Instructions

After having read Chapters 1-3 and reviewed the learning materials for this week, please complete the following case study. Remember that your answers may be combined with medical terminology, but they must be defined and explained in physiological terminology.

Mrs. K.B. is age 64 and has been a patient of yours for many years. You are calling her today to tell her the results of her Pap test which was done last week during her routine annual checkup in your office. The test showed marked dysplasia of cervical cells but no sign of infection. Unfortunately, when you call, there is no answer.

Since you saw Mrs. K.B. last week she has had gastritis with severe vomiting for 3 days. She has a history of heart problems and is presently feeling dizzy and lethargic. Her eyes appear sunken, her mouth is dry, she walks unsteadily, and she complains of muscle aching, particularly in the abdomen, and she is concerned about her chronic back pain as well and how she is going to handle her pain if she can’t keep her medication down. She is thirsty but is unable to retain food or fluid. A neighbor has brought Mrs. K.B. to the hospital, where examination shows that her blood pressure is low, and her pulse and respirations are rapid. Laboratory tests demonstrate elevated hematocrit, hypernatremia, decreased serum bicarbonate, serum pH 7.35, and urine of high specific gravity. This case study illustrates a combination of fluid, electrolyte, and acid-base imbalances. Specific laboratory values are not given to focus on the basic concepts. For clarity, this case study is discussed in multiple parts. Further information about the specific problems involved is given in each part and is followed by a series of questions.

Part 1

Later in the afternoon, you receive a phone call from Mrs. K.B.’s daughter Sara who tells you that she has been admitted to the hospital with vomiting. Sara is asking about her mother’s test results. Please answer the following questions regarding your conversation with Sara.

1. Sara is requesting her Mother’s test results and she seems to know that her Mom had a Pap test last week. Sara is really concerned because her Mom had an abnormal Pap test a few years ago and her sister also has a history of Ovarian Cancer. How do you handle this conversation with Sara?
2. In thinking about how you might discuss these results with Mrs. K.B. or Sara, explain how each of these terms might apply to this scenario: prognosis, latent stage, remission, exacerbations, and predisposing factors.
3. Explain cellular adaptations and in particular, dysplasia and how testing and or additional testing is done regarding this condition.

Part 2: Day 1

Initially, Mrs. K.B. lost water, sodium in the mucus content, and hydrogen and chloride ions in the hydrochloric acid portion of the gastric secretions.

Alkalosis develops for two reasons, the first being the direct loss of _______________ ions, and the second being the effects of chloride ion loss. When chloride ions are lost in the gastric secretions, it is replaced by chloride from the serum (See Fig. 2.9 in Chapter 2 of your Gould text). To maintain equal numbers of cations and ____________ in the serum, chloride ions, and bicarbonate ions can exchange places when needed. Therefore, more bicarbonate ions shift into the serum from storages sites in the _______________ to replace the lost chloride ions. More bicarbonate ions in the serum raise serum pH, and the result is hypochloremic alkalosis.

1. Which compartments are likely to be affected in this case by early fluid-loss?
2. Explain how a loss of sodium ions contributes to dehydration.
3. Describe the early signs of dehydration in Mrs. K.B.
4. Describe the compensations for the losses of fluid and electrolytes that should be occurring in Mrs. K.B.
5. Explain why Mrs. K.B. may not be able to compensate for losses as well as a younger adult.

Part 3: Days 2-3

As Mrs. K.B. continues to vomit and is still unable to eat or drink any significant amounts, loss of the duodenal contents, which include intestinal, pancreatic, and biliary secretions, occurs. No digestion and absorption of any nutrients occurs.

Losses at this stage include water, sodium ions, potassium ions, and bicarbonate ions. Also, intake of glucose and other nutrients is minimal. Mrs. K.B. shows elevated serum sodium levels.

Sara has been at the hospital all morning waiting for the provider to come by with an update. Sara is rubbing her Mom’s back and she continues to complain back pain.

1. Explain why serum sodium levels appear to be in high in this case
2. Explain how high serum sodium levels might affect the intracellular fluid
3. Using your knowledge of normal physiology, explain how continued fluid loss is likely to affect the following:
   1. Blood volume
   2. Cell function
   3. Kidney function
4. Given Mrs. K.B.’s history, why might a potassium imbalance have more serious effects on her?
5. As the provider, when you enter the room, you find Sara rubbing her Mom’s back – you introduce yourself and what is the first thing that you would then need to do?
6. In regard to Mrs. K.B.’s back pain, what type of questions or history would you like to obtain?

