UNFOLDING Reasoning Simulation
Cirrhosis
Preparation for Care Activity
Recognizing Clinical Relationships
Review the medical history and home medications of this patient. For each home medication, identify the
pharm. classification and expected outcome for this patient its most common side effect (SE). Finally, draw a
line to determine which medication treats what condition.
Medical History
Hepatitis C
Home Medications
Ibuprofen 600 mg PO
every 6 hours PRN for
headache
Pharm. Classification
Expected Outcome Common SE
nsaid
pain relief
gastric ulcers, upset
stomach, impaired
kidney function
Part I: Developing Noticing and Interpreting Skills
1. Which findings from the present problem are most important and noticed by the nurse as clinically significant?
Most Important Findings
Clinical Significance
Abdominal pain, nausea and vomiting,
fatigue, decreased appitite, and Hep
C diagnosis
The presence of these symptoms, such as hepatic encephalopathy,
ascites, or spontaneous bacterial peritonitis, in this patient might signify a
severe complication linked to his hepatitis C or cirrhosis. They could
indicate the progression of liver disease or indicate malnutrition, both of
which can have negative effects on patients with liver disease. The
recent diagnosis and treatment imply that the patients liver disease may
not be effectively managed at this point. Additionally, these
circumstances also increase the likelihood of adverse reactions to
medications and potential interactions.
2. Which data from the social history is most important and noticed by the nurse as clinically significant?
Most Important Findings
Clinical Significance
He serves as a caregiver for his wife
who suffers from dementia while also
working part-time at a convenience
store.
This situation could potentially lead to increased stress levels for the patient, impacting his
ability to allocate time and energy towards maintaining his own health. It is possible that he
has been neglecting proper nutrition and sufficient rest, which could further exacerbate his
symptoms. Additionally, the financial burden he faces may contribute to physical
exhaustion. His job at the convenience store exposes him to different individuals, potentially
increasing the risk of infections, particularly given his compromised immune system due to
liver disease.
3. What psychosocial/holistic care priority will guide how the nurse responds to formulate a plan of care? List
interventions by priority and the expected outcome.
Psychosocial/Holistic Care Priority
Priority Interventions
Rationale
Expected Outcome
Alleviating stress and reducing
feelings of anxiety
The well-being of individuals can be
significantly impacted by the physical
discomfort caused by their symptoms. Also,
the presence of anxiety can exacerbate the
experience of pain and overall discomfort.
Pain relief and
reduced anxiety
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UNFOLDING Reasoning Simulation
4. To provide compassionate holistic care for this patient, answer the following questions.
They are probably facing considerable discomfort as a result of his physical symptoms, including abdominal pain, nausea, and vomiting.
What is the patient likely
Additionally, his lack of appetite and potential malnutrition may be causing fatigue and a general feeling of being unwell. Considering his
diagnosis of hepatitis C, he may be experiencing anxiety and fear regarding what lies ahead, particularly given his role as a
experiencing/feeling right now in recent
caregiver for his wife with dementia. The juggling act of balancing his part-time job, caregiving responsibilities, and his own health might
leave him feeling overwhelmed and stressed.
this situation?
What can you do to engage
yourself with this patient's
experience, and show that they
matter to you as a person?
Active listening: Dedicate time to actively listen to the the patient as they expresses his concerns, fears, and emotions. Encourage him to
openly share his experiences, and provide reassurance that his feelings are acknowledged and respected.
Empathy: Display empathy towards their situation, demonstrating understanding and compassion. Validate his feelings of stress and being
overwhelmed, considering the challenges he currently faces.
5. Which findings from the contextual factors are most important and noticed by the nurse as clinically significant?
Most Important Findings
Clinical Significance
The unit is currently experiencing a
shortage of staff, resulting in a busy
day at the urgent care facility.
The impact of these circumstances could potentially
compromise the level of care provided to every patient. It
raises the risk of errors, reduces the amount of time
allocated to each patient, and may lead to delays in
treatments and interventions.
Patient Care Begins
6.Which vital sign findings are most important and noticed by the nurse as clinically significant?
Most Important Data
Clinical Significance
Heart rate is 132
when he stands
This reading significantly exceeds the typical range and suggests the
presence of tachycardia.
