Question

Clinical Reasoning, Decision Making and Critical Thinking

We will use this scenario and build on it over the next 4 weeks.

Scenario:

Patient is a 68-year male patient who has a history of fluid and electrolyte imbalance. Mr. Donald is status post coronary artery bypass graft (CABG) 3 days ago. He also has multiple co-morbidities, colon cancer, anemia, and hypertension.   Alterations in fluid and electrolyte status are common in the elderly population. Therefore, maintaining and managing fluid and electrolyte balance is of utmost importance in preventing avoidable events, complications and mortality.

Mr. Donald has a history of colon cancer and sought treatment as soon as he noted visible blood in his stool. His bowel patterns are not regular as he experience severe diarrhea or constipation. Gastroenterologist was consulted by the attending physician.

Effective clinical reasoning and decision making skills will aid you in recognizing and managing patient’s change of condition. Oh, I failed to mention, also noting early s/s and intervening in a timing manner.

Now, it is clinical reasoning time.

First, we need to collect relevant data about his current condition. Review the following data:

Temperature	37.0 C
Heart rate	118
Respiratory rate	22
Blood pressure	92/50
Oxygen saturation	96%
Hourly urine output	27 ml/hr
Blood sugar	74 mg/dl

____________________________________________________

What other clinical assessment information do you need to collect? Review the list below and identify 5 of the most relevant assessment findings for Mr. Donald at this time. (3 points each)

			Rational Explain, what physiological changes or compensatory mechanism is causing these symptoms?
a	Color	Pale
b	Oral mucosa	Dry tongue with furrows
c	Level of thirst	Extremely thirsty
d	Pain level	4
e	Appetite	Poor
f	Cognitive state	Restless and anxious
g	Urine	High specific gravity

While relevant data requires you to review current information, it also mandates that you gather new information (recall related knowledge - anatomy, physiology, pathophysiology, pharmacology, etc).

Therefore, a strong foundation of nursing knowledge is needed to help you synthesize and apply that knowledge to nursing practice (I cannot emphasize this enough).

___________________________________________________________________

Answer the following questions with a rational for the right answer:     (3 points each). Failure to submit a rational with the right answer will result in 1.5 point deduction for the question.

Antidiuretic hormone is secreted by the:

Collecting ducts of the kidneys in response to dehydration

Posterior pituitary gland in response to decreased serum sodium levels

Anterior pituitary gland in response to increase serum albumin

Posterior pituitary gland in response to increase sodium osmolality

As an RN assessing Mr Donald with dehydration, you would expect the urine output to be:

Decreased with elevated specific gravity

Increased with elevated specific gravity

Increased with decreased specific gravity

Decreased with decreased specific gravity

The RN understands that oliguria

Is more than 30 mls per hour of urine excretion and is uncommon in the immediate post-operative period

Is common after major surgery, therefore, nothing for you to be concerned about

May be defined as an absence of urine production

Is less than 30 mls per hour of urine excretions, and if left untreated, may lead to acute renal failure.

The RN noted that early morning lab results: BUN 30, creatinine, 1.3, hematocrit 52. The initial nursing intervention is to:

Notify the healthcare provider

Continue monitoring the patient because the results are within normal limits

Decrease the IV rate and then notify the healthcare provider, as lab results indicate overhydration

Evaluate urine output for amount and specific gravity

On admission, Mr. Donald’s hemoglobin level was 9.0 g/dL. The highest priority nursing intervention should be to

Promote skin integrity

Encourage mobility

Conserve energy

Prevent constipation

Answer 1

Antidiuretic hormone is secreted by the:

1. Answer: Posterior pituitary gland in response to increase sodium osmolality

Rationale:

Dehydration (lose proportionately more water than solute (sodium)

↓

Osmolarity of your bodily fluids increases (hyperosmolarity)

↓

Sympathetic stimulation on Posterior Pituitary

                                                ↓

                Antidiuretic hormone release

                                                ↓

Lowers osmolarity (reducing sodium concentration) by increasing water reabsorption in the kidneys to dilute bodily fluids

                               

1. Collecting ducts of the kidneys in response to dehydration

Rationale:

Though collecting ducts acts to increase water permeability to decreased urine formation, only if the hormone aldosterone is present.

1. Posterior pituitary gland in response to decreased serum sodium levels

Rationale:

Dehydration occurs tend to lose proportionately more water than solute (sodium- hypernatremia) not decreased serum sodium levels.

As an RN assessing Mr Donald with dehydration, you would expect the urine output to be:

1. Decreased with elevated specific gravity

Rationale: Dehydration leads to lower blood volume and kidney will not be getting adequate blood to filter and that leads to decreased urine output and when water proportion is less compared to substances in your urine like glucose, bilirubin, red blood cells, white blood cells, crystals, bacteria, or even protein leads to elevation in specific gravity (more concentrated urine).

1. Decreased with decreased specific gravity

Rationale:

Dehydration leads to lower blood volume and kidney will not be getting adequate blood to filter and that leads to decreased urine output and when water proportion is less compared to substances in your urine like glucose, bilirubin, red blood cells, white blood cells, crystals, bacteria, or even protein leads to elevation in specific gravity (more concentrated urine), not decreased specific gravity.

1. Increased with elevated specific gravity

Rationale:

Dehydration leads to lower blood volume and kidney will not be getting adequate blood to filter and that leads to decreased urine output and when water proportion is less compared to substances in your urine like glucose, bilirubin, red blood cells, white blood cells, crystals, bacteria, or even protein leads to elevation in specific gravity (more concentrated urine), not Increased urine output.

The RN understands that oliguria

Answer: Is less than 30 mls per hour of urine excretions, and if left untreated, may lead to acute renal failure.

Rationale:

Normal urine output is 500 ml to 2000 ml.

Less than 30ml/hours indicates oliguria (less than 400 ml/day).

Blood flow into kidney and run through renal capsule is not adequate and persistent low output leads to kidney failure.

Is more than 30 mls per hour of urine excretion and is uncommon in the immediate post-operative period

Rationale:

More than 30 ml per hour of urine excretion is common as surgery is having less effects in fluid imbalance some amount of blood loss would not be causing any.

Is common after major surgery, therefore, nothing for you to be concerned about:

Rationale:

It is not common as surgery is having less effects in fluid imbalance some amount of blood loss would not be causing