Clinical II – SIM 4 – Case Studies

*to be done early in the semester

Case Study 1

Scenario

P.M., a 24-year-old house painter, was too ill to work the past 3 days. Arrived at your outpatient clinic with his girlfriend; he seems alert but acutely ill, with an average build & a deep tan over the exposed areas of his skin. He reports headaches, joint pain, a low-grade fever, cough, anorexia, & nausea and vomiting (N/V), especially after eating any fatty food: Clinical II – SIM 4 – Case Studies.

P.M. describes vague abdominal pain that started about the same time as the other problems. He states that he has been using “a lot of Tylenol” for his pain. His past medical history reveals he has no health problems, is a nonsmoker, & drinks “a few” beers each evening to relax.

Vital signs are 128/84, 88, 26, 100.6 ° F (38.1 ° C); awake, alert, & oriented × 3; moves all extremities well with complaints of aching pain in his muscles; very slight scleral jaundice present; heart & lung sound clear & without adventitious sounds; bowel sounds clear throughout abdomen & pelvis; & abdomen soft & palpable without distinct masses. You note moderate hepatomegaly measured at the midclavicular line; the liver edge is easily palpated & tender to palpation. P.M. mentions that his urine has been getting darker over the past 2 days.

1. Your institution uses electronic charting. Based on the health history and assessment described in the scenario, which of the following systems would you mark as “abnormal” as you document your findings? Mark abnormal findings with an X and provide a brief narrative.  

X Abnormal

Gastrointestinal: P.M. reports anorexia, nausea, vomiting, and abdominal pain, which suggest gastrointestinal issues likely caused by liver dysfunction.

Musculoskeletal: P.M. complains of muscle aches, potentially due to the systemic effects of hepatitis or inflammation from the infection.

Skin: P.M. shows slight scleral jaundice, indicating possible liver dysfunction or damage consistent with hepatitis.

Pain: P.M. experiences tenderness in the liver area (hepatomegaly), suggesting liver enlargement due to inflammation or infection, likely from hepatitis.

Case Study Progress

P.M. is manifesting key signs of hepatitis. Laboratory work is requested to identify his precise problem.

2. Which key diagnostic tests will determine exactly what type of hepatitis is present?

Laboratory Test Results

Sodium Potassium Chloride CO2 BUN Creatinine Platelets Indirect bilirubin Total bilirubin Albumin Total protein ALT AST LDH ALP PT/INR aPTT Urine urobilinogen Anti-HAV IgM HBsAg

140 mEq/L 3.9 mEq/L 102 mEq/L 26 mEq/L 10 mg/dL 1.3mg/dL 210,000/mm3 1.6 mg/dL 2.3 mg/dL 3.8 g/dL 6.5 g/dL 66 units/L 52 units/L 245 units/L 176 units/L 12 sec/1.06 32 sec 1.6 IU/L Negative Negative Positive

The following key diagnostic tests will help determine exactly what type of hepatitis is present based on the laboratory results provided:

1. Anti-HAV IgM:

This test detects the presence of Hepatitis A virus antibodies (IgM). P.M.’s result is negative (1.6 IU/L), meaning he does not have Hepatitis A.

1. HBsAg (Hepatitis B Surface Antigen):

This test detects the presence of Hepatitis B virus (HBV). P.M.’s result is positive (Positive), indicating that he has Hepatitis B and is currently infected. This confirms that P.M. has acute Hepatitis B.

3. Which of P.M.’s laboratory results specifically indicate liver disease? 

The following laboratory results specifically indicate liver disease in P.M.:

• ALT (66 units/L): Elevated, indicating liver cell injury or inflammation, commonly seen in hepatitis.
• AST (52 units/L): Elevated, supports liver inflammation, often elevated with ALT in hepatitis.
• Total Bilirubin (2.3 mg/dL): Elevated, indicating impaired liver function and contributing to jaundice.
• Indirect Bilirubin (1.6 mg/dL): Elevated, further suggesting liver dysfunction.
• LDH (245 units/L): Elevated, indicating liver damage, often seen in hepatitis or liver injury.

