Week 2 Basic Clinical Case Study PDF

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Clinical Case Study: Week 2

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Eating Disorder/Electrolyte Imbalance Clinical Case Study Davie Shatil Keiser University

History of Present Problem and Personal/Social History: 1. What data from the histories are RELEVANT and has clinical significance to the nurse? Relevant Data from Present Problem: ● Mandy is a 16 year old female who has been struggling with anorexia for 5 years. She self injures herself by cutting both her forearms and thighs with broken glass, and makes a statement to her mother saying, "I hate everything about me! I am so tired of living, I wish I were dead!" Mandy initially came to the ED with increasing weakness, lightheadedness, and a near syncopal episode that same evening. Mandy admits to inducing vomiting after meals the past three weeks and is 5'5" and weighs 83lbs with a BMI of 13.8. Clinical Significance: ● Weakness, lightheadedness, and a near syncopal episode may be a side effect from a possible electrolyte imbalance. Mandy is 5’5” and weighs 83lbs with a BMI of 13.8 which indicates that she is malnourished. Mandy continues to induce vomit after eating and admits to only drinking several large glasses of water which makes me believe even further that she has some sort of malnutrition and electrolyte imbalance. Mandy may also be suicidal because she self-harms herself, and told her mom “I hate everything about me! I’m so tired of living, I wish I were dead!” A sitter may be required to stay with

Clinical Case Study: Week 2

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Mandy to prevent her to do any harm to herself. Relevant Data from Social History: ● Mandi was sexually abused by her ex-stepfather. She lives with her mom, who divorced her ex-stepfather when she found out about the sexual abuse. Mandi is sexually active and promiscuous and uses Tinder to meet older men while her mother is working. Clinical Significance: ● The sexual abuse on Mandi may have caused her trauma and a consult for a mental health evaluation may be necassary. Mandi’s mom is not able to watch her while she is at work, so a babysitter may be necessary. Sexually active and promiscuous activity raises Mandi’s chances of contracting sexually transmitted infections that may cause infertility, reproductive disorders and UTIs. Also, she is at risk of getting pregnant. What VS data is relevant and must be recognized as clinically significant by the nurse? ● Relevant VS Data: ○ Her temperature is 96.2 F ○ Her BP is low: 86/44

● Clinical Significance: ○ Mandi’s body may be cooling down to save energy and calories. ○ Her BP may be low due to emesis and bleeding.

What physical assessment data is relevant and must be recognized as clinically significant by the nurse? ● Relevant Physical Data:

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○ Cardiac: Pitting edema of her feet and ankles, and weak pulses ○ GI: Abdominal scaphoid. Several 1 cm open ulcers in oral mucosa and her oral mucosa is dry and tacky. Hypoactive bowel sounds

● Clinical Significance: ○ Excess sodium may be present in her body due to hypovolemia causing water to pool in her extremities. Her weak pulses are due to hypovolemia. Due to inadequate nutrition and dehydration. May indicate she has an infection or that she is dehydrated. Mandi may have had an empty stomach due to emesis and intentional inadequate nutrition. Cardiac Telemetry Strip ● Rhythm Interpretation: Abnormal rhythm. ● Clinical Significance: Tissue perfusion and cardiac functions are altered due to hypovolemia.

Lab Results: Complete Blood Count (CBC:)

Current:

WBC (4.5–11.0 mm 3)

High/Low/WNL? 4.0

Previous:

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

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What lab results are relevant and must be recognized as clinically significant by the nurse? ● Relevant Lab Results: ○ WBC - Low ○ HGB - Low ○ Platelets - Low

● Clinical Significance: ○ A low WBC count causes automatic immune disease bone marrow suppression. ○ A low HGB count could be caused by anemia, hemorrhage, or kidney disease. ○ A low platelet count could be caused because of hemorrhage, leukemia, splenomegaly.

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

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

0.9

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What lab results are relevant and must be recognized as clinically significant by the nurse? ● Relevant Lab(s): ○ Sodium - Low ○ Potassium - Low ○ Chloride - Low ○ CO2 - Low ○ Glucose - Low ○ BUN - High ○ Creatinine - High

● Clinical Significance: ○ Na Low: Could indicate cardiac failure, dial obstruction, GI malabsorption. ○ K Low: Could indicate alkalosis, bradycardia, CHF, Crohn's disease, use of diuretics, vomiting. ○ Chloride Low: Causes could be due to metabolic alkalosis, GI losses, CHF. ○ CO2 Low: Could be compensation for metabolic acidosis. ○ Glucose Low: Malnutrition due to hypoglycemia ○ BUN High: Causes may be from CHF, excessive protein in GI tract, GI bleeding, hypovolemia, kidney disease, kidney failure, shock, urinary tract obstruction. ○ Creatinine High: Myasthenia gravis, muscular dystrophy.

● Trend - Improve/Worsening/Stable:

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○ Na is getting worse. ○ K is getting worse. ○ CO2 is getting worse. ○ Glucose is getting worse. ○ BUN is getting worse. ○ Creatinine is getting worse.

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 Female: 70–230 U/l

285

High

155

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): ○ Albumin - Low ○ Alkaline - High ○ Phosphate - High ○ ALT and AST - High

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● Clinical Significance: ○ Can be seen in inflammation, shock, or malnutrition. ○ Can affect teeth and bones and are due to malnutrition and a deficiency in zinc. ○ Elevated ALT can be caused by liver dysfunction. ○ Elevated AST can be caused by liver dysfunction or other tissue damage in the body. ● Trend - Improve/Worsening/Stable: ○ Albumin: Worsening ○ Alkaline: Worsening ○ Phosphate: Worsening ○ ALT and AST: 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

Neg

n/a

n/a

(T3) Triiodothyronine (80-210 ng/dL)

64

Low

n/a

(T4) Thyroxine (0.8-1.8 ng/dL)

0.5

Low

n/a

Thyroid stimulating hormone (0.4-5.0 mIU/L)

0.2

Low

n/a

Thyroid Profile:

What lab results are relevant and must be recognized as clinically significant by the nurse? ● Relevant Lab(s):

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○ Magnesium: Low ○ Phosphorus: Low ○ T3: Low ○ T4: Low ○ TSH: Low ● Clinical Significance: ○ Low magnesium due to malnourishment. Could cause cardiac arrhythmias. ○ Low phosphorus could be from eating disorders, DKA, Vitamin D deficiency. May cause respiratory depression hypertension metabolic acidosis ascending motor paralysis. ○ Low T3 could indicate hypothyroidism. ○ Low T4 indicates hypothyroidism. ○ Low TSH indicate hypothyroidism ● Trend - Improve/Worsening/Stable: ○ All of the levels are worsening.

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

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Bilirubin (neg)

Neg

Blood (neg)

WNL Neg

Nitrite (neg) WNL

WNL Neg

LET (Leukocyte Esterase) (neg) WNL

RBCs (...