NR 572 Week 8 Acute Case Synthesis Example

Acute Case Synthesis, Admission to Discharge: A 77-Year-Old With Diarrhea, a Potassium of 6.6 and a Heart Rate of 34, Told With the Timeline Visible at Every Decision

Student Name

College of Nursing, Chamberlain University

NR 572: Advanced Acute Care Management

Instructor Name

Month Day, Year

Acute Case Synthesis, Admission to Discharge: A 77-Year-Old With Diarrhea, a Potassium of 6.6 and a Heart Rate of 34, Told With the Timeline Visible at Every Decision

Arrival, Day 0, 16:00

A 77-year-old with permanent atrial fibrillation, diastolic heart failure and stage 3a kidney disease arrived at the emergency department after three days of watery diarrhea, caught during an outbreak at a senior center. Home medicines were metoprolol succinate 100 mg, apixaban, lisinopril, spironolactone and furosemide. Pressure was 104/62, heart rate 64 in atrial fibrillation. Creatinine was 1.9 against a baseline of 1.2; potassium was 5.4.

The admitting team held lisinopril and furosemide and started fluid at 75 mL per hour. Metoprolol and spironolactone continued. The first decision is the one I return to below, because it was made at 17:30 on day 0, with the potassium already at 5.4 and the creatinine rising, and nothing in the note explained it.

The Night, Day 1, 05:40 to 06:50

At 05:40 the heart rate was 34 and the pressure 76/42. The rapid assessment recorded cool hands, 20 mL of urine per hour, a tracing with widened complexes and peaked T waves, and a patient drowsy but answering. The first working explanation, too little fluid plus too much beta blockade, guided atropine and a fluid bolus. Atropine did nothing by 05:50, which broke that explanation.

At 05:52, with the potassium result about 30 minutes away, my preceptor and I gave calcium. The rate rose to 52 within five minutes. At 06:10 a working differential brief pointed the next hour of treatment at the potassium and the blocker together, even though volume depletion with beta blocker effect was more likely, because of the consequence within the hour and the low cost of a wrong guess. At 06:20 the potassium came back at 6.6 and the creatinine at 2.9.

In the term's reading, Farkas et al. (2020) supplied the frame for the night: drug, kidney and potassium locked in a loop, each worsening the others.

Stabilization and Escalation, Day 1, 06:25 to 14:00

At 06:25 the rate fell to 40 as the calcium wore off. A second calcium dose, insulin with dextrose, albuterol, a second liter of fluid and the discontinuation of metoprolol, spironolactone and lisinopril all started together. At 06:32 the rate was 46 and the pressure 80/46, so an epinephrine infusion began, supported by the bradycardia guideline as a step after failed atropine (Kusumoto et al., 2019). By 06:40 the rate was 60.

Escalation to intensive care was a decision with criteria: the patient needed continuous rhythm monitoring and a titratable infusion with nursing at one to two, which the ward could not supply (Nates et al., 2016). The transfer happened at 06:50. The escalation plan written there set numeric triggers for rate, pressure, potassium, glucose and urine, with durations and named responders.

Over the day the potassium came down steadily on shifting therapy, a binder and fluid, reaching normal by the evening sample. Dialysis was not needed. Epinephrine stopped at 14:00.

Handoff and the Middle Days, Day 1 to Day 3

At 07:00 the night team handed off to the day team with the unstable problem first, then what had been done and what it achieved, then the compressed history, then risks with triggers and outstanding items with owners. At 16:00 on day 1, as the metoprolol wore off, the atrial fibrillation rate rose to 118. The team gave a small dose of oral metoprolol tartrate, 12.5 mg, rather than the home dose, and the rate settled in the 90s. Creatinine peaked at 3.1 on day 2 and was 2.2 on day 3. The patient moved to the step-down unit on day 2 and to the general ward on day 3, each when the stepping-down criteria in the escalation plan had been met for the required duration.

