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: