Abdullah, Asniah.

BSN 4
ADVENTIST MEDICAL CENTER COLLEGE
Brgy. San Miguel, Iligan City

SCHOOL OF NURSING

Competency Appraisal 1

First Semester, AY 2018 – 2019

1. HYPOCALCEMIA (25 points)

SITUATION: A 60-year-old man is admitted at the Adventist Medical Center because of

numbness and tingling of the lower extremities, muscle cramping, and hypotension. His serum
calcium level is 5 mg/dL. His dietary history reveals that he has lactose intolerance. He lives an
inactive life with less exposure to sunlight.

1. What are the assessment findings that lead to the hypocalcemia of the client?(5)
a. Numbness and tingling of the lower extremeties
b. Muscle cramping
c. Hypotension
d. Serum calcium level is 5 mg/dL
e. Lactose intolerance
(Hinkle and Cheever, 2015) pg. 246
2.The nurse tested the client for Chvostek’s sign and Trousseau’s sign. How are these
tests being done? (2)
a. Chvostek’s sign: a contraction of the facial muscle elicited in response to
light tap over the facial nerves in front of the ear. (Porth, 2011)
b. Trousseau’s sign: a carpopedal spasm induced by inflaming a blood
pressure cuff above systolic blood pressure. (Porth, 2011)

Reference: (Hinkle and Cheever, 2015) pg. 259

3. The doctor prescribes calcium gluconate for the client. What are the nursing
responsibilities if this drug will be administered? (5)
a. Give slowly as ordered
b. Monitor cardiac status and cardiac dysrhythmias
c. Assess for infiltration and phlebitis
d. Check if the patient is in digitalis- derived medications
e. The patient is kept on bed during IV infusion, and BP is monitored

Reference: (Hinkle and Cheever, 2015) pg. 260

4. What is the most serious manifestation (2)as well as serious complications of a client
with hypocalcemia? (6)
Serious manifestion: seizure and respiratory arrest
Complications
a. Delirium
b. Osteoporosis
c. Impaired memory
d. Fragile bones
e. Confusion
f. Eye dysfunction

Reference; : (Hinkle and Cheever, 2015) pg. 259

5. What are the food sources rich in calcium that should be recommended to the client?
(5)
a. Green leafy vegetables
b. Milk products
c. Canned salmon
d. Sardines
 e. Fresh oysters

Reference; : (Hinkle and Cheever, 2015) pg. 260

2. HYPERCALCEMIA (20 points)

SITUATION: A 35-year-old client has hyperparathyroidism and has a serum calcium

greater than 12 mg/dL. She suffers from muscle weakness and fatigue. She receives
furosemide, calcitonin, and intravenous fluid of 0.9% NaCl .

1. Explain the mechanism of action of the drugs and intravenous fluid that he receives. (3

a. IV adm of 0.9% NaCl solution may temporarily dilutes the calcium level and
increases urinary calcium exretion by inhibiting tubular reabsorption of
calcium.

b. Furosemide is often used in conjunction with administration of saline

solution; in addition to causing diuresis, furosemide increases calcium
exretion.

c. Calcitonin can be used to lower the serum calcium level and reduces bone
resorption , increases deposition of calcium and phosphorus in the bones.
(Karch , 2012)

Reference; : (Hinkle and Cheever, 2015) pg. 261

2. In case of an emergency what medication will be administered for rapid reversal of
hypercalcemia.(1) Discuss briefly the action of the drug. (2)

Calcitonin can be used to lower the serum calcium level and reduces bone resorption ,
increases deposition of calcium and phosphorus in the bones. (Karch , 2012)

Reference; : (Hinkle and Cheever, 2015) pg. 261

3. What nursing diagnosis will be formulated based on the manifestations of the client?(2)
Include the nursing interventions with the corresponding rationale.(3 each for interventions
and 3 each for rationale=12)