6. What assessment data needs to be noticed as most important? Interpret clinical significance.
Most Important Data
Clinical Significance
Abdominal pain, nausea, and
vomiting
The pain experienced by the patient might serve as an indication
of a liver disease complication, such as ascites. This could imply
a deterioration in his liver disease condition or possibly signify
the presence of other gastrointestinal problems.
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UNFOLDING Reasoning Simulation
Auscultate Breath Sounds
Place a circle on the chest where the nurse would place the stethoscope to
auscultate the right upper lobe.
Click this link to listen. Identify what type of breath sounds are heard, and
interpret their clinical significance.
Breath Sounds
Clinical Significance
Stridor
The clinical significance of stridor lies in its
indication of a potentially critical respiratory
issue that warrents urgent attention.
Auscultate Heart Sounds
Place a circle on the chest where the nurse would place the stethoscope to
auscultate the apical pulse.
Click this link to hear breath sounds. Identify what type of heart sounds are
heard, and interpret their clinical significance.
Heart Sounds
Clinical Significance
Normal sinus
rhythem
Heart appears healthy
As you complete the head-to-toe assessment, you notice this softball-sized
discoloration on his abdomen.
7. Which findings are most important and noticed by the nurse as clinically significant?
Most Important Findings
Clinical Significance
Bruising
The possibility of a coagulopathy arises, which is a bleeding disorder that
may occur as a complication of advanced liver disease, characterized by
reduced production of clotting factors.
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UNFOLDING Reasoning Simulation
8. Which findings are most important and noticed by the nurse as clinically significant?
Most Important Findings
Clinical Significance
These spots might serve as
indications of various conditions.
Could be indicative of a clotting problem
Lab Results
Hematology: Complete Blood Count (CBC)
WBC
HGB
PLTS
% Neuts
% Lymphs
% Monos
% Eosin
Bands
Which diagnostic findings are most important and noticed by the nurse as clinically significant?
Most Important Data
Clinical Significance
TREND Improved/Declined/No
Change
White blood cells,
hemoglobin, and
platelet count
The WBC count has risen from 9.5 to 12.8, which can be indicative of an
infection or inflammation within the body. The hemoglobin level has
decreased from 11.5 to 10.2, which signifies the presence of anemia.
The platelet count has decreased from 126 to 75, a common occurrence
in cirrhosis as a result of reduced production and increased destruction
in the spleen, known as thrombocytopenia.
All declined
Metabolic Panel
Na
K
Cl
CO2
AG
Gluc
Ca
BUN
Creat
GFR
Which diagnostic findings are most important and noticed by the nurse as clinically significant?
Most Important Data
Clinical Significance
TREND Improved/Declined/No
Change
8 high
Creatinine- 1.5 high
An elevated BUN level may indicate reduced
kidney function or dehydration, both of which
are potential occurrences in cirrhosis.
Similarly to BUN, an increased creatinine level
can suggest impaired kidney function, which is
commonly observed in advanced cirrhosis.
Both declined
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UNFOLDING Reasoning Simulation
Liver Panel
Albumin
Ammonia
Total
Bili
Direct
Bili
InDirect
Bili
Alk
Phos
ALT
AST
Which diagnostic findings are most important and noticed by the nurse as clinically significant?
Most Important Data
Clinical Significance
TREND Improved/Declined/No
Change
Low levels of albumin, a liver-produced protein, can indicate poor liver function, malnutrition, or absorption issues. This can contribute to fluid
imbalance and edema, which are common complications of cirrhosis. In this case, the albumin level is significantly elevated, surpassing the
normal range of approximately 0.1-1.2 mg/dL.High levels of bilirubin, a waste product processed by the liver, can indicate liver dysfunction or bile
duct obstruction. This can result in jaundice, a condition characterized by yellowing of the skin and eyes.The alkaline phosphatase level is 285
IU/L, which exceeds the normal range of about 44-147 IU/L. Elevated alkaline phosphatase levels can occur in conditions that damage the liver or
bile ducts, indicating liver dysfunction or bile duct disease. The ALT level is 128 U/L, indicating elevated levels compared to the normal range of
about 7-55 U/L. ALT is an enzyme predominantly found in the liver, and increased levels can suggest liver damage. Similarly, the AST level is 124
U/L, also exceeding the normal range of approximately 8-48 U/L. Like ALT, AST is an enzyme present in the liver, and elevated levels can
indicate liver damage
Albumin
Total bili
Alk Phos
ALT
AST
All have declined
Coagulation
Reference Range:
Current
Prior adm.
INR
0.9-1.1
1.5 !
1.1
PT
10-13 seconds
--
aPTT
25-35 seconds
--
Which diagnostic findings are most important and noticed by the nurse as clinically significant?
Most Important Data
Clinical Significance
TREND Improved/Declined/No
Change
The current INR reading is 1.5, showing an increase from the prior admission's value of 1.1. The
normal range for INR is 0.9-1.1. A high INR can signify an extended blood clotting time,
potentially indicating a bleeding disorder or the influence of blood-thinning medication. This
becomes particularly significant for patients with liver disease, as the liver plays a role in
producing the necessary proteins for blood clotting. A rising INR in a cirrhosis patient may
suggest a deterioration in liver function, as the liver's ability to produce these proteins diminishes,
elevating the risk of bleeding.
INR
Declined
Lab Planning Activity
Identify the most important lab values to monitor for this patient. They can
be normal or abnormal. Then record the normal range of each relevant lab
value, the critical or red flag value, its physiologic significance and priority
nursing assessments and/or interventions.
Lab Name
ALT
Normal Range
Critical Value
Physiologic Significance
Albumin, which is synthesized by the liver, plays a crucial role in maintaining osmotic pressure and
preventing fluid leakage from blood vessels. A low albumin level can suggest malnutrition or poor
liver function, contributing to fluid imbalance and edema. Nursing interventions involve monitoring for
signs of fluid overload, such as peripheral edema, ascites, and shortness of breath. Regular
assessment of nutritional status is necessary, and a high-protein, high-calorie diet should be
provided as tolerated.
Total Bilirubin: Normal Range: 0.1-1.2 mg/dL, Critical Value: >2.5 mg/dL. Bilirubin is a byproduct of
red blood cell breakdown and is metabolized by the liver. Elevated levels can result in jaundice and
indicate liver dysfunction. Nursing interventions include monitoring for signs of jaundice and changes
in stool or urine color. Adequate hydration should be encouraged to facilitate bilirubin excretion.
ALT and AST: Normal Range: ALT 7-55 U/L, AST 8-48 U/L, Critical Value: >3 times the upper limit of
normal. These enzymes are released into the bloodstream when liver cells are damaged. Increased
levels suggest liver damage or inflammation. Monitor for signs of liver dysfunction, including
jaundice, dark urine, pale stools, and confusion or altered mental status.
BUN and Creatinine: Normal Range: BUN 7-20 mg/dL, Creatinine 0.6-1.2 mg/dL, Critical Value: BUN
>50 mg/dL, Creatinine >3 mg/dL. These waste products are cleared by the kidneys. Elevated levels
can indicate impaired kidney function. Monitor for signs of fluid overload, changes in urine output,
and alterations in electrolytes. Adequate hydration should be ensured.
Priority Nursing Assessments
Nursing interventions involve regular monitoring
for indicators of fluid overload, such as
peripheral edema, ascites, and difficulty
breathing. Nutritional status should be
consistently assessed, and a diet rich in protein
and calories should be offered based on
individual tolerance.
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UNFOLDING Reasoning Simulation
Part II: Developing Responding Skills
1. Interpreting clinical data collected, list at least two problems that are possible for this patient? Which
problem is the priority?
Possible Problems Priority Problem
Pathophysiology of Priority Problem
Deteriorated liver function due to
cirrhosis is evident, with potential
ascites indicated by a notable
discoloration on the abdomen,
decreased albumin levels, and
elevated bilirubin, AST, and ALT.
There is a possibility of Hepatorenal
Syndrome, as evidenced by elevated
BUN and creatinine levels.
Cirrhosis is an advanced phase of liver
scarring that occurs as a result of various
liver diseases and conditions, including
hepatitis and chronic alcoholism. In this
patient's case, the diagnosis of Hepatitis
C suggests that it is likely the underlying
cause of his cirrhosis.
Decompensated cirrhosis follows the compensated stage and is
characterized by the emergence of complications. The presence of a
substantial discoloration on Darius's abdomen, along with his
abdominal discomfort, raises significant concern for the development
of ascites
2. What body system(s) will you assess most thoroughly based on the primary medical problem? What specific
assessments will you implement?
