Clinical Reasoning, Decision Making and Critical Thinking We will use this scena
ID: 239142 • Letter: C
Question
Clinical Reasoning, Decision Making and Critical Thinking
We will use this scenario and build on it over the next 4 weeks.
Scenario:
Patient is a 68-year male patient who has a history of fluid and electrolyte imbalance. Mr. Donald is status post coronary artery bypass graft (CABG) 3 days ago. He also has multiple co-morbidities, colon cancer, anemia, and hypertension. Alterations in fluid and electrolyte status are common in the elderly population. Therefore, maintaining and managing fluid and electrolyte balance is of utmost importance in preventing avoidable events, complications and mortality.
Mr. Donald has a history of colon cancer and sought treatment as soon as he noted visible blood in his stool. His bowel patterns are not regular as he experience severe diarrhea or constipation. Gastroenterologist was consulted by the attending physician.
Effective clinical reasoning and decision making skills will aid you in recognizing and managing patient’s change of condition. Oh, I failed to mention, also noting early s/s and intervening in a timing manner.
Now, it is clinical reasoning time.
First, we need to collect relevant data about his current condition. Review the following data:
Temperature
37.0 C
Heart rate
118
Respiratory rate
22
Blood pressure
92/50
Oxygen saturation
96%
Hourly urine output
27 ml/hr
Blood sugar
74 mg/dl
____________________________________________________
What other clinical assessment information do you need to collect? Review the list below and identify 5 of the most relevant assessment findings for Mr. Donald at this time. (3 points each)
Rational
Explain, what physiological changes or compensatory mechanism is causing these symptoms?
a
Color
Pale
b
Oral mucosa
Dry tongue with furrows
c
Level of thirst
Extremely thirsty
d
Pain level
4
e
Appetite
Poor
f
Cognitive state
Restless and anxious
g
Urine
High specific gravity
While relevant data requires you to review current information, it also mandates that you gather new information (recall related knowledge - anatomy, physiology, pathophysiology, pharmacology, etc).
Therefore, a strong foundation of nursing knowledge is needed to help you synthesize and apply that knowledge to nursing practice (I cannot emphasize this enough).
___________________________________________________________________
Answer the following questions with a rational for the right answer: (3 points each). Failure to submit a rational with the right answer will result in 1.5 point deduction for the question.
Antidiuretic hormone is secreted by the:
Collecting ducts of the kidneys in response to dehydration
Posterior pituitary gland in response to decreased serum sodium levels
Anterior pituitary gland in response to increase serum albumin
Posterior pituitary gland in response to increase sodium osmolality
As an RN assessing Mr Donald with dehydration, you would expect the urine output to be:
Decreased with elevated specific gravity
Increased with elevated specific gravity
Increased with decreased specific gravity
Decreased with decreased specific gravity
The RN understands that oliguria
Is more than 30 mls per hour of urine excretion and is uncommon in the immediate post-operative period
Is common after major surgery, therefore, nothing for you to be concerned about
May be defined as an absence of urine production
Is less than 30 mls per hour of urine excretions, and if left untreated, may lead to acute renal failure.
The RN noted that early morning lab results: BUN 30, creatinine, 1.3, hematocrit 52. The initial nursing intervention is to:
Notify the healthcare provider
Continue monitoring the patient because the results are within normal limits
Decrease the IV rate and then notify the healthcare provider, as lab results indicate overhydration
Evaluate urine output for amount and specific gravity
On admission, Mr. Donald’s hemoglobin level was 9.0 g/dL. The highest priority nursing intervention should be to
Promote skin integrity
Encourage mobility
Conserve energy
Prevent constipation
Temperature
37.0 C
Heart rate
118
Respiratory rate
22
Blood pressure
92/50
Oxygen saturation
96%
Hourly urine output
27 ml/hr
Blood sugar
74 mg/dl
Explanation / Answer
Antidiuretic hormone is secreted by the:
Answer: Posterior pituitary gland in response to increase sodium osmolality
Rationale:
Dehydration (lose proportionately more water than solute (sodium)
Osmolarity of your bodily fluids increases (hyperosmolarity)
Sympathetic stimulation on Posterior Pituitary
Antidiuretic hormone release
Lowers osmolarity (reducing sodium concentration) by increasing water reabsorption in the kidneys to dilute bodily fluids
Collecting ducts of the kidneys in response to dehydration
Rationale:
Though collecting ducts acts to increase water permeability to decreased urine formation, only if the hormone aldosterone is present.
Posterior pituitary gland in response to decreased serum sodium levels
Rationale:
Dehydration occurs tend to lose proportionately more water than solute (sodium- hypernatremia) not decreased serum sodium levels.
As an RN assessing Mr Donald with dehydration, you would expect the urine output to be:
Decreased with elevated specific gravity
Answer:
Rationale: Dehydration leads to lower blood volume and kidney will not be getting adequate blood to filter and that leads to decreased urine output and when water proportion is less compared to substances in your urine like glucose, bilirubin, red blood cells, white blood cells, crystals, bacteria, or even protein leads to elevation in specific gravity (more concentrated urine).
Decreased with decreased specific gravity
Rationale:
Dehydration leads to lower blood volume and kidney will not be getting adequate blood to filter and that leads to decreased urine output and when water proportion is less compared to substances in your urine like glucose, bilirubin, red blood cells, white blood cells, crystals, bacteria, or even protein leads to elevation in specific gravity (more concentrated urine), not decreased specific gravity.
Increased with elevated specific gravity
Rationale:
Dehydration leads to lower blood volume and kidney will not be getting adequate blood to filter and that leads to decreased urine output and when water proportion is less compared to substances in your urine like glucose, bilirubin, red blood cells, white blood cells, crystals, bacteria, or even protein leads to elevation in specific gravity (more concentrated urine), not Increased urine output.
The RN understands that oliguria
Answer: Is less than 30 mls per hour of urine excretions, and if left untreated, may lead to acute renal failure.
Rationale:
Normal urine output is 500 ml to 2000 ml.
Less than 30ml/hours indicates oliguria (less than 400 ml/day).
Blood flow into kidney and run through renal capsule is not adequate and persistent low output leads to kidney failure.
Is more than 30 mls per hour of urine excretion and is uncommon in the immediate post-operative period
Rationale:
More than 30 ml per hour of urine excretion is common as surgery is having less effects in fluid imbalance some amount of blood loss would not be causing any.
Is common after major surgery, therefore, nothing for you to be concerned about:
Rationale:
It is not common as surgery is having less effects in fluid imbalance some amount of blood loss would not be causing
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