VERY and dehydration. When the sodium is low, the patient is at LOW) risk for seizures
• Low chloride levels - The low potassium is very alarming because the patient
• Low CO2 (bicarb) could go into cardiac arrest
• High BUN - Low chloride levels are alarming because this could show
• High creatinine (VERY that she is already having heart problems HIGH) - The low CO2 shows that she may be in metabolic acidosis
  • The high BUN and high creatinine are related to her kidneys and show that she could be experiencing kidney failure

Liver Function Test (LFT:) Current: High/Low/WNL? Previous: Albumin (3.5–5.5 g/dL) 2.4 Low^ 2. Total Bilirubin (0.1–1.0 mg/dL) 0.5 WNL^ 0. Alkaline Phosphatase male: 38 – 126 U/l female: 70 – 230 U/l

(^285) High 155

ALT (8– 20 U/L) 128 High 85 AST (8– 20 U/L) 124 High^78 Ammonia (11– 35 mcg/dL) 15 WNL^17

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Lab(s): Clinical Significance: TREND:

Improve/Worsening/Stable: Low albumin High Alkaline Phosphate High AST and ALT

• Low albumin is present when someone is experiencing malnutrition
• High alkaline phosphate and AST and ALT show liver damage and cirrhosis of the liver and could be due to the malnutrition

All lab values are worsening

Misc. Labs: Current: High/Low/WNL? Previous: Magnesium (1.6–2.0 mEq/L) 1.2 Low^ 1. Phosphorus (2.5-4.5 mg/dL) 1.9 Low^ 2. Urine pregnancy Negative n/a Thyroid Profile: (T3) Tri-iodothyronine (80- 210 ng/dL) 64 Low n/a (T4) Thyroxine (0.8-1.8 ng/dL) 0.5 Low^ n/a (TSH) Thyroid stimulating hormone (0.4-5.0 mIU/L) 0.2 Low^ n/a

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Lab(s): Clinical Significance: TREND:

Improve/Worsening/Stable: Low magnesium

• Low phosphorus
• Low TSH, T3 and T
  • Low magnesium is due to laxative use and vomiting. This is important because it can cause cardiac problems
  • Low phosphorus is due to malnutrition and the low TSH, T and T4 show that she could have euthyroid sick syndrome

Magnesium and phosphorus are worsening

Urine Analysis (UA:) Current: WNL/Abnormal? Color (yellow) Amber Abnormal Clarity (clear) Clear WNL Specific Gravity (1.015-1.030) 1.035 Abnormal Protein (neg) Neg WNL Glucose (neg) Neg WNL Ketones (neg) Pos/Large Abnormal Bilirubin (neg) Neg WNL Blood (neg) Neg WNL Nitrite (neg) Neg WNL LET (Leukocyte Esterase) (neg) Neg WNL MICRO: RBCs (<5) 3 WNL WBCs (<5) 5 WNL Bacteria (neg) Neg WNL Epithelial (neg) neg WNL

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Lab(s): Clinical Significance:

• Her urine is amber
• high specific gravity
• Positive for ketones
  • Dark urine can show dehydration and the fact that her specific gravity is high can also show dehydration. This is concerning because she states drinking a lot of water
  • Ketones in the urine could mean diabetes ketoacidosis and this is a very serious problem that can lead to death

Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: Normal Value:

Clinical Significance: Nursing Assessments/Interventions Required:

Potassium

Value: 1.

Critical Value: 3.5- 5

• Potassium helps carry electrical signals to the cells in your body and helps with the functioning of nerves and muscles in the body
  • EKG monitoring
  • Use caution with ambulation
  • Provide oral potassium or IV potassium
  • Continuous heart monitoring
  • Provide hydtration
  • Check vitals

Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: Normal Value:

Clinical Significance: Nursing Assessments/Interventions Required:

Magnesium

Value: 1.

Critical Value: 1.6-2.

