GNRS 555 Case Studies,
#1Case Study Upper Resp
Mr. Davidson is a 24-year old boxer. He had a boxing game and received with a nose injury. Due to heavy nosebleed, he was transferred to ER.
Health Assessment and Phys
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GNRS 555 Case Studies,
#1Case Study Upper Resp
Mr. Davidson is a 24-year old boxer. He had a boxing game and received with a nose injury. Due to heavy nosebleed, he was transferred to ER.
Health Assessment and Physical Exam:
Diagnostic Test:
Deviated septum is observed. X-ray is done to confirm the diagnosis.
# 2: Allergic Rhinitis
Mrs. Jones is a 32-year old who has a history of persistent allergic rhinitis.
# 3: Acute Viral Rhinitis (Common Cold)
• Mr. Richards has developed a common cold. He tells you that last week he worked 7 days in a row 14 hours a day. He asks you if there was a connection between working "to much" and getting the cold. What should your response be?
o Yes, stress increases chances of getting sick
• What are the latent viruses? and where do they live?
o Dormant, live inside body
• Mr. Richards says "I'm going to see my doctor to get an antibiotic", what do you think?
o No, virus are not effective
• What does Mr. Richards need to treat the symptoms of his cold?
o Rest, fluids, decongestants
• Five days later, Mr. Richards informs you that his symptoms got worse and now he has fever of 104.0 F and greenish discharge. Explain what happened and how will the treatment change now
o 2nd bacterial infection, may need antibiotics, high Fever and discharge bacterial
o Viral: no green discharge, low grade fever
# 4: Influenza (flu)
You are participating in setting up a "Flu Clinic" to vaccinate the local community. The following patients are present and you need to decide who should receive the inactivated vaccine and who should receive live attenuated vaccine
# 5: Sinusitis
Chris is a 27-year old who is a professional swimmer. He has developed a bacterial sinusitis.(inflammation of sinuses blocking mucus from draining)
# 6: Acute Pharyngitis
• Susan is a 19-year old freshman student presents to APU health center complaining of "scratcy throat". Through examination, acute pharyngitis is suspected.
# 7: Laryngeal Cancer
Mr. Ghali is a 63-year old who has been diagnosed with laryngeal cancer.
ABG Exercise:
1. pH 7.31, PaO2 80 mmHg, PaCO2 55 mmHg, HCO3 24 mEq. Respiratory acidosis
2. pH 7.30, PaO2 85 mmHg, PaCO2 40 mmHg, HCO3 18 mEq. Metabolic acidosis
3. pH 7.53, PaO2 90 mmHg, PaCO2 29 mmHg, HCO3 25 mEq. Respiratory alkalosis
4. pH 7.50, PaO2 82 mmHg, PaCO2 37 mmHg, HCO3 30 mEq. Metabolic Alkalosis
Case Study: History
Mr. B is a 38 year old homeless male consults presents to ED c/o cough, sputum production and mild hemoptysis. He has had evening rise of temperature for the past one month and claims to have lost 30 lbs. over a three month period.
1. What can you identify in this patient's history that put him at high risk for this present illness?
2. Based on the clinical presentation, the MD suspects tuberculosis (TB). Assuming the diagnosis is accurate, what microorganism causes TB? How did Mr. B get infected with TB (think from the route of acquiring causing microorganism)?
3. Based on the history of Mr. B, it is very likely that he was exposed to TB many years ago but until recently became active. What are the difference between active and inactive TB? Why Mr.B's inactive TB became active?
Mr. B's Physical Exam Findings
On exam, Mr. B appeared to be chronically ill and wasted. Cavernous breath sounds are heard over the right apex.
4. The MD suspects TB and orders a series of tests. Place the interventions in the order that they should be performed.
5. After the PPD skin test. The result of Mr. B will be considered positive if, after 48-72 hours, he develops an induration that measures over___mm? What is the rationale? Think from different patient populations.
6. How to conduct a PPD skin test? route? read time window? how to interpret? Clinical significance? False positive in what kinds of populations?
7. What's the isolation precaution for Mr. B? Criteria to discontinue isolation? Visitor education?
8. What's the best time to collect sputum culture? Clinical significance? Protocol for sputum specimen collection?
9. What's the clinical significance of having CXR in Mr. B? What would you see on CXR on a confirmed TB patient? What diagnostic exams are used to confirm the diagnosis of active TB?
Nursing Science: Pharmacological Considerations
10. After Mr.B has been confirmed of active TB, you would anticipate the MD to prescribe what medications? for how long? What are the difference in medication treatments between inactive and active TB?
11. Which TB medication may change the color of body fluids (urine, sweat, tears etc)? Accordingly, what patient education should you include before Mr. B start TB medications?
12. Due to possible side effects of INH, Mr.B's meals should include high amounts? (think from a specific nutrient/vitamin/supplement etc)
Pneumonia Case Study
o Mr. A is a 68 year old man who developed a harsh, productive cough four days. The sputum is thick and yellow with streaks of blood. He developed a fever, shaking, chills and malaise along with the cough. One day ago he developed pain in his right chest that intensifies with inspiration.
o The patient lost 15 lbs. over the past few months but claims he did not lose his appetite. "I just thought I had the flu." Past history reveals that he had a chronic smoker's cough for "10 or 15 years" which he describes as being mild, non-productive and occurring most often in the early morning. He smoked 2 packs of cigarettes per day for the past 50 years. The patient is a retired truck driver who has been treated for mild hypertension, bronchitis, appendicitis (as a young adult), hemorrhoids and a fractured femur and splenic injury. (motorcycle accident). Patient reports having about 10 sexual partners in the last 5 years.
