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

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

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.

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, T3 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- -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

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:

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

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