Chapter 1 Cardiovascular Disorders Case Study 13

Brief Contents PART ONE MEDICAL-SURGICAL CASES, 1

Chapter 1 Chapter 2 Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 Chapter 8 Chapter 9

Cardiovascular Disorders, 1 Respiratory Disorders, 83 Musculoskeletal Disorders, 149 Gastrointestinal Disorders, 189 Genitourinary Disorders, 235 Neurologic Disorders, 273 Endocrine Disorders, 341 Immunologic Disorders, 367 Oncologic and Hematologic Disorders, 393

PART TWO PEDIATRIC, MATERNITY, AND PSYCHIATRIC CASES, 439

Chapter 10 Chapter 11 Chapter 12 Chapter 13

Pediatric Disorders, 439 Maternal and Obstetric Disorders, 505 Women's Health Disorders, 533 Psychiatric Disorders, 559

PART THREE OTHER/ADVANCED CASES, 591

Chapter 14 Alternative Therapies, 591 Chapter 15 Patients with Multiple Disorders, 599 Chapter 16 Emergency Situations, 625 Appendix: Abbreviations and Acronyms, 663 Illustration Credits, 669

5TH EDITION

Critical Thinking Cases In Nursing Winningham's

Medical-Surgical, Pediatric, Maternity, and Psychiatric

MARIANN HARDING, MSN, RN

Associate Professor Department of Nursing Kent State University at Tuscarawas New Philadelphia, Ohio

JULIE S. SNYDER, MSN, RN-BC

Adjunct Faculty School of Nursing Old Dominion University Norfolk, Virginia

BARBARA A. PREUSSER†, PHD, FNPC

Family Nurse Practitioner Veterans Administration Medical Center Salt Lake City, Utah Deceased



3251 Riverport Lane St. Louis, Missouri 63043 WINNINGHAM'S CRITICAL THINKING CASES IN NURSING: MEDICAL-SURGICAL, PEDIATRIC, MATERNITY, AND PSYCHIATRIC

ISBN: 978-0-323-08325-6

Copyright © 2013 by Mosby, Inc., an affiliate of Elsevier Inc. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including ­photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher's permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, ­methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a ­professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or ­formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own ­experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any ­liability for any injury and/or damage to persons or property as a matter of products liability, negligence or ­otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the ­material herein. Previous editions copyrighted 2009, 2005, 2001, 1996 Library of Congress Cataloging-in-Publication Data Harding, Mariann.   Winningham's critical thinking cases in nursing : medical-surgical, pediatric, maternity, and psychiatric / Mariann Harding, Julie S. Snyder, Barbara A. Preusser. – 5th ed.    p. ; cm.   Critical thinking cases in nursing   Rev. ed. of: Critical thinking in medical-surgical settings / Maryl L. Winningham and Barbara A. Preusser. 2nd ed. c2011.   Includes bibliographical references.   ISBN 978-0-323-08325-6 (pbk. : alk. paper)   I. Snyder, Julie S. II. Preusser, Barbara A. III. Winningham, Maryl Lynne, 1947–2001. Critical thinking in medical-surgical settings. IV. Title. V. Title: Critical thinking cases in nursing.   [DNLM: 1. Nursing Process–Case Reports. 2. Nursing Process–Problems and Exercises. 3. Nursing Care– Case Reports. 4. Nursing Care–Problems and Exercises. WY 18.2]  610.73–dc23 2012003221 Executive Content Strategist: Lee Henderson Content Development Specialist: Jacqueline Twomey Publishing Services Managers: Hemamalini Rajendrababu & Deborah L. Vogel Project Managers: Anitha Sivaraj & John W. Gabbert Design Direction: Karen Pauls

Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1

To Drs. Maryl L. Winningham and Barbara A. Preusser Drs. Winningham and Preusser, authors of this text for the previous four editions, dedicated their lives to the care of others and the pursuit of excellence in nursing practice. They have bequeathed a nursing heritage of integrity, excellence, courage, and service to their students, ­colleagues, and readers.

This page intentionally left blank

Contributors Ann Campbell, RN, MSN, CPNP Faculty School of Nursing Old Dominion University Norfolk, Virginia

Sara B. Forbus, MSN, RN

Faculty School of Nursing Old Dominion University Norfolk, Virginia

Contributors to Previous Editions Elizabeth Jane Bell, MSN, ANPc Lesley A. Black, BSN, MS, ANPc, CWOCN Kent Blad, MS, FNPc, ACNP-C, FCCM Jamie Clinton-Lont, BSN, FNPc Susan L. Croft, BSN, MS Joyce Foster, PhD, CNM, FACNM, FAAN Shellagh Gutke, BSN, CWOCN Nancy Hayden, MSN, FNPc Sondra Heaston, MS, FNPc, CEN Janice Hulbert, RN, MS Lisa Jensen, BSN, MS, APRN, CS Stephanie C. Kettendorf, MS, RN, CNS, NCBF Julie Killebrew, BSN, MS Karen Kone, BSN, ACRN Kathleen Kuntz, MSN, APRN, SANE

Janet G. Madsen, PhD Debra Ann Mills, RN, MS Jeanie O'Donnell, MSN Deb Plasman-Coles, PAc Laura Lee Scott, MSN, FNPc Mary Seegmiller, MSN Sandra Smeeding, MS, FNPc Deborah D. Smith, BSN Ann Speirs, BSN Ronald Ulberg, BSN, MSN Kristy Vankatwyk, MSN, FNPc Annette S. Wendel, BSN Wendy Whitney, MSN, FNPc, CANP Mary Youtsey, BSN, CDE

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

v

Reviewers Diane K. Daddario, MSN, ACNS-BC, RN, BC, CMSRN Nurse Specialist Geisinger Medical Center Danville, Pennsylvania; Staff Nurse Evangelical Community Hospital Lewisburg, Pennsylvania; Nursing Instructor Pennsylvania College of Technology Williamsport, Pennsylvania

Jennifer Duhon, RN, MS

Director of Health Services Lutheran Senior Services Peoria, Illinois

Sara B. Forbus, MSN, RN

Faculty School of Nursing Old Dominion University Norfolk, Virginia

Mimi Haskins, MS, RN, CMSRN

Nursing Staff Development Instructor Roswell Park Cancer Institute Buffalo, New York

Suzanne Jed, MSN, APRN-BC

Clinical Instructor, Family Medicine Keck School of Medicine University of Southern California Los Angeles, California

vi

Jamie Lynn Jones, MSN, RN

Assistant Professor, Nursing University of Arkansas at Little Rock Little Rock, Arkansas

Tamara M. Kear, PhD, MSN, RN

Assistant Professor of Nursing Villanova University Villanova, Pennsylvania

Cheryl A. Lehman, PhD, RN, CNS-BC, RN-BC, CRRN

CNS Program Coordinator Department of Health Restoration & Care Systems Management (HRCSM) Clinical Associate Professor The University of Texas Health Science Center at San Antonio San Antonio, Texas

Casey Norris, MSN, BSN

Adjunct Instructor, Nursing South College Pulmonary Clinical Nurse Specialist East Tennessee Children's Hospital Knoxville, Tennessee

Brenda K. Shelton, MS, RN, CCRN, AOCN

The Sidney Kimmel Cancer Center at Johns Hopkins Baltimore, Maryland

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

Introduction There is an urgent need for nurses with well-practiced critical thinking skills. As new graduates, you will make decisions and take actions of an increasingly sophisticated nature. You will encounter problems you have never seen or heard about during your classroom and clinical experiences. You are going to have to make complex decisions with little or no guidance and limited resources. We want you to be exposed to as much as possible during your student days, but more importantly, we want you to learn to think. You cannot memorize your way out of any situation, but you can think your way out of any situation. We know that students often learn more and faster when they have the freedom to make mistakes. This book is designed to allow you to experiment with finding answers without the pressure of someone's life hanging in the balance. We want you to do well. We want you to be the best. It is our wish for you to grow into confident, competent professionals. After all, someday we will be one of those people you care for, and when that day comes, we want you to be very, very good at what you do!