Nursing Science : Physiological Integrity
• 1. What can you identify in this patient's history that put him at high risk for the present illness?
• 2. Based on the clinical presentation, this patient is suspected of pneumonia. Assuming the diagnosis is accurate, when you auscultate his chest, you would expect to hear? Rational? What are the normal breath sounds?
• 3. How many types of commonly seen pneumonia? What are they? Rationale to differentiate types of pneumonia? Based on this patient's clinical presentation and due to the large number of sexual partners, MD is suspecting HIV induced pneumonia. What specific type of pneumonia is that?
• 4. Cervical lymph nodes are normally not palpable. What will happen to lymph nodes in viral or bacterial infections?
• 5. When you further assess the patient, you observed the following. What is that? Pathophysiology rationale?
Mr. A's Physical Exam Findings
o The patient is an elderly man who appears tired haggard and underweight. His complexion is sallow. He coughs continuously. Sitting in a chair, he leans to his right side, holding his right chest with his left arm. Vital signs are as follows: blood pressure 152/90, apical heart rate 112/minute and regular, respiratory rate 24/minute and somewhat labored, temperature 102.6 F.
o Examination of the neck reveals a large, non-tender hard lymph node in the right supraclavicular fossa.
o Both lungs are resonant by percussion with one exception: the right mid-anterior and right mid-lateral lung fields are dull.
o Auscultation reveals bilateral diminished vesicular breath sounds. Bronchial breath sounds, rhonchi and late inspiratory crackles (are heard) in the area of the right mid-anterior and right mid-lateral lung fields. The remainder of the lung fields is clear.
Nursing Science : Physiological Integrity
• 6. The MD orders CBC with differentials. What would you find from CBC to confirm the diagnosis of pneumonia? What else lab results will you find from CBC? What are the normal ranges?
From the CBC, results showing elevated white blood cells–particularly elevations in neutrophils and neutrophil bands–would help confirm a diagnosis of pneumonia.
• 7. The MD orders CXR. Which CXR would confirm the diagnosis of pneumonia? What is the difference between Xray, CT scan and MRI? What will be different in regarding to patients' preparation (think from radiation, contrast, claustrophobia, medications to hold)?
CXR B would confirm the diagnosis of pneumonia.
• 8. You are about to collect a sputum culture from this patient. What is the common nursing protocol regarding sputum culture collection? Rationale?
• 9. What's the common causing organisms for hospital or community acquired pneumonia? What are the differences in regards to treatments?
Nursing Science : Management of Care
• 10. What will be the isolation precautions for Mr. A? What kinds of patient you may place in the same room with Mr. A?
Mr. A will be placed on isolation for droplet precautions, meaning that he can only be placed in the same room as other patients with pneumonia as well. All who enter the room must wear PPE consisting of gloves, gown, and mask as well. They must also practice strict medical asepsis, wash their hands before and after entering the patient’s room, wash or gel hands before and after providing care or upon removing gloves. Handling any respiratory devices must be done with sterile aseptic care.
• 11. Based on the clinical presentations, what nursing diagnoses should be high priority diagnoses for Mr. A? What are the appropriate nursing goals? What are the possible nursing interventions to achieve these goals?
Nursing Science: Pharmacological Considerations
• 12. The MD decides to admit Mr. A into the med/surg unit. What antibiotics do you anticipate the physician may order? What are the route?
• 13. How to calculate the IV flow rate? Levofloxacin (Levaquin) 750mg IVPB is ordered. The dose is available in 250ml of 5% dextrose and to be infused over 90 minutes. How would you run the IV pump? This IV wound be runned as a piggy back or secondary IV line.
•
• 14. If no IV pump is available and the IV infusion tubing administration set has a drop factor of 15 drops per ML. How many drops per minute would you regulate the above IV infusion?
• 41.7 drops
• 15. What is the relevant patient education information about pneumococcal vaccines (think from eligibility, route, expiration years etc)?
Questions while reading:
Is there a difference between pulmonary edema and pleural effusion? If so, what is it?
COPD
Case Study: History
• M.B. is a 65-year-old male who is being admitted from the emergency department to the cardiopulmonary unit with an exacerbation of chronic obstructive pulmonary disease (COPD).
Nursing Science : Physiological Integrity and Adaptation
1. While continuing M.B. assessment, you recognize that sometimes it is difficult to distinguish COPD from asthma since their clinical manifestations may be identical. However, some clinical features and pathophysiology mechanism are different. What are the difference between COPD and asthma?
2. In order to expedite M.B. admission, you delegate some nursing actions to the nursing assistive personnel (NAP). What are the possible relevant actions can be delegated?
3. This patient's ABG results are: pH 7.31; PaO2 68mmHg; PaCO2 58mmHg; HCO3- 32mEq/L; SaO2 85%. You would interpret that these findings indicate what respiratory status?
