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Eating Disorder/Electrolyte Imbalances comprehensive study notes
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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: RELEVANT Data from Social History: Clinical Significance:
Self-injurious behavior (SIB) Sexually abused as a child What medications treat which conditions? Draw a line to identify what illness is being managed by what medication? 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).
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
No apparent problem What MSE assessment data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Assessment Data: Clinical Significance:
Cardiac Telemetry Strip: Rhythm Interpretation:
Clinical Significance: Decrease in oxygenated blood delivery to the body, therefore patient is at risk for organ failure and/or death © 2016 Keith Rischer/www.KeithRN.com
Lab Results: Complete Blood Count (CBC:) Current: High/Low/WNL? Previous: WBC (4.5–11.0 mm 3) 4.0 Low 5. Hgb (12–16 g/dL) 9.8 (^) Low 10. Platelets (150-450 x10 3 /μl) 85 Low 125 Neutrophil % (42–72) 60 WNL 68
Improve/Worsening/Stable:
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?
Improve/Worsening/Stable:
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
ALT (8–20 U/L) 128 High 85 AST (8–20 U/L) 124 High 78 Ammonia (11–35 mcg/dL) 15 WNL 17
Improve/Worsening/Stable:
Improve/Worsening/Stable:
© 2016 Keith Rischer/www.KeithRN.com
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?
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:
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:
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Collaborative Care: Nursing
3. What can the nurse do to establish a therapeutic rapport/relationship in this setting?
4. What principles of therapeutic communication would be relevant to establish a therapeutic relationship?
5. How could the nurse explore her comments that suggest suicidal ideation?
6. What MENTAL HEALTH nursing priorities will guide your plan of care?
7. What interventions will you initiate based on this MENTAL HEALTH priority (ies)? Nursing Interventions: Rationale: Expected Outcome:
NANDA-I as well as non-NANDA-I nursing diagnostic statements are relevant and need to be considered in this
9. What interventions will you initiate based on this PHYSICAL priority (ies)? Nursing Interventions: Rationale: Expected Outcome:
10. What body system(s) will you assess most thoroughly based on the primary/priority concern?
11. What is the worst possible/most likely complication to anticipate?
12. What nursing assessments will identify this complication EARLY if it develops?
13. What nursing interventions will you initiate if this complication develops?
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:
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:
RELEVANT Assessment Data: Clinical Significance:
3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?
4. Based on your current evaluation, what are your nursing priorities and plan of care?
© 2016 Keith Rischer/www.KeithRN.com
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: B ackground: A ssessment: R ecommendation: 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) 0.9% Normal Saline (NS) 1000 mL IV bolus Admit to ICU Medication Dosage Calculation: Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations: Amiodarone 150 mg IV bolus 150 mg in 100 mL of D5W Hourly Rate to Administer: © 2016 Keith Rischer/www.KeithRN.com
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?
2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?
Caring and the “Art” of Nursing
1. What is the patient likely experiencing/feeling right now in this situation?
2. What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person?
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?
