Clinical II – SIM 4 – Case Studies

*to be done early in the semester

Case Study 1

Scenario

P.M., 24-year-old house painter, 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 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; 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

☐ Neurologic:

☐ Respiratory:

☐ Cardiovascular:

☒ Gastrointestinal: Hepatomegaly with tenderness, nausea, vomiting, and scleral jaundice suggest liver dysfunction.

☒ Genitourinary: Dark urine indicative of bilirubin excretion.

☒ Musculoskeletal: Joint and muscle pain reported.

☒ Skin: Scleral jaundice observed.

☒ Pain: Generalized muscle and joint aches present.

Case Study Progress

P.M. is manifesting key signs of hepatitis. Laboratory work is requested for identification of his precise problem.

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

Diagnostic tests include ALT, AST, bilirubin levels, ALP, and specific serological markers (Anti-HAV, HBsAg, and anti-HCV) to determine the type of hepatitis.

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

 

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

Elevated ALT (66 units/L), AST (52 units/L), total bilirubin (2.3 mg/dL), indirect bilirubin (1.6 mg/dL), and abnormal urobilinogen indicate liver damage and dysfunction (Lala et al., 2020).

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

HBsAg is the surface antigen of the hepatitis B virus, signifying active infection. HBsAb is the antibody indicating immunity post-infection or vaccination (Gao et al., 2022).

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

Chronic alcohol consumption and excessive acetaminophen use exacerbate hepatic injury and increase ALT levels.

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

A high-calorie, low-fat diet rich in carbohydrates and protein is recommended to reduce liver stress and promote recovery, as stated by Hansen et al. (2023).

7. For each characteristic below, identify whether it describes hepatitis A (A) or hepatitis B (B).  

____Hepatitis A__a. Fecal-oral transmission.

____Hepatitis B__ b. Transmitted by sharing needles.

____Hepatitis B__ c. Transmitted by blood transfusions.

____Hepatitis B __ d. Vaccination is a three-shot series.

____Hepatitis A__ e. Illness is usually mild, similar to a flulike infection.

____Both__ f. Symptoms include anorexia, nausea, vomiting, fever, fatigue, and jaundice.

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?  

Hepatitis B is contagious. Use standard precautions, including wearing gloves, proper disposal of sharps, and sanitization of equipment.

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

Interventions include antihistamines, cool baths, emollients, avoiding hot showers, and maintaining hydration.

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

Hepatitis B typically resolves in acute cases but may progress to chronic liver disease. Encourage adherence to follow-up and abstaining from alcohol.

11. P.M. is living at home with his parents and four younger siblings. The youngest is 4 years old. His parents ask how to prevent the rest of the family from getting hepatitis. What specific instructions will you give?  

Vaccinate uninfected members, avoid sharing personal items, and emphasize hand hygiene.

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

 Use teach-back techniques to confirm comprehension of preventive measures and care instructions.

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

Emphasize limiting alcohol, proper nutrition, safe practices (e.g., avoiding needle sharing), and attending follow-ups.

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 is not able to go back to work & he hopes his family is not too afraid to have him return home.

14. What action will you take?  

Provide counseling for guilt and emotional distress, and refer P.M. to support groups or financial aid programs.

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	To compensate for reduced blood volume
Blood pressure	Decreased	Due to hypovolemia
Serum hematocrit	Increased	Due to hemoconcentration
Urinary output	Decreased	With concentrated urine
Urine specific gravity	Elevated	Due to dehydration
Weight	Decreased	From fluid loss

 

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

Thirst.

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

Isotonic solutions (e.g., 0.9% saline, lactated Ringer’s) restore extracellular fluid.

The preceptor tells you to go ahead & initiate an IV site and start the fluids. The fluid order is to start 1000 mL of fluid as ordered at 150 mL/hr. The infusion tubing has a drop factor of 15 gtt/mL.

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) 

Rate = (150 Ml/hr × 15gtt/mL) ÷ 60 = 37.5 gtt/min. Round to 38gtt/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.

Avoid tattooed areas prone to infection; consider non-tattooed sites or use a vein finder.

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?

Use warm compresses, lower the limb, or lightly tap the vein.

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?

Stop infusion, assess for infiltration, and check for redness or swelling.

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.

Encourage oral hydration with preferred fluids, schedule regular drinking intervals, and use electrolyte-rich beverages.

• 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?

Highlight wearing breathable clothing, taking hydration breaks, and using shade during work.

*Turn in to SIM4 Case Study Folder in D2L Dropbox

References

Gao, N., Yu, H., Zhang, J., Mo, Z., Chu, J., Xie, C., Peng, L., & Gao, Z. (2022). Role of hepatitis B surface antibody in seroreversion of hepatitis B surface antigen in patients achieving hepatitis B surface antigen loss with pegylated interferon‐based therapy. Journal of Viral Hepatitis, 29(10), 899–907. https://doi.org/10.1111/jvh.13734

Hansen, C. D., Gram-Kampmann, E.-M., Hansen, J. K., Hugger, M. B., Madsen, B. S., Jensen, J. M., Olesen, S., Torp, N., Rasmussen, D. N., Kjærgaard, M., Johansen, S., Lindvig, K. P., Andersen, P., Thorhauge, K. H., Brønd, J. C., Hermann, P., Beck-Nielsen, H., Detlefsen, S., Hansen, T., & Højlund, K. (2023). Effect of calorie-unrestricted low-carbohydrate, high-fat diet versus high-carbohydrate, low-fat diet on type 2 diabetes and nonalcoholic fatty liver disease. Annals of Internal Medicine, 176(1), 10–21. https://doi.org/10.7326/m22-1787

Lala, V., Goyal, A., Bansal, P., & Minter, D. A. (2020). Liver function tests. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/29494096/

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Case Study 1

Scenario

P.M., 24-year-old house painter, 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 skin. He reports headaches, joint pain, a low-grade fever, cough, anorexia, & nausea and vomiting (N/V), especially after eating any fatty food.

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; 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

☐ Neurologic:

☐ Respiratory:

☐ Cardiovascular:

☐ Gastrointestinal:

☐ Genitourinary:

☐ Musculoskeletal:

☐ Skin:

☐ Pain:

Case Study Progress

P.M. is manifesting key signs of hepatitis. Laboratory work is requested for identification of 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

 

3. Which of P.M.’s laboratory results specifically indicate liver disease?
   
4. What is the difference between the hepatitis B surface antigen (HbsAg) and the hepatitis B surface antibody (HbsAb)?  

 

5. What factors in his history could have compounded the increased ALT levels?  
6. Considering the basic pathology of hepatitis, what type of diet will you strongly encourage P.M. to follow? 
7. For each characteristic below, identify whether it describes hepatitis A (A) or hepatitis B (B).  

______a. Fecal-oral transmission.

______ b. Transmitted by sharing needles.

______ c. Transmitted by blood transfusions.

______ d. Vaccination is a three-shot series.

______ e. Illness is usually mild, similar to a flulike infection.

______ f. Symptoms include anorexia, nausea, vomiting, fever, fatigue, and jaundice.

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?  

 

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

 

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

 

11. P.M. is living at home with his parents and four younger siblings. The youngest is 4 years old. His parents ask how to prevent the rest of the family from getting hepatitis. What specific instructions will you give?  

 

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

 

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

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 is not able to go back to work & he hopes his family is not too afraid to have him return home.

14. What action will you take?  

 

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
Blood pressure
Serum hematocrit
Urinary output
Urine specific gravity
Weight

 

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

 

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

The preceptor tells you to go ahead & initiate an IV site and start the fluids. The fluid order is to start 1000 mL of fluid as ordered at 150 mL/hr. The infusion tubing has a drop factor of 15 gtt/mL.

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)
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.  

 

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? 
   

   Clinical II – SIM 4 – Case Studies

 

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?  

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.  

• 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?  

*Turn in to SIM4 Case Study Folder in D2L Dropbox