Mrs. K.B. reports using herbal compresses at home to help her back pain and that she usually takes two “extra-strong” Acetaminophen tablets every 4 hours and a Tylenol #3 whenever the pain is severe. Sara states that she has tried to get her Mom to use “more natural” treatments for her back but she “loves her Tylenol.”

1. When considering sources for Herbal and Natural Remedies there are many to choose from but not all are FDA approved, and who has time to vet every website. Take a look at Natural Medicines, which is in the Research Guides at the Regis Library. What type of Natural Medicine treatment would you recommend for Mrs. K.B. knowing that her back pain is due to arthritis that was diagnosed 10 years prior, that could offer her relief from her back pain?
2. What should Mrs. K.B. and Sara understand about the dosage of acetaminophen that she is taking?
3. Finally, Sara commented that her Mom seems to be suffering more frequently from insomnia but claims that her medication controls her back pain. Could the Tylenol #3 tablets be interring with her sleep and if so how is this occurring?

Part 4: Day 3

Mrs. K.B. has spent the night in the ED due to a bed shortage and she is finally admitted to Med-Surg.

After a prolonged period of vomiting, metabolic acidosis develops. This change results from several factors.

• Loss of bicarbonate ions in duodenal secretions
• Lack of nutrients leading to ______________ of stored fats and protein with production of excessive amounts of ketoacids
• Dehydration and decreased blood volume leading to decreased excretion of acids by the __________________
• Decreased blood volume leading to decreased tissue perfusion, less oxygen to cells, and increased _________________ metabolism with increased lactic acid.
• Increased muscle activity and stress leading to increased metabolic acid production.
• These factors lead to an increased amount of acids in the blood, which bind with bicarbonate buffer and result in decreased serum bicarbonate and decreased serum pH or metabolic _________________.

1. List several reasons why Mrs. K.B. is lethargic and weak.
2. Predict the serum level of carbon dioxide, lactic acid, pH, pO2, K+, Na+, LFTs—note you should indicate low, normal or high and explain why in a brief sentence to indicate you understand the pathophysiology of the process.
3. If Mrs. K.B. continues to lose body fluid, why might serum pH decrease below 7.35?
4. If serum pH drops below 7.35 what signs would be observed in Mrs. K.B.
5. Describe the effect of acidosis on serum potassium levels.
6. Mrs. K.B. will be given replacement fluid therapy. Why is it important that sodium and potassium be given as well as water?

Case Study Rubric

Note: Scholarly resources are defined as evidence-based practice, peer-reviewed journals; textbook (do not rely solely on your textbook as a reference); and National Standard Guidelines. Review assignment instructions, as this will provide any additional requirements that are not specifically listed on the rubric.

Case Study Rubric – 100 PointsCriteriaExemplary
Exceeds ExpectationsAdvanced
Meets ExpectationsIntermediate
Needs ImprovementNovice
InadequateTotal PointsContent of Case StudyThe writer demonstrates a well-articulated understanding of the case study subject matter in a clear, complex, and informative manner. The case study content and theories are well developed and linked to the course content, assignment requirements, and practical experience. The case study includes relevant material that fulfills all objectives of the assignment.

Cites three or more references, using at least one new scholarly resource that was not provided in the course materials.

30 pointsThe writer demonstrates an understanding of the subject matter, and the components of the case study are accurately represented with evidence-based practice, ethics, theory, and/or role content. Course materials and scholarly resources are present to support required concepts. The paper includes relevant material that fulfills all objectives of the case study.

Cites two references.

26 pointsThe writer demonstrates a moderate understanding of the subject matter, as evidenced by components of the case study and use of evidence-based practice, theory, or role-development. Course content is present but missing depth and/or development.

Cites only one reference.

23 pointsAbsent application to evidence-based practice, theory, or role development.

Demonstrates incomplete understanding of content and/or inadequate preparation.

Significant content of case study is vague, inaccurately portrayed, or missing.

No references cited.

Submits assignment late.

20 points30Analysis and Synthesis of Case Study Content and MeaningThrough critical analysis, the submitted case study provides an accurate, clear, concise, and complete summary of the scenario.

Information from scholarly resources is synthesized, providing new information or insight related to the context of the assignment by providing both supportive and alternative information or viewpoints.

All instruction requirements noted.

30 pointsCase study is complete, providing evidence of further synthesis of course content via scholarly resources.

Information is synthesized to help fulfill the case study requirements. The content supports at least one viewpoint.

Submission provides clarification of the assignment by correctly answering all posed questions within the instructions.

All instruction requirements noted.

26 pointsLacks clarification or new information. Scholarly reference supports the content without adding any new information or insight. Case study content may be confusing or unclear, and the summary may be incomplete.

Most instruction requirements are noted.

23 pointsSubmission is primarily a summation of the assignment without further synthesis of course content or analysis of the scenario.

Demonstrates incomplete understanding of content and/or inadequate preparation.

Missing some instruction requirements.

Submits assignment late.

20 points30Application of KnowledgeThe summary of the case study provides information validated via scholarly resources that offer a multidisciplinary approach to the scenario provided.

The student’s application in practice is accurate and plausible, and additional scholarly resource(s) supporting the application are provided.

All questions posed within the assignment are answered correctly in a well-developed manner, applying knowledge with citations for validation.

All instruction requirements noted.

30 pointsA summary of the study, findings, and knowledge gained from the assignment is presented.

Student indicates how the information will be used within their professional practice.

All questions posed within the assignment are answered within the case study. The answer to one question may be vague and/or limited in development, but as a whole all answers are correct.

All instruction requirements noted.

26 pointsObjective criteria are not clearly used, allowing for a more superficial application of knowledge between the assignment and the broader course content.

One question is answered incorrectly and/or two case study answers are vague or limited in development but remain correct.

Student’s indication of how they will apply this new knowledge to their clinical practice is vague.

Most instruction requirements are noted.

23 pointsThe application of knowledge is significantly lacking.

Demonstrates incomplete understanding of content and/or inadequate preparation.

Student’s indication of how they will apply this new knowledge to their clinical practice is not practical or feasible.

Application of knowledge is incorrect and/or student fails to explain how the information will be used within their personal practice.

Multiple questions are not answered or are answered incorrectly (e.g., two questions answered incorrectly, or three case study answers are vague or limited in development but remain correct).

Missing some instruction requirements.

Submits assignment late.

20 points30OrganizationWell-organized content with a clear and complex purpose statement and content argument. Writing is concise with a logical flow of ideas.

5 pointsOrganized content with an informative purpose statement, supportive content, and summary statement. Argument content is developed with minimal issues in content flow.

4 pointsPoor organization and flow of ideas distract from content. Narrative is difficult to follow and frequently causes reader to reread work. Purpose statement is noted.

3 pointsIllogical flow of ideas. Prose rambles. Purpose statement is unclear or missing.

Demonstrates incomplete understanding of content and/or inadequate preparation.

No purpose statement.

Submits assignment late.

2 points5APA, Grammar, and SpellingCorrect APA formatting with no errors.

The writer correctly identifies reading audience, as demonstrated by appropriate language (avoids jargon and simplifies complex concepts appropriately).

Writing is concise, in active voice, and avoids awkward transitions and overuse of conjunctions.

There are no spelling, punctuation, or word-usage errors.

5 pointsCorrect and consistent APA formatting of references, and cites all references used. No more than two unique APA errors.

The writer demonstrates correct usage of formal English language in sentence construction. Variation in sentence structure and word usage promotes readability.

There are minimal to no grammar, punctuation, or word-usage errors.

4 pointsThree to four unique APA formatting errors.

The writer occasionally uses awkward sentence construction or overuses/inappropriately uses complex sentence structure. Problems with word usage (evidence of incorrect use of thesaurus) and punctuation persist, often causing some difficulties with grammar. Some words, transitional phrases, and conjunctions are overused.

Multiple grammar, punctuation, or word usage errors.

3 pointsFive or more unique formatting errors, or no attempt to format in APA.

The writer demonstrates limited understanding of formal written language use; writing is colloquial (conforms to spoken language).

The writer struggles with limited vocabulary and has difficulty conveying meaning such that only the broadest, most general messages are presented.

Grammar and punctuation are consistently incorrect. Spelling errors are numerous.

Submits assignment late.

2 points5Total Points100