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

© 2016 Keith Rischer/www.KeithRN.com

UNFOLDING 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:
she has a history of anorexia nervosa -phyical and emotional disorder-history of not eating
- electrolyte imbalance- decrease sodium
drinks several large glasses of water daily - risk for injury
self injurious behavior - infection risk
lacerations - cardiac disrhythmias- or electrolyte imbalance
- risk for falls- dehydration- electrolyte imbalance
weakness, lightheadedness and a syncopal (fainting) - suicide risk- hurt herself
states that "I wish I was dead" -mental health disorder
BMI is 13.8- she is 5'5" and 83 lbs -vomiting causes dehydration along with hyponatremia, hypochloremia, and hypokalemia. - may cause ulcers cause of the
acid build up
doesn't want to be there
induce vomiting

RELEVANT Data from Social History: Clinical Significance:

sexually abused from the age of six - emotional trama-mental status
sexually active and promiscuous - not being protected- can get a STD
meet anonymous sexual encounter - could get hurt

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect.)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
Anorexia nervosa Citalopram 20 mg PO daily Antidepressant- SSRI - not depressed
Depression
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).

© 2016 Keith Rischer/www.KeithRN.com

 Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
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/35.7 C (oral) - to conserve energy the body
-To conserve heart muscle and thus keep the entire body functioning as well as possible there will be a slowing of
P-50 on the low side heart rate, called bradycardia.
BP- 86/44- low -the heart can struggle to pump blood when the body doesn’t produce enough fuel. As a result, the heart can
Orthostatic hypotension- become malnourished and hypotension can occur.
Lying 50- standing 78= -individuals with abnormally low blood pressure can deal with dizziness, nausea, fatigue and blurred vision.
increase by 28 -the diagnosis of orthostatic hypotension is defined as at a 20 mm/Hg fall in systolic blood pressure and at 10mm/Hg
MAP 58 fall in the diastolic pressure.
-the presence of orthostatic hypotension represents an increase in risk of cardiac or heart related deaths
-If blood flow to the brain drops too much then we will pass out
-MAP less than 60 indicates that your blood may not be reaching your major organs. Without blood and nutrients, the
tissue of these organs begins to die, leading to permanent organ damage

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: 2+ bilateral pitting edema of feet and ankles, pulses weak - It is caused by hormonal changes brought on by starvation or by purging and is seen in both
GU: urine clear/dark amber, she has not had her menses the
past 6 months restricting and binge-purge subtype. Edema can also be seen as patients with anorexia begin to
SKIN: Numerous vertical old scars from SIB present on both forearms, weight restore (refeeding edema).
has several recent - dehydration
vertical lacerations that are partial thickness on her left forearm, hair
on head is -Amenorrhea occurs most commonly when the body is starving and in which caloric intake is
thinning, skin is dry with lanugo body hair apparent on both arms. inadequate relative to energy burned. This disrupts the hormone cycle that regulates menses.
GI: Abdomen scaphoid, several 1 cm open ulcers present on oral -Lanugo-like body hair is a frequent sign in AN, especially in younger patients. It is not a sign of
mucosa that are also dry and tacky, soft and tender to gentle palpation
in epigastrium, bowel sounds hypoactive and audible per auscultation virilization and has been associated with decreased activity of the 5-α-reductase enzyme system,
in all four quadrants probably due to hypothyroidism.
- it is indicative of malnutrition and dehydration

© 2016 Keith Rischer/www.KeithRN.com

 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 No apparent problem
ABILITY:

What MSE assessment data is RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Assessment Data: Clinical Significance:
APPEARANCE: Wearing oversized baggy shirt. Emaciated
appearance with little subcutaneous body fat, breasts atrophied - Her oversized shirt is used to hid how emaciated she is.
MOOD/AFFECT: Flat affect, appears depressed, does not maintain
eye contact - depressed mode
THOUGHT CONTENT: No overt delusions, but does indicate possible
distorted body image stating “I am just a little overweight” despite - thinks she's overweight- body image distorted
emaciated appearance
SUICIDAL/HOMICIDAL: Denies homicidal ideation. Suicidal ideation is
-she wants to harm herself
present. Stated, “I am so tired of living, I wish I were dead!” Admits - she thinks she's fat. Distorted body image is affecting her
to cutting as a way to relieve frustration.
INSIGHT/JUDGMENT: Poor insight as evidenced by ongoing physical
decline related to anorexia nervosa. Poor judgment is indicated by her
lifestyle
desire to exercise excessively and wanting to go for a long walk
despite her current weakness

Cardiac Telemetry Strip:

Rhythm Interpretation:

Sinus Bradycardia- with PVC

Clinical Significance:
50 bpm- bradycardia due to electolye imbalance- confirms irritability of the heart

© 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 5.2
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 low -A low white blood cell count is a serious sign of nutritional Worsening
Hgb 9.8 low deficiency- weaken the body's defenses to infections Worsening
- anemia lack enough healthy red blood cells to carry
Platelets 85 low oxygen to body tissues. Anemia is a condition that typically Worsening
Neutrophil % from 68 causes people to feel weak, dizzy and fatigued. Worsening
to 60 -important in the formation of clots and in rare cases, there
is the possibility of a bleeding tendency when the platelets
are low.
- are important for fighting certain infections, especially
those caused by bacteria. first responders

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! 3.4
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/RED FLAG! 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 (135–145 mEq/L) -low nutritional intake- dehydration- too much Worsening
132 LOW water intake decreases sodium
Potassium (3.5–5.0 mEq/L) - can cause rhythm changes in the heart Worsening
1.9 LOW/RED FLAG!
Chloride (95–105 mEq/L) 88
- electrolye imbalance from vomiting- starvation Worsening
LOW
CO2 (Bicarb) (21–31 - electrolye imbalance from vomiting- starvation- Worsening
mmol/L) 16 LOW can cause metabolic alkalosis
Glucose (70–110 mg/dL) 60 -Food restriction and excessive exercise enacted Worsening
LOW
during anorexia leads to the depletion of
glycogen- less fuel for the brain and body
BUN (7–25 mg/dl) 35 HIGH -High BUN/creatinine ratio can occur in severe Worsening
14 dehydration
- poor renal perfusion- sever dehydration Worsening
Creatinine (0.6–1.2 mg/dL)
1.5 HIGH/RED FLAG!

© 2016 Keith Rischer/www.KeithRN.com

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 285 155
male: 38–126 U/l female: 70–230 U/l High
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 (3.5–5.5 - malnutrition. It can also mean that you have liver worsening
g/dL) 2.4 disease or an inflammatory disease.
Alkaline Phosphatase -liver has been damaged worsening
285 -liver has been damaged- more specific
worsening
ALT (8–20 U/L) 128
-liver has been damaged
AST (8–20 U/L) 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
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 (1.6–2.0 mEq/L) -excessive gastrointestinal or renal losses. worsening
1.2 Hypomagnesemia is low levels of magnesium in the blood worsening
Phosphorus (2.5-4.5 mg/dL) and can be caused by chronic abuse of laxatives, among
1.9 other purging methods- can cause cardiac rhythm changes worsening
Thyroid Profile: -When a gradual breakdown of tissue takes place during worsening
(T3) Tri-iodothyronine starvation, total depletion of the body's phosphate stores worsening
(80-210 ng/dL) 64
may develop
(T4) Thyroxine (0.8-1.8
ng/dL) 0.5 -indicate hypothyroidism or starvation
(TSH) Thyroid stimulating -underactive thyroid, also known as hypothyroidism.
hormone (0.4-5.0 mIU/L) 0.2 -indicate hyperthyroidism. This is also known as an
overactive thyroid.

