The healthcare provider (HCP) prescribes pantoprazole for a client who experienced partial and full thickness burns. The client is questioning the nurse if this medication is necessary. Which action(s) should the nurse implement? Select all that apply.

A. Use insulin sliding scale until symptoms are resolved: Starting insulin without an evaluation would be inappropriate. A sliding scale may eventually be needed if blood sugars fluctuate, but the priority is to assess the cause of the gastrointestinal symptoms first.

B. Return to the clinic for laboratory tests for an infection: Although an infection could be a cause, nausea, vomiting, and diarrhea in a diabetic client also raise concern for possible medication issues, dehydration, or even metabolic disturbances. Immediate evaluation is necessary before simply ordering lab tests.

C. Schedule a visit for evaluation by the healthcare provider (HCP): New gastrointestinal symptoms could indicate a significant underlying issue such as medication intolerance, dehydration, or even diabetic ketoacidosis (though less common in type 2). An urgent clinical assessment by the HCP is most appropriate.

D. Increase oral fluid intake until these symptoms subside: While staying hydrated is important, advising fluids alone without a thorough assessment risks missing a serious underlying cause. Symptom management should not replace a proper medical evaluation.

Potential Conditions

Anemia: Anemia commonly causes fatigue and weakness, but it does not typically explain diarrhea. Additionally, the use of spironolactone, a potassium-sparing diuretic, makes electrolyte imbalance a more likely cause of these symptoms rather than anemia.

Hepatic failure: While hepatic failure could cause fatigue and systemic symptoms, it usually presents with jaundice, ascites, or confusion in advanced cases. There are no signs of liver-related symptoms in this scenario, making hepatic failure less likely.

Hyperkalemia: Hyperkalemia is the most likely condition because spironolactone can cause potassium retention. Symptoms such as fatigue, muscle weakness, and gastrointestinal disturbances like diarrhea are classic early signs of elevated potassium levels.

Hyperuricemia: Hyperuricemia is characterized by elevated uric acid levels, often leading to gout attacks rather than gastrointestinal symptoms or muscle weakness. Therefore, it is not the primary concern with this client’s current presentation.

Actions to take

Check the client's oxygen saturation: Although oxygen saturation is important in many acute settings, the client’s symptoms suggest a metabolic issue rather than a respiratory problem. Checking oxygenation would not directly address suspected hyperkalemia.

Do a point of care glucose check: Checking glucose is appropriate for clients with symptoms of hyperglycemia or hypoglycemia, but this client’s symptoms and medication history point more toward an electrolyte imbalance rather than a glucose-related disorder.

Measure the client's abdominal girth: Measuring abdominal girth is useful for detecting fluid accumulation, such as ascites in liver failure, but it is not relevant in the assessment of hyperkalemia. It would not provide information needed for the client’s immediate concern.

Ask the client about their diet: Dietary habits, particularly potassium intake, can significantly impact potassium levels when using potassium-sparing medications like spironolactone. Understanding the client's diet can help identify factors contributing to hyperkalemia.

Do a blood chemistry panel: A blood chemistry panel would provide critical information about serum electrolytes, including potassium levels. It is essential for diagnosing and confirming hyperkalemia and guiding further treatment decisions.

Parameters to Monitor

Edema: While edema monitoring is important in some chronic conditions like heart failure, it is not a primary concern with hyperkalemia. Hyperkalemia affects muscle and cardiac conduction, not typically fluid balance or peripheral swelling.

Skin color: Monitoring skin color can reveal perfusion issues but does not directly help detect or manage hyperkalemia. Changes in skin color would not provide early or specific warning signs of worsening potassium levels.

Pedal pulses: Pedal pulses are useful in assessing circulatory problems such as peripheral arterial disease but are not directly related to the cardiac conduction disturbances seen in hyperkalemia. Focus should instead be on heart rhythm.

Potassium level: Potassium level monitoring is essential because hyperkalemia can progress quickly and lead to life-threatening cardiac complications. Keeping track of potassium levels helps assess the severity of the imbalance and the response to treatment.

Heart Rhythm: Monitoring heart rhythm is critical, as hyperkalemia can cause bradycardia, peaked T waves, and even cardiac arrest. Continuous cardiac monitoring allows for early detection of dangerous arrhythmias resulting from elevated potassium.