Eating Disorder

Eating Disorder/Electrolyte Imbalances Case Study
PERSONAL/SOCIAL HISTORY
What data from the histories are relevant and has clinical significance to the nurse?
Relevant data from present problem: Self-injurious behavior (SIB), increasing weakness, lightheadedness and the likelihood of syncopal episode.
Clinical significance: The data would help identify personal/biological factors causing the patient’s condition.
Relevant data from social history: Sexual abuse by her stepfather, living with a single mom, and sexual behaviors.
Clinical significance: It would help identify social/family factors contributing to the condition.
What is the relationship of your patient’s past medical history (PMH) and current meds? What medications treat which conditions?
PMH
Home Meds:
Pharm. Classification
Expected Outcome

Anorexia nervosa
Depression
Self-injurious behavior (SIB)
Sexually abused as a child
Citalopram 20 mg PO daily
Selective Serotonin Reuptake Inhibitor (SSRI)
Reduction of depressive and eating disorder symptoms and protection against recurrence.
One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in his/her life?
· Circle what PMH problem likely started FIRST.
· Underline what PMH problem(s) FOLLOWED as domino(s).
PATIENT CARE BEGINS
What VS data is relevant and must be recognized as clinically significant by the nurse?
Relevant VS data: T: 96.2 F/35.7 C (oral), BP: 86/44 MAP: 58
Clinical significance: Low body temperature and blood pressure are indicators of hypothermia and hypotension, which are vital signs of anorexia nervosa.
What physical assessment data is relevant and must be recognized as clinically significant by the nurse?
Relevant assessment data: No menses for the past 6 months, dry skin with lanugo body hair, thinning hair on head, and vertical lacerations.
Clinical significance: Diagnosis of anorexia nervosa and other health conditions (dominos).
What MSE assessment data is relevant and must be recognized as clinically significant by the nurse?
Relevant assessment data: Emaciated appearance, generalized weakness, depression symptoms, lack of eye contact, suicidal ideation, and poor insight and poor judgment.
Clinical significance: Diagnosis of mental health issues affecting the patient.
Rhythm interpretation: Regular heart rate since the interval between the R waves is regular.
Clinical significance: Identification of any abnormal components on the EKG.
LAB RESULTS
1. Complete Blood Count (CBC)
What lab results are relevant and must be recognized as clinically significant by the nurse?
Relevant lab(s): Hgb (12–16 g/dL).
Clinical significance: Slightly exceeds the normal range.
Trend (Improve/Worsening/Stable): Stable
2. Basic Metabolic Panel (BMP)
What lab results are relevant and must be recognized as clinically significant by the nurse?
Relevant lab(s): Sodium (135–145 mEq/L), Potassium (3.5–5.0 mEq/L), Chloride (95–105 mEq/L), CO2 (Bicarb) (21–31 mmol/L), Glucose (70–110 mg/dL), BUN (7–25 mg/dl), and Creatinine (0.6–1.2 mg/dL).
Clinical significance: Understanding patient’s generalized weakness and other vital signs.
Trend (Improve/Worsening/Stable): Worsening
3. Liver Function Test
What lab results are relevant and must be recognized as clinically significant by the nurse?
Relevant lab(s): All tests are within normal range.
Clinical significance: Detect any abnormalities in liver function.
Trend (Improve/Worsening/Stable): Stable
4. Misc. Labs and Thyroid Profile
What lab results are relevant and must be recognized as clinically significant by the nurse?
Relevant lab(s): Magnesium (1.6–2.0 mEq/L) and Phosphorus (2.5-4.5 mg/dL)
Clinical significance: To determines any electrolyte disturbances.
Trend (Improve/Worsening/Stable): Stable
5. Urine Analysis
What lab results are relevant and must be recognized as clinically significant by the nurse?
Relevant lab(s): All signs are within normal range
Clinical significance: Detection of urinary tract symptoms
Lab Planning: Creating a Plan of Care with a PRIORITY Lab
Lab: Potassium Value:1.9
Normal Value: Critical Value: 3.7
Clinical significance: Low level of potassium in the blood could indicate hypokalemia.
Nursing assessments/interventions required: Management of vomiting tendencies, which causes loss of potassium.
Lab: Magnesium Value:1.2
Normal Value: Critical Value: 1.7
Clinical significance: Low level of magnesium in the blood could indicate hypomagnesaemia
Nursing assessments/interventions required: Magnesium replacement
CLINICAL REASONING BEGINS
1. What is the primary problem that your patient is most likely presenting with?
Anorexia Nervosa
2. What is the underlying cause/pathophysiology of this primary problem?
Low self-esteem, relationship problems and stressful life events.
Collaborative Care: Medical Management
Care Provider Orders
Rationale
Expected Outcome
Pelvic exam/obtain cultures to assess for STDs
Establish peripheral IV x2
0.9% Normal Saline (NS) 1000 mL IV bolus
Continuous cardiac monitor