© 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?
RELEVANT Lab(s): Clinical Significance:
Urine- Amber -decreased urinary output are two warning signs of kidney failure-
Specific Gravity: 1.035 dehydration and electrolyte imbalance
Ketones- pos/large -dehydration
- the body is starved of food and nutrients, indicate the body is "eating its
own fat" for energy. Accumulation of ketones in the blood can lead to
ketoacidosis, which can cause coma and death.

Lab Planning: Creating a Plan of Care with a PRIORITY Lab:

Lab: Normal Clinical Significance: Nursing Assessments/Interventions Required:
Value:
NV: 3.5-5.2mmol/L
CV:2.5 mmol/L -Explain need to use caution when ambulating, particularly when climbing or descending stairs.
Potassium -results from vomiting, diarrhea, adrenal
gland disorders, or use of diuretics
-Teach to take potassium supplement after breakfast and supper, diluted in 4 oz of juice or water, and
to sip it slowly over a 5- to 10-minute period. Advise to call if gastric irritation occurs.
Critical - Potassium helps carry electrical signals -Discuss dietary sources of potassium; provide a list of potassium-rich foods.
to cells in your body. It is critical to the - record I&O
Value: Value: proper functioning of nerve and muscles -check vital signs
cells, particularly heart muscle cells. -ECG monitoring
-disrhythmia - Give antiemetic
1.9 -Provide calm and quite environment so that patient can sleep.
-Give psychological support to reduce anxiety.

Lab Planning: Creating a Plan of Care with a PRIORITY Lab:

Lab: Normal Clinical Significance: Nursing Assessments/Interventions Required:
Value:
NV: 1.6 to 2.6 mg/dL Monitor cardiac, GI, respiratory, neuro status. Place on a cardiac monitor (watching for any EKG
CV: 1.2 mg/dL changes prolonging of PR interval and widening QRS complex)
Magnesium -excessive gastrointestinal or renal
losses. Hypomagnesemia is low levels
May administer potassium supplements due to hypokalemia (hard to get magnesium level up if
potassium level is down)
Critical of magnesium in the blood and can be Administering calcium supplements (oral calcium supplements w/ Vitamin-D or 10% Calcium
caused by chronic abuse of laxatives, Gluconate)
Value: among other purging methods Administer Magnesium Sulfate IV route. Monitor Mg+ level closely because patient can become
Value: -are important for the maintenance of magnesium toxic (***Watch for depressed or loss of deep tendon reflexes)
heart and nervous system function. Place patient in seizure precautions
1.2 Oral forms of Magnesium may cause diarrhea which can increase magnesium loss so watch out for
this
Watch other electrolyte levels like calcium and potassium
Encourage foods rich in Magnesium:

© 2016 Keith Rischer/www.KeithRN.com

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?
Distortion of body image. The patient is refusing to eat and is constantly exercising.

Collaborative Care: Medical Management

Care Provider Orders: Rationale: Expected Outcome:
Pelvic exam/obtain cultures - negative for STD
- screening for sexually transmited disease- make sure she's not
to assess for STDs pregnant

Establish peripheral IV x2 -with two iv sites you can infuse multiple fluids and medications - site established, clean with no
signs of infection

-fluids to help restore perfusion to systems and raise BP

0.9% Normal Saline (NS) - increase BP and systemic
1000 mL IV bolus perfusion
-ECG monitoring are indicated for patients with severe hypokalemia
Continuous cardiac monitor and hypomagesima -monitor dsyrhythmia - ECG stable- no dysrhythmia

Magnesium sulfate 4 gm - magnesium levels are within

- magnesium and potassium go hand in hand. If mag is low so will
range
IVPB over 4 hours. Recheck potassium. Low mag can cause irregular heart beat.
potassium per hospital
protocol
-potassium levels are within
Potassium Chloride 10 mEq - low potassium can cause arrhythmias. range
IVPB (x4) each dose over 1
hour. Recheck potassium per
hospital protocol
- mental health evaluation
Assessment and referral - patient is depressed, cuts herself and expresses that she doesn't
mental health assessment want to live- she needs psychiatric evaluation
- patient is safe
1:1 sitter/security watch - safety precaution, patient wanted to hurt herself or commit suicide

PRIORITY Setting: Which Orders Do You Implement First and Why?