Magnesium helps maintain the functions of the body, especially the heart and nervous system

• Monitor cardiac, respiratory, and neurological systems
• Supplement magnesium either orally or by IV
• Electrolyte lab values
• Vital signs

Clinical Reasoning Begins…

1. What is the primary problem that your patient is most likely presenting with?

She is experiencing anorexia nervosa and this has caused electrolyte imbalances and she could be experiencing organ

failure

2. What is the underlying cause/pathophysiology of this primary problem?

The patient is vomiting and refusing to eat which causes electrolyte imbalances and malnutrition. This can cause

severe stress on the heart, lungs and kidneys and cause organ failure because the body is not getting the right nutrients

and electrolytes needed to properly function

Collaborative Care: Medical Management Care Provider Orders: Rationale: Expected Outcome: Pelvic exam/obtain cultures to assess for STDs

Establish peripheral IV x

0.9% Normal Saline (NS) 1000 mL IV bolus

Continuous cardiac monitor

Magnesium sulfate 4 gm IVPB over 4 hours. Recheck potassium per hospital protocol

Potassium Chloride 10 mEq IVPB (x4) each dose over 1 hour. Recheck potassium per hospital protocol

Assessment and referral mental health assessment

1:1 sitter/security watch

• She is receiving a pelvic exam and being screened for STDs because she is sexually active
• She is being given 2 IV sites so that she can get more medications as well as the proper electrolytes and hydration needed
• This will help with the patients dehydration which will hopefully help with her low BP and low HR as well as skin dryness
• Since the patient is hypokalemic, and has hypomagnesmia this can put severe stress on the heart and can cause heart failure. It is important to monitor the heart for changes in rhythm and rate
• She is hypokalemic and has hypognesmia and therefore potassium and magnesium are going to be given to try and raise these levels
• The patient has an ED and is self-harming and therefore will benefit from inpatient psychiatric care
• She is on a 1:1 sitter because she has been harming herself and this will help keep her safe
  • The patient will not have STDs or will be treated for STDs
  • Patient will know status of pregnancy
  • The IV sites will be ready to use
  • The patients blood pressure will increase
  • The patient will become hydrated
  • The patient will not have cardiac arrhythmias and the heart rate will return to WNL
  • Magnesium levels will be WNL
  • Potassium levels will be WNL
  • The patient will be transferred to inpatient when stabilized

PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority: Rationale:

Establish peripheral IV

0.9% Normal Saline (NS) 1000 mL IV bolus

Continuous cardiac monitor

1:1 sitter/security watch

Potassium Chloride 10 mEq IVPB x

Magnesium sulfate 4 gm IVPB over 4 hours.

1. Peripheral IV
2. Normal saline
3. Potassium
4. Magnesium
5. Cardiac monitor
6. 1:1 sitter/watch

The first thing that needs to be done is get the IV in because then they will be able to give normal saline and any electrolytes that are needed. Then it is important to give the electrolytes to stabilize. Then it is important to continuously monitor the heart and have a sitter to make sure she is safe

Collaborative Care: Nursing

3. What can the nurse do to establish a therapeutic rapport/relationship in this setting? The nurse can establish trust with the patient by actively listening to her, connecting with her, and not judging her. She can also be sure to carry out and meet the patient’s needs. 4. What principles of therapeutic communication would be relevant to establish a therapeutic relationship?

The patient must listen to the patient and establish trust with the patient. She should be there to answer questions and

keep the patient and family calm.

5. How could the nurse explore her comments that suggest suicidal ideation?

The nurse could talk to the patient about her thoughts and assess her plans

6. What MENTAL HEALTH nursing priorities will guide your plan of care?

Safety, she is at risk for suicide and has been self-harming.

-Ineffective coping

-Impaired body image

-Low self esteem

-Depression/anxiety

7. What interventions will you initiate based on this MENTAL HEALTH priority (ies)? Nursing Interventions: Rationale: Expected Outcome:

• Safety to the patient by putting her on suicide - This is very important so that she does not self - Patient will express precautions harm herself and commit suicide concerns and their suicide
• Evaluate the patient and preform suicide risk - It is important to assess the risk of suicide intent assessment - It is important to build trust with the patient so - Patient will be safe
• Create a trust with the patient that they will communicate with you

8. What PHYSICAL nursing priority (ies) will guide your plan of care? (if more than one-list in order of PRIORITY)

NANDA-I as well as non-NANDA-I nursing diagnostic statements are relevant and need to be considered in this scenario: Fluid and electrolyte imbalances Malnutrition Inadequate cardiac perfusion

9. What interventions will you initiate based on this PHYSICAL priority (ies)? Nursing Interventions: Rationale: Expected Outcome:

• Monitor the electrolyte values
• EKG and cardiac monitoring
• Normal saline IV
• Provide electrolytes via IV as prescribed
  • We want to monitor the patient to make sure that she isn’t getting worse or that she is improving
  • We want to hydrate the patient
  • We want to get the electrolytes WNL
    • All electrolytes are WNL
    • Patient is hydrated
    • Cardiac output is improved 10. What body system(s) will you assess most thoroughly based on the primary/priority concern?

