ANOREXIA CLINICAL REASONING CASE STUDY

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 RAPID Reasoning Case Study: STUDENT 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: Drinks a lot of water Injures herself Low BMI Complaints of increasing weakness, lightheadedness, and syncopal episode Inducing vomiting after meals “I hate everything about me! I am so tired of living. I wish I were dead!” Diluting her electrolytes since she is not replacing them back Some teens find this as way of coping from anger and frustration and can also cause infection. Nurse should seek psychiatrist for pt Indication of anorexia and should understand how this disease affects the pt emotionally and physically This is probably due to dehydration, malnutrition deficient fluid volume, electrolyte deficiency Dangerous and she is depleting her electrolytes in the body The pt is at risk for suicide and should be monitored carefully and free from objects that she can use to harm herself RELEVANT Data from Social History: Clinical Significance: Has been sexually abused by stepfather from age six to twelve Pt is sexually active and promiscuous. Uses tinder to meet older men for sexual encounter when her mother is working This must have been a traumatic experience for her and may be a reason for self-harm and inducing vomiting Pt is 16 years old and sleeping with multiple older men and this is risky and can be a case Patient Care Begins: T: 96.2 F/35.7 C (oral) Provoking/Palliative: Denies P: 50 (regular) Quality: R: 16 (regular) Region/Radiation: BP: 86/44 MAP: 58 Severity: O2 sat: 99% room air Timing: Orthostatic BP’s Position: HR: BP: Lying 50 86/44 Standing 78 72/40 What VS data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: T: 96.2 F Temp is low because the pt is starving herself P: 50 reg Not getting enough calories and nutrition to support the heart BP: 86/44 MAP: 58 Blood volume is low from low blood volume. MAP should be 65 and up, pt MAP is low which means blood is not reaching major organs Orthostatic BP Pt has orthostatic hypotension from fluid volume deficit. Lightheadedness upon standing so safety measures should be considered 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: Cardiac: Pale pink, cool and dry, 2+ bilateral pitting edema, weak pulse GI: abdomen scaphoid, several 1 cm open ulcers Edema can be sign of malnutrition and related to improper intake of protein especially with albumin. Weak pulses are a sign of dehydration From lack of proper nutrition/ underweight. When stomach acids pass through the mouth it can cause ulcers and mucous membranes to be dehydrated GU: urine clear/dark amber and has not had her menstrual period in 6 months Skin: numerous vertical old scars on both arms, has several recent vertical lacerations hair in the head is thinning, skin is dry with lanugo body hair on both arms Dark amber urine is a sign of dehydration, amenorrhea commonly occurs when someone experiences drastic weight loss and starvation The scars are indicated from self-harm. Thin hair can be from lack of proper nutrition, dry skin is from dehydration, lanugo grows to insulate the body Cardiac Telemetry Strip: Rhythm Interpretation: bradycardia Clinical Significance: The heart is not pumping enough oxygenated blood throughout the body which puts the pt at risk for organ failure or death. Lab Results: Complete Blood Count (CBC:) Current: High/Low/WNL? Previous: WBC (4.5–11.0 mm 3) 4.0 Low 5.2 Hgb (12–16 g/dL) 9.8 Low 10.5 Platelets (150-450 x103/µl) 85 Low 125 Neutrophil % (42–72) 60 WNL 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: WBC: 4.0 Hgb: 9.8 She is prone to infection since her wbc count is low and weakening Low hemoglobin indicates anemia Worsening Worsening Worsening Stable Platelets: 85 Neutrophils: WNL Are low due to low hgb Normal and is a type of WBC 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 3.4 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 8.6 BUN (7–25 mg/dl) 35 High 14 Creatinine (0.6–1.2 mg/dL) 1.5 High 0.9 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Sodium: 132 Most likely due to large fluid intake Cardiac dysrhythmias can occur since potassium is essential in cardiac function Metabolic acidosis Is low from constant vomiting From malnutrition Kidney function impairment Impairment of the kidneys and fluid deficit Worsening Potassium: 1.9 Worsening Low CO2 Worsening Chloride: 85 Worsening Glucose: 88 Worsening BUN: 35 Creatinine: 1.5 Worsening Worsening Liver Function Test (LFT:) Current: High/Low/WNL? Previous: Albumin (3.5–5.5 g/dL) 2.4 Low 2.9 Total Bilirubin (0.1–1.0 mg/dL) 0.5 WNL 0.6 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: Albumin: 2.4 Inadequate intake of protein and causing edema in ankles Indicates liver function This is expected in a pt with anorexia from cardiac dysfunction Also expected to by high from anorexia Worsening Alkaline phosphate: 285 Worsening ALT: 128 Worsening AST: 124 Worsening Misc. Labs: Current: High/Low/WNL? Previous: Magnesium (1.6–2.0 mEq/L) 1.2 Low 1.6 Phosphorus (2.5-4.5 mg/dL) 1.9 Low 2.5 Urine pregnancy Negative N/A 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: Magnesium: 1.2 Cardiac dysrhythmias can occur from this essential Worsening Phosphorus: 1.9 From starvation and malnutrition Worsening T3: 64 This is expected to be low from anorexia and malnutrition T4: 0.5 TSH: 0.2 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: Urine color: amber Large ketones Specific gravity: 1.035 From dehydration and fluid volume deficit Possibly from starvation and inadequate nutrition and metabolism From fluid volume deficiency Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting with? Anorexia nervosa 2. What is the underlying cause/pathophysiology of this primary problem? This disorder is an abnormal low body weight along with the constant fear of gaining weight with a strict perception of weight. With anorexia, values and standards are set high and