Fast Questions and Case Studies
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The client is a hospitalized 74-year-old recovering from a cholecystecomy with a history of MI 2 years ago, adrenalectomy 4 years ago, and COPD. Client quit smoking 7 years ago.
Temp: 99.8º F, HR 105 BPM; BP 90/58 mm Hg; RR 16 bpm. Pain 2 on a scale of 0 to 10. SpO2 = 95% on RA
1000 am: Client is drowsy this morning with severe nausea, vomiting, and diarrhea. Client is able to answer questions and states that he feels weak and very tired. Lungs clear to auscultation, all peripheral pulses palpable 1+, no generalized edema, hyperactive bowel sounds x 4 quadrants, skin moist and pale. Foley w/urine output of 20ml/hr. Urine is dark and concentrated.
- Sodium 130 mEq/L (135-145 mEq/L)
- Potassium 5.3 mEq/L (3.5-5 mEq/L
- Chloride 96 mEq/L (96-106 mEq/L)
- Blood Urea Nitrogen 20 mg/dl (7-20 mg/dl)
- Creatinine 1.3 mg/dl (0.7-1.3 mg/dl)
- Blood Sugar 58 mg/dl (100-125 mg/dl)
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For each body system below, click to specify the assessment finding(s) that needs follow up. Each body system may support more than one assessment finding.
Rationale
- The first thing you should have noticed is that the client had an ADRENALECTOMY. Anyone with an adrenalectomy needs to be on life-long steroids. During surgery/stress clients need extra steroids to prevent Addisonian crisis. If you don’t see this yet, go back and review the content please.Â
- Everything points to an Addisonian crisis: all the hypo’s except for one hyper. Right? Hypotension, hypovolemia, hyponatremia, hypoglycemia, and hyperkalemia. It is all there.Â
- For the treatment: fluid resuscitation, glucose, and the steroids. The low urine output is due to hypovolemia and the low BP is due to the Addisonian Crisis and hypovolemia. There is no need to start dopamine or irrigate Foley.
- Sodium 134 mEq/L (135-145 mEq/L)
- Potassium 5.0 mEq/L (3.5-5 mEq/L
- Chloride 96 mEq/L (96-106 mEq/L)
- Blood Urea Nitrogen 20 mg/dl (7-20 mg/dl)
- Creatinine 1.3 mg/dl (0.7-1.3 mg/dl)
- Glucose 101 mg/dl (100-125 mg/dl)
Follow up note: 1130: Client continues to be drowsy, but still answers questions. peripheral pulses 1+. skin dry but pale. Urine output 20 ml last hour. Vital signs: Temp 98.6 º F, BP 105/56, HR 99 BPM, RR 16 regular and unlabored.Â
Use the above case study to answer these questions
Stand Alone Questions
Case Study
A 59-year-old male client is admitted with COPD exacerbation. The client is on oxygen 2L nasal cannula at home. The client has a history of CHF, DM, and CKD stage 4. Home medications include: ipratropium-albuterol inhaler, beclamethasone inhaler, oral dexamethasone for the last 6 months, digoxin, captopril, and furosemide.
Client is alert, oriented, but restless. Noted truncal obesity with supraclavicular fat pads and thin extremities, and barrel chest. Bruising noted to both arms and straiae over trunk and thighs. Lungs diminished in all fields. Client is using pursed-lip breathing. Client states that he is having difficult breathing. S1, S2 present, no additional heart sounds. No peripheral edema. BS present x 4 quadrants. Moves all extremities equally.
Temp: 98.6º F, BP 168/55, HR 89, RR 24 BPM, Oxygen saturation on 2L NC 90%.
Admission Labs:
- Sodium 145 mEq/L (135-145 mEq/L)
- Potassium 3.4 mEq/L (3.5-5 mEq/L
- Chloride 105 mEq/L (96-106 mEq/L)
- Blood Urea Nitrogen 20 mg/dl (7-20 mg/dl)
- Creatinine 1.3 mg/dl (0.7-1.3 mg/dl)
- Blood Sugar 289 mg/dl (100-125 mg/dl)