The cardiovascular system

11. What is the worst possible/most likely complication to anticipate?

The patient has heart failure, goes into cardiac arrest, and death

12. What nursing assessments will identify this complication EARLY if it develops?

-Continuous cardiac monitoring, check electrolyte values

13. What nursing interventions will you initiate if this complication develops?

-Administer electrolytes, administer medications as prescribed, assess neuro and respiratory status, cardiac monitoring, CPR

Evaluation: Thirty minutes later… The cardiac monitor HIGH priority alarm suddenly goes off. You observe the following rhythm on the monitor:

Cardiac Telemetry Strip:

Rhythm Interpretation:

A-fib?

Clinical Significance:

This is a life-threatening rhythm and shows that she is experiencing cardiac arrest due to her electrolyte

imbalances

When you enter the room to assess Mandy, this rhythm is on the screen: Cardiac Telemetry Strip:

Rhythm Interpretation: Clinical Significance:

Bradycardia

This is significant because she could go into cardiac arrest and die

Mandy admits that she just felt lightheaded for about five seconds and does not know why. She currently feels better. You quickly collect the following clinical data:

Current VS: Most Recent: Current Pain

Assessment PQRST:

T: 96.0 F/35.6 C T: 96.2 F/35.7 C (oral) Provoking/Palliative: Denies P: 48 P: 50 ( regular) Quality: R: 14 R: 16 (regular) Region/Radiation: BP: 74/42 BP: 86/44 Severity: O2 sat: 100% room air

O2 sat: 99% room air Timing:

Current Assessment: GENERAL APPEARANCE:

Appears anxious

RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort CARDIAC: Pale, cool and dry, 2+ bilateral pitting edema of feet and ankles, heart sounds regular with no abnormal beats, pulses weak, equal with palpation at radial/pedal/post-tibial landmarks, cap refill <3 seconds NEURO: Alert^ &^ oriented^ to^ person,^ place,^ time,^ and^ situation^ (x4),^ flat^ affect,^ does^ not^ maintain^ eye contact GI: Abdomen scaphoid, several 1 cm open ulcers present on oral mucosa that are also dry and tacky, soft and tender to gentle palpation in epigastrium, bowel sounds hypoactive and audible per auscultation in all four quadrants GU: Voiding without difficulty, urine clear/dark amber, she has not her menses the past 6 months SKIN: Numerous vertical old scars from SIB present on both forearms, has several recent vertical lacerations that are partial thickness on her left forearm, hair on head is thinning, skin is dry with lanugo body hair apparent on both arms

1. What data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: P 48 T 96 BP 74/

Her vital signs are worsening which means her condition is worsening

• She has a low body temperature which may mean she is not getting the amount of blood that she needs and therefore her body temperature is lowering
• Her pulse is low which shows bradycardia. She is having difficulty pumping blood and circulating blood and the heart is not working at full capacity.
• She has a low BP because she is not getting enough blood circulation and the low MAP shows that blood may not be getting to the bodies organs

RELEVANT Assessment Data: Clinical Significance:

