Joyce W is a young lady presenting to the ED after being found by her fiancé unresponsive in the bathroom with large amounts of vomitus. He immediately called 911 and she was transported to the hospital. When we first meet Joyce, she is lying on the cart with her fiancé Austin at her bedside.  She appears awake and alert.  Nurse Terri enters.  She reports the vital signs have already been completed.  Nurse Terri asks Joyce if she has any pain (which Joyce denies) and informs her of the plan to complete an assessment.  
Nurse Terri reviews the details previously stated.  She asks Joyce if this has ever happened before.  Joyce reports she does have issues with vomiting.  She continues to elaborate on this event.    What are 3 possible diagnoses to consider at this time?   Explain your rationale.                       
As a nurse, what labs or diagnostics would you request/expect to be ordered?   Explain your rationale.                           
After hearing more about events Joyce reveals, does this change any of your priorities at this time?   Explain your rationale.                         
After seeing the lab results, what are your priorities?  Be specific with your responses.   Hematology Chemistry Urinalysis CBC CMP U/A   WBC 13.8 Na 131 Color amber RBC 3.95 K 3.1 Appearance clear Hgb 19.1 Cl 95 Glucose neg HCT 50.2 CO2 18 Bilirubin neg MCV 96 Glucose 78 Ketones pos MCH 31.2 Ca 8.4 Spec Grav 1.030 MCHC 32.6 BUN 22 Blood neg RDW 13.2 Creat 1.4 pH 5.4 PLT 322 GFR 90 Protein neg MPV 10.4 Albumin 3.9 Urobili 0.8 Neutrophils 78 Total protein 6.2 Nitrite neg Bands 23.7 Bili 0.9 Leukocyte est neg Lymphocytes 28 ALP 106 Monocytes 4.9 AST (SGOT) 22 Eosinophils 2.1 ALT (SGPT) 33 Basophils 0.5         
Refer to the Electrolyte Replacement Protocol.  What should you administer to this patient based on the lab results?   See Protocol at the end of this case.       
Are there any other considerations for her discharge plan that were not addressed?   List her discharge plans:   _________________________________________   _________________________________________   _________________________________________   _________________________________________                         

Scenario from Montgomery College Nursing Simulation: Eating Disorder

Intravenous Potassium Protocol

Current Serum Potassium LevelIV Administration- Peripheral IV AccessMonitoring
Below 3 mEq/LGive KCl 10 mEq/100mL IVPB (premixed bag) every hour x 4 doses    Infuse each bag over 1 hour  Call Physician   Check K+ one hour after the 4th dose
3 to 3.3 mEq/LGive KCl 10 mEq/100mL IVPB (premixed bag) every hour x 4 doses   Infuse each bag over 1 hour  Check K+ one hour after the 4th dose
3.4 to 4 mEq/LGive KCl 10 mEq/100mL IVPB (premixed bag) every hour x 2 doses.    Infuse each bag over 1 hour  Check K+ 15 minutes after the 2nd dose
4.1 to 5.1 mEq/LNo Treatment  No Treatment
Above 5.1 mEq/LCall Physician  Call Physician
If patient has complaints of burning and irritation at infusion site, contact pharmacy to make Potassium IVPB in 250 mL NS.  Add 5 mL (50 mg) of lidocaine 1% to IVPB of Potassium

Oral Potassium Protocol

Current Serum Potassium LevelOral AdministrationMonitoring
Below 3 mEq/LGive PO KCl 20 mEq (tablet or liquid) every 2 hours x 3 doses   Call Physician   Check K+ level one hour after the 3rd dose  
3 to 3.3 mEq/LGive PO KCl 20 mEq (tablet or liquid) every 2 hours x 2 doses   Check K+ level one hour after the 2nd dose
3.4 to 4 mEq/LGive PO KCl 20 mEq x 1 dose Check K+ level in 12 hours or at next scheduled lab draw, whichever comes first after the dose  
4.1 to 5.1 mEq/LNo Treatment  No Treatment
Above 5.1 mEq/LCall Physician  Call Physician
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