Care Provider Orders: Order of Priority: Rationale:
Establish peripheral IV 1. 1:1 sitter/security watch 1. priority is making sure she is safe and not
2. Continuous cardiac causing harm to herself.
0.9% Normal Saline (NS) monitor
3. Establish peripheral IV 2. Because of dysrhythmia we need to monitor
1000 mL IV bolus cardiac rhythm.
4. 0.9% Normal Saline (NS)
1000 mL IV bolus 3. IV needed to administer IV fluids and meds
Continuous cardiac monitor 5. Potassium Chloride 10 4. patient is severly dehydrated, we need fluid
mEq IVPB x4 volume replacement
1:1 sitter/security watch 6. Magnesium sulfate 4 gm
IVPB over 4 hours. 5. given to stabilize cardiac irritability and prevent
Potassium Chloride 10 mEq possible life-threatening dysrhythmias
IVPB x4 6. next we give magnesium sulfate to also prevent
dysrhythmias
Magnesium sulfate 4 gm
IVPB over 4 hours.
© 2016 Keith Rischer/www.KeithRN.com
Collaborative Care: Nursing
3. What can the nurse do to establish a therapeutic rapport/relationship in this setting?
Get to know the patient, try to establish some trust, be an active listener, make sure
patient needs are being met, be respectful, don't judge
4. What principles of therapeutic communication would be relevant to establish a therapeutic relationship?
be an active listener, sit and talk, be compasionate, honest and empathic, ask open ended
questions.
5. How could the nurse explore her comments that suggest suicidal ideation?
talk more to the patient, try to evaluate the potential for self-injury, make sure the patient is
safe.
6. What MENTAL HEALTH nursing priorities will guide your plan of care?
risk for suicide, hopelessness, depression, ineffective coping, low self esteem

7. What interventions will you initiate based on this MENTAL HEALTH priority (ies)?
Nursing Interventions: Rationale: Expected Outcome:
- patient will express her
-Patients considering suicide may display verbal and intent on suicide
-Talk to the patient to evaluate the behavioral cues about their intent to end their life.
potential for self-injury. - make sure room is safe, no sharp objects, no -patient will remain safe
- make sure the evironment is safe sheets, cabinets are locked
-Suicide may be an impulsive act with little or no
- 1:1 watch warning. Close supervision is a must. -patient is safe
-Present opportunities for the patient to -It is helpful for the patient to talk about suicidal
express thoughts, and feelings in a thoughts and intentions to harm themselves. - patient expresses her
Expressing their thoughts and feelings may lessen feelings and thoughts
nonjudgmental environment. their intensity. Also, they need to see that staff are
open to discussion.

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 Volume Deficit, Fluid and Electrolyte Imbalance, Malnourishment

9. What interventions will you initiate based on this PHYSICAL priority (ies)?
Nursing Interventions: Rationale: Expected Outcome:
- administer fluids - to restore fluid deficit - patient hydrate
- BP-low, HR fluctuates because of electrolyte
-Assess vitals- BP, HR, urine imbalance, urine dark color because of dehydration - BP increase, urine
electrolyte imbalances -sign of dehydration yellow
- administer potassium - potassium and magnesium was low because of -levels are improving
starvation
-administer magnesium sulfate

10. What body system(s) will you assess most thoroughly based on the primary/priority concern?
Cardiovascular and Neuro will be assessed most thoroughly.
11. What is the worst possible/most likely complication to anticipate?
Cardiac arrest because of hypokalemia and hypomagnesia. Seizures from
hypomagnesium.
12. What nursing assessments will identify this complication EARLY if it develops?
hypokalemia, hypomagnesima, hyponatremia, cardiac dysrhythmia.
13. What nursing interventions will you initiate if this complication develops?
© 2016 Keith Rischer/www.KeithRN.com Administer medications as prescribed and electrolyte
replacements. Monitor the heart and neuro
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:
V-Tac (ventricular tachycardia)

Clinical Significance:
Life threatening rhythm that can cause cardiac arrest and death. It is present due to low potassium
and magnesium.