• Appears anxious
• Pale, cool and dry, 2+ bilateral pitting edema of feet and ankles
• Abdomen scaphoid, several 1 cm open ulcers present on oral mucosa that are also dry and tacky, soft and tender to gentle palpation in epigastrium, bowel sounds hypoactive and audible per auscultation in all four quadrants
• urine clear/dark amber, she has not her menses the past 6 months
• Numerous vertical old scars from SIB present on both forearms, has several
• The fact that the patient appears anxious means that her problem could be worsening
• The patient may be experiencing the dry and cool skin because of dehydration and her heart may not be pumping efficiently due to the malnutrition and the electrolyte imbalances. This is also why the patients pulses may be weak
• The patient is experiencing pitting edema which could be due to electrolyte imbalances with sodium. She could be experiencing hyponatremia. Her pulses may also be weak because she has a low HR and she has been drinking increased fluid and therefore could have fluid retention which can also cause edema
• The patient may have a scaphoid abdomen and ulcers in oral mucosa due to her vomiting and anorexia. She does not have anything in her stomach and therefore it may look sunken. She may have the ulcers because the acid from

recent vertical lacerations that are partial thickness on her left forearm, hair on head is thinning, skin is dry with lanugo body hair apparent on both arms

vomiting is causing ulcers in her mouth. Her bowel sounds are hypoactive because she has not been eating and her stomach is not digesting anything

• The urine could be dark amber due to dehydration and her menstrual cycle is affected due to malnutrition
• The fact that her hair is thinning means she could be lacking vitamins and she is experiencing malnutrition from the anorexia
• The lacerations on her forearms show she is self harming and is a suicide risk 2. Has the status improved or not as expected to this point?

No, the patients status has not improved and is worsening

3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? The main priority is still on the cardiac and electrolyte imbalances 4. Based on your current evaluation, what are your nursing priorities and plan of care?

The primary nursing properties are monitoring her heart and electrolyte values. It is also very important to make sure she is hydrated and is being administered her medications as prescribed

As the primary nurse, you contact ED physician and give the following concise SBAR. Because the patient is still in the ED, you can keep the SBAR concise and on point by emphasizing the following: SBAR: Nurse-to-Primary Care Provider

S ituation:

Mandy White is a 16 - year-old female who reports to the emergency department with increasing weakness, lightheadedness and anorexia nervosa

B ackground:

Mandy White has a history of anorexia nervosa and self-harming behavior. She was sexually abused by her step father from age 6 - 12. The patient has suicidal ideation and has been self harming with lacerations in her forearm.

A ssessment: Vital signs: T:96 ºF BP: 74/42 P: 48 R: 14

RELEVANT body system nursing assessment data:

The patient appears anxious. Her skin is pale, cool and dry, 2+ bilateral pitting edema of feet and ankles. Abdomen

scaphoid, several 1 cm open ulcers present on oral mucosa that are also dry and tacky, soft and tender to gentle palpation in epigastrium, bowel sounds hypoactive and audible per auscultation in all four quadrants. Her urine clear/dark amber, she has not her menses the past 6 months. Numerous vertical old scars from SIB present on both forearms, has several recent vertical. Lacerations that are partial thickness on her left forearm, hair on head is thinning, skin is dry with lanugo body hair apparent on both arms

RELEVANT lab values: Hgb: 9. platelets: 85 Na: 132 K: 1. Albumin: 2. Mg: 1. ALT: 128 AST: 124 Phosphorous: 1.

R ecommendation:

I suggest that this patient is admitted to the ICU, I also suggest that her heart is monitored with an EKG. Monitor neuro and respiratory status. Q15 vitaks. 1:1 sitter for suicidal ideation. Admission to inpatient psych when stable

The primary care provider orders the following: Medical Management: Rationale for Treatment and Expected Outcomes Care Provider Orders: Rationale: Expected Outcome:

12 lead EKG stat

Amiodarone 150 mg IV bolus over 10” followed by 360 mg over 6 hours ( mg/minute) and 540 mg over the next 18 hours (0. mg/minute)

• It is important to get an EKG to monitor the hearts rhythm immediately because she has been having changed on the telemetry
• This medication helps treat irregular heart rhythms and will help maintain a steady beat

0.9% Normal Saline (NS) 1000 mL IV bolus

• Hydration can help elevate the BP

Admit to ICU

• She is now in very critical condition and needs to be sent to the ICU for further help. She could experience death

Medication Dosage Calculation: Medication/Dose: Mechanism of Action: (^) Volume/time frame to Safely Administer:

Nursing Assessment/Considerations:

Amiodarone 150 mg IV bolus

This is an antiarrhythmic medication and works by blocking potassium rectifier currents that are responsible for the repolarization of the heart