4. What is the difference between the hepatitis B surface antigen (HBsAg) and the hepatitis B surface antibody (HbsAb)?  

The Hepatitis B Surface Antigen (HBsAg) is a protein found on the surface of the Hepatitis B virus. A positive result indicates an active infection with Hepatitis B, meaning the person is infected and can transmit the virus. It is used to diagnose acute or chronic Hepatitis B and is present during active infection.

The Hepatitis B Surface Antibody (HBsAb), on the other hand, is produced by the body in response to a Hepatitis B infection or vaccination. A positive result indicates immunity to the virus, either through recovery from infection or vaccination. It helps protect the body from future infections.

What factors in his history could have compounded the increased ALT levels? 

Several factors in P.M.’s history could have compounded his elevated ALT levels:

1. Excessive Tylenol (Acetaminophen) Use: P.M.’s use of large amounts of Tylenol for pain relief can lead to hepatotoxicity, overwhelming the liver’s ability to process the drug and increasing ALT levels.
2. Alcohol Consumption: Regular alcohol use can cause liver damage, including fatty liver disease and alcoholic hepatitis, exacerbating liver inflammation and raising ALT levels.
3. Hepatitis B Infection: The acute Hepatitis B infection itself directly inflames the liver, leading to elevated ALT as the liver cells are damaged and release enzymes into the bloodstream.

6. Considering the basic pathology of hepatitis, what type of diet will you strongly encourage P.M. to follow? 

Given P.M.’s diagnosis of acute Hepatitis B and the pathology of liver disease, the following dietary guidelines should be strongly encouraged to support liver function, aid recovery, and reduce further stress on the liver:

Given P.M.’s diagnosis of acute Hepatitis B, the following dietary guidelines are crucial to support liver function, aid recovery, and minimize further liver stress:

P.M. should follow a high-protein diet to support liver repair, including lean meats, fish, eggs, and legumes. A low-fat, low-cholesterol diet is crucial to reduce liver strain, with healthy fats from avocados, olive oil, and nuts. Adequate carbohydrates from whole grains, fruits, and vegetables provide energy while stabilizing blood sugar.

Hydration is important for detoxification, so P.M. should drink water, herbal teas, and clear broths. Small, frequent meals help manage nausea and maintain steady nutrition. Avoid alcohol, and ensure sufficient vitamins, minerals, and a low sodium intake for overall liver health.

7. For each characteristic below, identify whether it describes hepatitis A (A) or hepatitis B (B).  
8. Fecal-oral Transmission: A

Hepatitis A is primarily spread through the fecal-oral route, usually by consuming contaminated food or water.

1. Transmitted by sharing needles: B

Hepatitis B is transmitted through blood, often through sharing needles (as in intravenous drug use).

1. Transmitted by blood transfusions: B

Hepatitis B can be transmitted through blood transfusions, as it is a bloodborne virus.

1. Vaccination is a three-shot series: B

Hepatitis B requires a three-shot vaccine for long-term protection, typically given over several months.

1. Illness is usually mild, similar to a flulike infection: A

Hepatitis A is often mild and resembles a flu-like illness, with symptoms such as fatigue, fever, and gastrointestinal discomfort.

1. Symptoms include anorexia, nausea, vomiting, fever, fatigue, and jaundice: A and B

Both Hepatitis A and B can present with similar symptoms, including anorexia, nausea, vomiting, fever, fatigue, and jaundice (yellowing of the skin and eyes).

8. In P.M.’s case, the HbsAg is positive. This result indicates that P.M. is infected with hepatitis B and is in the acute period of the disease. Is this disease contagious? What precautions would you take while he is in the hospital?  

 Yes, Hepatitis B is contagious during the acute period, especially when the HbsAg is positive. To prevent transmission in the hospital, the following precautions should be taken: Standard precautions, which include hand hygiene before and after contact, wearing gloves when handling body fluids, and using masks, eye protection, and gowns when splashes are possible.

Place P.M. in a private room and ensure personal items are not shared. Disinfect surfaces and equipment with hospital-grade disinfectants. Dispose of sharps safely. Educate P.M. on Hepatitis B transmission and hygiene and offer vaccination to close contacts.

9. Pruritus is usually associated with jaundice. What will you do to ease this problem for P.M.? Name five interventions.  

Pruritus (itching) associated with jaundice is common in Hepatitis B due to bilirubin buildup. Here are five interventions to ease P.M.’s pruritus:

1. Cool Baths and Compresses: Soak in cool water or use cool compresses to soothe the skin and reduce itching. Encourage P.M. to take cool baths or apply damp, cool cloths several times a day.
2. Calamine Lotion or Antihistamines: Apply calamine lotion to itchy areas or use oral antihistamines (e.g., diphenhydramine) to block histamine responses and reduce itching, especially at night.
3. Topical Steroids: Use hydrocortisone cream to reduce inflammation and itching. Apply it to affected skin areas, avoiding open wounds.
4. Moisturizing Lotion: Use fragrance-free, alcohol-free lotions to keep the skin hydrated and prevent dryness, which exacerbates itching.
5. Avoid Skin Irritants: Advise P.M. to avoid hot showers, use gentle soaps, and wear loose-fitting, cotton clothing to reduce irritation.

9. How will you explain to P.M. the likely progression of his disease?  

To explain the progression of acute Hepatitis B to P.M., I would reassure him that during the acute phase, his liver is inflamed, causing symptoms like jaundice, fatigue, and abdominal pain. Most people recover within 6 months, but some may develop chronic Hepatitis B, leading to cirrhosis or liver cancer.

We’ll monitor his liver function with blood tests. I’d emphasize rest, a healthy diet, and avoiding alcohol. Regular follow-ups are key, and medications can help manage chronic infection.

10. To prevent the spread of Hepatitis B to P.M.’s family, the following precautions should be taken

To prevent the transmission of Hepatitis B, ensure all family members are vaccinated with the three-shot series. Advise P.M. not to share personal items like toothbrushes, razors, or towels, as they may contain blood or body fluids. In this case, central messages should include the importance of hand washing, especially with soap, after using the lavatory. Clear visible fluids, clean surfaces where they touched, and practice safe sex; the regular use of condoms would help.

12. How will you know that these instructions are understood?  

To ensure P.M. and his family understand the instructions for preventing Hepatitis B transmission, the following steps should be taken:

1. Teach-back Method: Ask them to repeat the instructions in their own words to confirm understanding.
2. Demonstration: Show how to wash hands, disinfect areas, and use personal protective equipment.
3. Written Materials: Provide written instructions or flyers as reminders for later reference.
4. Answer Questions: Encourage them to ask any questions to clarify doubts.
5. Follow-up: Schedule a follow-up call to check on their progress and offer additional support if needed.

13. Given P.M.’s lifestyle, what specific patient teaching points must you emphasize?

P.M. should avoid alcohol to prevent further liver damage and limit Tylenol use, consulting a healthcare provider before taking any medications. Practicing good hygiene and preventing transmission through vaccination for family members is crucial. Ensure plenty of rest, follow a liver-friendly diet, and schedule regular follow-up visits to monitor liver function.

Case Study Progress

P.M. is ready for discharge in a few days, & he confides to you that he feels so “guilty” about having hepatitis and endangering his girlfriend and family. He tells you he was at a party and did not think the one-time needle use could hurt him. He has lost his job because he cannot return to work & he hopes his family is not too afraid to have him return home.

14. What action will you take?  

In response to P.M.’s feelings of guilt, I would take the following steps:

1. Provide Emotional Support: Reassure P.M. that many people recover from acute Hepatitis B and that his family is at low risk with the right precautions.
2. Address Stigma: Educate P.M. about transmission and encourage vaccination for his family.
3. Discuss Returning Home: Review precautions like hygiene and not sharing personal items.
4. Job Loss: Suggest speaking with a social worker for financial support.
5. Follow-Up: Schedule regular appointments to monitor his health and provide emotional support.

Case Study 2

As a senior student, you are assigned to work with a preceptor in the emergency department. It is a remarkably busy day, & it seems as if every patient, regardless of chief complaint, has an issue with fluid, electrolyte, and or acid-base balance.

The first patient you see is a thirty-seven-year-old landscaper who is brought to the ED after collapsing on a job at the local country club. He is slightly confused but can tell you he feels dizzy & weak. His skin is flushed, dry, and with poor turgor.

He has dry, sticky mucous membranes. The nurse identifies a nursing diagnosis of deficient fluid volume.

1. Describe how each of the following would change and the rationale for the change in the presence of deficient fluid volume

Parameter	Expected Change	Rationale
Heart rate	Increased (Tachycardia)	When fluid volume is low, the body compensates by increasing the heart rate to maintain cardiac output and perfusion to vital organs.
Blood pressure	Decreased (Hypotension)	Low fluid volume leads to reduced blood volume, causing hypotension as there is less fluid to circulate through the vessels.
Serum hematocrit	Increased	As the body loses fluid, the blood becomes more concentrated, leading to an elevated hematocrit (the percentage of red blood cells in the blood). This is a compensatory mechanism to maintain oxygen delivery despite reduced plasma volume.
Urinary output	Decreased	The kidneys conserve water to prevent further fluid loss, leading to reduced urinary output. This is part of the body’s effort to retain fluid and maintain hydration.
Urine specific gravity	Increased	As the body conserves water, the urine becomes more concentrated, resulting in increased urine specific gravity (the measure of urine concentration).
Weight	Decreased	Fluid loss, without corresponding intake, will result in a decrease in body weight, especially if dehydration is severe. This is due to the loss of water weight.

 

2. What is usually the first indicator that an individual needs more fluids?  

The first indicator that an individual needs more fluids is typically thirst.

• Rationale: Thirst is triggered by the hypothalamus in response to increased blood osmolarity or decreased blood volume, signaling dehydration.

3. The ED physician orders IV fluids for this patient. What types of fluids are indicated for a fluid volume deficit due to dehydration?  

For a patient with fluid volume deficit due to dehydration, the following types of IV fluids are typically indicated:

1. Isotonic Fluids (First-Line Treatment for Fluid Resuscitation):

Examples: Normal Saline (0.9% NaCl) and Lactated Ringer’s (LR)

Rationale: Isotonic fluids help restore intravascular volume without significantly affecting the electrolyte balance. These fluids have a similar concentration of electrolytes as blood, making them ideal for initial fluid resuscitation in dehydrated patients. They expand blood volume and improve circulation.

1. Normal Saline (0.9% NaCl):
   • Rationale: Normal Saline is commonly used to correct hypotension and hypovolemia due to dehydration caused by vomiting, diarrhea, or excessive sweating (Kanbay et al., 2019).
2. Lactated Ringer’s (LR):
   • Rationale: LR contains electrolytes such as sodium, chloride, potassium, and calcium. It helps correct metabolic acidosis that may accompany severe dehydration. LR is often used when there’s an electrolyte imbalance.

4. This infusion will run by gravity rather than an infusion pump. How many drops per minute should you time the infusion at to ensure the correct hourly rate? (See Chapter 22 in “Calculate with Confidence) 

Steps to calculate Drops per Minute:

1. Volume to be infused (mL) = 1000 mL
2. Infusion rate = 150 mL/hour
3. Drop factor = 15 gtt/mL
4. Time in minutes = 60 minutes (for 1 hour)

Formula:

Formula:

Calculation:

We round to 38 gtt/min.

5. The patient has a “full sleeve” tattoo on both arms. Discuss the implications of this finding and how you will initiate the intravenous site.  

A full sleeve tattoo can complicate IV insertion by obscuring veins and making them harder to locate or palpate. The ink and scarring may affect vein visibility, and the skin could be more sensitive or prone to irritation.

To initiate an IV:

1. Assess Non-Tattooed Areas: Start with non-tattooed areas or those with minimal tattoos (upper arms or wrist).
2. Palpate Veins: Feel for accessible veins in both tattooed and non-tattooed areas.
3. Use Ultrasound: If veins are hard to locate, consider ultrasound guidance.
4. Smaller Gauge Needle: Use a smaller gauge (22-24) for tattooed areas.
5. Aseptic Technique: Follow strict aseptic technique to prevent infection.

6. You have difficulty finding a vein in the presence of the deficient fluid volume. What strategies can you employ to help make a vein more visible/palpable?  

To improve vein visibility and palpability in the presence of deficient fluid volume (dehydration), use the following strategies:

1. Apply Heat: Use a warm compress or heating pad for 5-10 minutes to help dilate veins.
2. Hydration: If possible, encourage the patient to drink fluids or administer IV fluids to restore volume and improve vein prominence.
3. Lower the Arm: Position the arm below the level of the heart to help veins fill with blood.
4. Gentle Tapping: Lightly tap or massage the vein to encourage it to dilate.
5. Use a Tourniquet: Apply a tourniquet above the insertion site to engorge veins, making them easier to find.

These methods can help make veins more accessible and easier to insert an IV.

7. After 30 minutes of the infusion, the patient states, “My arm where the needle is feels funny.” What should you do first? What further data do you need from the patient?  

First Action:

1. Stop the Infusion: Immediately stop the IV infusion to prevent further complications, such as infiltration, phlebitis, or other adverse reactions.
2. Assess the Site: Check the IV insertion site for signs of complications, such as swelling, redness, pain, or coolness (which could indicate infiltration of the IV fluid into surrounding tissue).
3. Ensure Patient Safety: Reassure the patient and ensure they are comfortable while you assess the situation.

Several hours later the patient is feeling better & is now oriented x 3. The ED physician wants the patient to be drinking oral fluids without difficulty prior to being discharged from the ED.

8. Discuss the strategies to increase fluid intake that are most appropriate to this setting.  

To increase fluid intake and prepare for discharge, the following strategies can be used:

1. Small, Frequent Sips: Encourage sipping fluids slowly to prevent nausea.
2. Variety of Fluids: Offer water, clear broths, electrolyte drinks, and diluted fruit juices to make drinking more appealing.
3. Use a Straw: If the patient is weak or tired, a straw can help make drinking easier.
4. Right Temperature: Offer fluids at a cool or room temperature for comfort.
5. Monitor and Encourage: Remind and encourage the patient to drink regularly, ensuring hydration goals are met

• The patient is discharged after adequate hydration. Discharge teaching includes ways to prevent this from happening again on the job. What key points should the nurse include in the teaching applicable to the job site?  

To prevent future dehydration at work, encourage the patient to:

1. Drink Fluids Regularly: Stay hydrated with water or electrolyte drinks before, during, and after work, especially in hot conditions.
2. Recognize Early Signs of Dehydration: Watch for symptoms like dry mouth, dizziness, or dark urine and drink fluids immediately.
3. Wear Proper Clothing: Use light, loose-fitting clothes and a hat to reduce heat exposure.
4. Take Breaks in the Shade: Rest in shaded or air-conditioned areas to cool down and rehydrate.
5. Monitor Fluid Intake: Drink electrolyte solutions after physical exertion to replace lost salts and minerals.
   

References

Kanbay, M., Yilmaz, S., Dincer, N., Ortiz, A., Sag, A. A., Covic, A., Sánchez-Lozada, L. G., Lanaspa, M. A., Cherney, D. Z. I., Johnson, R. J., & Afsar, B. (2019). Antidiuretic hormone and serum osmolarity physiology and related outcomes: What is old, what is new, and what is unknown? The Journal of Clinical Endocrinology & Metabolism, 104(11), 5406–5420. https://doi.org/10.1210/jc.2019-01049

ORDER A PLAGIARISM-FREE PAPER HERE

We’ll write everything from scratch

---