Case study:  A 68 year old client presents to the emergency department with severe fatigue and a 4 day history of vomiting. The individual states he had very little to eat or drink during the last 4 days due to nausea. The client also reports he has not taken his prescribed medications due to the vomiting.

Admission vital signs:  Temperature 102.7 F, heart rate 116, respiratory rate 20 breaths / minute, blood pressure 86/54

Admission assessment findings:  Dry mucus membranes, tenting of the skin on the hands and arms, dark amber urine and the client reports having less urine than usual, nausea and vomiting, lethargy, muscle weakness.

Medical history: Hypertension, hyperlipidemia, history of heart failure, the client reports that a household family member had a confirmed case of influenza recently.

Laboratory values:  Sodium 150, potassium 5.5, chloride 110, BUN 42, creatinine 0.8, pH 7.32, PaC02 35, HC03- 20, Pa02 90, 02 saturation (pulse ox) on room air 98%

Physician (HCP) orders: Insert IV and infuse 0.45% normal saline at 100 ml/hour, monitor vital signs every 2 hours and administer routine medications when it is appropriate.  Medications: furosemide 40 mg by mouth daily in AM, metoprolol 25 mg by mouth 2 times a day.

Discussion Questions:

1. What type of fluid balance problem is the client exhibiting?
2. Discuss each of the electrolyte abnormalities present. What signs and symptoms would you expect for each one? How would each be treated? Provide rationale.
3. What is a collaborative plan of care for this client? What was the rationale for the IV fluids ordered? What would be the most appropriate course of action related to the client’s routine medications immediately following admission?
4. What are the nursing considerations related to the client’s medical history, history of present illness and the treatment plan?
5. What is your interpretation of this arterial blood gas sample? Discuss anticipated signs and symptoms for the ABG interpretation.
6. Explain the high potassium in this client.
7. SBAR note: Write an SBAR note from the perspective of the nurse calling the provider (HCP) related to the scenario following the client’s admission to the medical-surgical unit.

ANSWER

Comprehensive Nursing Analysis of a Complex Medical Case

The presented case involves a 68-year-old client admitted to the emergency department with severe fatigue, vomiting, and a myriad of concerning symptoms. This comprehensive analysis will address the clinical presentation, electrolyte abnormalities, collaborative plan of care, nursing considerations, arterial blood gas interpretation, high potassium, and the development of an SBAR note.

Fluid Imbalance

The client is exhibiting signs of hypovolemic shock, a type of fluid imbalance. The low blood pressure, increased heart rate, dry mucus membranes, tenting of skin, dark amber urine, and decreased urine output are indicative of hypovolemia, a state characterized by inadequate circulating blood volume.

Electrolyte Abnormalities

The laboratory values show elevated sodium (hypernatremia) and elevated potassium (hyperkalemia). Hypernatremia can cause dehydration, dry mucous membranes, and lethargy. Hyperkalemia can result in muscle weakness and cardiac arrhythmias. Treatment for hypernatremia includes fluid replacement, while hyperkalemia might require administering medications like calcium gluconate, insulin and glucose, or sodium bicarbonate.

Collaborative Plan of Care

The collaborative plan includes administering IV fluids (0.45% normal saline) to address hypovolemia. The rationale for IV fluids is to replenish fluid volume and improve perfusion. Routine medications are withheld due to vomiting. Furosemide and metoprolol may be resumed once vomiting is controlled and fluid balance stabilized.

Nursing Considerations

Given the client’s history of heart failure and hypertension, monitoring fluid balance, vital signs, and cardiac status is crucial. The history of a family member with influenza raises concerns about potential infection transmission. The client’s vomiting history indicates a need for antiemetic therapy to prevent further dehydration.

Arterial Blood Gas (ABG) Interpretation

The ABG shows a pH of 7.32, PaCO2 of 35, and HCO3- of 20. This indicates metabolic acidosis, possibly due to vomiting and decreased intake. Signs might include lethargy, confusion, and Kussmaul breathing. Treatment may involve fluid replacement and addressing the underlying cause.

High Potassium Interpretation

The elevated potassium could be attributed to the acute kidney injury resulting from dehydration. Kidney dysfunction impairs potassium excretion, leading to hyperkalemia.

SBAR Note

Subject: Urgent Update on Admitted Patient
Background: The 68-year-old patient was admitted with severe fatigue, vomiting, and dehydration symptoms. History of hypertension, heart failure, and recent family influenza exposure.
Assessment: Patient’s vitals show low BP (86/54), elevated HR (116), dry mucous membranes, and dark amber urine. Sodium (150) and potassium (5.5) levels are elevated.
Recommendation: I recommend IV fluid replacement (0.45% NS) for hypovolemia and close monitoring of vital signs, fluid balance, and cardiac status. Routine medications withheld due to vomiting. Consider interventions for hypernatremia and hyperkalemia as needed.

In conclusion, this complex case demands an integrated approach to address fluid imbalance, electrolyte abnormalities, and overall patient well-being. By understanding the underlying pathophysiology, nurses can develop a comprehensive care plan that aligns with evidence-based practice, thus optimizing patient outcomes.