Question

1

Case Study: Fluid and Electrolytes Imbalance

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 to keep the patient safe.

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

____________________________________________________

Rational 10 points

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: the courses you thought you did not need:

o anatomy & physiology

o pathophysiology

o pharmacology

o chemistry

o nutrition

• 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).

___________________________________________________________________

Clinical Reasoning, Decision Making and Critical Thinking

PROCESSING INFORMATION

Now, Mr. Donald had a partial colectomy and a colostomy, day 1 post-op. Morphine via PCA pump and an IVF NS + 20 mEq KCL at 75 mL/hr. Experienced insomnia and required 2 bolus of Normal Saline for hypotension. He has a hemovac and it drained 200 mLs of serous sanguinous drainage over 24 hours. Surgical dressing to the mid abdominal area dry and intact. He has a colostomy bag, currently with no effluent noted. Oxygen via nasal cannula at 4 L/min. O2 sat 95% on 02 at 4L via nasal cannula. Blood sugar are well controlled. He lives alone.

The next step of the clinical reasoning cycle is to interpret the data (cues) that you have by carefully analyzing and then applying your knowledge about fluid and electrolyte balance. Remember you must know normal versus abnormal finding to get a complete understanding of Mr. Donald’s signs and symptoms.

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

1. Which of the following of the vital signs are considered to be within normal parameters for Mr. Donald. What are the normal values for the other vital signs? (2 points)

a. Temperature

b. Pulse rate

c. Respiratory rate

d. Blood pressure

2. His 02 sats are OK, right. A normal 02 sat level for Mr. Donald would be: (2 points)

a. 80-85%

b. 85-90%

c. 90-95%

d. 95-100%

True or false. Rational for your answer 3 points each. 1.5 point deducted for incorrect rational. Refer to the table

Statements

T or F

Rational

3. He is hypertensive from excessive IV fluids

T or F

Rational

4. He is hypoxic as a result of the extended anesthetic period

T or F

Rational

5. He is hypotensive from the preoperative bowel prep

T or F

Rational

6. He is hypertensive as a result of surgical blood loss

T or F

Rational

7. He has a post operative wound infection

T or F

Rational

8. He has severe postoperative pain

T or F

Rational

9. He is oliguric from hypotension

T or F

Rational

Now that we identified the relationships above, let’s make inferences based on your analysis. From what you know about your patient’s, Mr. Donald’s history, surgery, s/s, and your knowledge about fluid balance, which pair of inferences are correct? Include the rationals for your choices: 5 points

a) Normotensive and bradycardic

b) Hypertensive and tachycardic

c) Febrile and normotensive

d) Oliguric and tachycardic

e) Hypertensive and afebrile

f) Polyuric and hypotensive

g) Hypotensive and afebrile

************************************************

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.

1. Antidiuretic hormone is secreted by the:

a. Collecting ducts of the kidneys in response to dehydration

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

c. Anterior pituitary gland in response to increase serum albumin

d. Posterior pituitary gland in response to increase sodium osmolality

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

a. Decreased with elevated specific gravity

b. Increased with elevated specific gravity

c. Increased with decreased specific gravity

d. Decreased with decreased specific gravity

3. The RN understands that oliguria

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

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

c. May be defined as an absence of urine production

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

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

a. Notify the healthcare provider

b. Continue monitoring the patient because the results are within normal limits

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

d. Evaluate urine output for amount and specific gravity

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

a. Promote skin integrity

b. Encourage mobility

c. Conserve energy

d. Prevent constipation

6. The unlicensed assistive personnel (UAP) inform the nurse that a postoperative client is complaining of abdominal pain and has a respiratory rate of 28 breaths per minute and O2 sat of 93%. What action should the nurse implement?

a. Assess the client and assist with the use of an incentive spirometer

b. Use a numeric scale to determine client’s pain intensity

c. Administer a prn order for oxygen per nasal cannula

d. Delegate to the UAP to recheck the client’s vital signs in 30 minutes

7. After receiving report from the off-going shift, which client is most likely to have an increased blood pressure since the most recent vital signs 4 hours ago?

a. A 32 year old client with increased urinary output following administration of IV furosemide

b. A 48 year old male receiving amlodipine

c. A 24 year old patient receiving anti-rejection meds following a cardiac transplant

d. A 65 year old male who received two units of packed red blood cells

8. The RN is administering a continuous IV infusion of norepinephrine drip, a potent vasoconstrictor. Which assessment finding indicates that the therapeutic effect has been achieved?

a. Clear breath sound bilaterally

b. Conversion to normal sinus rhythm

c. Increased blood pressure

d. Decrease in central venous pressure

9. The TPN (1 L) is running at 75 mL/hr and. The nurse knows the TPN will be empty in how many hours?

a. 13

b. 14

c. 24

d. 12

10. Pharmacy stated there will be a change in the TPN order due to an elevated potassium level of 5.9. Which action should the nurse take?

a. Notify pharmacy to bring the new bag with the changes in electrolyte in the TPN to the floor

b. Hang D5W via the infusion pump at 15 mL/hr

c. Hang D10W via the infusion pump at 75 mL/hr

d. Notify the healthcare provider that the new TPN is not on the unit

Answer 1

Ans for question 1 Antidiuretic hormone is secreted by the: is D. posterior pituitary gland in response to increase sodium is osmolality.

Justification: as posterior pituitary gland is involved in secretion of of hormones responsible for maintaing osmolality of body.

Ans for question 2

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

a. Decreased with elevated specific gravity.

As dehydration is happened to patient his water level within body and urination was reduced and specific gravity might get increased due to less water availability..

3. Ans for question 3 The RN understands that oliguria

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

4.

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

d. Evaluate urine output for amount and specific gravity

Justification: urination evaluation is the first primary diagnosis test for patients suffering from dehydration.