When you enter the room to assess Mandy, this rhythm is on the screen:
Cardiac Telemetry Strip:

Rhythm Interpretation:
Sinus Bradycardia

Clinical Significance:
50 bpm- shows the imbalance of magnesium and potassium

© 2016 Keith Rischer/www.KeithRN.com

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 O2 sat: 99% room air Timing:
air

Current Assessment:
GENERAL Appears anxious
APPEARANCE:
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 -Low heart rate results from the body's parasympathetic nervous system trying to
conserve energy- heart is starved and malnourished- monitor to make sure it doesn't
BP: 74/42 deteriorate
- while hypotension is due to a weakened heart muscle and in some cases,
dehydration that occurs commonly alongside anorexia.- also monitor for deterioration

RELEVANT Assessment Data: Clinical Significance:

GENERAL - she could be scared
APPEARANCE:Appears anxious - doesn't know what's going on
NEURO: does not maintain eye - doesn't have control of the situation
contact

2. Has the status improved or not as expected to this point?

Not improved. Her BP and Rate is decreasing which isn't a good sign especially since her
potassium and mag levels are low
3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?
Yes. Keep replacing electrolytes. Monitor HR, bp and general apperance
4. Based on your current evaluation, what are your nursing priorities and plan of care?
Nutritional priority, create a pleasent environment during meals, give small meals and
supplements and snacks. Refer her to a counselor, good mental, social service support.
© 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
Situation:
Mandy White the patient in ED. Went into a 5-second non-sustained ventricular tachycardia

Background:
Already known to ED physician. No need to repeat

Assessment:
The patient was symptomatic and felt lightheaded. Her vital signs are in and assessments are essentially unchanged.
The lower blood pressure has dropped from 86/44 to 74/42. She is currently resting comfortably with no other change
in status.

Recommendation:
IV bolus for low BP, start amiodarone, bolus 150 mg and then start at 1mg/minute as well as facilitate transfer to ICU

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 - need to keep an eye on any cardiac rhythm changes because - EKG placed correctly
of low potassium and magnesium levels. dysrhythmia
Amiodarone 150 mg IV -This medication is used to treat certain types of serious -No dysrhythmias
bolus over 10” followed by (possibly fatal) irregular heartbeat (such as persistent
360 mg over 6 hours (1 ventricular fibrillation/tachycardia). It is used to restore normal
mg/minute) and 540 mg over heart rhythm and maintain a regular, steady heartbeat.
Amiodarone is known as an anti-arrhythmic drug.
the next 18 hours (0.5
mg/minute)
- Fluid bolus can help elevate BP -BP increases
0.9% Normal Saline (NS)
1000 mL IV bolus
-This patient is critical - patient transfered to ICU

Admit to ICU

Medication Dosage Calculation:

Medication/Dose: Mechanism of Action: Volume/time frame to Nursing Assessment/Considerations:
Safely Administer:
Amiodarone Amiodarone is a primarily a class III
antiarrhythmic. It blocks potassium currents 150 mg in 100 mL Hourly Rate to Admin: 600mL/hr
that cause repolarization of the heart muscle
150 mg during the third phase of the cardiac action of D5W - Most common side effects include: dizziness,
potential. As a result amiodarone increases fatigue, bradycardia,
IV bolus the duration of the action potential as well as
the effective refractory period for cardiac hypotension
cells (myocytes). Therapeutic effect is to -Serious reactions include heart failure, worsening of
suppress atrial as well as ventricular
arrhythmias
Hourly Rate to arrhythmia.
-Pulmonary fibrosis is a complication of long-term
Administer: therapy.
-Amiodarone takes up to 2 hours to onset