4. Based on the results of ABG, what high priority nursing interventions should be implemented?
5. When you review the results of other lab tests (esp. CBC and BMP) and CXR, what you would expect to find as a result of M.B's exacerbation of COPD? (Hint: think from XCR, HCO3-, RBC counts etc)
6. What kinds of diet will be appropriate for M.B to meet his nutritional needs?
The diet that is recommended is a high-calorie, high-protein diet. Around 3L/day recommended of fluids. It is recommended to eat 5-6 small meals daily to avoid bloating and satiety.
Nursing Science : Pharmacological Considerations
7. How should you teach M.B about using MDI? (Hint: open mouth, hold breath, shake, rinse mouth, spacer, how to know it is empty etc)
8. You formulate a nursing diagnosis of imbalanced nutrition: less than body requirements for this patient. What appropriate nursing interventions should you implement?
ASTHMA
• Case Study: History
o C.J., a 20-year-old female college student, is admitted to the emergency department (ED) with a severe asthma attack after engaging in a tennis match . She is accompanied by her tennis partner, who drove her to the ED. On an initial assessment you see that she is sitting in an upright position , using her accessory muscles to breathe. She appears restless and anxious . Her vital signs are T 98.4° F (36.9° C), P 128, R 34, BP 160/82. Auscultation indicates faint wheezing on inspiration and expiration , and her expiration is prolonged . Hyperresonance is noted upon percussion. C.J. manages to tell you that she has a long history of asthma but that this is the worst attack she has ever experienced. She cannot identify any triggers that she may be sensitive to and has never been tested for allergens. She does not smoke or use alcohol. She uses a bronchodilator metered-dose inhaler about once a day but has misplaced it. She also has a peak flow meter but has never used it.
• Nursing Science : Physiological Integrity and Adaptatio
• 1. What is the pathophysiology nature of asthma? What's the difference between asthma and COPD in pathophysiology?
2. What ABG results you may expect to find during C.J's early attack?
• Nursing Science : Safe and Effective Care
• 3. What nursing actions/interventions have the highest priority for C.J. at this point?
6. Treatment for C.J. will be initiated immediately. What initial interventions that you would anticipate to be implemented for this patient? (Think from nursing actions, medication treatments)
7. What signs/symptoms from C.J may indicate he is improving?
O2 sat, louder wheezing
8. C.J has a minimal-moderate response to the initial treatments, and the MD orders IV methylprednisolone (Solu-Medrol) to be given. What should you explain this drug to the patient? (Think from indication, side effects, patient education etc)
9. As you provide timely care to this patient, what nursing activities could be most appropriately delegate to nursing assistive personnel (NAP)?
10. C.J. is to received albuterol nebulizer treatment Q2h and PRN, Methypredisolone 60mg IVP Q6h and O2 tx NC at 4LPM. ABG is drawn and results show pH 7.36; PaO2 70mmHg; PaCO2 44mmHg; HCO3- 24mEq/L; SaO2 92%. Based on the information, what will be your best nursing action?
11. Nursing Science : Pharmacological Considerations
12. 9. What are the difference between long and short acting β- adrenergic agonists? Nursing considerations? Patient education?
10. Name of few example medications of long and short acting β- adrenergic agonists.
Listed above
13. Nursing Science : Health Promotion and Maintenance
14. 11. What should nurses be monitoring for when administering Albuterol (Proventil) to relieve severe asthma? What are the rationale?
15. What C.J received Adrenergic beta agonist for asthma, he complains of palpitation, chest pain and throbbing headache. What is the most appropriate nursing action? What should patients be screened for before start taking such medication? Rationale?
Pleural Effusion
Pleural Effusion:
Case Study: History
o Mr. C is a 25-year-old man presents with a 5-day history of right-sided chest pain and describes it as a ‘catch in the breath’. It gets worse with deep breathing and coughing. During this period, he has developed a fever, which is more pronounced in the evening. He also complains of a dry cough. Over the past 2 days, he has developed breathlessness, which has worsened rapidly. He is an otherwise healthy bank clerk who has not suffered from any other illness. He does not smoke or drink alcohol and is not taking any medication.
Mr. C's Physical Exam Findings
o Physical examination reveals mild pallor. His pulse is regular at 110 beats/min and his blood pressure is 120/82 mmHg. Respiratory rate is 26/min.
o The trachea is shifted to the left side and the apical impulse is shifted laterally.
o The right side of the chest moves less with respiration.
o Tactile vocal fremitus is reduced.
o On percussion, a stony dull note is elicited on the right side and this dullness does not shift with change in posture.
o Breath sounds and vocal resonance are almost absent on the right side. There is no succussion splash.
o Abdominal, cardiovascular and neurological examinations are normal. The rest of the physical examination is unremarkable.
Nursing Science : Physiological Integrity
• 1. What clinical presentations will support Mr.C's diagnosis of pleural effusion? Main Symptoms:
• 2. When you auscultate Mr. C, what would you expect to hear or find? Hint: adventitious breath sounds, reduce/absent or clear lung sounds, deviation of trachea etc?
• Mr. C's Diagnostic Findings
o A chest radiograph reveals a dense uniform opacity in the lower and lateral parts of the right hemithorax, shading off above and medially into the translucent lung, suggestive of a right-sided pleural effusion.
• 3. What diagnostic study is to confirm the diagnosis of pleural effusion?
• 4. What procedure is used to remove fluid/air from pleural space to alleviate respiratory distress or obtain a specimen for diagnostic purposes?
• 5. What positions should the patient assume for the procedure of thoracentesis?
6. What are the serious complications from thoracentesis? What may patient present if you suspect some serious complication develop after the procedure?
Pulmonary Embolism
Lower Respiratory Case Study- Pulmonary Embolism
1. What can you identify from the patient's history that put her at high risk for the present illness?
2. Based on the clinical presentation, pulmonary embolism is suspected as a result of DVT. What is the non-invasive diagnostic study that can identify DVT?
3. What types of patient population have the highest risks for developing a PE?
4. A patient has a total hip replacement. What clinical presentations from the patient indicate that the plan to prevent postoperative thrombus formation has been ineffective?
5. What blood work would you be expected to find in Mr.D's case? (Hint: D-dimer, aPTT, PT/INR?) What's the clinical significance of D-dimer?
6. The MD orders heparin IV drip and Coumadin (Warfarin) after the sign of PE and DVT have subsided. What are the mechanism differences between heparin and Coumadin treatment in Mr.D's case? What are the antidote to each medication? What lab values should you monitor for each medication?
Hypertension Case Study Questions 1-7
● J. G. is a 50-year-old African American man who comes monthly to the community health
screening for blood pressure checkups. He says he had some headaches lately and a little
dizziness.
● Initial Objective Data
● Alert and oriented and cooperative
● 5 feet 10 inches, 240 pounds
● Blood pressure 172/94, pulse 90, respirations 24, temperature 97.0° F
● Subjective Data
○ Is a truck driver and eats a lot of fast foods
○ It is hard to eat healthy on the road
○ Smokes one-half pack of cigarettes per day for 30 years
○ Drinks at least a 6-pack of beer a day when he is not working
○ States that he feels fine and is not a “hyper” person
○ Has heard that BP drugs “make you impotent”
1. What misconceptions about hypertension should be corrected?
a) “Hyper” and hypertension are the same diagnosis.
Being hyper and having hypertension are two completely, unrelated topics. Having a
diagnosis of hypertension does not have anything to do with what type of characteristics
you have as an individual, such as being calm, passive, hyper or energetic. Being Hyper
just means you are hyperactive or have a lot of energy. Hypertension is the diagnosis of
having high blood pressure, meaning that the force of your blood against your artery walls
is too high. This diagnosis is based on certain body characteristics and habits, but none
having to do with your personality.
b) Hypertension is called the “silent” killer because it does not always cause visible
symptoms.
Hypertension is often called the “silent killer.” This is because it is frequently
asymptomatic until it becomes severe and target organ disease occurs.
c) Erectile dysfunction is something all men have to deal with when taking
antihypertensive medications.
Sexual problems may occur with many of the antihypertensive drugs. Changing to another
antihypertensive drug can decrease or remove side effects such as reduced libido or erectile
dysfunction. It is important to educate the patient to voice any concerns dealing with
sexual issues so that change in medication can be done.
d) Hypertension cannot be treated without medication
Although hypertension and prehypertension can be treated without medication, it is
encouraged for those suffering from the disease to take medication in order to reach their
goal blood pressure. Some lifestyle changes can be made to help lower blood pressure.
Lifestyle modifications are indicated for all patients with prehypertension and
hypertension. These modifications include: weight reduction, dietary approaches to stop
hypertension (DASH) eating plan, dietary sodium reduction, moderation of alcohol intake,
regular physical activity, avoidance of tobacco use, and management of psychosocial risk
factors.
2. What are the classifications of hypertension? What are the typical clinical s/s of
hypertension?
3. What risk factors for hypertension does R.L. have?
-
7. What classification of hypertension does J. G. have? J.G has Secondary Hypertension exact
cause is related to his Left Ventricular Hypertrophy, which is due to his sutsained high BP,
causing an increase in his cardiac overload. The increased contractility increases myocardial
work and O2 demand.
8. The most important long-term goal for a client with hypertension would be to?
Lower BP, no longer require meds, prevent heart disease (CHF) or further complications of organ damage (kidney, eye, heart, blood vessels, brain). Need education, compliance, lifestyle change, annual screening.
9. How to obtain the diagnosis of hypertension?
Take BP and 2 or more times the BP is elevated. If white coat moniter BP at home
10. What assessment findings can possibly indicate of target organ damage?
Kidney (creatinine high), heart enlarged (apical pulse at clavicular line and EKG), Eyes
11. What possible side effects or adverse reactions are important for nurses to consider when initiating treatment of hypertension using ACE-inhibitors or ARB’s?
Hypotension (both), orthostatic hypotension, (BOTH)dry mouth/cough (ACE), angioedema (ARB), hyperkalemia (ACE), Ace inhibitor less effective in African americans
12. When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge of propranolol which may include:
need to be careful with patient with asthma or COPD, hold beta-blocker if HR is low, check potassium for diuretic (3.5-5 normal), Ace inhibitor (check kidney function serum creatinine BUN, potassium)
13. What information should the nurse include in discharge education for this patient?
side effects, what to look for, when to call DR.