1. Impaired urinary elimination related to decrease urinary output

1.1 Assess for complaints of flank or abdominal pain & strain urine ( To look
for stone formation

1.2 Keep patient hydrated ( Decrease chance of renal stone formation)

1.3 Monitor I and O (To obtain baseline data)

2. Impaired physical mobility e related to muscle weakness

2.1 Keep patient safe from falls or injury ( Top prevent further stress, injury)

2.2 Encouraged patientto take few steps aday.® (This will help the patient to
mobilize and recover faster)

2.3 Decrease calcium rich foods and intake of calcium-preserving drugs

like thiazides, supplements, Vitamin D (prevent the cause of condition

3. HYPOMAGNESEMIA/HYPERMAGNESEMIA (25 points)

SITUATION: A client has colorectal cancer and had to undergo an ileostomy. Electrolyte
studies show that the magnesium level is 1.0 mEq/L. She receives magnesium sulfate IV.
1. What are the expected manifestations for a client with hypomagnesemia? (5)How will you
contrast this with hypermagnesemia since the client receives magnesium sulfate IV? (10)

HYPOMAGNESEMIA MANIFESTATIONS HYPERMAGNESEMIA MANIFESTATIONS

Tachycardia Bradycardia

Hypertension Hypotension
- Twitches; paresthesias - Diminished or absent DTRs
- (+) Trousseau’s & Chvostek’s signs
- ↑DTRs

Anorexia, Diarrhea Flushed skin

Nausea and vomiting Sweating
- Hyperfeflexia; ↑DTRs - Skeletal muscle weakness &
paralysis

Irritabity Drowsiness
Confusion Lethargy
Emotions lability Coma
Weakness

Reference: PPT by Ma'am Bucayan, FLUIDS-ELECTROLYTES-MOSBY Slides 100-101

2. What will be your action if the client will experience hypoactive or absent deep
tendon reflexes? (2)
2.4 Ensure safety from falls and injury

2.5 Keep the bed rails up

Reference: PPT. HYPOMAGNESEMIA AND HYPERMAGNESEMIA,

Slide 23.
Ma'am Bucayan

3. Why is the client at risk for injury?

3.1 Hypoactive

3.2 Diminished deep tendon reflex

3.3 Depressed CNS as wells as Peripheral neuromuscular junction

How will you prevent injury? (3)

1. Seizure precautions

2. Monitor neuro status

3. Monitor DTR’s

4. Clear Pathway

5. Assist the client

6. Bonsoir shoes

Reference: PPT. HYPOMAGNESEMIA AND HYPERMAGNESEMIA, Slide 23.

(Ma'am Bucayan )

4. Give your dietary instructions for the client. (5)

4.1 Green vegetables

4.2 Nuts
4.3 Legumes
 4.4 Bananas
4.5 Oranges

Reference; : (Hinkle and Cheever, 2015) pg. 263

4. HYPOPHOSPHATEMIA/HYPERPHOSPHATEMIA (20)

Contrast hypophosphatemia and hyperphosphatemia in terms of the following:(20)

HYPOPHOSPHATEMIA(10) HYPERPHOSPHATEMIA (10)
1. RISK FACTORS 1. Insufficient phosphorus 1. Decrease Renal exretion
intake 2. Tumor lysis syndrome
3. Increase intake of
2. Adm. of calories phosphorus
-Malnutrition (protein- 4. Phosphate containing
calorie and starvation laxative or enemas
(anorexia) 5. Hypoparathyroidism
6. Excess vitamin D
3. Overzealous intake of
7. Addison's disease
adm. Of simple CHO 8. Renal failure
4. Hyperparathyroidism 9. Impaired colonic
activity
5. Hypergycemia 10. Rhabdomyolysis

6. Respiratory Alkalosis

7. Oncongenic
osteomalacia

8. Alcholism

9. Thermal burns

10. Electrolyte imbalances

2. PATHOPHYSIOLOGY 1. May occur during the adm

of calories to patients with
severe- protein malnutrition
3. MANIFESTATIONS 1. Decrease contractility 1. Tachycardia
and CO 2. Palpitations
2. Slowed peripheral pulses 3. Dysrythimias
3. Shallow respirations 4. Irritable skeletal muscles
4. Weakness an fatigue 5. Twitches, cramps, tetany
5. Numbness seizures
6. Decrease DTRs 6. Restlessness
7. Decrease bone density 7. Bone and Joint pain
8. Irritability, confusion, 8. Painful muscle spasm in
coma calf or foot
9. Decrease platelet 9. Paresthesia's
aggregation 10. Hyperactive DTRs
10. Immunosuppresion 11. Trousseau’s and
Chvostek positive
12.
4. NURSING CARE 1. Administer Oral 1. Administer Phosphate
Phosphorus with vit D binding drugs
2. Ensure patient safety due 2. Avoid using phosphate
to bone fractures medication
3. Encourage foods high in 3. Restric foods high in
vitamins ( fish, organ meats, phosphate such as
Nuts, pork, beef, chicken , laxative and enema
whole grain and cereals) 4. Prepare the patient
4. f patient is receiving TPN for dialysis if in
watch for patient complaints failure
of muscle pain or weakness
(may be due to
 rhabdomyolysis or
refeeding syndrome)

5. COMMUNITY-BASED CARE

Reference: PPT. HYPOPHOSPHATEMIA AND HYPERPHOSPHATEMIA, Slide 4-11.

(Ma'am Bucayan )

(Hinkle and Cheever, 2015) pg. 264-265

5. FLUID VOLUME DEFICIT (15)

SITUATION: An older adult man who lives independently is admitted to the acute care
setting after his daughter found him to be weak, feverish, and confused. His admission
temperature is 38.8°C orally, heart rate 92 bpm, respirations 28 and BP 110/60, even
though he has a history of hypertension. His oral mucous membranes are dry, his skin
turgor is poor, and his urine is concentrated with a high urine specific gravity.

1. What assessment findings are consistent with the presence of fluid volume deficit? (10)

a. dry oral mucous membranes

b. poor skin turgor

c. high urine specific gravity

d. concentrated urine

e. BP of 110/60 bpm

f. weakness

g. temp. of 38.8°C orally/feverish

h. confusion

i. HR of 92 bpm

j. increase RR, RR of 28 bpm

(Hinkle and Cheever, 2015) pg. 246

2. Is the client experiencing hypovolemia or cellular dehydration? (1) The client is

experiencing hypovolemia because even if there is no statement that there is loss of
serum electrolytes but still a concentrated urine and high urine specific gravity
proves it. (Hinkle and Cheever, 2015) pg. 245

3. How does fluid volume deficit differ from cellular dehydration? (2)

Cellular dehydration refers to loss of water alone with increased serum sodium levels.
FVD occurs when loss of ECF volume exceeds the intake of fluid, it occurs when water
and electrolytes are lost in the same proportion as they exist in normal body fluids,
thus the ratio of serum electrolytes to water remains the same.

(Hinkle and Cheever, 2015) pg. 245

4. What collaborative actions are appropriate for addressing the client’s altered fluid
volume? (2)
a. Oral fluids, offer pt with oral rehydration solution (e.g. Rehydralyte, Elete,
Cytomax). If it can’t be corrected by oral fluids, enteral or parenteral route may be
used, isotonic fluids are prescribed to increase ECF volume. (Hinkle and Cheever,
2015) pg. 249

b. Administer oxygen as prescribed (Maam Bucayan’s ppt, FLUIDS-ELECTROLYTES-

MOSBY Slide 49)

6. FLUID VOLUME EXCESS (10)

SITUATION: An older client with congestive heart failure is readmitted to the acute
care facility with dyspnea, weakness, weight gain, 3+ pitting edema of both lower
extremities and bilateral crackles in the bases of his lungs. His pulse is bounding and
his BP is elevated.

1. What data supports the presence of fluid volume excess? (6)

a. weight gain

b. pitting edema 3+ of both lower extremities

c. dyspnea

d. bounding pulse

e. bilateral crackles in the bases of pt’s lungs

f. elevated BP

(Hinkle and Cheever, 2015) pg. 246

2. Why is fluid volume excess a common complication of CHF? (1)

CHF predisposes a person to FVE because the heart’s ability to pump blood is
decreased, failure of this pumping action interferes with renal perfusion and thus
with water and electrolyte regulation. Hence, there is now a disruption of the
homeostatic mechanisms responsible for regulating fluid balance and this leads to
fluid overload in the body. (Hinkle and Cheever, 2015) pg. 242 and 249

3. The practitioner prescribes a diuretic for the client’s CHF, but there is little urine output in
response. Give an explanation for why this is possible. (3) This is possible because the
kidneys retain sodium and water when there is decreased ECF volume as a result of
decreased cardiac output from heart failure. (Hinkle and Cheever, 2015) pg. 251

7. TOTAL PARENTERAL NUTRITION (15)

SITUATION: A 54-year-old man with pancreatitis is unable to intake oral food or fluids
due to pain, nausea, and vomiting. He is a severely weakened state, has lost 12
pounds, and has a fever of 38.6°C PO. Subsequently, a central line is placed and TPN is
initiated, which contains 50% dextrose.

1. What factors most likely persuaded the practitioner to initiate TPN therapy? (5)

a. Client has pancreatitis

b. Inability to take oral food or fluids

c. In a severely weakened state

d. Nutritionally deficient, Client has lost 12 pounds

e. Is in pain, nauseous and vomiting

(Maam Bucayan’s ppt, FLUID-ELECTROLYTES-MOSBY Slide 375-376)

2. Even though TPN can be administered via a peripheral line, why is the central venous
route preferred? (1)

Solutions with higher concentrations of dextrose , such as 50% dextrose in water, are
strongly hypertonic and must be administered into central veins so that they can be
diluted by rapid blood flow. (Hinkle and Cheever, 2015) pg. 273

3. How can the nurse protect the client from the developing complications related to his TPN
therapy? (5)

Air embolism Make sure all catheter connection are secure

Clamp the catheter when not in use (follow agency protocol for flushing and
clamping the catheter)

Instruct the client in the Valsalva maneuver for tubing and cap changes

For tubing and cap changes, place the client in the Trendelenburg position (if
not contraindicated, with the head turned in the opposite direction of the
insertion site; client should hold breath and bear down

Hyperglycemia Assess the client for a history of glucose intolerance

Assess the client’s medication history

Begin infusion at a slow rate as prescribed

Monitor blood glucose levels

Use strict aseptic technique

Hypervolemia Assess client’s history for risk for hypervolemia

Ensure proper function of the electronic infusion device

Monitor intake and output

Monitor weight daily

Hypoglycemia Gradually decrease PN solution when discontinued

Infuse 10% dextrose at same rate as the PN to prevent hypoglycemia when the
PN solution is discontinued

Monitor glucose levels when insulin is being given

Infection Use strict aseptic techniques

Monitor temperature

Assess IV site for signs of infection

Change site dressing, solution, and tubing as prescribed by agency policy

Do not disconnect tubing unnecessarily

Pneumothorax Monitor for signs of pneumothorax

Obtain a chest x-ray after insertion of the catheter to ensure proper catheter
placement

PN is not initiated until correct catheter placement is verified and the absence
of pneumothorax is confirmed

(Maam Bucayan’s ppt, FLUIDS-ELECTROLYTES-MOSBY Slide 401-407)

4. Why is it necessary for the nurse to monitor for both hyperglycemia and hypoglycemia
while the client is receiving TPN? (4) Because of the high concentration of dextrose in a
solution , if the client receives the solution too rapidly and does not have enough
insulin or contracts an infection, hyperglycemia can occur. And when the TPN is
abruptly discontinued or when too much insulin is administered , hypoglycaemia can
occur. Maam Bucayan’s ppt, FLUIDS-ELECTROLYTES-MOSBY Slides 394-397

8. HYPERNATREMIA (HYPERTONIC DEHYDRATION)

SITUATION: A 47-year-old woman was taken to the emergency department after she
developed a rapid heart rate and agitation. Physical assessment revealed dry oral mucous
membranes, poor skin turgor, and fever of 38°C orally. The client’s daughter said that her
mother had been very hungry as of late and drinking more fluids than usual. Suspecting
diabetes mellitus, the practitioner obtained serum electrolytes and glucose levels, which
revealed serum sodium of 163 mEq/L and serum glucose of 360 mg/dL.

1. Interpret the client’s data. Base on the client’s data, she is experiencing
hypernatremia (Hinkle and Cheever, 2015) pg. 253

2. Why are clients with diabetes mellitus prone to development of hypernatremia? Client’s
whom have diabetes mellitus are prone to development of hypernatremia because
they does not experience or cannot respond to thirst and sometimes fluids are
excessively restricted to them. (Hinkle and Cheever, 2015) pg. 253

3. What precautions should the nurse take when caring for the client with hypernatremia?

a. The nurse should assess for abnormal losses of water or low water intake and for
large gains of sodium, as might occur with ingestion of OTC medications that have a
high sodium content (e.g., Alka-Seltzer). (Hinkle and Cheever, 2015) pg. 254

b. The nurse must obtain a medication history, because some prescription

medications have a high sodium content. (Hinkle and Cheever, 2015) pg. 254

c. The nurse should note the client’s thirst or elevated body temperature. (Hinkle and
Cheever, 2015) pg. 254

d. The nurse should monitor for changes in behavior, such as restlessness,

disorientation and lethargy. (Hinkle and Cheever, 2015) pg. 254

e. Monitor the client closely for signs of a potassium imbalance. A potassium

imbalance can cause cardiac dysrhythmias that can be life-threatening! (Maam
Bucayan’s ppt, FLUIDS-ELECTROLYTES-MOSBY Slide 66)

9. HYPONATREMIA (HYPOTONIC DEHYDRATION)

SITUATION: An 87-year-old man was admitted to the acute care facility for gastroenteritis of
two days duration. He is vomiting, has severe, watery diarrhea and complaining of
abdominal cramping. His serum electrolytes are consistent with hyponatremia related to
excessive sodium loss.

1. What is the relationship between vomiting, diarrhea, and hyponatremia?

Vomiting and diarrhea causes hyponatremia to a patient. In this case, low urine
sodium occurs as the kidney retains sodium to compensate for nonrenal fluid loss.
(Hinkle and Cheever, 2015) pg. 251

2. What signs and symptoms should the client be monitored for that indicate the presence of
sodium deficit?

Cardiovascular  Normovolemic: rapid pulse rate,

normal BP

 Hypovolemic: Thready, weak, rapid

 PR; hypotension; flat neck veins;
normal or low CVP

 Hypervolemic: rapid, bounding

pulse; BP normal or elevated; normal
or elevated CVP

Respiratory  Shallow, ineffective respiratory

movement is a late manifestation
related skeletal muscle weakness

Neuromuscular  Generalized skeletal muscle

weakness that is worse in the
extremities

 Diminished deep tendon reflexes

CENTRAL NERVOUS SYSTEM  Headache

 Personality changes

 Confusion

 Seizures

 Coma

Gastrointestinal  Increased motility and hyperactive

bowel sounds

 Nausea

 Abdominal cramping and diarrhea

Renal  Increased urinary output

Integumentary  Dry mucous membrane

Lab Findings  Serum sodium level <135 mEq/L

 Decreased urinary specific gravity

(Maam Bucayan’s ppt, FLUIDS-ELECTROLYTES-MOSBY Slides 58-60)

3. In addition to examining the client’s serum electrolytes findings, how will the nurse know
when the client’s sodium level has returned to normal? Through I&O result and patient’s
daily body weight, absence of GI manifestations such as anorexia,nausea, vomiting
and abdominal cramping. (Hinkle and Cheever, 2015) pg. 253

10. HYPERKALEMIA

SITUATION: A 33-year-old woman who takes large doses of over the counter NSAIDs to
control her chronic headaches develops nausea and heart irregularities. Concerned
that she is having a heart attack she visits her health care provider who assesses her
serum electrolytes. Her serum potassium is 5.8 mEq/L.