150 mg in 100 mL of D5W

Hourly Rate to Administer: 100ml an hour

• Monitor serum levels
• Monitor cardiac rhythm continuously
• Only use for life threatening arrhythmias
• Give with meals
• Blood tests and liver enzymes need to be tested along with thyroid hormone levels
• Side effects: dizziness, fatigue, bradycardia, hypotension
• May take up to 2 hours

It is now time to transfer Mandy to ICU. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient:

SBAR: Nurse-to-Nurse

S ituation: Name/age: Mandy White is a 16-year-old female

BRIEF summary of primary problem:

Day of admission/post-op #:

Today B ackground: Primary problem/diagnosis: Anorexia nervosa and fluid and electrolyte imbalances

RELEVANT past medical history: The patient has a past medical history of anorexia nervosa, depression and self-harming tendencies

RELEVANT background data: She was sexually abused by her step father between the ages of 6- 12 years old. She is currently sexually active A ssessment: Vital signs: T:96 ºF BP: 74/42 P: 48 R: 14

RELEVANT body system nursing assessment data:

The patient appears anxious. Her skin is pale, cool and dry, 2+ bilateral pitting edema of feet and ankles. Abdomen

scaphoid, several 1 cm open ulcers present on oral mucosa that are also dry and tacky, soft and tender to gentle palpation in epigastrium, bowel sounds hypoactive and audible per auscultation in all four quadrants. Her urine clear/dark amber, she has not her menses the past 6 months. Numerous vertical old scars from SIB present on both forearms, has several recent vertical. Lacerations that are partial thickness on her left forearm, hair on head is thinning, skin is dry with lanugo body hair apparent on both arms

RELEVANT lab values: Hgb: 9.6 platelets: 85 Na: 132 K: 1.9 Albumin: 2.5

Mg: 1.2 ALT: 128 AST: 124 Phosphorous: 1.9

How have you advanced the plan of care?

12 lead EKG stat

Amiodarone 150 mg IV bolus over 10” followed by 360 mg over 6 hours (1 mg/minute) and 540 mg over the next 18 hours (0.5 mg/minute)

0.9% Normal Saline (NS) 1000 mL IV bolus

Admit to ICU

Patient response:

The patients status is worsening

INTERPRETATION of current clinical status (stable/unstable/worsening): Worsening R ecommendation: Suggestions to advance plan of care: I suggest that this patient is admitted to the ICU, I also suggest that her heart is monitored with an EKG. Monitor neuro and respiratory status. Q15 vitaks. 1:1 sitter for suicidal ideation. Admission to inpatient psych when stable

Mandy has been transferred to the ICU. Ten minutes later, you hear an overhead page for “Code Blue” to the same room that Mandy was just transferred to…

Education Priorities/Discharge Planning

1. If Mandy survives, what will be the most important discharge/education priorities that you will reinforce with her medical condition to help prevent future readmission with the same problem?

The number one discharge education is electrolyte and nutrition priority because the patient could die from anorexia

and malnutrition. I would also educate about group therapies and therapist that can help her with her diagnosis.

2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?

I can use the teach back method and have the patient state back to me what I just told them. This way I will be able to identify if they understood the teaching

Caring and the “Art” of Nursing

1. What is the patient likely experiencing/feeling right now in this situation?

The patient is likely feeling very scared and also sad right now. She is very depressed and has been saying she does

not want to live anymore so even with all of the complications going on, she could actually feel satisfied.

2. What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person?

The nurse can make sure that she creates trust with the patient and is there for the patient to talk to. The nurse can

also be an advocate for the patient if the patient has increasing feelings of sadness. The nurse can remain calm and

be kind to the patient. It is also important for the nurse to make themselves available to the patient if the patient feels like

talking.

Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment.

1. What did I learn from this scenario? This scenario taught me the signs and symptoms associated with anorexia nervosa. It taught me the warning signs to look out for if the patient has electrolyte imbalances and organ failure due to her anorexia. It taught me that it is possible to die from being anorexic. 2. How can I use what has been learned from this scenario to improve patient care in the future? I can use this information by knowing if someone comes into the hospital and is anorexic, I will assess their lab values, check their neuro and respiratory status, get an EKG to monitor their heart. I will administer elecrolytes as prescribed and prepare and IV. I will also know that it can cause cardiac arrest so it is very important to monitor the heart.