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
© 2016 Keith
Rischer/www.KeithRN.com
,ANOREXIA CLINICAL REASONING CASE
STUDY
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 Diluting her electrolytes since she is not replacing them back
Injures herself Some teens find this as way of coping from anger and frustration and
can also cause infection. Nurse should seek psychiatrist for pt
Low BMI 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,
Complaints of increasing weakness,
electrolyte deficiency
lightheadedness, and syncopal episode
Dangerous and she is depleting her electrolytes in the body
Inducing vomiting after meals
“I hate everything about me! I am so tired The pt is at risk for suicide and should be monitored carefully and free
of living. I wish I were dead!” from objects that she can use to harm herself
RELEVANT Data from Social History: Clinical Significance:
Has been sexually abused by stepfather This must have been a traumatic experience for her and may be
from age six to twelve a reason for self-harm and inducing vomiting
Pt is sexually active and promiscuous. Pt is 16 years old and sleeping with multiple older men and this is risky
Uses tinder to meet older men for sexual and can be a case
encounter when her mother is working
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
© 2016 Keith
Rischer/www.KeithRN.com
,ANOREXIA CLINICAL REASONING CASE
STUDY
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
Pt has orthostatic hypotension from fluid volume deficit. Lightheadedness upon standing so
Orthostatic BP
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:
© 2016 Keith
Rischer/www.KeithRN.com
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
© 2016 Keith
Rischer/www.KeithRN.com
,ANOREXIA CLINICAL REASONING CASE
STUDY
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 Diluting her electrolytes since she is not replacing them back
Injures herself Some teens find this as way of coping from anger and frustration and
can also cause infection. Nurse should seek psychiatrist for pt
Low BMI 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,
Complaints of increasing weakness,
electrolyte deficiency
lightheadedness, and syncopal episode
Dangerous and she is depleting her electrolytes in the body
Inducing vomiting after meals
“I hate everything about me! I am so tired The pt is at risk for suicide and should be monitored carefully and free
of living. I wish I were dead!” from objects that she can use to harm herself
RELEVANT Data from Social History: Clinical Significance:
Has been sexually abused by stepfather This must have been a traumatic experience for her and may be
from age six to twelve a reason for self-harm and inducing vomiting
Pt is sexually active and promiscuous. Pt is 16 years old and sleeping with multiple older men and this is risky
Uses tinder to meet older men for sexual and can be a case
encounter when her mother is working
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
© 2016 Keith
Rischer/www.KeithRN.com
,ANOREXIA CLINICAL REASONING CASE
STUDY
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
Pt has orthostatic hypotension from fluid volume deficit. Lightheadedness upon standing so
Orthostatic BP
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:
© 2016 Keith
Rischer/www.KeithRN.com