Disposition, Day 5

The patient went home with the sister on day 5. The disposition was argued against three criteria. Physiology: potassium 4.6 and creatinine 1.5 on the morning of discharge, heart rate 84 to 98 in atrial fibrillation on metoprolol succinate 50 mg, pressure 118/70, diarrhea resolved. Function: walking the hallway independently, as before admission. Support: the sister at home and a primary care visit booked for day 9 with a potassium and creatinine check. A skilled nursing stay was discussed and declined by the patient, and nothing in the physiology or function required it.

Medicines at discharge: spironolactone stopped; lisinopril held until the primary care visit; metoprolol halved; apixaban continued at the full dose, since the patient met only one of the criteria for dose reduction; furosemide held until the visit. After a major trial of spironolactone in heart failure was published, prescriptions rose sharply in older adults taking ACE inhibitors, and so did hospital admissions and deaths from hyperkalemia (Juurlink et al., 2004). The discharge summary explains each change.

Talking With the Patient and the Sister

At 07:10 on day 1, once the rate was stable on epinephrine, the intensive care nurse practitioner confirmed with the patient that full treatment, including resuscitation, was wanted; the patient said yes without hesitation. The sister was told by phone at 07:30 what had happened and why, in plain words: a combination of a heart medicine and a high potassium level had slowed the heart, and both were being corrected. At discharge, both heard which medicines had stopped and why, were told to avoid salt substitutes, which are often potassium chloride, and were given the symptoms that should bring a call: dizziness, a very slow pulse on the home monitor, or diarrhea returning.

The Decision I Would Change

Most decisions in this case were reasonable at their hour, including the first working explanation at 05:40, which fit the facts available. The decision I would change was made 12 hours earlier: leaving spironolactone running at 17:30 on day 0, when the first bloods already showed potassium at the upper edge and kidney function slipping. Nobody recorded a reason for it, because I think nobody made a decision; the drug was carried forward from the home list. The bradycardia, the calcium, the epinephrine and the intensive care stay all followed from a chain that one held medicine might have broken.

What the Case Adds

The synthesis shows one pattern across the term's documents: the explanation that is most likely is not always the one to act on, and the decision that matters most may be made long before the emergency, by default rather than by choice.

References

Farkas, J. D., Long, B., Koyfman, A., & Menson, K. (2020). BRASH syndrome: Bradycardia, renal failure, AV blockade, shock, and hyperkalemia. Journal of Emergency Medicine, 59(2), 216-223. https://doi.org/10.1016/j.jemermed.2020.05.001

Juurlink, D. N., Mamdani, M. M., Lee, D. S., Kopp, A., Austin, P. C., Laupacis, A., & Redelmeier, D. A. (2004). Rates of hyperkalemia after publication of the Randomized Aldactone Evaluation Study. New England Journal of Medicine, 351(6), 543-551. https://doi.org/10.1056/NEJMoa040135

Kusumoto, F. M., Schoenfeld, M. H., Barrett, C., Edgerton, J. R., Ellenbogen, K. A., Gold, M. R., Goldschlager, N. F., Hamilton, R. M., Joglar, J. A., Kim, R. J., Lee, R., Marine, J. E., McLeod, C. J., Oken, K. R., Patton, K. K., Pellegrini, C. N., Selzman, K. A., Thompson, A., & Varosy, P. D. (2019). 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay. Circulation, 140(8), e382-e482. https://doi.org/10.1161/CIR.0000000000000628

Nates, J. L., Nunnally, M., Kleinpell, R., Blosser, S., Goldner, J., Birriel, B., Fowler, C. S., Byrum, D., Miles, W. S., Bailey, H., & Sprung, C. L. (2016). ICU admission, discharge, and triage guidelines: A framework to enhance clinical operations, development of institutional policies, and further research. Critical Care Medicine, 44(8), 1553-1602. https://doi.org/10.1097/CCM.0000000000001856