What Is Critical Thinking? Critical thinking is not memorizing lists of facts or the steps of procedures. Instead, critical thinking is an analytical process that can help you think through a problem in an organized and efficient manner. Five steps are involved in critical thinking. Thinking about these steps may help you when you work through the questions in your cases. Here are the five steps with an explanation of what they mean.  1. Recognize and define the problem by asking the right questions: Exactly what is it you need to know? What is the question asking?  2. Select the information or data necessary to solve the problem or answer the question: First you have to ask whether all the necessary information is there. If not, how and where can you get the additional information? What other resources are available? This is one of the most difficult steps. In real clinical experiences, you rarely have all of the information, so you have to learn where you can get necessary data. For instance, patient and family interviews, nursing charting, the patient medical chart, laboratory data on your computer, your observations, and your own physical assessment can help you identify important clues. Of course, information can rapidly become outdated. To make sure you are accessing the most current and accurate information, you will occasionally need to use the Internet to answer a question.  3. Recognize stated and unstated assumptions; that is, what do you think is or is not true? Sometimes answers or solutions seem obvious; just because something seems obvious doesn't mean it is correct. You may need to consider several possible answers or solutions. Consider all clues carefully and do not dismiss a possibility too quickly. Remember, “You never find an answer you don't think of.”

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

vii

INTRODUCTION

 4. Formulate and select relevant and/or potential decisions. Try to think of as many possibilities as you can. Consider the pros and cons of the consequences of making each decision. What is the best answer/solution? What could go wrong? This requires considering many different angles. In today's health care settings, decision-making often requires balancing the wellbeing needs of the patient, the preferences and concerns of the patient and caregiver, and financial limitations imposed by the reimbursement system. In making decisions, you need to take into account all relevant factors. Remember, you may need to explain why you rejected other options.  5. Draw a valid, informed conclusion: Consider all data; then determine what is relevant and what makes the most sense. Only then should you draw your conclusion. It may look as if this kind of thinking comes naturally to instructors and experienced nurses. You can be certain that even experienced professionals were once where you are now. The rapid and sound decision-making that is essential to good nursing requires years of practice. The practice of good clinical thinking leads to good thinking in clinical practice. This book will help you practice the important steps in making sound clinical judgments until the process starts to come naturally. The practice of good clinical thinking leads to good thinking in clinical practice.

The “How to” of Case Studies When you begin each case, read through the whole story once, from start to finish, getting a general idea of what it is about. Write down things you have to look up. This will help you move through the case smoothly and get more out of it. How much you have to look up will depend on where you are in your program, what you know, and how much experience you already have. Preparing cases will become easier as you advance in your program.

viii

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

Acknowledgments We would like to express our appreciation to the editorial Elsevier staff—Kristen Geen, Lee Henderson, Jamie Horn, and Jacqueline Twomey—for their professional support and contributions in guiding this text to publication. We extend a special thanks to our reviewers who gave us helpful suggestions and insights as we developed this edition. Mariann's gratitude goes to the most important people in her life—her husband, Jeff, and her daughters, Kate and Sarah—for their giving of love, support, and time during the months of writing. She gives a special thanks to her students, colleagues, and patients; each has taught her much and fueled her passion for nursing and education. Finally, Mariann gives her thanks to God, who made all things possible. Julie thanks her husband, Jonathan, for his love, support, and patience during this project. She is grateful for the encouragement from daughter Emily, son-in-law Randy, and parents Willis and Jean Simmons. Julie appreciates the hard work of colleagues Ann Campbell and Sara Forbus as contributors to this edition. She is especially thankful to the students, whose eagerness to learn is an inspiration. Most importantly, Julie gives thanks to God, our source of hope and strength.

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

ix

This page intentionally left blank

Contents PART ONE   Medical-Surgical Cases, 1

1

2

3

Cardiovascular Disorders, 1 Case Study 1,  1 Case Study 2,  5 Case Study 3,  11 Case Study 4,  17 Case Study 5,  21 Case Study 6,  25 Case Study 7,  31 Case Study 8,  35 Case Study 9,  39 Case Study 10,  43 Case Study 11,  47 Case Study 12,  53 Case Study 13,  57 Case Study 14,  63 Case Study 15,  67 Case Study 16,  73 Case Study 17,  79 Respiratory Disorders,  83 Case Study 18,  83 Case Study 19,  87 Case Study 20,  91 Case Study 21,  95 Case Study 22,  101 Case Study 23,  105 Case Study 24,  109 Case Study 25,  113 Case Study 26,  117 Case Study 27,  123 Case Study 28,  127 Case Study 29,  133 Case Study 30,  139 Case Study 31,  143 Musculoskeletal Disorders,  149 Case Study 32,  149 Case Study 33,  153 Case Study 34,  155

Case Study 35,  Case Study 36,  Case Study 37,  Case Study 38,  Case Study 39,  Case Study 40,  Case Study 41, 

159 165 169 173 177 181 185

4

Gastrointestinal Disorders,  189 Case Study 42,  189 Case Study 43,  193 Case Study 44,  197 Case Study 45,  201 Case Study 46,  207 Case Study 47,  211 Case Study 48,  217 Case Study 49,  221 Case Study 50,  225 Case Study 51,  229

5

Genitourinary Disorders,  235 Case Study 52,  235 Case Study 53,  239 Case Study 54,  243 Case Study 55,  247 Case Study 56,  251 Case Study 57,  257 Case Study 58,  261 Case Study 59,  265 Case Study 60,  269

6

Neurologic Disorders,  273 Case Study 61,  273 Case Study 62,  277 Case Study 63,  281 Case Study 64,  285 Case Study 65,  289 Case Study 66,  293 Case Study 67,  299

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

xi

CONTENTS

Case Study 68,  Case Study 69,  Case Study 70,  Case Study 71,  Case Study 72,  Case Study 73,  Case Study 74,  Case Study 75, 

7

8

303 307 311 317 323 327 331 337

Immunologic Disorders,  367 Case Study 82, 367 Case Study 83, 371 Case Study 84,  375 Case Study 85, 379 Case Study 86, 383 Case Study 87, 387

Endocrine Disorders,  341 Case Study 76,  341 Case Study 77,  345 Case Study 78,  349 Case Study 79,  353 Case Study 80,  359 Case Study 81,  363

9

Oncologic and Hematologic Disorders,  393 Case Study 88, 393 Case Study 89, 397 Case Study 90, 401 Case Study 91, 405 Case Study 92, 409 Case Study 93, 413 Case Study 94, 419 Case Study 95, 425 Case Study 96, 429 Case Study 97, 433

PART TWO   Pediatric, Maternity, and Psychiatric Cases, 439

10

Pediatric Disorders,  439 Case Study 98, 439 Case Study 99, 441 Case Study 100, 447 Case Study 101, 451 Case Study 102,  455 Case Study 103, 459 Case Study 104, 465 Case Study 105, 471 Case Study 106, 475 Case Study 107, 479 Case Study 108, 483 Case Study 109, 487 Case Study 110, 491 Case Study 111, 497 Case Study 112, 501

11

xii

12

Women’s Health Disorders,  533 Case Study 120, 533 Case Study 121, 537 Case Study 122, 541 Case Study 123, 547 Case Study 124, 551 Case Study 125, 555

13

Maternal and Obstetric Disorders,  505 Case Study 113, 505 Case Study 114, 509 Case Study 115, 513 Case Study 116, 517

Case Study 117, 521 Case Study 118, 525 Case Study 119, 529

Psychiatric Disorders,  559 Case Study 126, 559 Case Study 127, 563 Case Study 128, 567 Case Study 129, 571 Case Study 130, 575 Case Study 131, 579 Case Study 132, 583 Case Study 133, 587

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

   Contents

PART THREE   Other/Advanced Cases, 591

14

Alternative Therapies,  591 Case Study 134,  591 Case Study 135, 595

15

Patients with Multiple Disorders, 599 Case Study 136, 599 Case Study 137, 605 Case Study 138, 609 Case Study 139, 615 Case Study 140, 619

16

Emergency Situations,  625 Case Study 141, 625 Case Study 142, 629 Case Study 143, 633 Case Study 144, 635 Case Study 145, 639 Case Study 146, 643 Case Study 147, 647 Case Study 148, 651 Case Study 149, 655 Case Study 150, 659

APPENDIX:  Abbreviations and Acronyms, 663 ILLUSTRATION CREDITS, 669

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

xiii

This page intentionally left blank

PART ONE Medical-Surgical Cases

1 Cardiovascular

1

Cardiovascular Disorders Case Study 1 Name

Class/Group

Date

Group Members INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.

scenario XX

M.G., a “frequent flier,” is admitted to the emergency department (ED) with a diagnosis of heart failure (HF). She was discharged from the hospital 10 days ago and comes in today stating, “I just had to come to the hospital today because I can't catch my breath and my legs are as big as tree trunks.” After further questioning, you learn she is strictly following the fluid and salt restriction ordered during her last hospital admission. She reports gaining 1 to 2 pounds every day since her discharge.

1. What error in teaching most likely occurred when M.G. was discharged 10 days ago?

CAsE sTudY PRoGREss During the admission interview, the nurse makes a list of the medications M.G. took at home.

■ Chart View Nursing Assessment: Medications Taken at Home Enalapril (Vasotec) 5 mg PO bid Pioglitazone (Actos) 45 mg PO every morning Furosemide (Lasix) 40 mg/day PO Potassium chloride 20 mEq/day PO

2. Which of these medications may have contributed to M.G.'s heart failure? Explain.

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

1

PART 1

MEdiCAl-suRGiCAl CAsEs

1 Cardiovascular

3. How do angiotensin-converting enzyme (ACE) inhibitors, such as enalapril (Vasotec), work to reduce heart failure? (Select all that apply.) ACE inhibitors: a. prevent the conversion of angiotensin I to angiotensin II. b. cause systemic vasodilation. c. promote the excretion of sodium and water in the renal tubules. d. reduce preload and afterload. e. increase cardiac contractility. f. block sympathetic nervous system stimulation to the heart.

CAsE sTudY PRoGREss After reviewing M.G.'s medications, the physician writes these medication orders:

■ Chart View Medication Orders

Enalapril (Vasotec) 5 mg PO bid Carvedilol (Coreg) 100 mg PO every morning Glipizide (Glucotrol) 10 mg PO every morning Furosemide (Lasix) 80 mg IV push (IVP) now, then 40 mg/day IVP Potassium chloride (K-Dur) 20 mEq/day PO

4. What is the rationale for changing the route of the furosemide (Lasix)?

5. You administer furosemide (Lasix) 80 mg IVP. Identify three parameters you would use to monitor the effectiveness of this medication.

6. What laboratory tests should be ordered for M.G. related to the order for furosemide (Lasix)? (Select all that apply.) a. Magnesium level b. Sodium level 2

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

CHAPTER 1  Cardiovascular Disorders  CASE STUDY 1

1 Cardiovascular

c. Complete blood count (CBC) d. Serum glucose levels e. Potassium level f. Coagulation studies

7. What is the purpose of the beta blocker carvedilol? It is given to: a. increase the contractility of the heart b. cause peripheral vasodilation c. increase urine output d. reduce cardiac stimulation by catecholamines

CASE STUDY PROGRESS The next day, M.G. has shown only slight improvement, and digoxin (Lanoxin) 125 mcg PO daily is added to her orders.

8. What is the action of the digoxin? Digoxin: a. causes systemic vasodilation. b. promotes the excretion of sodium and water in the renal tubules. c. increases cardiac contractility and cardiac output. d. blocks sympathetic nervous system stimulation to the heart.

9. Which findings from M.G.'s assessment would indicate an increased possibility of digoxin toxicity? Explain your answer. a. Serum potassium level of 2.2 mEq/L b. Serum sodium level of 139 mEq/L c. Apical heart rate of 64 beats/minute d. Digoxin level 1.6 ng/mL

10. When you go to give the digoxin, you notice that it is available in milligrams (mg) not micrograms (mcg). Convert 125 mcg to mg.

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

3

PART 1  MEDICAL-SURGICAL CASES

1 Cardiovascular

11. M.G.'s symptoms improve with IV diuretics and the digoxin. She is placed back on oral furosemide (Lasix) once her weight loss is deemed adequate to achieve a euvolemic state. What will determine whether the oral dose will be adequate to consider her for discharge?

12. M.G. is ready for discharge. Using the mnemonic MAWDS, what key management concepts should be taught to prevent relapse and another admission?

4

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

CHAPTER 1

CARdiovAsCulAR disoRdERs

CASE STUDY 2

Case Study 2 Name

Class/Group

Date

Group Members

1 Cardiovascular

INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.

scenario XX

M.P. is a 65-year-old African-American woman who comes to your clinic for a follow-up visit. She was diagnosed with hypertension (HTN) 2 months ago and was given a prescription for a thiazide diuretic but stopped taking it 2 weeks ago because “it made me dizzy and I kept getting up during the night to empty my bladder.” During today's clinic visit, she expresses fear because her mother died of a cerebrovascular accident (CVA, stroke) at her age, and M.P. is afraid she will suffer the same fate. She states, “I've never smoked and I don't drink, but I am so afraid of this high blood pressure.” You review the data on her past clinic visits.

■ Chart View Family History

Mother, died at age 65 years of CVA Father, died at age 67 years of myocardial infarction (MI) Sister, alive and well, age 62 years Brother, alive, age 70 years, has coronary artery disease, HTN, type II diabetes mellitus (DM)

Patient Past History

Married for 45 years, two children, alive and well, six grandchildren Cholecystectomy, age 42 years Hysterectomy, age 48 years

Blood Pressure Assessments

January 2: 150/92 January 31: 156/94 (Given prescription for hydrochlorothiazide [HCTZ] 25 mg PO every morning) February 28: 140/90

1. According to the most recent Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, M.P.'s blood pressure falls under which classification?

2. What could M.P. be doing that is causing her nocturia?

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

5

PART 1  MEDICAL-SURGICAL CASES CASE STUDY PROGRESS During today's visit, M.P.'s vital signs were BP: 162/102, P: 78, R: 16, T: 98.2 ° F (36.8 ° C). Her most recent basic metabolic panel (BMP) and fasting lipids were within normal limits. Her height is 5 ft, 4 in., and she weighs 110 lb. She tells you that she tries to go on walks but does not like to walk alone so has done so only occasionally.

1 Cardiovascular

3. What risk factors does M.P. have that increase her risk for cardiovascular disease?

CASE STUDY PROGRESS Because M.P.'s BP continues to be high, the internist decides to put her on another drug and recommends that she try again with the HCTZ.

4. According to national guidelines, what drug category or categories are recommended for M.P. at this time?

5. M.P. goes on to ask whether there is anything else she should do to help with her HTN. She asks, “Do I need to lose weight?” Look up her height and weight for her age on a body mass index chart. Is she considered overweight?

6. What nonpharmacologic lifestyle alteration measures might help someone like M.P. control her BP? (List two examples and explain.)

6

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

1 Cardiovascular

CHAPTER 1  Cardiovascular Disorders  CASE STUDY 2

CASE STUDY PROGRESS The internist decreases M.P.'s HCTZ dosage to 12.5 mg PO daily and adds a prescription for benazepril (Lotensin) 5 mg daily. M.P. is instructed to return to the clinic in 1 week to have her blood work checked. She is also instructed to monitor her BP at least twice a week and return for a medication management appointment in 1 month with her list of BP readings.

7. Why did the internist decrease the dose of the HCTZ?

8. You provide M.P. with education about the common side effects of benazepril, which can include which conditions? (Select all that apply.) a. Headache b. Cough c. Shortness of breath d. Constipation e. Dizziness

9. It is sometimes difficult to remember whether you've taken your medication. What techniques might you teach M.P. to help her remember to take her medication each day? (Name at least two.)

10. After the teaching session, which statement by M.P. indicates a need for further instructions? a. “I need to rise up slowly when I get out of bed or out of a chair before standing up.” b. “I will leave the salt shaker off the table and not salt my food when I cook.” c. “It's okay to skip a few doses if I am feeling bad as long as it's just for a few days.” d. “I will call if I feel very dizzy, weak, or short of breath while on this medicine.”

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

7

PART 1

MEdiCAl-suRGiCAl CAsEs

CAsE sTudY PRoGREss M.P. returns in 1 month for her medication management appointment. She tells you she is feeling fine and does not have any side effects from her new medication. Her BP, checked twice a week at the senior center, ranges from 132 to 136/78 to 82 mm Hg.

1 Cardiovascular

11. When someone is taking HCTZ and an ACE inhibitor, such as benazepril, what laboratory tests would you expect to be monitored?

■ Chart View Laboratory Test Results (Fasting) Potassium Sodium Chloride CO2 Glucose Creatinine BUN Magnesium

3.6 mEq/L 138 mEq/L 100 mEq/L 28 mEq/L 112 mEq/L 0.7 mg/dL 18 mg/dL 1.9 mEq/L

12. What lab results, if any, are of concern at this time?

13. You take M.P.'s BP and get 134/82 mm Hg. She asks whether these BP readings are okay. On what do you base your response? 14. List at least three important ways you might help her maintain her success.

CAsE sTudY ouTCoME M.P. comes in for a routine follow-up visit 3 months later. She continues to do well on her daily BP drug regimen, with average BP readings of 130/78 mm Hg. She participates in a senior citizens group-walking program at the local mall. She admits she has not done as well with decreasing her salt intake but that she is trying. She tells you she was recently at a luncheon with her garden club and that most of those women take different BP pills than she does. She asks why their pills are different shapes and colors. 8

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

CHAPTER 1  Cardiovascular Disorders  CASE STUDY 2

1 Cardiovascular

15. How can you explain the difference to M.P.?

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

9

Intentionally left as blank

CHAPTER 1

CARdiovAsCulAR disoRdERs

CASE STUDY 3

Case Study 3 Name

Class/Group

Date

Group Members

1 Cardiovascular

INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.

scenario XX

You are a nurse at a freestanding cardiac prevention and rehabilitation center. Your new patient in risk-factor modification is B.T., a 41-year-old traveling salesman, who is married and has three children. He tells you that his work does not let him slow down. During a recent evaluation for chest pain, he underwent a cardiac catheterization procedure that showed moderate single-vessel disease with a 50% stenosis in the mid right coronary artery (RCA). He was given a prescription for sublingual (SL) nitroglycerin (NTG), told how to use it, and referred to your cardiac rehabilitation program for sessions of 3 days a week. B.T.'s wife comes along to help him with healthy lifestyle changes. You take a nursing history, as indicated in the following.

■ Chart View Family History

Father died suddenly at age 42 of a myocardial infarction (MI) Mother (still living) had a quadruple coronary artery bypass graft (CABG × 4) at age 52

Past History and Current Medications

Metoprolol (Lopressor) 25 mg PO every 12 hours Aspirin (ASA) 325 mg per day PO Simvastatin (Zocor) 20 mg PO every evening

Lifestyle Habits

Smokes an average of 1½ packs of cigarettes per day (PPD) for the past 20 years Drinks an “occasional” beer, and “a 6-pack every weekend when watching football” Dietary history: High in fried and fast foods because of his traveling Exercise: “I don't have time to take walks.”

General Assessment White Male Weight Height Waist circumference Blood pressure Pulse Respiratory rate Temperature

235 lb 5 ft, 8 in. 48 in. 148/88 mm Hg 82 beats/min 18 breaths/min 98.4° F (36.9° C)

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

11

PART 1

MEdiCAl-suRGiCAl CAsEs

1. Calculate B.T.'s smoking history in terms of pack-years.

1 Cardiovascular

2. There are several risk factors for coronary artery disease (CAD). For each risk factor listed, mark whether it is nonmodifiable or modifiable. a. Age b. Smoking c. Family history of CAD d. Obesity e. Physical inactivity f. Gender g. Hypertension h. Diabetes mellitus i. Hyperlipidemia j. Ethnic background k. Stress l. Excessive alcohol use

3. Circle the nonmodifiable and modifiable risk factors that apply to B.T.

CAsE sTudY PRoGREss You review B.T.'s most recent lab results.

■ Chart View Laboratory Testing (Fasting) Total cholesterol HDL LDL Triglycerides

240 mg/dL 35 mg/dL 112 mg/dL 178 mg/dL

4. Which lab values are of concern at this time? Explain your answers.

12

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

CHAPTER 1  Cardiovascular Disorders  CASE STUDY 3

1 Cardiovascular

5. B.T. asks you, “So, how is my ‘good cholesterol’ doing today?” Which is considered the “good cholesterol,” and why? What do his HDL and LDL levels indicate to you?

CASE STUDY PROGRESS B.T. laughingly tells you he believes in the five all-American food groups: salt, sugar, fat, chocolate, and caffeine.

6. Identify health-related problems in this case description; the problem that is potentially life threatening should be listed first.

7. Of all of his behaviors, which one is the most significant in promoting cardiac disease?

8. What is the highest priority problem that you need to address with B.T.? How will you determine this? Identify the teaching strategy you would use with him.

9. What is the second problem you would work with B.T. to change? Identify an appropriate strategy to resolve the problem.

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

13

1 Cardiovascular

PART 1  MEDICAL-SURGICAL CASES

10. B.T.'s wife takes you aside and tells you, “I'm so worried for B. I grew up in a really dysfunctional family where there was a lot of violence. B. has been so good to the kids and me. I'm so worried I'll lose him that I have nightmares about his heart stopping. I find myself suddenly awakening at night just to see if he's breathing.” How are you going to respond?

CASE STUDY PROGRESS Six weeks after you start working with B.T., he admits that he has been under a lot of stress. He is walking on the treadmill and rubs his chest and says, “It feels really heavy on my chest right now.” You feel his pulse and note that his skin is slightly diaphoretic and that he is agitated and appears to be anxious.

11. What is the first action you are going to do? What other information will you obtain? Explain.

12. B.T. is still uncomfortable, and he has an unopened bottle of sublingual nitroglycerin (SL NTG) tablets. You decide to give him one tablet. After 5 minutes, which is the appropriate action to take? a. If the chest discomfort is relieved, call 911. b. If the chest discomfort is not relieved, give another SL NTG tablet, and wait 5 minutes more. c. If the chest discomfort is not relieved, have someone else call 911, while you give B.T. another SL NTG tablet. d. If the chest discomfort is not relieved, do a 12-lead electrocardiogram (ECG) to look for ischemic changes, and call 911.

13. What other actions will you take at this time?

14

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

CHAPTER 1  Cardiovascular Disorders  CASE STUDY 3

1 Cardiovascular

14. Five minutes after the first NTG tablet, B.T. states that the discomfort is still there and only slightly relieved. Explain what you can expect to be doing while waiting for emergency medical system (EMS) to arrive.

CASE STUDY OUTCOME B.T. is transported to the ED of a local hospital and undergoes another cardiac catheterization with ­coronary stent placement.

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

15

Intentionally left as blank

CHAPTER 1

CARdiovAsCulAR disoRdERs

CASE STUDY 4

Case Study 4 Name

Class/Group

Date____________________

Group Members

1 Cardiovascular

INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.

scenario XX

S.P. is a 68-year-old retired painter who is experiencing right leg calf pain. The pain began approximately 2 years ago but has become significantly worse in the past 4 months. The pain is precipitated by exercise and is relieved with rest. Two years ago, S.P. could walk two city blocks before having to stop because of leg pain. Today, he can barely walk across the yard. S.P. has smoked two to three packs of cigarettes per day (PPD) for the past 45 years. He has a history of coronary artery disease (CAD), hypertension (HTN), peripheral vascular disease (PVD), and osteoarthritis. Surgical history includes quadruple coronary artery bypass graft (CABG × 4) 3 years ago. He has had no further symptoms of cardiopulmonary disease since that time, even though he has not been compliant with the exercise regimen his cardiologist prescribed, he continues to eat anything he wants, and continues to smoke two to three PPD. Other surgical history includes open reduction internal fixation of the right femoral fracture 20 years ago. S.P. is in the clinic today for a routine semiannual follow-up appointment with his primary care provider. As you take his vital signs, he tells you that, besides the calf pain, he is experiencing right hip pain that gets worse with exercise, the pain doesn't go away promptly with rest, some days are worse than others, and his condition is not affected by a resting position.

■ Chart View General Assessment

Weight Height Blood pressure Pulse Respiratory rate Temperature Laboratory Testing (Fasting) Cholesterol Triglycerides HDL LDL Current Medications Lisinopril (Zestril) Metoprolol (Lopressor) Aspirin Simvastatin (Zocor)

261 lb 5 ft, 10 in. 163/91 mm Hg 82 beats/min 16 breaths/min 98.4° F (36.9° C) 239 mg/dL 150 mg/dL 28 mg/dL 181 mg/dL

20 mg/day 25 mg twice a day 325 mg/day 20 mg/day

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

17

PART 1  MEDICAL-SURGICAL CASES

1 Cardiovascular

1. What are the likely sources of his calf pain and his hip pain?

2. S.P. has several risk factors for claudication. From his history, list two risk factors, and explain the reason they are risk factors.

3. You decide to look at S.P.'s lower extremities. What signs do you expect to find with intermittent claudication? (Select all that apply.) a. Cool or cold extremity b. Thin, dry, and scaly skin c. Brown discoloration of the skin d. Decreased or absent pedal pulses e. Ankle edema f. Thick, brittle nails

4. Where would you expect S.P. to complain of pain if he had superficial femoral artery stenosis? Popliteal stenosis?

5. What is the purpose of the daily aspirin listed in his current medication?

18

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

CHAPTER 1  Cardiovascular Disorders  CASE STUDY 4 CASE STUDY PROGRESS S.P.'s primary care provider has seen him and wants you to schedule the patient for an ankle-brachial index (ABI) test to determine the presence of arterial blood flow obstruction. You confirm the time and date of the procedure and then call S.P. at home.

1 Cardiovascular

6. What will you tell S.P. to do to prepare for the tests?

CASE STUDY PROGRESS S.P.'s ABI results showed 0.43 right (R) leg and 0.59 left (L) leg. His primary care provider discusses these results with him and decides to wait 2 months to see whether his symptoms improve with medication changes and risk factor modification before deciding about surgical intervention. S.P. receives a prescription for clopidogrel (Plavix) 75 mg daily and is told to discontinue the daily aspirin. In addition, S.P. received a consult for physical therapy.

7. What do these ABI results indicate?

8. You counsel S.P. on risk factor modification. What would you address, and why?

9. How will the physical therapy help?

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

19

PART 1  MEDICAL-SURGICAL CASES

1 Cardiovascular

10. In addition to risk factor modification, what other measures to improve tissue perfusion or to prevent skin damage should you recommend to S.P.?

11. S.P. tells you his neighbor told him to keep his legs elevated higher than his heart and ask for compression stockings to keep swelling down in his legs. How should you respond?

12. S.P. has been on aspirin therapy and now will be taking clopidogrel. What is the most important aspect of patient teaching that you will emphasize with this drug?

CASE STUDY OUTCOME S.P. asks for nicotine patches to assist with smoking cessation and makes an appointment for a physical therapy evaluation and a nutritional assessment. He assures you he doesn't want to lose his leg and will be more careful in the future.

20

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

CHAPTER 1  Cardiovascular Disorders  CASE STUDY 5

Case Study 5 Name

 Class/Group

  Date

Group Members

1 Cardiovascular

INSTRUCTIONS  All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.

Scenario XX

You are the nurse working in an anticoagulation clinic. One of your patients is K.N., who has a l­ong-standing history of an irregularly irregular heartbeat (atrial fibrillation, or A-fib) for which he takes the oral ­anticoagulant warfarin (Coumadin). Recently, K.N. had his mitral heart valve replaced with a mechanical valve.

1. How does atrial fibrillation differ from a normal heart rhythm?

2. What is the purpose of the warfarin (Coumadin) in K.N.'s case?

CASE STUDY PROGRESS K.N. calls your anticoagulation clinic to report a nosebleed that is hard to stop. You ask him to come into the office to check his coagulation levels. The laboratory technician draws a PT/INR test.

3. What is a PT/INR test, and what are the expected levels for K.N.? What is the purpose of the INR?

4. When you get the results, his INR is critical at 7.2. What is the danger of this INR level?

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

21

PART 1  MEDICAL-SURGICAL CASES CASE STUDY PROGRESS The health care provider does a brief focused history and physical examination, orders additional lab tests, and determines that there are no signs of bleeding other than the nosebleed, which has stopped. The provider discovers that K.N. recently went to the local urgent care center for a sinus infection and had received a prescription for the antibiotic co-trimoxazole (sulfamethoxazole-trimethoprim) (Septra).

1 Cardiovascular

5. What happened when K.N. began taking the antibiotic?

6. What should K.N. have done to prevent this problem?

7. The provider gives K.N. a low dose of vitamin K orally, asks him to hold his warfarin dose that evening, and asks him to come back tomorrow for another PT/INR blood draw. Why do you tell K.N. to take the vitamin K?

8. You want to make certain K.N. knows what “hold the next dose” means. What should you tell him? 9. K.N. asks you why his PT/INR has to be checked so soon. How will you respond?

CASE STUDY PROGRESS K.N.'s INR the next day is 3.7, and the health care provider made no further medication changes. K.N. is instructed to finish the remaining 2 days of antibiotics and return again in 7 days to have another PT/INR drawn.

10. Why should the INR be checked again so soon instead of the usual monthly follow-up?

11. K.N. grumbles about all of the lab tests but agrees to follow through. You provide patient education to K.N. and start with reviewing the signs and symptoms (S/S) of bleeding. What are potential S/S of bleeding that should be taught to K.N.? (Select all that apply.) a. Black, tarry stool b. Stool that is pale in color c. New onset of dizziness d. Insomnia

22

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

CHAPTER 1  Cardiovascular Disorders  CASE STUDY 5

1 Cardiovascular

e. New joint pain or swelling f. Unexplained abdominal pain

12. What other patient education needs to be stressed at this time? (Identify two.)

13. Four months later, K.N. informs you that he is going to have a knee replacement next month. What will you do with this information? CASE STUDY PROGRESS You know that sometimes the only needed action is to stop the warfarin (Coumadin) several days before the surgery. Other times, the provider initiates “bridging therapy,” or stops the warfarin and provides anticoagulation protection by initiating low-molecular-weight heparin. After reviewing all of his anticoagulation information, the provider decides that K.N. will need to stop the warfarin (Coumadin) 1 week before the surgery and, in its place, be started on enoxaparin (Lovenox) therapy.

14. Compare the duration of action of warfarin (Coumadin) and enoxaparin (Lovenox), and explain the reason the provider switched to enoxaparin at this time.

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

23

PART 1  MEDICAL-SURGICAL CASES CASE STUDY PROGRESS K.N. is in the office and ready for his first enoxaparin (Lovenox) injection.

1 Cardiovascular

15. Which nursing interventions are appropriate when administering enoxaparin? (Select all that apply.) a. Monitor activated partial thromboplastin (aPTT) levels. b. Administer via intramuscular (IM) injection into the deltoid muscle. c. The preferred site of injection is the lateral abdominal fatty tissue. d. Massage the area after the injection is given. e. Hold extra pressure over the site after the injection.

CASE STUDY OUTCOME K.N. undergoes knee surgery without complications and does not experience any thrombotic events or bleeding episodes during his recovery.

24

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

CHAPTER 1

CARdiovAsCulAR disoRdERs

CASE STUDY 6

Case Study 6 Name

Class/Group

Date

Group Members

1 Cardiovascular

INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.

scenario XX

You are working in the internal medicine clinic of a large teaching hospital. Today your first patient is 70-year-old J.M., a man who has been coming to the clinic for several years for management of coronary artery disease (CAD) and hypertension (HTN). A cardiac catheterization done a year ago showed 50% stenosis of the circumflex coronary artery. He has had episodes of dizziness for the past 6 months and orthostatic hypotension, shoulder discomfort, and decreased exercise tolerance for the past 2 months. On his last clinic visit 3 weeks ago, a chest x-ray (CXR) showed cardiomegaly, and a 12-lead electrocardiogram (ECG) showed sinus tachycardia with left bundle branch block (LBBB). You review his morning blood work and initial assessment.

■ Chart View Laboratory Testing Chemistry Sodium Chloride Potassium Creatinine Glucose BUN CBC WBC Hgb Hct Platelets

142 mEq/L 95 mEq/L 3.9 mEq/L 0.8 mg/dL 82 mg/dL 19 mg/dL

5400/mm3 13 g/dL 41% 229,000/mm3

Initial Assessment

Complains of increased fatigue and shortness of breath, especially with activity, and “waking up gasping for breath” at night, for the past 2 days.

Vital Signs Temperature Blood pressure Heart rate Respiratory rate

97.9° F (36.6° C) 142/83 mm Hg 105 beats/min 18 breaths/min

1. As you review these results, which ones are of possible concern, and why?

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

25

PART 1  MEDICAL-SURGICAL CASES

1 Cardiovascular

2. Knowing his history and seeing his condition this morning, what further questions are you going to ask J.M. and his daughter?

CASE STUDY PROGRESS J.M. tells you he becomes exhausted and has shortness of breath climbing the stairs to his bedroom and has to lie down and rest (“put my feet up”) at least an hour twice a day. He has been sleeping on two ­pillows for the past 2 weeks. He has not salted his food since the physician told him not to because of his high blood pressure, but he admits having had ham and a whole bag of salted peanuts 3 days ago. He denies having palpitations but has had a constant, irritating, nonproductive cough lately.

3. You think it's likely that J.M. has heart failure (HF). From his history, what do you identify as probable causes for his HF?

4. You are now ready to do your physical assessment. For each potential assessment finding for HF, indicate whether the finding indicates left-sided heart failure (L) or right-sided heart failure (R).   1. Fatigue, weakness, especially with activity   2. Jugular (neck) vein distention   3. Dependent edema (legs and sacrum) 26

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

CHAPTER 1

CASE STUDY 6

Hacking cough, worse at night Enlarged liver and spleen Exertional dyspnea Distended abdomen Weight gain S3/S4 gallop Crackles/wheezes in lungs

1 Cardiovascular

4. 5. 6. 7. 8. 9. 10.

CARdiovAsCulAR disoRdERs

■ Chart View Medication Orders

Enalapril (Vasotec) 10 mg PO twice a day Furosemide (Lasix) 20 mg PO every morning Carvedilol (Coreg) 6.25 mg PO twice a day Digoxin (Lanoxin) 0.5 mg PO now, then 0.125 mg PO daily Potassium chloride 10 mEq tablet PO once a day

CAsE sTudY PRoGREss

The physician confirms your suspicions and indicates that J.M. is experiencing symptoms of early left-sided heart failure. Medication orders are written. 5. For each medication listed, identify its class, and describe its purpose for the treatment of HF.

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

27

PART 1  MEDICAL-SURGICAL CASES

6. When you go to remove the medications from the automated dispensing machine, you see that carvedilol (Coreg CR) is stocked. Will you give it to J.M.? Explain.

1 Cardiovascular

7. As you remove the digoxin tablet from the automated medication dispensing machine, you note that the dosage on the tablet label is 250 mcg. How many tablets would you give?

8. Based on the new medication orders, which blood test or tests should be monitored carefully? Explain your answer.

9. When you give J.M. his medications, he looks at the potassium tablet, wrinkles his nose, and tells you he “hates those horse pills.” He tells you a friend of his said he could eat bananas instead. He says he would rather eat a banana every day than take one of those pills. How will you respond?

CASE STUDY PROGRESS This is J.M.'s first episode of significant HF. Before he leaves the clinic, you want to teach him about lifestyle modifications he can make and monitoring techniques he can use to prevent or minimize future problems.

10. List five suggestions you might make and the rationale for each.

28

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

1 Cardiovascular

CHAPTER 1  Cardiovascular Disorders  CASE STUDY 6

11. You tell J.M. the combination of high-sodium foods he had during the past several days might have contributed to his present episode of HF. He looks surprised. J.M. says, “But I didn't add any salt to them!” To what health care professional could J.M. be referred to help him understand how to prevent future crises? State your rationale.

12. You also include teaching about digoxin toxicity. When teaching J.M. about the signs and symptoms of digoxin toxicity, which should be included? (Select all that apply.) a. Dizziness when standing up b. Visual changes c. Loss of appetite or nausea d. Increased urine output e. Diarrhea

CASE STUDY OUTCOME J.M.'s condition improves after 5 days of treatment, and he is discharged to home. He has a follow-up appointment with a cardiologist in 2 weeks.

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

29

Intentionally left as blank

CHAPTER 1  Cardiovascular Disorders  CASE STUDY 7

Case Study 7 Name

 Class/Group

 Date

Group Members

1 Cardiovascular

INSTRUCTIONS  All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.

Scenario XX

It is midmorning on the cardiac unit where you work, and you are getting a new patient. G.P. is a 60-yearold retired businessman, who is married and has three grown children. As you take his health history, he tells you that he began feeling changes in his chest about 10 days ago. He has hypertension (HTN) and a 5-year history of angina pectoris. During the past week, he has had frequent episodes of mid-chest discomfort. The chest pain responds to nitroglycerin (NTG), which he has taken sublingually (SL) about 8 to 10 times over the past week. During the week, he has also experienced increased fatigue. He states, “I just feel crappy all the time.” A cardiac catheterization done several years ago revealed 50% stenosis of the right coronary artery (RCA) and 50% stenosis of the left anterior descending (LAD) coronary artery. He tells you that both his mother and father had coronary artery disease (CAD). He is currently taking amlodipine (Norvasc), metoprolol (Lopressor), atorvastatin (Lipitor), and aspirin 81 mg/day.

1. What other information are you going to ask about his episodes of chest pain?

2. What are common sites for radiation of ischemic cardiac pain? 3. You know that G.P. has atherosclerosis of the coronary arteries. You need to know his risk factors for CAD in order to plan teaching for lifestyle modifications. What will you ask him about?

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

31

PART 1  MEDICAL-SURGICAL CASES

1 Cardiovascular

4. Although he has been taking sublingual nitroglycerin (SL NTG) for a long time, you want to be certain he is using it correctly. Which actions are correct when taking SL NTG for chest pain? (Select all that apply.) a. Stop the activity and lie or sit down. b. Call 911 immediately. c. Call 911 if the pain is not relieved after taking one SL tablet. d. Call 911 if the pain is not relieved after taking three SL tablets, 5 minutes apart. e. Chew the tablet slowly then swallow. f. Place the NTG tablet under the tongue.

5. What other information would you need to make certain he understands the side effects and storage of SL NTG?

CASE STUDY PROGRESS When you first admitted G.P., you placed him on telemetry and observed his cardiac rhythm.

6. Identify the rhythm:

CASE STUDY PROGRESS As you check his chart, you note that his vital signs (VS) and all of his lab tests were within normal range, including troponin and creatinine phosphokinase (CPK) levels; potassium (K) was 4.7 mEq/L. Within the hour, he spontaneously converted with medication (diltiazem [Cardizem]) to sick sinus syndrome with long sinus pauses that caused lightheadedness and hypotension. 32

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

CHAPTER 1  Cardiovascular Disorders  CASE STUDY 7

1 Cardiovascular

7. What risks does the new rhythm pose for G.P.?

CASE STUDY PROGRESS Because G.P.'s dysrhythmia is causing unacceptable symptoms, he is taken to surgery and a permanent DDDR pacemaker is placed and set at a rate of 70 beats/min.

8. What does the code DDDR mean?

9. The pacemaker insertion surgery places G.P. at risk for several serious complications. List three potential problems that you will monitor for as you care for him.

10. G.P. will need some education regarding his new pacemaker. What information will you give him before he leaves the hospital?

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

33

PART 1  MEDICAL-SURGICAL CASES

1 Cardiovascular

11. G.P.'s wife approaches you and anxiously inquires, “My neighbor saw this science fiction movie about this guy who got a pacemaker and then he couldn't die. Is that for real?” How are you going to respond to her?

12. G.P. and his wife tell you they have heard that people with pacemakers can have their hearts stop because of theft and security sensors in stores and airports. Where can you help them find more information?

CASE STUDY OUTCOME After discharge, G.P. is referred to a cardiac rehabilitation center to start an exercise program. He will be exercise tested, and an individualized exercise prescription will be developed for him, based on the e ­ xercise test.

13. What information will be obtained from the graded exercise (stress) test (GXT), and what is included in an exercise prescription?

34

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

CHAPTER 1

CARdiovAsCulAR disoRdERs

CASE STUDY 8

Case Study 8 Name

Class/Group

Date

Group Members

1 Cardiovascular

INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.

scenario XX

You are assigned to care for L.J., a 70-year-old retired bus driver who has just been admitted to your medical floor with right leg deep vein thrombosis (DVT). L.J. has a 48-pack-year smoking history, although he states he quit 2 years ago. He has had pneumonia several times and frequent episodes of atrial flutter/ fibrillation. He has had two previous episodes of DVT and was diagnosed with rheumatoid arthritis 3 years ago. Two months ago he began experiencing shortness of breath on exertion and noticed swelling of his right lower leg that became progressively worse until it extended up to his groin. His wife brought him to the hospital when he complained of increasingly severe pain in his leg. When a Doppler study indicated a probable thrombus of the external iliac vein extending distally to the lower leg, he was admitted for bed rest and to initiate heparin therapy. His basic metabolic panel was normal; other laboratory results are listed as follows:

■ Chart View Laboratory Testing PT INR aPTT Hgb Hct Cholesterol

12.4 sec 1.11 25 sec 13.3 g/dL 38.9% 206 mg/dL

1. List six risk factors for DVT.

2. Identify at least five problems from L.J.'s history that represent his personal risk factors.

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

35

PART 1  MEDICAL-SURGICAL CASES

3. Something is missing from the scenario. Based on his history, L.J. should have been taking an important medication. What is it, and why should he be taking it?

1 Cardiovascular

4. Keeping in mind L.J.'s health history and admitting diagnosis, what are the most important assessments you will make during your physical examination and assessment?

5. What is the most serious complication of DVT? CASE STUDY PROGRESS Your assessment of L.J. reveals bibasilar crackles with moist cough; normal heart sounds; blood pressure (BP) 138/88 mm Hg; pulse 104 beats/min; 3+ pitting edema of right lower extremity; mild erythema of right foot and calf; and severe right calf pain. He is awake, alert, and oriented but a little restless. His Sao2 is 92% on room air. He denies chest pain but does have shortness of breath with exertion.

6. List at least eight assessment findings you should monitor closely for in the development of the complication identified in Question 5.

CASE STUDY PROGRESS L.J. is placed on 72-hour bed rest with bathroom privileges and given acetaminophen (Tylenol) for pain. The physician also writes orders for enoxaparin (Lovenox) injections.

7. L.J. asks, “Why do I have to get these shots? Why can't I just get a Coumadin pill to thin my blood?” What would be your response? a. “Good idea! I will call to ask the physician to switch medications.” b. “It would take the Coumadin pills several days to be effective.” c. “Your physician prefers the injections over the pills.” d. “The enoxaparin will work to dissolve the blood clot in your leg.”

36

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

CHAPTER 1  Cardiovascular Disorders  CASE STUDY 8

8. The order for the enoxaparin reads: Enoxaparin 70 mg every 12 hours subcut. L.J. is 5 ft, 6 in. and weighs 156 lb. Is this dose appropriate?

1 Cardiovascular

9. What special techniques do you use when giving the subcutaneous injection of enoxaparin? (Select all that apply.) a. Rotate injection sites. b. Give the injection near the umbilicus. c. Expel the bubble from the prefilled syringe before giving the injection. d. After inserting the needle, do not aspirate before giving the injection. e. Massage the injection site gently after the injection is given.

10. True or False: Enoxaparin dosage is directed by monitoring activated partial thromboplastin time (aPTT) levels. Explain your answer.

11. What instructions will you give L.J. about his activity?

12. What pertinent laboratory values or test results would you expect the physician to order and you to monitor? Explain the reason for each test.

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

37

PART 1  MEDICAL-SURGICAL CASES

1 Cardiovascular

13. You identify pain as a key issue in the care of L.J. List four interventions you will choose for L.J. to address his pain.

14. You evaluate L.J.'s ECG strip. Name this rhythm, and explain what consequences it could have for L.J.

CASE STUDY PROGRESS A week has passed. L.J. responded to heparin therapy, was started on warfarin therapy, and is being discharged to home with home care follow-up. “Good,” he says, “just in time to fly out West for my grandson's wedding.” His wife, who has come to pick him up, rolls her eyes and looks at the ceiling. You almost drop the discharge papers in disbelief. (You thought you had done such a good job of discharge teaching!)

15. What are you going to tell him?

CASE STUDY OUTCOME L.J. listens to you, and Mrs. J. is quite relieved. L.J.'s son arranges to record the wedding ceremony, and guests at the reception record special greetings for him. It's been 2 weeks, and he seems quite pleased. He watches the recording daily and points out his favorite parts to the home care nurse every time she visits.

38

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

CHAPTER 1  Cardiovascular Disorders  CASE STUDY 9

Case Study 9 Name

 Class/Group

 Date

Group Members

1 Cardiovascular

INSTRUCTIONS  All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.

Scenario XX

A.H. is a 70-year-old retired construction worker who has experienced lumbosacral pain, nausea, and upset stomach for the past 6 months. He has a history of heart failure, high cholesterol, hypertension (HTN), sleep apnea, and depression. His chronic medical problems have been managed over the years with oral medications: benazepril (Lotensin) 5 mg/day, fluoxetine (Prozac) 40 mg/day, furosemide (Lasix) 20 mg/day, KCl 20 mEq bid, and lovastatin (Mevacor) 40 mg with the evening meal. A.H. has just been admitted to the hospital for surgical repair of a 6.2-cm abdominal aortic aneurysm (AAA) that is now causing him constant pain. On arrival on your floor, his vital signs are 109/81, 61, 16, and 98.3° F (36.8° C). When you perform your assessment, you find that his apical heart rhythm is regular and his peripheral pulses are strong. His lungs are clear, and he is awake, alert, and oriented. There are no abnormal physical findings; however, he hasn't had a bowel movement for 3 days. His electrolytes, blood chemistries, and clotting studies are within normal range, except his hematocrit is 30.1%, and ­hemoglobin is 9 g/dL.

1. A.H. has several common risk factors for AAA, which are evident from his health history. Identify and explain three factors.

CASE STUDY PROGRESS While A.H. awaits his surgery, it is important that you monitor him carefully for decreased tissue perfusion.

2. Identify five things you would assess for, and state your rationale for each.

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

39

PART 1  MEDICAL-SURGICAL CASES

3. What is the most serious, life-threatening complication of AAA, and why?

1 Cardiovascular

4. What single problem mentioned in the first paragraph of this case study presents a risk for AAA rupture? Why?

5. During your assessment, you notice a pulsation in A.H.'s upper abdomen, slightly left of the midline, between the umbilicus and the xiphoid process. True or False: You will need to palpate this mass as part of your physical assessment. Explain your answer.

CASE STUDY PROGRESS The resection of A.H.'s aneurysm was successful, but, for the first 3 postoperative days, he was delirious and required one-to-one nursing care before he became coherent and oriented again. He was still ­somewhat confused when he was transferred back to your floor.

6. What assessments should be made specific to his postoperative care?

7. List five problems that are high priorities in A.H.'s postoperative care.

8. During the postoperative period after an aneurysmectomy, the nurse will implement which actions? (Select all that apply.) a. Keep the head of bed (HOB) elevated at 60 degrees. b. Keep firm pressure on the abdominal incision during coughing exercises. c. Change dressings as ordered with aseptic technique. d. Monitor peripheral pulses on both lower extremities. e. Use the bed's knee gatch to allow for knee flexion during bed rest. 40

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

1 Cardiovascular

CHAPTER 1  Cardiovascular Disorders  CASE STUDY 9

CASE STUDY PROGRESS When A.H. is being prepared for discharge, you talk to him about health promotion and lifestyle change issues that are pertinent to his health problems.

9. Identify four health-related issues you might appropriately address with him and what you would teach in each area.

10. A.H. will be receiving follow-up visits from the home health care nurse to change his dressing and evaluate his incision. What can you discuss with A.H. before discharge that will help him understand what the nurse will be doing?

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

41

Intentionally left as blank

CHAPTER 1  Cardiovascular Disorders  CASE STUDY 10

Case Study 10 Name

 Class/Group

 Date

Group Members

1 Cardiovascular

INSTRUCTIONS  All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.

Scenario XX

R.K. is an 85-year-old woman who lives with her husband, who is 87. Two nights before her admission to your cardiac unit, she awoke with heavy substernal pressure accompanied by epigastric distress. The pain was reduced somewhat when she rolled onto her side but did not completely subside for about 6 hours. The next night, she experienced the same chest pressure. The following morning, R.K.'s husband took her to the physician, and she was subsequently hospitalized to rule out myocardial infarction (MI). Labs were drawn in the emergency department. She was started on oxygen (O2) at 2 L via nasal cannula and given nonenteric-coated aspirin 325 mg to be chewed and swallowed. An IV was started. You obtain the following information from your history and physical examination: R.K. has no history of smoking or alcohol use, and she has been in good general health, with the exception of osteoarthritis of her hands and knees and some osteoarthritis of the spine. Her only medications are simvastatin (Zocor), ibuprofen as needed for bone and joint pain, and “herbs.” Her admission vital signs (VS) are 132/84, 88, 18, and 99° F (37.2° C). Her weight is 114 lb and height is 5 ft, 4 in. Moderate edema of both ankles is present, but capillary refill is brisk, and peripheral pulses are 1+. You hear a soft systolic murmur. You place her on telemetry, which shows the rhythm in the figure, as follows. She denies any discomfort at present.

1. Identify her cardiac rhythm.

2. Give at least two reasons an IV would be inserted.

3. Explain the purpose of the aspirin tablet. Why is “nonenteric-coated” aspirin specified? What would be a contraindication to administering aspirin?

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

43

PART 1  MEDICAL-SURGICAL CASES

1 Cardiovascular

4. What additional history and physical information should you obtain related to her admitting diagnosis?

5. List seven laboratory or diagnostic tests you would expect to be performed; suggest what each might contribute.

6. What other source, besides cardiac ischemia, might be responsible for her chest and abdominal discomfort? (Specify.)

44

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

CHAPTER 1

CARdiovAsCulAR disoRdERs

CASE STUDY 10

1 Cardiovascular

7. Define the concept of differential diagnosis, and explain how the concept applies to R.K.'s symptoms.

CAsE sTudY PRoGREss After some rest, R.K.'s chest pain has subsided, and she tells you that she feels much better now. You review her laboratory results.

■ Chart View Laboratory Results

12-lead ECG: Light left-axis deviation, normal sinus rhythm with no ventricular ectopy Serial CPK tests are 30 units/L (admission), 32 units/L (4 hours after admission) Cardiac troponin T is less than 0.01 ng/mL (admission) and same result 4 hours after admission Cardiac troponin T is less than 0.03 ng/mL (admission) and same result 4 hours after admission D-dimer test less than 250 ng/mL

8. On the basis of the information presented so far, do you believe she had an MI? What is your rationale?

9. While you care for R.K., you carefully observe her. Identify two possible complications of coronary artery disease (CAD) and the signs and symptoms associated with each.

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

45

PART 1  MEDICAL-SURGICAL CASES

1 Cardiovascular

10. R.K. rings her call bell. When you arrive, she has her hand placed over her heart and tells you she is “having that heavy feeling again.” She is not diaphoretic or nauseated but states she is short of breath. What else do you assess, and what can you do to make her more comfortable?

CASE STUDY PROGRESS R.K.'s husband is upset. He tells you they have been married for 62 years and he doesn't know what he would do without his wife. One way to help people deal with their anxieties is to help them focus on concrete issues.

11. What information would be useful to get from him? What other health care professional might be able to help with some of these issues?

CASE STUDY PROGRESS R.K. has no further episodes of chest pain, and she is discharged to home the next day. As you present the discharge instructions, you review the proper technique for taking sublingual nitroglycerin for chest pain.

12. Which statement by R.K. indicates that further teaching is needed? a. “At the first sign of chest discomfort, I will stop what I'm doing and sit down.” b. “I will place one nitroglycerin tablet under my tongue.” c. “If the chest pain does not stop, I can take another tablet in 5 minutes.” d. “My husband will need to call 911 if the chest pain does not stop after 3 nitroglycerin tablets.”

46

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

CHAPTER 1  Cardiovascular Disorders  CASE STUDY 11

Case Study 11 Name

 Class/Group

 Date

Group Members

1 Cardiovascular

INSTRUCTIONS  All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.

Scenario XX

The time is 1900. You are working in a small, rural hospital. It has been snowing heavily all day, and the medical helicopters at the large regional medical center, 4 hours away by car (in good weather), have been grounded by the weather until morning. The roads are barely passable. W.R., a 48-year-old plumber with a 36-pack-year smoking history, is admitted to your floor with a diagnosis of rule out myocardial infarction (R/O MI). He has significant male-pattern obesity (“beer belly,” large waist circumference) and a barrel chest, and he reports a dietary history of high-fat food. His wife brought him to the emergency department after he complained of unrelieved “indigestion.” His admission vital signs (VS) were 202/124, 106, 18, and 98.2° F (36.8° C). W.R. was put on oxygen (O2) by nasal cannula (NC) titrated to maintain Sao2 (arterial oxygen saturation) over 90% and started on an IV of nitroglycerin (NTG). He was given aspirin 325 mg to chew and swallow and was admitted to Dr. A.'s service. There are plans to transfer him by helicopter to the regional medical center for a cardiac catheterization in the morning when the weather clears. Meanwhile, you have to deal with limited laboratory and pharmacy resources. The minute W.R. comes through the door of your unit, he announces he's just fine in a loud and angry voice and demands a cigarette. He also says he has no time to fool around with hospitals.

1. From the perspective of basic human needs, what is the first priority in his care?

2. Are these VS reasonable for a man of his age? If not, which one(s) concern(s) you? Explain why or why not.

3. Identify five priority problems associated with the care of a patient like W.R.

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

47

PART 1  MEDICAL-SURGICAL CASES

1 Cardiovascular

4. Which laboratory tests might be ordered to investigate W.R.'s condition? If the order is appropriate, place an “A” in the space provided. If inappropriate, mark with an “I,” and provide rationales for your decisions. 1. CBC 2. EEG in the morning 3. Chem 7 (electrolytes) 4. PT/PTT 5. Bilirubin 6. Urinalysis (UA) 7. STAT 12-lead ECG 8. Type and crossmatch for 2 units of packed RBCs (PRBCs)

5. What significant lab tests are missing from the previous list?

6. How are you going to respond to W.R.'s angry demands for a cigarette? He also demands something for his “heartburn.” How will you respond?

CASE STUDY PROGRESS You phone Dr. A.'s partner, who is on call. She prescribes morphine sulfate 4 to 10 mg IV push (IVP) q1h prn for pain (burning, pressure, angina).

7. Explain two reasons for this order.

48

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.

CHAPTER 1  Cardiovascular Disorders  CASE STUDY 11

1 Cardiovascular

8. What special precautions should you follow when administering morphine sulfate IVP?

mL

3

21/2

2

11/2

1

1/

2

9. The pharmacy supplies morphine for injection in vials of 5 mg/mL only. For the first dose, you will be giving 4 mg of morphine. How many milliliters will you give for this dose? Mark the syringe with your answer.

Я хочу открыть этот проклятый файл и ознакомиться с созданной Танкадо программой. Сьюзан была столь же любопытна, как и ее шеф, но чутье подсказывало ей, что расшифровка алгоритма Цифровой крепости неразумна, какой бы интерес это ни представляло. В данный момент эта чертова программа надежно зашифрована и абсолютно безопасна.

Comments

Leave a Reply

Your email address will not be published. Required fields are marked *