RNSG 1360Case study 2 make up.docx

RNSG 1360 Case study 2 make up.docx 1. Which assessment findings during the nurse’s visit are consistent with heart failure? 2. Why did the visiting nurse ask Mrs. Yuma about back pain, stomach pain, confusion ...

RNSG 1360 Case study 2 make up.docx 1. Which assessment findings during the nurse’s visit are consistent with heart failure? 2. Why did the visiting nurse ask Mrs. Yuma about back pain, stomach pain, confusion, dizziness, or a feeling that she might faint? 3. Discuss anything else the nurse should assess during her visit with Mrs. Yuma. 4. Explain what the following terms indicate and include the normal values: cardiac output, stroke volume, afterload, preload, ejection fraction, and central venous pressure. 5. Discuss the body’s compensatory mechanisms during heart failure. Include an explanation of the Frank-Starling law and the neurohormonal model in your discussion. 6. Heart failure can be classified as left or right ventricular failure, systolic versus diastolic, according to the New York Heart Association (NYHA) and using the ACC/AHA (American Heart Association) Guidelines. Explain these four classification systems and the signs and symptoms that characterize each. 7. According to each classification system discussed above in question #6, how would you label the type? of heart failure Mrs. Yuma is experiencing? 8. Discuss Mrs. Yuma’s predisposing risk factors for heart failure. Is her age, gender, or ethnicity significant? 9. Provide a rationale for why each of the following medications are included in Mrs. Yuma’s medication regimen: aspirin, clopidogrel bisulfate, lisinopril, and carvedilol. Lisinopril: is used by itself or in combination with other medications to treat high blood pressure and heart failure. This drug is in a class of medications known as angiotensin-converting enzyme (ACE) inhibitors. It works to treat hypertension, heart failure symptoms, left ejection fraction, and improves overall functional in heart failure patients. (Lilly & Snyder, p.379) Carvedilol: is used primarily in the treatment of heart failure but is also beneficial for hypertension and angina. It has been shown to slow the progression of heart failure and to decrease the frequency of hospitalization in patients with mild to moderate (class II or III) heart failure. (Lilly & Snyder, p.379) 10. The nurse is teaching Mrs. Yuma about her newly prescribed furosemide. Explain the rationale for adding furosemide to Mrs. Yuma’s medication regimen, when she should expect to see the therapeutic results (urination), and instructions regarding the administration of furosemide. Diuretics are the mainstay of treatment in patients with volume overload. Diuretics act to decrease sodium reabsorption at various sites within the nephrons, thereby enhancing sodium and water loss. Decreasing intravascular volume with the use of diuretics reduces venous return (preload) and subsequently the volume returning to the LV. This allows the LV to contract more efficiently. CO is increased, pulmonary vascular pressures are decreased, and gas exchange is improved. (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014, p. 773-774) The administration of furosemide is from 20 to 120 mg/day for adult. Electrolyte loss and dehydration, which can result in circulatory failure, are the main toxic effects of loop diuretics that require attention. (Lilly, Snyder, p.454 - 455). 11. The visiting nurse asks the primary health care provider if he/she will prescribe potassium chloride for Mrs. Yuma. Why has the nurse suggested this? Long-term using furosemide can cause hypokalemia. To prevent hypokalemia, patient often receive potassium supplement along with furosemide. (Lilly & Snyder, p.454) 12. What information will each of the following blood tests provide: CBC, BMP, BNP, troponin, CPK, CK-MB, and albumin? CBC: A complete blood count is the calculation of the total cellular elements of blood. This tells the quantity, percentage, concentration, and quality of blood cells. The complete blood count is the measure of the body’s concentration of white blood cell, red blood cell, platelets, and hemoglobin. (Pagana, Pagana & Pagana, 2015, p.280) BMP: Basal metabolic panel correlate positive and at high levels