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STUDENT-Eating - Disorder-F&E-UNFOLDING Reasoning
STUDENT-Eating - Disorder-F&E-UNFOLDING Reasoning
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
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
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
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).
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
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
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
Rhythm Interpretation:
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
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!
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
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.
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.
Establish peripheral IV x2 -with two iv sites you can infuse multiple fluids and medications - site established, clean with no
signs of infection
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
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
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
Admit to ICU
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.
Assessment:
Vital signs: Vital signs: T: 96.0 F/35.6 C, P: 52, R: 14, BP: 88/48 O2 stst: 100%
How have you advanced the plan of care? 2nd peripheral IV established
Magnesium 1 mg IV push administered
Amiodarone 150 mg bolus infusing
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…
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.
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.
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.