specific. Self-worth and esteem is altered during the process. Collaborative Care: Medical Management Care Provider Orders: Rationale: Expected Outcome: Pelvic exam/obtain cultures to assess for STDs The pt is engaged in risky sexual activities and can be at risk for diseases The first IV is for normal saline and second for electrolytes To add rehydration back into the body To measure and monitor for dysrhythmias To increase magnesium back in the body and prevent dysrhythmias To increase potassium back for heart to prevent heart from dysrhythmias Because the pt mentioned wanting to end her life and does self-injury Risks of self-harm Establish peripheral IV x2 Intact IV, getting fluids and electrolytes needed 0.9% Normal Saline (NS) Increase BP and decrease of 1000 mL IV bolus resolve orthostatic hypotension Continuous cardiac monitor prevent heart arrest Magnesium sulfate 4 gm IVPB over 4 hours. Recheck potassium per hospital protocol maintain normal heart rhythms maintain normal heart rhythms Potassium Chloride 10 mEq IVPB (x4) each dose over 1 hour. Recheck potassium per hospital protocol Assessment and referral mental health assessment Pt will be safe from environment 1:1 sitter/security watch Collaborative Care: Nursing 3. What can the nurse do to establish a therapeutic rapport/relationship in this setting? The nurse can keep to pt aware of any procedures that will take place, provide care in a judge free way, encourage or let the pt know you are there for her if she wants to talk about anything 4. What principles of therapeutic communication would be relevant to establish a therapeutic relationship? Aspects such as integrity and honesty are important in establishing a nurse-patient relationship 5. How could the nurse explore her comments that suggest suicidal ideation? Asking questions about risks for suicide 6. What MENTAL HEALTH nursing priorities will guide your plan of care? Establish a trusting relationship with the patient Risks of self-harm, suicide, low self-esteem, hopelessness 7. What interventions will you initiate based on this MENTAL HEALTH priority(ies)? Nursing Interventions: Rationale: Expected Outcome: Discover suicide plan and assess her intentions of doing it Establish a nurse-patient relationship Ensure a safe environment The more descriptive a pt is about the way they plan on suicide the more likely they would do it. All suicides should be taking serious regardless This could encourage the client to trust you as the nurse and possibly open up and express their emotions and thoughts The pt should have no access to potential harming objects and limiting access to cabinet doors The pt will open and express her thoughts and feelings The nurse will form a nurse-patient bond Maintain safety 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: To correct electrolyte imbalances, increase fluid intake to correct fluid volume deficit, and malnutrition 9. What interventions will you initiate based on this PHYSICAL priority (ies)? Nursing Interventions: Rationale: Expected Outcome: Establish IV to administer fluids as needed To restore the fluid lost to the body to prevent dehydration Fluid Volume Deficit is corrected Administer electrolytes replacement as ordered Correcting electrolytes abnormalities will Electrolyte abnormality prevent the development of complications is corrected related to that electrolyte 10. What body system(s) will you assess most thoroughly based on the primary/priority concern? The Cardiovascular and Neurological 11. What is the worst possible/most likely complication to anticipate? Hypokalemia due to low potassium levels, Hypomagnesemia due to low magnesium levels, Hyponatremia due to low sodium level. Hyponatremia and Hypomagnesemia can cause seizures while Hypokalemia can result in cardiac dysrhythmia. 12. What nursing assessments will identify this complication EARLY if it develops? Hypokalemia, hypomagnesemia, hyponatremia 13. What nursing interventions will you initiate if this complication develops? Administer electrolyte replacement Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation? I can imagine the pt is experiencing pain emotionally and often thinks about her traumatic experience with sexual abuse in the past. The pt is most likely dealing with extreme body disturbance and struggles with self-love and acceptance. On top of that, especially as a female teen, the pressure of being “perfect” weighs a ton on teenagers. She is dealing with a lot of emotional pain and probably going through a very dark time in her life and believes that self-injury, and suicide is the only option. 2. What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person? This pt should feel she can trust the nurse. It is important to educate the pt about anorexia and self struggles. Little things to comfort the pt such as making her feel appreciated and resting a hand on her arm. Grant her needs, maintaining her privacy, and performing interventions competently 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? In this scenario I learned that past personal history plays a huge part of the growth in the development and growth or a child. This pt clearly went through something traumatic and I do not blame her for the way she is feeling. Its important to talk and share emotions when you are going through something life changing. You never know what someone is going through so it is so important to always be kind and make someone smile every day. I also learned something new that I did not know which was how edema is from not getting enough protein and albumin in the body from malnutrition. 2. How can I use what has been learned from this scenario to improve patient care in the future? In this scenario, I learned what can be used for future pt is to build a patient relationship and really understand the patient’s feelings and thoughts. Communication is so important and can learn so much about someone just by listening to them speak.