14. Whats the difference between hypertensive urgency and Hypertensive emergency?
Chest Pain
Mr. Cameron is a 66-year old Caucasian gentleman who has a history of
CAD. This morning while he was gardening, he felt “some chest pain.”
He drove himself to the ED.
Chest Pain
Mr. Cameron is a 66-year old Caucasian gentleman who has a history of CAD. This morning while he was gardening, he felt “some chest pain.” He drove himself to the ED.
Mr. Cameron indicated that his pain is in the middle of his chest and radiates to his left arm. It is about 6/10. He added that this was not the first time he had this pain. He said that the pain usually starts few minutes after gardening or climbing stairs and is relieved by rest. Angina is suspected.
You connect Mr. Cameron to ECG and observe the following rhythm:
9. How do you interpret the above rhythm?
10. T-wave inversion on EKG indicate____?
11. The ED MD examines this patient and based on the ECG findings diagnosed him angina. The MD orders MONA, what does MONA stand for?
12. Before you administer Nitroglycerin, what should you assess? What's the interaction of NTG with Viagra? What are the two most common side effects of NTG? Rationale and how to treat these side effects?
13. For ASA treatment, what are the common route? dosage? Nursing consideration?
14. For Morphine, what are the commonly used dosage? Route? Rationale of giving morphine?
15. Knowing this patient also has COPD, how will that impact the oxygen therapy decision?
16. What cardiac enzymes that are routinely tested in ACS?
17. Which cardiac enzyme is the most sensitive and specific for myocardiac damage? How often does it get tested? Other clinical significance?
18. Why another 12-lead ECG is ordered here?
19. When you reassess Mr. Cameron. He says the pain is now 4/10 but not complete relieved, BP 90/50, HR 110, SaO2 92%, RR 22. Why patient's BP dropped?
20. Mr. Cameron tells you that he is not sure that the NTG is still good. How can you tell if NTG has expired or still active? Where should NTG be stored?
• 21. How would you teach the patient to prepare for the stress test? MIBI stress test? (hint: diet, medication, skin prep etc)
• 22. How would you explain the stress test to Mr. Cameron? When to terminate the test based on the patient's complains or vital signs?
• 23. If Mr. Cameron can't tolerate a physical stress test, what are his options?
• 24. What information should you include when developing a healthy life style teaching plan for Mr. Cameron? (hint: modifiable risk factors, diet, exercise etc)
• Six months later, Mr. Cameron comes back with severe chest pain. Per Mr. Cameron, this time the pain started while he was sleeping. He took 3 pills of NTG, but it didn't help, so he called 911 and was brought to ED. You connect him to ECG monitor and observe the following:
•
• 25. How do you interpret this rhythm?
• 26. ST elevation indicates 27. Serum troponin is ordered. The result is 0.4ng/dL, what is the normal range for troponin? How to interpret this value? Is one test/value of troponin enough to confirm or rule out the diagnosis?
• 28. What is the major pathology of AMI? What is the goal of treatment?
• 29. What are the treatment options of AMI?
• 30. What is fibrinolytic therapy? How does it work?
• Mr. Cameron has a history of atrial fibrillation and has been taking Coumadin (Warfarin) and therefore he is not a candidate for fibrinolytic therapy. Instead, urgent cardiac catheterization is scheduled.
• 31. You are preparing to care for Mr. Cameron after the cardiac catheterization performed through the femoral artery. Which position and activity level should the patient assume?
• 32. Mr. Cameron is diabetic. Which medications should you hold after the procedure? (hint: insulin, glipizide, metformin?)
Heart Failure
• Mrs. M. H. developed 5/10 substernal chest pain (on a 0-10 pain scale) and shortness of breath.
Admitting Data:
• Name: M. H.
• Age: 60-year-old.
• Gender: Female.
• Medical History:
• 1. Substernal pain is highly associated with cardiovascular events. True OR False?
true
2. Notice how many pillows the patient is using and what that may indicate?
Paroxysmal nocturnal dyssnpea ???
2. From this patient's history, what are the modifiable and non-modifiable cardiovascular risk factors?
Age, gender, ethnicity, family hx, smoking, alcohol use,
4. Knowing that Mrs. M.H developed HF after MI. Her MI was most likely Q-wave MI or non Q-wave MI?
Q-wave MI deeper and longer Q wave, deprived of circulation for more than 2 hours MI cell going into necrosis
5. Since the patient is allergic to Penicillin, she should not receive
Amoxil (Amoxicillin)
Vancomycin
Cefepime (Maxipime)
Levofloxacin (Levaquin)
6. Since the patient is allergic to Lisinopril, her alternative would be: Lisinopril (ace inhibitor) if can’t tolerate use ARB; Statin-check liver enzymes to monitor function, assess for muscle pain
Atenolol (Tenormin)
Simvastatin (Zocor)
Amlodipine (Norvasc)
Losartan (Cozaar)
• • History of Present Illness:
• Mrs. M. H. developed 5/10 substernal chest pain (on a 0-10 pain scale) and shortness of breath in the airport after flying into Los Angeles from Florida. Paramedics responded and transported her to the hospital.
