medical-surgical floor case study

QUESTION

You are an LPN working on a medical-surgical floor in a team that consists of an RN and a medical assistant. Read through some of the chart entries over a 48-hour period and answer the questions at the end. Please make sure you cite any sources using APA format. You will find when there is a major clue.

0130: Admission nurses note (RN): Client arrived via EMS from long-term-care for evaluation of “low blood sugar.” Pt. arrived confused (alert and oriented X 1) and is a known diabetic. Finger stick was 45. Orange juice and crackers, given repeat finger stick 104. Pt now alert and oriented X 4. Report from the charge nurse at the long-term-care facility indicates that the client has been having frequent bouts of hypoglycemia.

0530: (RN) Foley catheter inserted for incontinence–pt. “too weak” to get up to the bathroom and is experiencing bouts of incontinence.

600 mL clear yellow urine noted. The nurse indicates that the ER is “very busy” and “short-staffed.” 0545 (Admitting Physician) See history and physical. Pt. admitted to the medical-surgical service for evaluation of recurrent hypoglycemia.

View the ER chart before the pt. is transferred to the floor:

0730: (RN) Report is given to RN on 3 North.

Emergency Department Chart

Client: Mabel Simpson

DOB: 4/23/1941

Admission Date 8/16/2019

Medical Diagnosis: recurrent hypoglycemia

Allergies: None

Vitals/ Data Collection: Temp.- 97.3 PO

History: Diabetes (insulin dependent)

Medications: Insulin R titrated to finger sticks

Allergies: None

Vitals/ Data Collection: Pulse- 68

History: Hypertension

Medications: Furosemide 20 MG twice per day

Allergies: None

Vitals/ Data Collection: Respirations- 18

History: Atrial Fibrillation

Medications: Warfarin 5 Mg Mon, Wed, Fri 2 Mg Tues, Thurs

Allergies: None

Vitals/ Data Collection: Blood Pressure- 122/86

History: Rheumatoid Arthritis

Medications: Enalapril 5 Mg once per day

Allergies: None

Vitals/ Data Collection: No C/O pain

History: Mild Heart Failure (class 1)

Medications: Proventil inhaler as needed for wheezing

Allergies: None

Vitals/ Data Collection: Alert and oriented X 4

History: Former Smoker- smoked 1 pack per day X 40 years- last smoked 10 years ago

Medications: Methotrexate 2.5 Mg per day

Allergies: None

Vitals/ Data Collection: Lungs: No adventitious sounds

History: Appendectomy as a child

Medications: Tylenol 650 Mg as needed for pain or fever

Allergies: None

Vitals/ Data Collection: + Bowel sounds

History: Mobility (baseline): able to ambulate slowly with minimal assist

Clear yellow urine draining from Foley catheter in adequate amts.

Medications:

Allergies: None

Vitals/ Data Collection: Clear yellow urine draining from Foley catheter in adequate amts.

History:

Medications:

Allergies: None

8/16/2019

10:00: (RN) Pt received on 3 North. Alert and oriented X 4. Fingerstick 81. Eating breakfast. Offering no complaints.

8/17/2019 (Medical Assistant)

0130: Sleeping Soundly

0700: (LPN) alert and oriented Finger stick 124. Offering no complaints. Medications given as ordered. Foley catheter draining cloudy yellow urine- RN notified.

1100: (Case Manager note): Pt. alert and oriented. Blood sugar stable. Will speak to the physician about discharge tomorrow morning.

1300: (Physical Therapy): Ambulated to the hallway 200 feet. Ambulates slowly- baseline as per long-term-care facility charge nurse. Recommend physical therapy after discharge, however, ambulated well enough for discharge.

1600: (LPN) Pt found to be confused (alert and oriented X 1). RN notified. Fingerstick 130. Vitals 97.5 (axillary), 110, 24, 98/64

1800: (Medical assistant) 400 cc’s emptied from catheter bag.

0100: (RN) Pt confused and combative. Attempting to pull out her IV and repeatedly removing her gown. Pt’s physician was paged- ordered Lorazepam 1 MG IM. Medicated as ordered and slept the remainder of the night with no incident.