Priority Body System(s)
Priority Assessments
Consistently evaluate the size of the abdomen and diligently observe for any increases, as they may
suggest a deterioration of ascites. Regularly track vital signs. Cirrhosis, particularly when accompanied
by ascites, can lead to fluctuations in blood pressure and heart rate. Closely monitor urine output, as a
decrease in urine production can be indicative of deteriorating renal function or the development of
hepatorenal syndrome, a complication associated with cirrhosis.
Gastrointestinal System
Cardiovascular System
Renal System
Medical Management of Care
3. Identify the rationale for each provider order and its expected outcome.
Provider Orders:
Rationale:
Establish peripheral IV
The client is experiencing symptoms of nausea and vomiting, which
NS 0.9% bolus of 1000 mL
Ondansetron 4 mg IV every
4 hours PRN
Recheck orthostatic BP
following bolus.
increase the risk of dehydration. Establishing IV access enables the
administration of fluids and medications. This order is intended to
restorethe client's fluid balance due to vomiting, potential decreased
intake, and possible redistribution of fluids caused by ascites.
Normal saline is an isotonic solution that maintains the body's
electrolyte balance. Ondansetron is an antiemetic medication used
to alleviate nausea. Given the client's persistent symptoms of
nausea and vomiting, this medication can help manage these
symptoms and prevent further disruptions in fluid and electrolyte
levels caused by excessive vomiting. Orthostatic blood pressure
measurement is employed to assess how the cardiovascular system
responds to changes in body position. It can provide insight into
volume depletion and dehydration.
4. For the order of ondansetron, complete the table below.
Mechanism of Action
Most Common Side Effects
Ondansetron functions
by inhibiting the action of
serotonin, a natural
substance in the body
responsible for inducing
vomiting.
The most frequently
observed adverse
effects of
ondansetron include
headache,
dizziness,
drowsiness, and
constipation.
Expected Outcome:
The anticipated outcome is to
preserve and enhance the client's
hydration level while establishing a
means for medication delivery. The
desired outcome is an improved
hydration status, normalized blood
pressure, and a reduced risk of
additional kidney damage.The
intended outcome is a decrease in
nausea and vomiting, resulting in
enhanced comfort, increased oral
intake, and improved hydration
status.The expected outcome
involves consistent blood pressure
readings, indicating a suitable
cardiovascular response to the
administered fluids.
Client Education Before Administering
Prior to administering ondansetron, it is
essential to notify the client that this medication
is employed to alleviate his symptoms of
nausea and vomiting. He should be provided
with information regarding potential side effects
and instructed to promptly report any severe
symptoms, such as blurred vision or irregular
heartbeat.
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UNFOLDING Reasoning Simulation
Priority Setting
5. Determine the order of priority the nurse will implement each order and the rationale for the order you chose.
Care Provider Orders
Order of Priority
Rationale
1. Establish peripheral IV
IV, Normal Saline bolus,
2. NS 0.9% bolus of 1000
Ondansetron, Recheck
mL
BP
3. Ondansetron 4 mg IV
every 4 hours PRN nausea
4. Recheck orthostatic BP
This is the first priority as it allows for fluid and medication administration. It ensures a route for subsequent interventions and is crucial for addressing
dehydration and potential medication needs. The administration of normal saline bolus is the next priority after establishing IV access. It aims to
replenish fluid balance due to vomiting, reduced intake, and potential third spacing of fluids caused by ascites. Addressing dehydration is essential for
maintaining overall stability. After addressing fluid balance, managing nausea is the subsequent priority. Ondansetron, as an antiemetic medication,
helps control nausea and prevents further fluid and electrolyte imbalances due to excessive vomiting. Administering it on an as-needed basis provides
symptom relief. Once the immediate interventions for fluid administration and symptom management are in progress, rechecking orthostatic blood
pressure is the final priority. This assessment helps evaluate the cardiovascular response to position changes and provides insight into volume
depletion, guiding further interventions if necessary. The order of priority ensures that immediate needs are addressed first followed by symptom
management and a subsequent assessment to evaluate the effectiveness of interventions.
Nursing Management of Care
6. After interpreting clinical data collected, identify the nursing priority and three priority interventions. For each
intervention write the rationale and expected outcome.
Nursing Priority
Priority Intervention(s)
Rationale
Administer the prescribed fluid therapy of
a 1000 mL bolus of normal saline
Administer the prescribed medication
Given the client's symptoms of nausea, vomiting, and potential dehydration, it is vital to
restore his fluid and electrolyte balance. The anticipated outcome is to enhance his
hydration status, increase blood volume, and support kidney function.
Effectively managing the client's nausea will contribute to his overall comfort and may
reduce further episodes of vomiting and associated fluid loss. The expected outcome is a
reduction in nausea and vomiting, improved comfort, and an enhanced ability to consume
oral intake.
Expected Outcome
Expected outcomes include
improved hydration,
increased blood volume,
and enhanced kidney
function.
Problem Recognition
7. To prevent a complication based on the primary problem, answer each question in the table below.
Based on the client's diagnosis of cirrhosis and his symptoms, the leading
Identify the worst
potential serious complication is likely hepatic encephalopathy,
characterized by a deterioration in brain function caused by advanced liver
possible/most likely
disease.
complication?
What interventions can
prevent this complication
from developing? (if
applicable)
What clinical data will
indicate this complication
early?
What nursing interventions
will the nurse implement if
the anticipated complication
develops?
Effective management of the client's hepatitis C and cirrhosis requires regular medical check-ups, monitoring of
laboratory tests, and adherence to prescribed medications and dietary recommendations.
Timely intervention is crucial to address potential triggers such as infections, gastrointestinal bleeding, or electrolyte
imbalances.Vigilant monitoring and appropriate management of constipation are essential to prevent excessive
ammonia absorption, a significant factor in the development of hepatic encephalopathy.
Initial indications of hepatic encephalopathy may manifest as alterations in personality, mood, or sleep patterns,
along with confusion, forgetfulness, decreased concentration, and reduced mobility. Advanced symptoms may
encompass pronounced confusion, drowsiness, and in severe instances, loss of consciousness. The client's
ammonia levels may elevate, and liver function tests may exhibit further decline.
Promptly alert the healthcare provider: This situation necessitates immediate notification of the healthcare provider
to facilitate urgent diagnostic assessments and treatment.
Promote patient safety: In the event of confusion or drowsiness, precautions must be implemented to prevent
potential falls or harm.
Monitor vital signs and neurological condition: Consistent monitoring allows for the evaluation of condition
advancement and treatment efficacy.
Administer prescribed medications: Medications like lactulose and rifaximin may be administered to lower blood
ammonia levels.
Education/Discharge Planning
8. To prepare this client for discharge, what educational topics need to be included in a teaching plan for this patient
and/or family?
Priority Topics
Rationale
Understanding of cirrhosis,
hepatitis C and medication
management
Offer comprehensive information about these conditions, their consequences, progression, and common symptoms to be
vigilant about. This will enhance the client and his family's comprehension of his condition and the rationale behind his care
plan. Provide instruction on each medication, including its intended purpose, timing, and possible side effects. This
encompasses his antiviral therapy and any prescribed medications to address symptoms or complications associated with
cirrhosis.
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UNFOLDING Reasoning Simulation
9. Which interprofessional team member would the nurse need to consult and collaborate with to promote and
maintain health after discharge?
Team Member
Rationale
Part III: Developing Evaluation Skills
Darius was discharged from the emergency department following fluid resuscitation
and resolution of his nausea and vomiting.
Today, six months later, he arrives in the emergency department via EMS after being
found unresponsive by his son.
Current VS:
• T: 99.5 F/37.5 C (oral)
• P: 118 (regular)
• R: 22
• BP: 92/50
• O2 sat: 95% room air
When you remove his shirt to place Darius in a gown, this is what you notice:
1. From this picture, which two assessment findings
are most important and noticed by the nurse as
clinically significant?
Most Important Findings
Ascites
Altered mental status
Clinical Significance
Ascites refers to the buildup of fluid in the abdominal cavity, often caused by portal hypertension associated with cirrhosis. The client's significant ascites indicates the progression of his
liver disease, potentially leading to worsened liver function and decompensated cirrhosis. It can cause discomfort, limited mobility, and respiratory difficulties due to pressure on the
diaphragm. The severity of his ascites suggests a high risk for complications such as spontaneous bacterial peritonitis or hepatorenal syndrome.
The client's unresponsiveness, as reported earlier, is a critical observation. It can be indicative of hepatic encephalopathy, a complication of advanced liver disease like cirrhosis.
Hepatic encephalopathy occurs when the liver fails to adequately remove toxins from the blood, resulting in the accumulation of toxins that impair brain function. It can manifest as mild
confusion, complete unresponsiveness, or even coma.