Magnesium sulfate 4 gm IVPB over 4 hours. Recheck potassium per hospital protocol

Potassium Chloride 10 mEq IVPB (x4) each dose over 1 hour. Recheck potassium per hospital protocol

Assessment and referral mental health assessment



1:1 sitter/security watch
The patient is sexually active


Patient has shown signs of electrolyte imbalances


Anorexia nervosa is associated with electrolyte imbalances and various cardiac conditions

Patient shows signs of low levels of magnesium in the blood


Patient shows signs of low levels of potassium in the blood


Mental health examination is required given the patient’s depressive symptoms and self-injurious behaviors

Continuous patient assessment
No STDs


Electrolyte replenishment



Detection of any irregular heartbeats and cardiac conditions

Magnesium replacement




Potassium replacement




Detection of any underlying mental health issues



Identification of changes in the patient’s status and condition




PRIORITY Setting: Which Orders Do You Implement First and Why?
Care Provider Orders
Order of Priority
Rationale
Establish peripheral IV
0.9% Normal Saline (NS) 1000 mL IV bolus
Continuous cardiac monitor
1:1 sitter/security watch
Potassium Chloride 10 mEq IVPB x4
Magnesium sulfate 4 gm IVPB over 4 hours.
5
1
4
6
3
2
The patient is sexually active
Patient has shown signs of electrolyte imbalances
Signs of irregular heartbeat need urgent attention to improve the patient’s cardiac wellbeing and avoid further complications
Treatment process requires continuous monitoring to determine effectiveness and any need for changes
Patient shows signs of low levels of potassium in the blood
Patient shows signs of low levels of magnesium in the blood. Magnesium replacement is required before potassium replacement
COLLABORATIVE CARE: NURSING
3. What can the nurse do to establish a therapeutic rapport/relationship in this setting?
The nurse can establish a therapeutic rapport/relationship in this setting through demonstrating an interest in the patient’s life. Using persuasion, the nurse should provide insights regarding the disorder and clarify his/her role in caring for the patient.
4. What principles of therapeutic communication would be relevant to establish a therapeutic relationship?
Some principles of therapeutic communication that are necessary in this setting include ensuring the patient is the primary focus of interaction, maintaining a professional attitude, cautious use of self-disclosure, and avoiding social relationship with the patient.
5. How could the nurse explore her comments that suggest suicidal ideation?
Through asking the patient about her feelings regarding life and probable suicide thoughts.
6. What MENTAL HEALTH nursing priorities will guide your plan of care?
a. Mood and affect
b. Depressive symptoms
c. Suicide ideation
7. What interventions will you initiate based on this MENTAL HEALTH priority (ies)?
Nursing Interventions
Rationale
Expected Outcome
Cognitive-behavioral intervention
Supportive psychotherapy
To address altered mood, perceptions and depressive symptoms
Need to address the patient’s experience and emotional impact
Improve patient’s engagement in the care process and reduce depressive symptoms
Enhanced patient commitment to the recovery process
8. What PHYSICAL nursing priority (ies) will guide your plan of care? (if more than one-list in order of PRIORITY) NANDA-I as well as non-NANDA-I nursing diagnostic statements are relevant and need to be considered in this scenario:
a. Disturbed body image
b. Poor eating habits
c. Self-care deficit
9. What interventions will you initiate based on this PHYSICAL priority (ies)?
Nursing Interventions
Rationale
Expected Outcome
Patient education
Nutritional interventions
Motivational enhancement therapy
Patients with anorexia nervosa have little information regarding the condition and how to cope with it
Promoting appropriate eating habits is essential in management of anorexia nervosa
Positive self-image is critical toward avoiding depressive symptoms and self-injurious behaviors
Enhanced involvement in care and self-care practices by being fully informed
Development of suitable eating behaviors and habits
Improved self-esteem
10. What body system(s) will you assess most thoroughly based on the primary/priority concern?
Body mass index and cardiovascular system
11. What is the worst possible/most likely complication to anticipate?
Electrolyte imbalances and irregular heart beat
12. What nursing assessments will identify this complication EARLY if it develops?
Basic metabolic panel assessment and cardiac assessment
13. What nursing interventions will you initiate if this complication develops?
Treatment using recommended medications
Evaluation: Thirty Minutes later…
Rhythm interpretation: Irregular heart rate
Clinical significance: Could be an indicator of cardiac complications
Rhythm interpretation: Regular heart rate
Clinical significance: The cause of irregular heart rate lasted for a few seconds/minutes
1. What VS data is relevant and must be recognized as clinically significant by the nurse?
Relevant VS Data
Clinical Significance
Temperature and blood pressure
Indicators of hypothermia, hypotension or cardiac arrest
Relevant Assessment Data
Clinical Significance
General appearance, cardiac, and skin
Indicators of changes in the patient’s condition or status
2. Has the status improved or not as expected to this point?
Not as expected to this point.
3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?
Yes. Nursing priority or plan of care needs to address cardiac complications.
4. Based on your current evaluation, what are your nursing priorities and plan of care?
Treatment using recommended medications for cardiac complications relating to anorexia nervosa.
SBAR: Nurse-to-Primary Care Provider
Situation
Anorexia Nervosa
Background
Patient has struggled with anorexia nervosa since aged 11. She has a good fluid intake but engages in self-injurious behavior of cutting both forearms and thighs with broken glass. At the ED, she presents increasing weakness, lightheadedness, and a near syncopal episode. She was sexually abused by her stepfather from the age of six to twelve and lives with her mother who is now divorced. She is sexually active and promiscuous and expressed suicide ideation to her mom.
Assessment
Her primary problem is anorexia nervosa caused by low self-esteem, relationship problems and stressful life events.
Recommendation
Nursing care plan for treatment of anorexia nervosa and cardiac complications
Medical Management: Rationale for Treatment and Expected Outcomes
Care Provider Orders
Rationale
Expected Outcome
12 lead EKG stat
Amiodarone 150 mg IV bolus over 10” followed by 360 mg over 6 hours (1 mg/minute) and 540 mg over the next 18 hours (0.5 mg/minute)
0.9% Normal Saline (NS) 1000 mL IV bolus
Admit to ICU
Anorexia nervosa is associated with electrocardiographic abnormalities and cardiac disorders
Patient has shown signs of irregular heart beat
Patient has shown signs of electrolyte imbalances
Patient is still unstable and requires further monitoring
Reduced electrolytic disturbances
Restoration of normal heart beat and maintenance of a regular, steady heart beat
Electrolyte replenishment
Improved patient monitoring and treatment
Medication Dosage Calculation
Medication/Dose
Mechanism of Action
Volume/timeframe to Safely Administer
Nursing Assessment/Considerations
Amiodarone
150 mg
IV bolus
Blocks sodium channels at fast pacing frequencies
150 mg in 100 mL of D5W
Hourly Rate to Administer: 2 hours
Reduced risk for hypotension and maintenance of effective suppression of arrhythmia
SBAR: Nurse-to-Nurse
Situation
Name/Age: Mandy White, 16 years old.
Brief summary of primary problem: Anorexia nervosa caused by low self-esteem, relationship problems and stressful life events.
Day of admission/post-op #: April 7, 2020
Background
Primary problem/diagnosis: Anorexia nervosa
Relevant past medical history: Citalopram 20 mg PO daily for treatment of depression
Relevant background data: Suffered from anorexia nervosa since aged 11. Has developed self-injurious behaviors, depressive symptoms, and is reluctant to treatment. She has increasing weakness, lightheadedness, and a near syncopal episode at the ED. She lives with her mom who is divorced. She is sexually active and promiscuous and expressed suicide ideation to her mom.
Assessment
Vital signs: Low body temperature and blood pressure.
Relevant body system nursing assessment data: No menses for the past 6 months, dry skin with lanugo body hair, thinning hair on head, and vertical lacerations.
Relevant lab values: Low level of potassium and magnesium in the blood.
How have you advanced the plan of care? Through focusing on mental health nursing and physical health nursing priorities.
Patient response: Has been stable, but had changes in her heart rate due to being lightheaded.
Interpretation of current clinical status (stable/unstable/worsening): Unstable
Recommendation
Suggestions to advance plan of care: Management of anorexia nervosa and associated cardiac complications.
EDUCATION PRIORITIES/DISCHARGE PLANNING
1. If Mandy survives, what will be the most important discharge/education priorities that you will reinforce with her medical condition to help prevent future readmission with the same problem?
Mandy will need more information regarding the condition and how to manage it. She will also receive information on self-care strategies and nutritional plans to help prevent future readmission with the same condition.
2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?
Effectiveness of teaching can be assessed through evaluating the patient’s diet, understanding of the problem, and engagement in self-care activities.
Caring and the “Art” of Nursing
1. What is the patient likely experiencing/feeling right now in this situation?
She is relatively stable and feels better.
2. What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person?
Through constant follow-up to determine her progress while encouraging her.
Use Reflection to Think Like a Nurse
1. What did I learn from this scenario?
This scenario has provided insights on the complexities involved in caring for a person and the need for collaborative care to help improve a patient’s condition and outcomes.
2. How can I use what has been learned from this scenario to improve patient care in the future?
Lessons obtained from this scenario can be used to improve patient care in the future through adopting a collaborative model of care in nursing practice.