© 2016 Keith Rischer/www.KeithRN.com

It is now time to transfer Mandy to ICU. Effective and concise handoffs are essential to
excellent care and if not done well can adversely impact the care of this patient. You have done
an excellent job to this point, now finish strong and give the following SBAR report to the
nurse who will be caring for this patient:

SBAR: Nurse-to-Nurse
Situation:
Name/age: Mandy White is a 16 year old woman .
She presented to the emergency department (ED) with increasing weakness,
BRIEF summary of primary problem: lightheadedness and a near syncopal episode this evening. She admits to inducing
vomiting after meals the past three weeks. Her initial rhythm was sinus
bradycardia in the 45 to 50 range. Within 30 minutes she went into a limited run of
ventricular tachycardia for approximately 5 seconds before it terminated. She was
lightheaded but did not lose consciousness during this episode.
She has received 2 g of magnesium IV and currently has potassium chloride infusing
Day of admission/post-op #: and also received 60 mEq of potassium orally.

Background:
Primary problem/diagnosis: Anorexia nervosa with low magnesium and low potassium. She admits to drinking several large glasses of water daily and has also been
recently engaging in self injurious behavior (SIB), cutting both forearms and thighs with broken glass, causing numerous lacerations and
scars. She is 5’5” and weighs 83 lbs/37.7 kg (BMI 13.8). Verbalized to mother a desire to no longer live.

Anorexia nervosa, Depression, Sexually Abused

RELEVANT past medical history:
Mandy is sexually active and promiscuous. She uses the Tinder app to meet older men for anonymous sexual
encounters when her mother is working.

RELEVANT background data:

Assessment:
Vital signs: Vital signs: T: 96.0 F/35.6 C, P: 52, R: 14, BP: 88/48 O2 stst: 100%

RELEVANT body system nursing assessment data:

GENERAL APPEARANCE: Appears anxious
RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort
CARDIAC: Currently SB around 50, 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 and oriented to person, place, time, and situation (x4), flat affect, does not maintain
RELEVANT body system nursing assessment data: 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 Patient denies she has an eating problem in spite of the low
weight and induced vomiting and doesn’t want to be in the hospital.

RELEVANT lab values:

RELEVANT lab values: Hgb: 9.8
Platelets: 85
Sodium: 132
Potassium:1.9
Albumin: 2.5
Magnesium: 1.2
Phosphorus: 1.9

Following new orders have been implemented:

2 nd 1000 mL bolus of NS is infusing

How have you advanced the plan of care? 2nd peripheral IV established
Magnesium 1 mg IV push administered
Amiodarone 150 mg bolus infusing

Patient response: Pending

INTERPRETATION of current clinical status (stable/unstable/worsening): Critical/unstable

Recommendation:
Suggestions to advance plan of care:
Transfer to ICU, monitor EKG, monitor vital signs

Mandy has been transferred to the ICU. Ten minutes later, you hear an overhead page
for “Code Blue” to the same room that Mandy was just transferred to…

© 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?
Nutritional priority, create a pleasent environment during meals, give small meals and
supplements and snacks. Refer her to a counselor, good mental, social service support.

2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?
Have the patient repeat what you explain to her. Make sure she includes the important
parts.

Caring and the “Art” of Nursing

1. What is the patient likely experiencing/feeling right now in this situation?
The patient is likely experiencing or feeling pain, anxiety and fear.

2. What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a
person?
Show that you care. Hold their hands, talk to her. Make sure the patient has privacy. Listen
to the patient.

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?
I learned about hypokalemia and hypomagnesemia. How important they are in our diet. If
the level are low, it affects the rhythm of our heart.

2. How can I use what has been learned from this scenario to improve patient care in the future?
I know how to treat a patient that has anorexia and depression. It very difficult to treat
these patients because they don't open up to outsiders.

© 2016 Keith Rischer/www.KeithRN.com