• 7. What's the estimated heart rate in this rhythm?
180 bpm
8. Atrial fibrillation is a dysrhythmia with irregular rhythm. True or False?
9. Atrial fibrillation puts patients at higher risks for thrombosis. The risks can be lowered by taking what medications?
• Clinical Presentation:
• Physical examination findings at admission:
________________________________________
• Diagnostic findings at admission:
________________________________________
Medical Diagnosis: Acute decompensated heart failure (ADHF).
________________________________________
• 10. Classify the clinical manifestations of right-sided vs. left-sides HF.
11. Mrs. M.H. has systolic or diastolic HF?
12. BNP is a major marker of CHF and is released in response to______
13. Explain to Mrs. M.H why she experiences paroxysmal nocturnal dyspnea
14. How to auscultate the mitral murmur (bell or diaphragm)? Where?
All physicians take money: 5th intercostal space left midclavicular line
15. The presence of JVD indicates_____________
Head-to-toe assessment on the day of care:
• ________________________________________
Diagnostic findings on the day of care:
Hematology:
________________________________________
HGh and HCT stroke volume and cardac output decreased, not enough blood circulation, kidney not enough blood- kidney produces erytheroprotein which affects HnH and HCT
Complete Metabolic Panel (Chemistry):
Creatinine most sensitive for renal function, high level renal impairment
BUN can be affected by high protein diet
INR elevated on purpose due to taking coumodin, 2 is therapeutic dose
• 16. Discuss the pathophysiology of abnormal lab values and physical assessments.
• Discuss above
Medications:
Drug Dose Route Classification Specific Indication
Lasix (Furosemide)
Lasix (Furosemide)
Hydrochlorothiazide
Capoten (Captoril)
Warfarin (Coumadin)
Digoxin (Lanoxin)
Potassium
Zocor (Simvastatin)
Morphine
• CHF after IMI- Ace inhibitor drug of choice
• Digoxin- hypokalemia- may experience toxicity, too much hyperkalemia- normal dose digoxin not effective ( need stronger dose)
Analysis and Synthesis:
Mrs. M. H. is a patient who has cardiovascular risk factors (i.e. HTN, smoking, MI) that lead to heart failure. Based on her symptoms, the patient is having stage III (or stage C) heart failure. She is hospitalized for acute decompensated heart failure as evidenced by her significant cardiovascular (edema, JVD) and pulmonary (dyspena, crakcles, desaturation) symptoms as well as diagnostic tests (high BNP, cardiomegaly and infiltration on CXR).
Chest Pain
Please interpret the following strip and regularity, calculate heart rate and explain relevant
nursing care accordingly.
1. This looks like normal sinus rhythm-no nursing intervention necessary.
Regularity:R-R intervals are constant
Rate:The atrial and ventricular rates are equal
P wave:P waves are uniform. There is one P wave in front of every QRS complex.
PRI: PR interval is 0.12 sec
QRS: QRS complex measures less than 0.12 sec
Heart rate calculation method( count number of R-R intervals in 6 Seconds -6 seconds is 30 big
boxes on ECG and then multiply by 10) In this case we have 10R-R X 10=100 is the HR.
2.
Sinus Bradycardia
Regularity: R-R are constant
HR: 50
Nursing Care: Treatment for bradycardia depends on the type of electrical conduction
problem, the severity of symptoms and the cause of your slow heart rate. If you have no
symptoms, treatment might not be necessary. If symptomatic: Atropine is the drug of
choice.
3.
Sinus Tachycardia
Regular
HR: 120
Nursing Care: Treat underlying cause (e.g. pain, stress, infection, etc.)
4.
Sinus Arrhythmia
HR 90
PR 16 secs
QRS 12 secs
P wave present
R-R not consistent
Nursing Care: make sure patient is asymptomatic. Ask about Heart disease, stress, Excessive
consumption like caffeine, nicotine, and alcohol, as well as Intake of medications like diet pills
as
well as cough and cold medicines. If patient is asymptomatic, typically no medication is
prescribed.
Dysrhythmias- EKG Rhythm interpretation Q 9-11
Please interpret the following strip and regularity, calculate heart rate and explain relevant
nursing care accordingly.
9.
● This strip is displaying ventricular fibrillation
● The ECG is seen as coarse and fine and is characterized by irregular waveforms of
varying shapes and amplitude.
● This represents the firing of multiple ectopic foci in the ventricle.
● The ventricle is quivering with no effective contraction, consequently, no CO occurs.
● Ventricular fibrillation (VF) is a lethal dysrhythmia.
● Heart rate is not measurable, rhythm is irregular and chaotic, P wave not visible,
and PR and QRS interval not measurable
● VF results in an unresponsive, pulseless, apneic state
● If not rapidly treated patient will not recover
● Treatment: consists of immediate initiation of CPR and advanced cardiovascular life
support (ACLS) with the use of a defibrillator and definitive drug therapy ( epinephrine,
vasopressin)
10.
● This strip is displaying ventricular tachycardia
● Wide QRS at 0.12 seconds
● Abnormal HR is a characteristic of Ventricular tachycardia (100-250 bpm)
○ HR calculated from this ECG: 150 bpm (Count the small boxes between 2
complexes. HR = 1500 divided by # of small boxes)
● P wave abnormal
● Regular rhythm
● Elevated Q
● Sustained VT causes a severe decrease in CO because of decreased ventricular
diastolic filling times and loss of atrial contractions. This results in hypotension,
pulmonary edema, decreased cerebral flow, and cardiopulmonary arrest.
● This dysrhythmia must be treated quickly. Episodes may recur if prophylactic treatment
is not given (VF may also develop)
● Treat the precipitating causes
● Discontinue drugs that can prolong the QT interval
● Drug therapy. Cardioversion used if drug therapy is ineffective
● VT without a pulse is life threatening
11.
● P wave upright, one P wave for every QRS complex, no Afib or flutter waves present
● Regular atrial rhythm -- atrial rate is 75 bpm
● PR interval is normal duration
● No q wave visible, Ventricular rhythm irregular -- ventricular rate is 75 bpm
● QRS complex is .10 seconds -- normal duration
● ST segment is not flat, is elevated
● T wave is upright, QT is prolonged -- 0.6 seconds
● HR is 75 bpm
● Irregular ventricular rhythm, ST segment elevation indicates pericarditis, leading to
possible MI
● Treatment: reduce pain and inflammation with aspirin or NSAIDs, and treat
underlying cause whether it is infection or not and determine if other more direct
treatment is required
Mr. Cameron is a 66-year old Caucasian gentleman who has a history of CAD. This morning while he was gardening, he felt “some chest pain.” He drove himself to the ED.
Mr. Cameron indicated that his pain is in the middle of his chest and radiates to his left arm. It is about 6/10. He added that this was not the first time he had this pain. He said that the pain usually starts few minutes after gardening or climbing stairs and is relieved by rest. Angina is suspected.
You connect Mr. Cameron to ECG and observe the following rhythm:
9. How do you interpret the above rhythm?
10. T-wave inversion on EKG indicate____?
11. The ED MD examines this patient and based on the ECG findings diagnosed him angina. The MD orders MONA, what does MONA stand for?
12. Before you administer Nitroglycerin, what should you assess? What's the interaction of NTG with Viagra? What are the two most common side effects of NTG? Rationale and how to treat these side effects?
13. For ASA treatment, what are the common route? dosage? Nursing consideration?
14. For Morphine, what are the commonly used dosage? Route? Rationale of giving morphine?
15. Knowing this patient also has COPD, how will that impact the oxygen therapy decision?
16. What cardiac enzymes that are routinely tested in ACS?
17. Which cardiac enzyme is the most sensitive and specific for myocardial damage? How often does it get tested? Other clinical significance?
18. Why another 12-lead ECG is ordered here?
19. When you reassess Mr. Cameron. He says the pain is now 4/10 but not complete relieved, BP 90/50, HR 110, SaO2 92%, RR 22. Why patient's BP dropped?
20. Mr. Cameron tells you that he is not sure that the NTG is still good. How can you tell if NTG has expired or still active? Where should NTG be stored?
• Active NTG should have a slight burning sensation if placed under the tongue. It should also be replaced every 6 months. Nitroglycerin should be in a dark, air-tight container (brown bottle) because it is photosensitive to light and air.
Endocarditis
Mr. Kobe Bryant is a 35 y/o African-American male who was admitted with fever and hypotension. A CBC was drawn and showed WBC = 13,000/mm3. His Echo showed "aortic valve vegetation" and "low ejection fraction".
Vegetation- Plaque growing on valve, can visualize from echo, could break off and cause PE
Ejection fraction: normal 50-70
The admitting physician updates the admitting diagnosis as "Infective Endocarditis".
Once you know Mr. Bryant's diagnosis, you look to see if the Emergency Department RN did which of the following?
Blood cultures most relevant, positive staph or strep, negative- cant simply rule out IE due to slow growing, keep specimen growing x2 weeks, clean area, draw 2 different sides, 30 mins apart
Sputum cultures clean area
Urinalysis
Occult Blood test
True or False. It is possible for someone with IE to come back with negative blood cultures.
True
False
Which one of the following reveals a risk factor / etiology for Mr. Bryant's condition?
2 congenital birth marks on backside
A single episode of diarrhea about one month ago
Family history of maternal and fraternal grandfathers with HTN
Medical history of strep throat about 4 months ago bacteria could move to heart
Cant stop antibiotics mid-way through b/c rheumatic heart disease, resistance to meds, and bacteria flow to kidneys
Mr. Bryant is concerned about his diagnosis. He tells you, "I have no medical background - I play basketball. The doctor didn't explain this to me - Can you please tell me what is going on in my body?"
Based on your understanding of the pathophysiology of infective endocarditis (IE), the following is an appropriate nursing diagnosis?
Decreased Cardiac output related to valvular dysfunction manifested by low EF
Endocarditis related to pharyngitis manifested by hypotension and fever.
Risk for infection related to group A beta-hemolytic streptococci infection
Fluid volume excess related to decrease contractility manifested by hypotension
On Day 2, you return for your second 12-hour shift. Which of the following findings indicates that the patient's endocarditis has worsened? Why?
Ejection fraction measures 65% normal 50-70
Serum potassium 4.8mEq/L normal 3.5-5
Absent of murmur good
WBC increases to 18,000/mm3
Clinical manifestations of IE could include which of the following? Select ALL that apply.
splinter hemorrhages
Osler's nodes
Janeway's Lesions
Hemorrhagic retinal lesions
Onset of new aortic or mitral murmur
Low-grade fever
What is the primary lesion of IE? How does it adversely affect the heart? What common complication occurs if these lesions mobilize?
Vegetation, impact heart contractility, clotsPE, DVT, stroke, kidney acute impairment, spleen impairment
You know that treatment for infective endocarditis involves which of the following? Select ALL that apply.
Accurate identification of infecting organism
Long-term antibiotic treatment2-3 months Bacterial use strong sensitive antibiotics, if fungal- valve replacement
Short-term antibiotic treatment
Corticosteroids
Mr. Bryant has greatly improved and is ready to be discharged. The rounding physician puts discharge orders in for you. Which of the following must be included in the teaching plan of the patient? Select ALL that apply.
Prophylactic antibiotic is required before any dental procedures.
Endocardiocentesis may be needed if the medical treatment fails.
Brush thoroughly 2-3 times a day and floss daily.
Prescribed antibiotics must be completed at home via IV route. rigorous long term antibiotics, so need long term IV
Prophylactic Coumadin (Warfarin) will be needed for the rest of his life.
Pleuralcentesis-fluid out of lung
Paracentesis- suck out ascites abdomen
Paracardiocentesis- fluid from heart
Percarditis
Mr. Daniel Craig is a 28 y/o Caucasian male who has been admitted with "Acute Pericarditis". He tells you he has "severe, sharp chest pain. It hurts so much that I can't take a deep breath or lie down".
Medical Hx: HTN x 2 years, HLD x 2 years
Surgical Hx: Tonsillectomy
Family Hx: Father died at 47 from MI, Mother alive with HTN, CAD, HLD, Uncle died at 52 from MI
Medications: None on record.
What position can you put him in to make him more comfortable?
High fowlers position
True or False: Most cases of acute pericarditis are idiopathic.
True.
False.
Chest Pain gets worse with breathing in and out b/c lung field has more pressure on pericardial sac
Which of the following are classical symptoms of pericarditis? Select ALL that apply.
auscultation of friction rub that correlates with patient's pulse.
auscultation of friction rub that correlates with patient's breathing.
Prominent heart sounds.
ST elevation in most leads in ECG.
Pleuritic pain that gets worse with inspiration.
Pain that worsens in supine position
Which tests are useful in diagnosis of pericarditis?
√ ECG ST elevation
√ Echocardiogram pleural effusion, cardiac tamponade
√ CBC
√ ESR
√ CRP
Urinalysis
Where would you best hear a pericardial friction rub? How would you describe it? What position would you put the patient in to hear this sound best?
Two major complications that may result from acute pericarditis are what?
Cardiac tamponade is suspected in a patient who has acute pericarditis. To assess presence of pulsus paradoxus, you should:
You understand that pericardiocentesis is possible with your patient. As you prepare yourself for this, you remember that this procedure involves what steps?
1. Prepare your access site.
at a 30 to 45 degree, head-up angle to permit pericardial fluid to pool on the inferior surface of the heart.
everything but a small area around the subxyphoid
4. Insert the pericardial needle.
5. Advance the needle into the pericardial space.
6. Confirm intra-pericardial position with hemodynamics or echo contrast imaging.
7. Place the pericardial drainage catheter.
8. Obtain serial echocardiograms before and after removal of the pericardial drainage catheter to confirm the absence of fluid re-accumulation.
You realize that anxiety and acute pain are two major nursing diagnoses relevant for your patient. What intervention would aid your patient with anxiety? Select ALL that apply.
Simple, complete explanations of all procedures
Simple, complete explanations of possible causes of pain
Alleviate pain with anti inflammatory medications as prescribed
Position patient at 30 degrees
Position patient at 45 degrees
Provide an overbed table for support
Leave the patient alone as often as possible
See a real patient with Pericarditis
https://www.youtube.com/embed/Edtxhc4Rixk?wmode=opaque
Peripheral artery disease
What is the difference between Peripheral artery disease and peripheral venous disease? How do the wounds differ? Which is more superficial?
PAD- arthrosclerosis plaque, cold feet and toes, no hair distribution, palor, dry, no enough nutrients, edema, dangle leg, numbness, lose sensation, prevent injuries, no bare foot,
Diagnose: Pallor, pale, prosthesis, uselessness, pain, intermittent pain while walking (cortication) rest and walk in a little bit
Test: Doppler, segmental BP- if drop from above the knee to below knee is less than 30 degrees It is PAD
Systolic BP from brachial to radial should drop
PAD or DVT- elevate leg, warm to touch, wet, hair growth, wet ulcer, edema, more superficial
Skin temp, pulse, color to check patency under bypass is fine
Your patient has chronic peripheral artery disease (PAD) of the legs and an ulcer on the left great toe. You would expect to find which of the following?
Positive Homan's sign
swollen dry scaly ankles
a large amount of drainage from the ulcer
prolonged capillary refill in all the toes
shiny taut appearance on skin of lower legs, ankles, and feet
Intermittent claudication is peripheral venous problem. True or False.
True.
False
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