with the degree of left ventricle failure. (Lewis, Brucher, Heitkemper &Harding, 2017, p.744) BNP: It aids in diagnosing the presence and severity of heart failure. Elevation helps to distinguish cardiac versus respiratory cause of dyspnea. (Lewis, Brucher, Heitkemper & Harding, 2017, p.673) Troponin: measures the levels of troponin T or troponin I proteins found in cardiac muscle. These specific proteins are released when damage has been caused to the heart, such as during a heart attack. The more damage to the heart, the greater the amount of troponin T and I there will be in the blood stream. (Lewis, Brucher, Heitkemper & Harding, 2017, p.673) CPK: Creatine kinase, also known as a total CK or creatine phosphokinase is an enzyme in the brain, heart muscle, and skeletal muscle. This test is used to support the diagnosis of myocardial muscle injury (infarction). (Pagana, Pagana & Pagana, 2015, p.308) CKMB: levels are tested in patients who are experiencing chest pain to diagnose whether they have had a heart attack or other myocardial injury. (Lewis, Brucher, Heitkemper & Harding, 2017, p.673) Albumin: Identifies cardiac ischemia in patients with chest pain. When combined with troponins, myoglobin, and ECG, the diagnosis of an ischemic cardiac event can be corroborated or ruled out. (Pagana, Pagana & Pagana, 2015, p.565) 13. What will the health care provider look for on the electrocardiogram, chest X-ray, and echocardiogram? What will each diagnostic test tell the physician? Electrocardiogram: Left atrial enlargement is known to cause characteristic P wave changes, which sometimes show parallel course with the clinical state. ECG criteria for atrial enlargement are critically reviewed. In cases with cardiac enlargement, which was improved in a relatively short period of time, R wave height often showed first increase and then decrease. (Lewis, Bucher, Heitkemper & Harding, 2017) Chest X-ray: is a non-invasive test that creates pictures of the chest, lungs, heart, large arteries, ribs, and diaphragm. Cardiomegaly, pulmonary vascular redistribution, interstitial edema, emphysema, pulmonary venous congestion, alveolar edema, mitral regurgitations. (Lewis, Bucher, Heitkemper & Harding, 2017) Echocardiogram: An echocardiogram is a common diagnostic tool used in patient with HF. It provides information on the EF. This helps to differentiate between HFpEF and HFrEF. An echocardiogram also provides information on the structure and function of the heart valves. (Lewis, Bucher, Heitkemper & Harding, 2017) 14. Mrs. Yuma’s son comes to stay with his mother so she will not be alone. What should the nurse tell Mr. Yuma about when he should bring his mother to the hospital? Mrs. Yuma's son should bring her to the hospital right away if any signs of a myocardial infarction present themselves or if she experiences respiratory distress. Another cause to bring Mrs. Yuma in would be if she stops responding to any of her outpatient therapy. 15. The visiting nurse returns the next day. Mrs. Yuma does not seem to be diuresing as well as the nurse anticipated. Mrs. Yuma is not worse, but the swelling in her legs is still considerable and there is no change in her weight. When asked about her frequency of voiding, Mrs. Yuma does not seem to have noticed much difference. While the nurse is unpacking her stethoscope to assess lung sounds, Mrs. Yuma says, “Honey, I was just making myself a ham salad sandwich. Would you like one?” The nurse declines and becomes concerned because of this offer. Why is the nurse concerned? The nurse is concerned when Mrs. Yuma mentions that she just made herself a ham sandwich because ham is a high-sodium food and Mrs. Yuma's sodium needs to be limited. Knowing information like this, the nurse could determine that it is possible the diet Mrs. Yuma has been eating may be partially responsible for her fluid retention, even though she has been on a diuretic. 16. The nurse asks Mrs. Yuma to tell her more about how she cooks. Specifically, the nurse asks Mrs. Yuma about the types of foods and food preparation. With great pride, Mrs. Yuma leads the nurse to the kitchen and explains, “Honey. I am from the South and We cook soul food. Today I am cooking my famous pea soup for the church dinner tonight. I use ham hocks. Have you ever had those? My son says they are not good for me. He has been trying to get me to eat healthier foods. Last week he brought me turkey sausage to try instead of my pork sausage in the morning. I know he means well but some foods are tradition and you don’t break soul food tradition.” What information has the nurse gathered that is? of concern? Mrs. Yuma is consuming a large amount of foods that are mostly all very high in sodium. Mrs. Yuma does not seem to want to change her eating habits and it is affecting her health. Poor adherence to a low-sodium diet and failure to take prescribed medications as directed are the two most common reasons for readmissions of HF patients to the hospital. (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014, p. 777) 17. The nurse arranges for Mrs. Yuma’s son to be present at the next home visit so that the nurse can teach them both about proper dietary choices and fluid restrictions. List five points of information that the nurse should include in the teaching. 1)Do not add salt or seasonings containing sodium when preparing foods. 2) Do not use salt at the table. 3) Limit milk products to 2 cups daily. 4) Avoid high-sodium foods (e.g., canned soups, processed meats, cheese, frozen meals) 5) Portion control. (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014, p. 778) 18. During the dietary teaching, the nurse asks Mrs. Yuma to describe a typical day of meals and snacks. Mrs. Yuma lists coffee with whole milk, eggs and sausage for breakfast, a sandwich or soup for lunch, fried chicken with vegetables for dinner, and fruit, pretzels, or rice pudding for snacks. Which of these foods will the nurse instruct Mrs. Yuma to limit and are there alternatives that the nurse can suggest? Too much milk can be detrimental to Mrs. Yuma’s health. The amount of dairy should be limited to no more than 2 cups a day, and 1% milk would be best rather than 2% or whole. The fried chicken that Mrs. Yuma says she has eaten is not a good choice. Mrs. Yuma should substitute fried chicken for baked chicken. The pretzels she has been eating have a very high salt content. She should eat almonds instead of pretzels as these are much healthier for her. 19. Since changing her diet, Mrs. Yuma has responded to her outpatient treatment plan and has noticed marked improvement in how she feels. The nurse wants to make sure that Mrs. Yuma understands the importance of monitoring her weight. What instructions should the nurse give Mrs. Yuma regarding how often to weigh herself, and what weight change should be reported to her health care provider or the nurse? Mrs. Yuma should weigh herself daily if possible or at least every other day. She should wear the same clothing and use the same scale to get an accurate weight. If Mrs. Yuma has 3 to 5 pounds weight gain in a week, she should report to her health care provider or the nurse. 20. Prioritize five nursing diagnoses that the visiting nurse should consider for the recent events regarding Mrs. Yuma’s care. 1) Risk for decreased cardiac tissue perfusion related to high blood pressure 2) Impaired gas exchange related to perfusion imbalance, as evidence by patient states that she feels a little bit tired than usual, respiration of 22 breaths per minutes, and bibasilar crackle auscultation in her lungs. 3) Decreased cardiac output related to impaired cardiac function as evidence by shortness of breath, lethargic, and edema. 4) Ineffective health management related to complexity of health status as evidence by insufficient energy to perform activities of daily living. 5) Excessive fluid volume related to impaired cardiac function as evidence by bilateral edema in lower extremities, 10 pounds gained in 2 weeks, and lethargy when try to walk more than 20 feet. References Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. (2014). Medical- surgical nursing: Assessment and management of clinical problems. St. Louis, MO: Elsevier/Mosby. Lewis, S.L., Bucher, L., Heitkemper M. M., Harding M. M. (2017). Medical-Surgical Nursing, Assessment and management of clinical problems. St. Louis. MO: Elsevier Pagana, K. D., Pagana T. J., Pagana T. N. (2015) Mosby’s Diagnostic & Laboratory Test Reference, St. Louis, MO: Elsevier. Taylor, C. Lynn. P & Bartlet. L. (2019). Fundamental of Nursing: The Art and Science of Person-Centered Care. New York, NY: Wolters Kluwer. RNSG 1360 Case study 2 make up.docx 1. Which assessment findings during the nurse’s visit are consistent with heart failure? 2. Why did the visiting nurse ask Mrs. Yuma about back pain, stomach pain, confusion, dizziness, or a feeling that she might faint? 3. Discuss anything else the nurse should assess during her visit with Mrs. Yuma. 4. Explain what the following terms indicate and include the normal values: cardiac output, stroke volume, afterload, preload, ejection fraction, and central venous pressure. 5. Discuss the body’s compensatory mechanisms during heart failure. Include an explanation of the Frank-Starling law and the neurohormonal model in your discussion. 6. Heart failure can be classified as left or right ventricular failure, systolic versus diastolic, according to the New York Heart Association (NYHA) and using the ACC/AHA (American Heart Association) Guidelines. Explain these four classification systems and the signs and symptoms that characterize each. 7. According to each classification system discussed above in question #6, how would you label the type? of heart failure Mrs. Yuma is experiencing? 8. Discuss Mrs. Yuma’s predisposing risk factors for heart failure. Is her age, gender, or ethnicity significant? 9. Provide a rationale for why each of the following medications are included in Mrs. Yuma’s medication regimen: aspirin, clopidogrel bisulfate, lisinopril, and carvedilol. Lisinopril: is used by itself or in combination with other medications to treat high blood pressure and heart failure. This drug is in a class of medications known as angiotensin-converting enzyme (ACE) inhibitors. It works to treat hypertension, heart failure symptoms, left ejection fraction, and improves overall functional in heart failure patients. (Lilly & Snyder, p.379) Carvedilol: is used primarily in the treatment of heart failure but is also beneficial for hypertension and angina. It has been shown to slow the progression of heart failure and to decrease the frequency of hospitalization in patients with mild to moderate (class II or III) heart failure. (Lilly & Snyder, p.379) 10. The nurse is teaching Mrs. Yuma about her newly prescribed furosemide. Explain the rationale for adding furosemide to Mrs. Yuma’s medication regimen, when she should expect to see the therapeutic results (urination), and instructions regarding the administration of furosemide. Diuretics are the mainstay of treatment in patients with volume overload. Diuretics act to decrease sodium reabsorption at various sites within the nephrons, thereby enhancing sodium and water loss. Decreasing intravascular volume with the use of diuretics reduces venous return (preload) and subsequently the volume returning to the LV. This allows the LV to contract more efficiently. CO is increased, pulmonary vascular pressures are decreased, and gas exchange is improved. (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014, p. 773-774) The administration of furosemide is from 20 to 120 mg/day for adult. Electrolyte loss and dehydration, which can result in circulatory failure, are the main toxic effects of loop diuretics that require attention. (Lilly, Snyder, p.454 - 455). 11. The visiting nurse asks the primary health care provider if he/she will prescribe potassium chloride for Mrs. Yuma. Why has the nurse suggested this? Long-term using furosemide can cause hypokalemia. To prevent hypokalemia, patient often receive potassium supplement along with furosemide. (Lilly & Snyder, p.454) 12. What information will each of the following blood tests provide: CBC, BMP, BNP, troponin, CPK, CK-MB, and albumin? CBC: A complete blood count is the calculation of the total cellular elements of blood. This tells the quantity, percentage, concentration, and quality of blood cells. The complete blood count is the measure of the body’s concentration of white blood cell, red blood cell, platelets, and hemoglobin. (Pagana, Pagana & Pagana, 2015, p.280) BMP: Basal metabolic panel correlate positive and at high levels with the degree of left ventricle failure. (Lewis, Brucher, Heitkemper &Harding, 2017, p.744) BNP: It aids in diagnosing the presence and severity of heart failure. Elevation helps to distinguish cardiac versus respiratory cause of dyspnea. (Lewis, Brucher, Heitkemper & Harding, 2017, p.673) Troponin: measures the levels of troponin T or troponin I proteins found in cardiac muscle. These specific proteins are released when damage has been caused to the heart, such as during a heart attack. The more damage to the heart, the greater the amount of troponin T and I there will be in the blood stream. (Lewis, Brucher, Heitkemper & Harding, 2017, p.673) CPK: Creatine kinase, also known as a total CK or creatine phosphokinase is an enzyme in the brain, heart muscle, and skeletal muscle. This test is used to support the diagnosis of myocardial muscle injury (infarction). (Pagana, Pagana & Pagana, 2015, p.308) CKMB: levels are tested in patients who are experiencing chest pain to diagnose whether they have had a heart attack or other myocardial injury. (Lewis, Brucher, Heitkemper & Harding, 2017, p.673) Albumin: Identifies cardiac ischemia in patients with chest pain. When combined with troponins, myoglobin, and ECG, the diagnosis of an ischemic cardiac event can be corroborated or ruled out. (Pagana, Pagana & Pagana, 2015, p.565) 13. What will the health care provider look for on the electrocardiogram, chest X-ray, and echocardiogram? What will each diagnostic test tell the physician? Electrocardiogram: Left atrial enlargement is known to cause characteristic P wave changes, which sometimes show parallel course with the clinical state. ECG criteria for atrial enlargement are critically reviewed. In cases with cardiac enlargement, which was improved in a relatively short period of time, R wave height often showed first increase and then decrease. (Lewis, Bucher, Heitkemper & Harding, 2017) Chest X-ray: is a non-invasive test that creates pictures of the chest, lungs, heart, large arteries, ribs, and diaphragm. Cardiomegaly, pulmonary vascular redistribution, interstitial edema, emphysema, pulmonary venous congestion, alveolar edema, mitral regurgitations. (Lewis, Bucher, Heitkemper & Harding, 2017) Echocardiogram: An echocardiogram is a common diagnostic tool used in patient with HF. It provides information on the EF. This helps to differentiate between HFpEF and HFrEF. An echocardiogram also provides information on the structure and function of the heart valves. (Lewis, Bucher, Heitkemper & Harding, 2017) 14. Mrs. Yuma’s son comes to stay with his mother so she will not be alone. What should the nurse tell Mr. Yuma about when he should bring his mother to the hospital? Mrs. Yuma's son should bring her to the hospital right away if any signs of a myocardial infarction present themselves or if she experiences respiratory distress. Another cause to bring Mrs. Yuma in would be if she stops responding to any of her outpatient therapy. 15. The visiting nurse returns the next day. Mrs. Yuma does not seem to be diuresing as well as the nurse anticipated. Mrs. Yuma is not worse, but the swelling in her legs is still considerable and there is no change in her weight. When asked about her frequency of voiding, Mrs. Yuma does not seem to have noticed much difference. While the nurse is unpacking her stethoscope to assess lung sounds, Mrs. Yuma says, “Honey, I was just making myself a ham salad sandwich. Would you like one?” The nurse declines and becomes concerned because of this offer. Why is the nurse concerned? The nurse is concerned when Mrs. Yuma mentions that she just made herself a ham sandwich because ham is a high-sodium food and Mrs. Yuma's sodium needs to be limited. Knowing information like this, the nurse could determine that it is possible the diet Mrs. Yuma has been eating may be partially responsible for her fluid retention, even though she has been on a diuretic. 16. The nurse asks Mrs. Yuma to tell her more about how she cooks. Specifically, the nurse asks Mrs. Yuma about the types of foods and food preparation. With great pride, Mrs. Yuma leads the nurse to the kitchen and explains, “Honey. I am from the South and We cook soul food. Today I am cooking my famous pea soup for the church dinner tonight. I use ham hocks. Have you ever had those? My son says they are not good for me. He has been trying to get me to eat healthier foods. Last week he brought me turkey sausage to try instead of my pork sausage in the morning. I know he means well but some foods are tradition and you don’t break soul food tradition.” What information has the nurse gathered that is? of concern? Mrs. Yuma is consuming a large amount of foods that are mostly all very high in sodium. Mrs. Yuma does not seem to want to change her eating habits and it is affecting her health. Poor adherence to a low-sodium diet and failure to take prescribed medications as directed are the two most common reasons for readmissions of HF patients to the hospital. (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014, p. 777) 17. The nurse arranges for Mrs. Yuma’s son to be present at the next home visit so that the nurse can teach them both about proper dietary choices and fluid restrictions. List five points of information that the nurse should include in the teaching. 1)Do not add salt or seasonings containing sodium when preparing foods. 2) Do not use salt at the table. 3) Limit milk products to 2 cups daily. 4) Avoid high-sodium foods (e.g., canned soups, processed meats, cheese, frozen meals) 5) Portion control. (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014, p. 778) 18. During the dietary teaching, the nurse asks Mrs. Yuma to describe a typical day of meals and snacks. Mrs. Yuma lists coffee with whole milk, eggs and sausage for breakfast, a sandwich or soup for lunch, fried chicken with vegetables for dinner, and fruit, pretzels, or rice pudding for snacks. Which of these foods will the nurse instruct Mrs. Yuma to limit and are there alternatives that the nurse can suggest? Too much milk can be detrimental to Mrs. Yuma’s health. The amount of dairy should be limited to no more than 2 cups a day, and 1% milk would be best rather than 2% or whole. The fried chicken that Mrs. Yuma says she has eaten is not a good choice. Mrs. Yuma should substitute fried chicken for baked chicken. The pretzels she has been eating have a very high salt content. She should eat almonds instead of pretzels as these are much healthier for her. 19. Since changing her diet, Mrs. Yuma has responded to her outpatient treatment plan and has noticed marked improvement in how she feels. The nurse wants to make sure that Mrs. Yuma understands the importance of monitoring her weight. What instructions should the nurse give Mrs. Yuma regarding how often to weigh herself, and what weight change should be reported to her health care provider or the nurse? Mrs. Yuma should weigh herself daily if possible or at least every other day. She should wear the same clothing and use the same scale to get an accurate weight. If Mrs. Yuma has 3 to 5 pounds weight gain in a week, she should report to her health care provider or the nurse. 20. Prioritize five nursing diagnoses that the visiting nurse should consider for the recent events regarding Mrs. Yuma’s care. 1) Risk for decreased cardiac tissue perfusion related to high blood pressure 2) Impaired gas exchange related to perfusion imbalance, as evidence by patient states that she feels a little bit tired than usual, respiration of 22 breaths per minutes, and bibasilar crackle auscultation in her lungs. 3) Decreased cardiac output related to impaired cardiac function as evidence by shortness of breath, lethargic, and edema. 4) Ineffective health management related to complexity of health status as evidence by insufficient energy to perform activities of daily living. 5) Excessive fluid volume related to impaired cardiac function as evidence by bilateral edema in lower extremities, 10 pounds gained in 2 weeks, and lethargy when try to walk more than 20 feet. References Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. (2014). Medical- surgical nursing: Assessment and management of clinical problems. St. Louis, MO: Elsevier/Mosby. Lewis, S.L., Bucher, L., Heitkemper M. M., Harding M. M. (2017). Medical-Surgical Nursing, Assessment and management of clinical problems. St. Louis. MO: Elsevier Pagana, K. D., Pagana T. J., Pagana T. N. (2015) Mosby’s Diagnostic & Laboratory Test Reference, St. Louis, MO: Elsevier. Taylor, C. Lynn. P & Bartlet. L. (2019). Fundamental of Nursing: The Art and Science of Person-Centered Care. New York, NY: Wolters Kluwer.