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UNFOLDING Reasoning Simulation
Current Assessment:
GENERAL SURVEY
PAIN
NEUROLOGICAL
HEAD
RESPIRATORY
CARDIAC
ABDOMEN
GENITOURINARY
INTEGUMENTARY
Disheveled, appears unkempt, lying in bed, eyes closed, no response to external
environment
Unable to assess
Speech mumbled, marked confusion
Head normocephalic. No obvious injury.
Non-labored respiratory effort
Warm & dry, 2+ pitting edema lower extremities, heart sounds regular, pulses strong,
equal with palpation at radial/pedal/post-tibial landmarks
Abdomen grossly distended, firm to touch, bowel sounds inaudible per auscultation
Small amount of brown, foamy urine
Skin integrity intact, color normal for patient ethnicity. Sclera yellow bilaterally.
2. For each finding, determine if it indicates the patient's condition has improved, has not changed, or has declined.
Assessment Finding
Improved No Change Declined
x
Marked confusion, mumbled speech
x
Non-labored respiratory effort
x
Abdomen grossly distended
x
Brown, foamy urine
x
Sodium 127 mEq/L
x
Potassium 2.9 mEq/L
x
Creatinine 1.9
x
INR 2.6 nmol/L
Ammonia 78 mcgl/dL
x
3. Is the overall status of your client:
DECLINED
a. Improved
b. Declined
c. No change
4. After evaluating the patient, identify the current nursing priority and which action(s) should the nurse take. List
interventions by priority and the expected outcome.
Nursing Priority
Priority Interventions:
Provide a detailed update to the
healthcare provider and administer
the prescribed medications for
hepatic encephalopathy.
Addressing hepatic encephalopathy and associated complications while
closely monitoring for any worsening signs and symptoms.
Rationale:
The client is displaying severe hepatic
encephalopathy symptoms and worsening
conditions, necessitating urgent medical intervention.
The healthcare provider will promptly devise an
action plan. Administer the prescribed medications
for hepatic encephalopathy. These medications aid
in lowering blood ammonia levels, a common
contributor to hepatic encephalopathy, resulting in
decreased confusion and improved consciousness.
Expected Outcome:
Reduced BUN level
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UNFOLDING Reasoning Simulation
5. Identify the rationale for each provider order and its expected outcome.
Provider Orders
Rationale
Lactulose 200 g/300 mL
Lactulose is effective in reducing blood ammonia levels.
rectal x1 NOW
Elevated ammonia levels can contribute to hepatic
encephalopathy, which could be responsible for the
client's confusion and unresponsiveness. There is a
Potassium Chloride 10 mEq
deficiency in potassium levels. This treatment aims to
IVPB (x4) each dose over 1
restore potassium levels and restore electrolyte balance.
hour. Recheck potassium per
Considering the client's critical clinical state, close
hospital protocol
monitoring and the potential need for immediate
intervention make an ICU setting the most suitable
option.
Transfer to ICU
Expected Outcome
The client experiences a
reduction in confusion, an
improvement in
consciousness, and a
decrease in blood
ammonia levels.
Potassium levels are
normalized, potentially
alleviating cardiac
irregularities and muscle
weakness. Enhanced
monitoring allows for early
detection of complications
and prompt intervention in
case of worsening
condition.
6. For the new order of lactulose and potassium, apply your knowledge to complete the table below.
Mechanism of Action
Most Common Side Effects
Client Education Before Administering
Inform the client that lactulose is administered to alleviate confusion by reducing ammonia
Lactulose
Diarrhea, bloating, gas, stomach levels.
Provide information about the potential side effects, with particular emphasis on diarrhea.
cramps
Potassium Chloride 10 mEq
IVPB
Nausea, vomiting, diarrhea, and abdominal discomfort,
and phlebitis at the IV site
Educate the client about the administration of potassium to address low blood levels. Discuss
the typical side effects and emphasize the close monitoring of the infusion. Instruct them to
promptly report any IV discomfort to the healthcare team.
The nurse has implemented all orders.
7. Five hours later, the potassium IVPBs are complete, and you reassess your patient. You complete a redraw of the
BMP and collect the following assessment data:
Assessment Finding
Improved
No Change
Declined
x
Alert to self, incomprehensible speech
x
Non-labored respiratory effort
x
Abdomen grossly distended
x
Brown urine
x
The patient has had 2 loose bowel movements
x
Sodium 132 mEq/L
x
Potassium 3.1 mEq/L
x
Creatinine 2.0
x
Ammonia 70 mcgl/dL
8. Write a concise narrative nurse's note to document what was most important at the end of your shift in the medical
record.