0700: (RN) Pt awake and alert but combative. Finger stick-124. Vitals: 98.9 (axillary), 116, 28, 90/55

1730: (LPN) Unable to administer medication. Pt appears extremely confused. RN notified.

1200: (LPN) Pt’s daughter at bedside. Daughter indicates that her mother is not normally confused and is concerned that she may have had a stroke and notes that her mom feels “very warm.” RN notified. Foley catheter draining cloudy urine.

1230: (Medical Assistant) Vital signs: T 103.6 (rectal), P=130, BP=84/43, resp rate=28

1300: (RN) Rapid response called (because of the change in condition) and client transferred to the ICU.

Update: The client spent 3 days in the ICU but unfortunately did not recover.

Please answer the following questions:

1. Why did this client become confused and combative?
2. What pivotal decision made in the ER directly caused this client’s worsening condition?
3. What type of incontinence did this client have? Explain your answer. (5-10 sentences)
4. What factors in the client’s medical history contributed to the client’s change in condition?
5. How did communication (or lack thereof) contribute to the poor outcome for this client?

ANSWER

Why did this client become confused and combative?

The client’s confusion and combative behavior can be attributed to multiple factors. Firstly, the elevated temperature of 103.6°F indicates the presence of fever, which can cause delirium and altered mental status. Secondly, the client’s vital signs show signs of hemodynamic instability, including a low blood pressure of 84/43 and a rapid pulse rate of 130. This suggests inadequate perfusion to the brain, leading to altered mental status. Additionally, the client’s history of hypertension, atrial fibrillation, and rheumatoid arthritis may contribute to the development of cognitive impairment or delirium. Lastly, the client’s aggressive behavior can be a manifestation of delirium, as it often presents with agitation and restlessness.

What pivotal decision made in the ER directly caused this client’s worsening condition?

The pivotal decision made in the ER that directly caused this client’s worsening condition was the decision to transfer the client to the medical-surgical floor without addressing the underlying cause of the recurrent hypoglycemia. The client’s primary complaint was “low blood sugar,” and the fingerstick upon admission was 45. While the initial treatment of providing orange juice and crackers raised the blood sugar level to 104, the root cause of the hypoglycemia was not investigated further. Failure to identify and address the underlying cause of the hypoglycemia could have resulted in recurrent episodes and subsequent complications, including confusion and combative behavior.

What type of incontinence did this client have? Explain your answer.

The client exhibited functional incontinence. Functional incontinence occurs when a person has difficulty reaching the bathroom or using the toilet due to physical or cognitive impairments. In this case, the client was experiencing bouts of incontinence because he was “too weak” to get up to the bathroom. This suggests a physical limitation that impairs the client’s ability to control his bladder function. The client’s reported weakness and inability to ambulate may be contributing factors to functional incontinence.

What factors in the client’s medical history contributed to the client’s change in condition?

Several factors in the client’s medical history may have contributed to the change in condition. These include the client’s history of diabetes, hypertension, atrial fibrillation, rheumatoid arthritis, and mild heart failure. Uncontrolled diabetes can lead to complications such as hypoglycemia, which was the primary complaint upon admission. Hypertension, atrial fibrillation, and heart failure can all contribute to hemodynamic instability, compromising blood flow to vital organs and potentially leading to altered mental status. Additionally, rheumatoid arthritis and associated medications can contribute to systemic inflammation, which may impact overall health and potentially exacerbate cognitive impairment.

How did communication (or lack thereof) contribute to the poor outcome for this client?

The lack of effective communication among the healthcare team members likely contributed to the poor outcome for this client. Communication breakdowns can lead to delays in addressing critical issues and coordinating appropriate interventions. In this case, there were instances where the LPN and medical assistant noted concerning changes in the client’s condition but failed to effectively communicate these findings to the RN. For example, the LPN was unable to administer medication and found the client extremely confused but only notified the RN. Additionally, the client’s daughter expressed concerns about her mother’s confusion and high fever, but there was no indication that this information was promptly relayed to the healthcare team. Timely and accurate communication is essential for early recognition and intervention in deteriorating patients, which could have potentially improved the client’s outcome.