1. What inference can be made based on the client’s symptoms and serum potassium level?
Client is having hyperkalemia which is iatrogenic or treatment induced. It is due to
large doses of over the counter NSAIDs. (Hinkle and Cheever, 2015) pg. 256-257

2. What is the significance of hyperkalemia to any client regardless of whether they are sick
or well? Hyperkalemia is usually more dangerous because cardiac arrest is most
frequently associated with high serum potassium levels. (Hinkle and Cheever, 2015)
pg. 256

3. What collaborative treatment measures will most likely be implemented to reduce the
client’s serum potassium?

a. Restrict dietary potassium and NSAIDs

b. obtain ECG

c. administration of either orally or by retention enema, of cation exchange resins

(e.g., sodium polysterene sulfonate (kayexalate). (Hinkle and Cheever, 2015) pg. 257

11. HYPOKALEMIA

SITUATION: A 69-year-old man has a medical history of congestive heart failure (CHF)
controlled by digitalis and furosemide drug therapy. Two weeks ago he developed diarrhea,
which has persisted in spite of his taking OTC antidiarrheal medications. His partner
transported him to the emergency department when she found him lethargic and confused.
Initial assessment of the client reveals heart rate at 86 bpm, respiratory rate 10, and blood
pressure 102/56 mmHg.

1. An electrolyte panel shows that the client’s serum potassium is 2.9 mEq/L. Does the nurse
have cause to be concerned about the client’s serum potassium? Why or why not?

Yes, because the client’s serum potassium level is below the normal range which is 3.5
to 5 mEq/L. The client is experiencing hypokalemia. If his condition is prolonged, it
can lead to an inability of the kidneys to concentrate urine causing dilute urine and
excessive thirst. Potassium depletion suppresses the release of insulin and results in
glocuse intolerance. And the client has CHF, severe hypokalemia can cause death
through cardiac and respiratory arrest. Hence the condition (vital signs and findings)
of the client must concern the nurse. (Hinkle and Cheever, 2015) pg. 254-255

2. What data supports the presence of hypokalemia in this client?

a. serum potassium level of 2.9 mEq/L

b. lethargic

c. BP of 10/56 mmHg

d. persistent diarrhea

(Hinkle and Cheever, 2015) pg. 246

3. What, if anything, should the nurse do?

The nurse should monitor closely for signs of digitalis toxicity because hypokalemia
potentiates the action of digitalis. (Hinkle and Cheever, 2015) pg. 256

1. Monitor cardiovascular, respiratory, neuromuscular, GI, and renal status, and

place the client on a cardiac monitor

2. Monitor electrolyte values

3. Administer potassium supplements orally or intravenously, as prescribed

4. Oral potassium supplements

a. Oral potassium supplements may cause nausea and vomiting and they should not
be taken on an empty stomach; if the client complains of abdominal pain, distention,
nausea vomiting, diarrhea, or GI bleeding, the supplement may need to be
discontinued

b. Liquid potassium chloride has an unpleasant taste and should be taken with juice
or another liquid

5. Intravenously administered potassium

 6. Institute safety measures for the client experiencing muscle weakness

7. Instruct the client about foods that are high in potassium content

(Maam Bucayan’s ppt, FLUIDS-ELECTROLYTES-MOSBY Slides 72-73)

4. What foods should the client be advised to eat that are high in potassium?

Avocado, Bananas, Cantaloupe, Carrots, Fish , Mushrooms , Oranges, Potatoes , Beef,

Raisins, Spinach, Strawberries , Tomatoes. (Maam Bucayan’s ppt, FLUIDS-
ELECTROLYTES-MOSBY Slide 74)

Fruit juices, bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats,
milk and whole grains. (Hinkle and Cheever, 2015) pg. 256