The client was reevaluated following the completion of potassium IVPBs. The patient remains awake, but their speech remains
unintelligible. Respiratory effort remains unchanged and non-labored.Abdominal distension persists and is firm to the touch, with no
audible bowel sounds on auscultation. The patient has experienced two loose bowel movements since the last assessment, possibly
due to the effects of lactulose. The patient's urine continues to appear brownThe latest laboratory results after potassium replacement
reveal a sodium level of 132 mEq/L, potassium level of 3.1 mEq/L, creatinine level of 2.0, and a decrease in ammonia levels to 70
mcgl/dL.These findings indicate an improvement in the patient's electrolyte imbalances; however, concerns remain regarding hepatic
function and renal indices. Continuous monitoring and reassessment of the patient's neurological status and overall condition are
advised. Further management will be continued in the ICU according to the healthcare provider's instructions.
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UNFOLDING Reasoning Simulation
Your patient is being transferred to ICU.
Write out your SBAR report to the nurse who will
be caring for your patient.
Situation:
Name/age:
Darius, a 67-year-old male with a history of Hepatitis C, was brought to the
emergency department by EMS after being discovered unresponsive by his
son. While his condition was stabilized in the ED, his lab results have shown
BRIEF summary of primary problem: changes, and persistent abdominal distension necessitates his transfer to the
intensive care unit for vigilant monitoring and comprehensive care.
Day of admission/post-op #:
Background:
Primary problem/diagnosis:
RELEVANT
RELEVANT
Six months ago, Darius was hospitalized to address fluid resuscitation and alleviate
symptoms of nausea and vomiting. During this current admission, he presented with
confusion, a visibly distended abdomen, foamy brown urine, and abnormal
past medical history: significant
laboratory findings. Currently, his sodium level is 132 mEq/L, potassium level is 3.1 mEq/L,
creatinine level is 2.0, and ammonia level is 70 mcg/dL. In the emergency department, he
background data: received Lactulose and Potassium Chloride. Subsequently, he experienced two instances
of loose bowel movements following the administration of Lactulose.
Assessment:
Current vital signs:
RELEVANT body system nursing assessment data:
RELEVANT lab values:
TREND of any abnormal clinical data (stable/increasing/decreasing):
Throughout his stay in the
emergency department, the
patient's condition has remained
stable, although he continues to
experience incomprehensible
speech and abdominal
distension. There have been no
indications of labored respiratory
effort. However, there is
evidence of deteriorating renal
function, as reflected by the
presence of brown urine and
elevated creatinine levels.
Although the administration of
lactulose has resulted in a slight
reduction in ammonia levels,
they still remain elevated.
How have you advanced the plan of care?
Patient response:
INTERPRETATION of current clinical status (stable/unstable/worsening):
Recommendation:
Darius requires diligent monitoring of his renal function and electrolyte levels. Given his recent episode of confusion, regular assessments of his mental status are necessary. It is important to closely
observe his response to Lactulose and monitor the frequency and consistency of his bowel movements, as Lactulose is being used to address his hyperammonemia. Given his distended abdomen, it is
crucial to monitor for signs of rising intra-abdominal pressure and related complications. Lastly, his history of Hepatitis C requires careful management.
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form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN
UNFOLDING Reasoning Simulation
Nurse Reflection
To strengthen your clinical judgment skills, reflect on your knowledge and the decisions made caring for this patient by
answering the reflection questions below.
Reflection Question
As you worked through this
simulation, how did it make you
feel?
What did you already know and
do well on this simulation?
Nurse Reflection
I was frustrated a few times becuase the text boxes were
sometimes uncooperative, but other than that it wasn't too terrible.
What areas do you need to
develop/improve?
I need to improve on my ability to put my thoughts into words that
make sense in a medical sense.
What did you learn? How will
you apply what was learned to
improve patient care?
I learned that liver issues can cause a wide variety of other problems that can be
challening to deal with as a healthcare worker. I think this can be applied in my own life
by teaching me the importance of looking beyond what is the pricniple problem
I was kinda familiar with cirrhosis becuase it is what killed my
grandfather, but this let me dive deeper into it.
© 2023 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN