Clinical Case Analysis
On June 12, 2018, a 74-year-old patient named WF presented to the Beaumont Emergency Room in Farmington Hills. His chief complaint to the triage nurse as she gathered his initial vital signs was “I was having my blood drawn at my primary care provider’s office and he told me to come to the ER because my potassium was high.” The triage nurse sent him back to the Emergency Centers ‘Green’ area. The green area is equipped with heart monitors and is close to the nurse’s station for closer monitoring. I began this case by conducting my initial assessment on the patient, which consisted of connecting him to a cardiac monitor, strategically conducing an emergency ABC (Airway, breathing, circulation) assessment in my head to ensure patient stability, asking the patient what was bringing him in today to hear his own side of the story, concluding with reviewing his past medical diagnosis and current medications with him. WF presented as a content patient who was in no acute distress. He reported no shortness of breath, no palpitations and even subjectively reported “I feel fine, nothing is wrong with me.”
Along with the assistance of an Emergency Room technician I conducted a 12-lead electrocardiogram which showed concerns for hyperkalemia. Hyperkalemia appears on an electrocardiogram as tall T waves and a short QT interval. According to Crawford (2014), “The initial significant finding is peaked T waves. Increasing levels of potassium are associated with progressive ECG changes, including a widening PR interval, loss of P waves, ST segment changes, and a widening QRS. Potential hyperkalemic-induced dysrhythmias include second- and third-degree heart block, wide-complex tachycardia, ventricular fibrillation, asystole, and pulseless electrical activity.”
Upon receiving the patient’s own words about what was bringing him into the EC today and establishing a rapport with the man I sat down at a computer to compare the information I heard from him with the information on his chart which was currently up to date because all of his doctors worked through Beaumont Hospitals.
Upon reading more about this patient I delved deeper into what his health concerns were and what should be considered when planning care for this patient today. The patient’s health history consisted of diagnosis of COPD, hypertension, prostate cancer, cardiomyopathy, CHF, a history of abnormal EKGs, and an NSTEMI. In April of 2016 he had an EGD Upper GI Scope, which was inconclusive. In September of 2016 he had a colonoscopy which was unremarkable. The patient had cardiac stents placed in 2013 upon diagnosis of having an NSTEMI. The patient also underwent a cardiac catheter procedure in 2016.
The patient is a retired man who lives at home with his wife, and he has an older daughter who no longer lives with them. No one was present with him during this emergency room visit. He attempted to use his phone to contact his family a few times but he would always run into the issue of myself, a doctor, or a respiratory therapist coming in his room and accidently interrupting.
WF was presenting with probable abnormal labs containing a high potassium. The interventions in my head I laid out were as follows: Monitor for any changes in difficulty breathing, obtain an IV line and send out blood work per the doctor’s orders, in particular a comprehensive metabolic panel which contains potassium but also along with other tests to get a variety of information. According to Crawford (2014), “The nurse should assess the patient’s cardiovascular status frequently, listening to heart sounds for irregularities, and assessing cardiac monitor patterns for any ECG changes/dysrhythmias related to hyperkalemia.”
WF’s medical diagnosis were underway, as the Emergency Center is all about piecing together pertinent information along with scans and blood work to help form a diagnosis. The patient’s potassium level came back elevated at 6.7 mEq/L, not hemolyzed. A normal range for potassium at Beaumont is considered 3.5-5.2mEq/L. The pathophysiology of having a high potassium level indicates possible changes in heart rhythm and concerns for cardiac health. According to Paparella, (2014) “Hyperkalemia, defined as a serum potassium level greater than 5.5 mEq/L, is a routine finding for patients seeking emergency care and is most often seen in elderly patients with renal disease.”
My patient’s electrocardiogram showed tall T waves with a narrow base and a shortened QT interval. According to Garcia (2015), “The purposes of the acquisition of an ECG are varied, from bedside monitoring to ambulatory event monitoring. A 12-lead ECG is the initial test for the patient with chest discomfort or any other acute coronary syndrome.” These findings are consistent with what the blood work showed and his chief complaint of hyperkalemia. WF’s hyperkalemia was consistent with what was already known about him. In his past medical history, it was known that he has had abnormal ECGs previously.
Along with a diagnosis of hyperkalemia we were also able to form a diagnosis of Anemia when WF’s hemoglobin level came back at 6.8g/dL. The normal level for Hgb is 13.5-17g/dL. This patient’s low hemoglobin level placed him at risk for shortness of breath, heart palpitations and severe dizziness. Hemoglobin is the protein of the red blood cell that carries oxygen everywhere in a person’s body.
At this point in the patients care it was extremely important for me to review what I was seeing from the patient, and what the testing results were indicating. I was continuously monitoring the patient and he remained in no distress and continuously reported no problems with breathing or palpitations. I recognized the inconsistency between what his laboratory and testing results were indicating and what the patient was subjectively telling and showing me. The plan was to take action before he felt the repercussions of his laboratory data.
The resident working with the patient ordered a chest X-Ray. The X-ray came back and was available for viewing on Epic, upon looking at it, it was clear there was an infection. There appeared to be a white shadow in both lower lobes of the lungs along with the patient’s anemia and hyperkalemia, the resident working on WF’s case concluded he was suffering from pneumonia. The pathophysiology of pneumonia begins with a bacterium that causes an infection in the lungs. This patient was at risk for pneumonia because of his age and chronic health problems such as COPD. The patients white blood cell count (WBC) was within normal range at 10,000 WBC per microliter.
About two hours after WF had arrived in the Emergency Center he started displaying symptoms. I was outside his room when he sat up in bed and gripped his chest. He was diaphoretic and appeared panicked. Acute distress had set in on this patient. This once extremely calm man now could not be consoled. He complained of shortness of breath, extreme tightness in his chest, and a racing heart rate. His heart rate was tachycardic at 110bpm, his blood pressure was 134/86, his oxygen saturation remained at 97%, and his temperature was 98 degrees Fahrenheit. We believed that he was finally feeling the effects of his anemia and hyperkalemia. We immediately conducted a repeat electrocardiogram and began drawing up his ordered medications.
WF’s three diagnosis of anemia, hyperkalemia, and pneumonia led to us giving specific medications to target each one of these. First, we gave 10 units of insulin and 25 grams of dextrose immediately after. The reasoning for this is supported in the Clinical Kidney Journal as well as the American Association of Critical Care Nurses.
“IV insulin leads to a dose-dependent decline in serum potassium levels. A combination of IV insulin dose of 10 units plus 25 g of dextrose reliably lowers the serum potassium level by 1 (mmol/L) within 10–20 minutes and the effect lasts about 4-6 hours” Subsequently, we gave Kayexalate 15grams in 60 ml. Kayexalate is a small drink that assists in lowering potassium levels, which was what we needed to correct this patient’s hyperkalemia, which would in turn correct his palpitations. Packed red blood cells were ordered and a type and screen blood tube was collected, the patients blood type was O+. We also gave the patient azithromycin 500mg, and Rocephin 1g. These two antibiotics were targeting the patient’s pneumonia and the rationale behind giving both is to cover all the bases since we could not be sure what bacteria was specifically causing the pneumonia. Respiratory therapy came by to administer albuterol 10mg as well. The albuterol assisted with the patients breathing and made it easier for him to take deep breaths.
Based on the assessments of ABC’s (Airway, breathing, circulation) the most important nursing diagnosis for this patient is as follows. Impaired gas exchange related to altered oxygen-carrying capacity of blood is imperative to consider for this patient. As the nursing student, I assessed the respiratory rate, and depth of the breaths the patient was taking. The rationale for this is to make sure the patient maintains adequate and appropriate breaths to promote circulation and gas exchange. I also assessed the color of the patients nail beds and skin to assess for pallor. The rationale behind this intervention is that pallor can indicate hypoxia, which would mean the patient is not getting enough oxygen. The preferred outcome from these interventions is that the patient will demonstrate adequate oxygenation and subjectively report no problems breathing by the end of care in about 3 hours. This is exactly what happened with WF, as the albuterol medication worked in his lungs and I helped him maintain a seated up right position.
Risk for decreased cardiac output related to hyperkalemia is important to consider for WF. After establishing that WF had an adequate airway and proper circulation it was important to consider his cardiac output and monitor for any dysrhythmias that may occur. The interventions I performed were connecting WF to a cardiac monitor which I was able to view in the patient’s room and outside of it. This let me monitor the patient and make sure he was not going into cardiac arrest and to monitor for any dysrhythmias. The rationale with this intervention is that cardiac arrest or irregular heart beat may occur with hyperkalemia. The outcome for WF was that his 12 lead EKG did show prolonged T waves as often seen with hyperkalemia but no other dysrhythmias were apparent with this patient during the time I was caring for him.
Ineffective Tissue Perfusion is also an important nursing diagnosis for this patient. This could be caused by the patient’s anemia and extremely low levels of hemoglobin which is what carries the oxygen to the peripheral parts of the body. This was evidenced by the patient’s chest pain during assessment and his restlessness when he was reporting he was having a hard time breathing. The interventions I included were assessing his pulse ox and making sure it stayed above 90%, which it consistently did stay at 97% or above. After the administration of blood, we were to draw another Hgb level and verify that the level was rising and not falling which would indicate a bleed. This level was to be drawn before the day was over. My care for this patient ended before I was able to see this level but it was important to communicate to the next nurse that was taking care of WF that this was an imperative part of his care to be completed before the day was over.
The care provided to WF was thorough and conducted with care and knowledge. He was closely monitored for any dysrhythmias while monitoring him to ensure a patent airway and that his body was circulating the oxygen it was receiving appropriately. The patient achieved care outcomes while he was under my care in the emergency center through monitoring of his heart, maintaining proper circulation and adequate tissue perfusion.
A systems approach is defined by using collaboration to achieve a better outcome for the patient. A systems approach was certainly used throughout WF’s care. Many members of the Beaumont team including nurses, doctors, respiratory therapists, laboratory technicians, radiologist technicians and transport team members all worked together to gather and relay the information that was pertinent to this patient’s care. Not only was this systems approach successful in gathering data and relaying patient information but when everyone is on the same page about a patients care and diagnosis the patient is able to hear the same information from each person providing care and therefore feel better taken care of. Communication was essential to the systems approach we took with WF’s care. I was constantly communicating with the physician and the emergency room technician so that the patient’s questions could be answered and he could feel autonomous in his care. Throughout the patients care in the emergency center the systems approach worked well due to the team members consistent communication.
It is very important to consider that planning for discharge begins at admission. The initial diagnosis for WF was hyperkalemia, although by the end of my shift WF was not close to discharge it is something to consider and begin planning for. If this patients hyperkalemia was due to a problem with his kidneys, I would begin to explain the benefits of dialysis and how dialysis works so that hyperkalemia does not happen again. I also was able to explain how hyperkalemia could be caused by the intake of foods high in potassium such as bananas, apricots and oranges. This patient would benefit from the consultation of a nephrologist and a cardiologist because of his diagnosis of hyperkalemia. The goal is to prevent this from occurring in the future. Anticipatory guidance for this patient includes teaching the patient how to monitor their own pulse rate. During my care with WF I showed him how to watch the monitor for his pulse rate and I educated him on why he was connected to the cardiac monitor. Another aspect of anticipatory guidance is to make sure WF understood the importance of having his blood drawn regularly for potassium levels. Health promotion is explained through educating the patient on healthy and low potassium levels in certain food such as asparagus and beans.
As the nurse, it is important to always consider patients spiritual and cultural needs. For this particular patient, he did not request any specific cultural care. He was attempting to contact his family through the phone and that was often interrupted because of the nature of his condition and our team working to get everything done in a timely fashion. Given more time, it would have been nice to ask more about his family and establish a support system he had or one that he imagined would help him.
A specific agency policy that was consulted during WF’s care was “The Clinical Nurse, LPN, or EDT may obtain an electrocardiogram in compliance with advance treatment protocols and/or a physicians order.” The procedure is indicated to evaluate the electrical activity of the heart. This policy greatly impacted the patients care in a positive way. The patient was able to benefit from the importance of performing this test in a timely manner. It gave information to the nurse, technician, cardiologist and emergency medicine doctor providing care for this patient. This policy is a facilitator for care and also a facilitator for a systems approach involving all parts of the patient’s care. In this instance, nursing leadership advocates for safe and quality care because it ensures that an important test evaluating the patient’s cardiac rhythm is done as soon as possible and is shared with all members of the patients care team.
It was incredibly important to ensure my patients autonomy during this emergency room visit. It is ethically important for the nurse to prioritize the patient feeling that they are in control and that they feel understood throughout the visit.
Additionally, to enhance the pathophysiology and pharmacology knowledge that I acquired from taking care of this patient, I was also gaining knowledge on how to properly speak to patients to include them on their care. I gained the insight on how to maintain a calm persona while a patient is experiencing panic, such as WF did when he was having trouble breathing. This situation in preceptorship prepared me for future situations with distressed patients.
References
Crawford, A. H. (2014). Hyperkalemia. Journal of Infusion Nursing,37(3), 167-175. doi:10.1097/nan.0000000000000036
Garcia, T. (2015). Acquiring the 12-lead Electrocardiogram: Doing It Right Every Time. Journal of Emergency Nursing,41(6), 474-478. doi:10.1016/j.jen.2015.04.014
Paparella, S. F. (2014). Insulin Misadministration: The Challenges of Treating Hyperkalemia. Journal of Emergency Nursing,40(1), 71-72 doi:10.1016/j.jen.2013.09.012
Tingting Li, Anitha Vijayan; Insulin for the treatment of hyperkalemia: a double-edged sword, Clinical Kidney Journal, Volume 7, Issue 3, 1 June 2014, Pages 239–241
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