Question

Case Study:    Fluid and Electrolytes Imbalance

          Week 2 of 4 is due 01/28/18 by 1159 pm EST

Clinical Reasoning, Decision Making and Critical Thinking

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

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 abd 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.

*****In part 1 of 4 you considered the patient situation and collected relevant cues and information.

Part 2 of 4 will focus on PROCESSING INFORMATION

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

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)

Temperature

Pulse rate

Respiratory rate

Blood pressure

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

80-85%

85-90%

90-95%

95-100%

True or false. Rational for your answer 3 points each. ½ point deducted for incorrect rational. Refer to the table

	T or F	Rational
He is hpertensive from excessive IV fluids	T or F	Rational
He is hypoxic as a result of the extended anesthetic period	T or F	Rational
He is hypotensive from the preoperative bowel prep	T or F	Rational
He is hypertensive as a result of surgical blood loss	T or F	Rational
He has a post operative wound infection	T or F	Rational
He has severe postoperative pain	T or F	Rational
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,you’re your knowledge about fluid balance, which of the two inferences are correct and include the rationals: 5 points

Normotensive and bradycardic

Hypertensive and tachycardic

Febrile and normotensive

Oliguric and tachycardic

Hypertensive and afebrile

Polyuric and hypotensive

Hypotensive and afebrile

Part 2 of 4,   30 possible points.

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Case study 1 of 4, already done. Refer to it as needed

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.

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 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 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)

Temperature

Pulse rate

Respiratory rate

Blood pressure

Ans : Temperature is in normal parameters.

           

The normal values of other vital signs are as followes

Pulse rate                   70-80 beats /mt

Respiratory rate        12-18 res/mt

Blood pressure           120/80mm Hg

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

80-85%

85-90%

90-95%

95-100%

Ans: 95%

True or false. Rational for your answer 3 points each. ½ point deducted for incorrect rational.  

Refer to the table

	T or F	Rational
He is hpertensive from excessive IV fluids	F	No , he is hypotensive since the normal blood pressure levels are 120/80 Hg
He is hypoxic as a result of the extended anesthetic period	F	Not hypoxic , since he has o2 sat level is with in normal i.e 95%
He is hypotensive from the preoperative bowel prep	F	He is hypotensive because has a hemovac and it drained 200 mLs of serous sanguinous drainage over 24 hours.
He is hypertensive as a result of surgical blood loss	F	He is not hypertensive , since his blood pressure is 92/50 mmHg, and due to blood loss hypovolemia occurs and causes hypotention, but not hypertention.
He has a post operative wound infection	F	No wound infection, since,surgical dressing to the mid abdominal area is dry and intact. Even though with a colostomy bag, currently with no effluent noted.
He has severe postoperative pain	F	No Pain due to administration of morphin via cpa pump
He is oliguric from hypotension	T	He is oliguric due to hypovolimia and further hypotention since urine output is 27ml/hr

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,you’re your knowledge about fluid balance, which of the two inferences are correct and include the rationals:  5 points

Normotensive and bradycardic

Hypertensive and tachycardic

Febrile and normotensive

Oliguric and tachycardic

Hypertensive and afebrile

Polyuric and hypotensive

Hypotensive and afebrile

Ans: 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 abd 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.

Oliguric and tachicardiac

            Hypotensive and afibrile       ,

These two statements are correct because, he lost the serous fluid , which also indicated through urinary output, Mr Donald’s urinary output is 27ml/hr. And the heart rate is 118/mt which should be arround 70-80/mt.And obviously in hypovolemia the heartrate increases to compensate the volume to vital organs.

He is hypotensive due to the serous sanginous fluid loss and also due to the surgery he also has a colostamy bag to messure.Afebrile since the temp is normal which is 37 ^oc

			Rational Explain, what physiological changes or compensatory mechanism is causing these symptoms?
a	Color	Pale	Due to blood loss in stools , causing anemia where hemoglobin is reduced
b	Oral mucosa	Dry tongue with furrows	It indicates dehydration
c	Level of thirst	Extremely thirsty	Due to fluid and electrolyte imbalance
d	Pain level	4	Along with CABG has multiple morbitities
e	Appetite	Poor	Colonal Ca ,and anemia may reduce the appatite
f	Cognitive state	Restless and anxious	Due to Multiple morbidity
g	Urine	High specific gravity	Oliguria causes high sp gravity due to concentrated urine.