Cardiac case study with answers as well PDF

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It is a case study assignment that has various scenarios regarding a cardiac patient and has answers as well....

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Cardiac Clinical Case #2 Decreased Perfusion from Hypertension and Heart Failure Related Concepts: Oxygenation, Mobility, Acid-base Balance Threaded Topics: Legal Issues, Error Identification, Communication, Teamwork, Patient Education, Medication Safety Patient: William Jones, age 69 Scenario: William Jones is a 69-year-old with a history of poorly controlled hypertension and secondary heart failure. He is a veteran and a fall risk from a leg wound he received in Vietnam. As the case progresses, he is admitted to the intensive care unit with hypertension and worsening heart failure. During this case, the nurse serves as a home-care nurse, communicator, and advisor while dealing with HIPAA and legal issues. The home care nurse is making an initial visit to his home today. Mr. Jones greets the nurse at the door. He is tall with a large build. He walks with a limp and is mildly short of breath. His home is small, but neat and well kept. There are no stairs or throw rugs. He has a small dog, barking as the nurse enters. The smell of food cooking comes from the kitchen. 1. The nurse performs an environmental assessment. Why would each observation listed be a potential concern and area for further assessment by the nurse? List the action that the nurse should take. - Large Build: Obesity can be a huge risk for elderly people diagnosed with hypertension and secondary heart failure. The nurse should suggest him ways to be physically active and educate him on choosing healthy diets to avoid obesity related disorders. - Walks with a limp: The nurse should determine if walking with a limp is the result of an accident or any other cause. After finding the cause, the nurse should educate him about risk of fall and ways to prevent it. - Mildly short of breath: The nurse should find out what’s causing the shortness of breath. Then, she should educate him regarding various breathing techniques. If he smokes, she should explain him that smoking can be dangerous to health. - Small dog: The nurse should find out if he’s able to take care of the dog. If not, she should recommend him to give the dog for adoption. Also, she should remind him to be careful while walking around the house since the dog is small and he can fall by tripping over the dog. - Smell of Food: The nurse should advise him to throw the food away if it is smelling bad as he could get food poison after eating it. Nursing Note September 1 0930

69 y.o. man discharged from the Veteran’s hospital after a 2 day stay for a hypertensive crisis. Health history includes hypertension x25 years, DM Type II x 2 years, and an enlarged prostate gland.

Surgical history includes cholecystectomy 30 years ago and significant orthopedic surgery after a “blown out left knee” in Vietnam at the age of 20 years. Client lives with his wife who was “high-school sweetheart.” VS = Temp. 97.6F, RR 22, HR 110, BP 167/89 (115) mmHg, Sat 93% on room air. Alert and oriented x 3. Moves all extremities. Grips and pushes equal in upper extremities. Left leg weaker than right and knee is swollen with some irregular beats. Fine bibasilar crackles. States feeling short of breath with activity. Bowel sounds active x 4. Last bowel movement yesterday and it looked “normal.” States hesitancy with urine flow but denies burning. Up to void 1-2 times each night. Client states morning blood glucose was 178, and he checks it daily. Height 6’1, Weight 263 lbs., BMI 34.7. 2. Evaluate the information within the admission note and pick the Top 3 Priority assessment concerns 1. Vitals: HR: 110, BP: 167/115 mm Hg 2. Shortness of breath with activity 3. Hyperglycemia 3. After further inquiry, it is discovered that no morning medications have been taken. Which medications should the nurse suggest Mr. Jones take now? Select all that apply. A. Lisinopril B. Atenolol C. Metformin D. Tamsulosin E. Celecoxib ANSWER: A, B, C, E 4. The nurse completes a Fall Risk Assessment for Mr. Jones. His score is 13 (at-risk is >10). Which intervention(s) would be most appropriate? Select all that apply. A. Ask him to find a new home for his dog. B. Request a physical therapy referral. C. Request an occupational therapy referral. D. Get a brace for his knee. E. Suggest grab bars in the bathroom. F. Place a red “Fall Risk” band on his wrist ANSWER: B, E 5. The nurse reviews Mr. Jones advanced directives. The forms indicate that he prefers not to be on life support but is accepting of being resuscitated should the situation arise. He has identified his wife as his Power of Attorney. How should the nurse interpret these preferences? Select all that apply. A. His wife is the proxy and will make his health care decisions.

B. C. D. E.

No intubation, should he stop breathing. Perform defibrillation if his heart stops. Provide nutritional support if he is in a vegetative state. Perform CPR if he is found unconscious and not breathing.

ANSWER: A, B, C, E 6. What additional concerns did the nurse not address on this visit? 1. Crackles in lungs, edema, shortness of breath: The nurse should have requested an order for a diuretic and implemented his daily weights. 2. Irregular heartbeats: The nurse should have followed up on this as it could be an electrolyte imbalance or heart problem. 3. The nurse did not provide dietary education about a low sodium diet. 7. One week later, Mr. Jones calls the home care nurse saying that he feels very short of breath since he awoke three hours ago and is having a hard time breathing. What actions should the nurse take next? A. Change the plan for the day and make a visit to Mr. Jones. B. Ask him to check his blood pressure and call you back. C. Have him take an extra antihypertensive medication and lay down. D. Tell him to hang up the phone and call an ambulance. ANSWER: D

Mr. Jones chooses to have his wife drive him to the emergency department, where he is admitted. The nurse makes these notes in the electronic health record. Vital Sign Record Time Sept 7 1010

BP (MAP) 210/114 (146)

HR 118 - irregular

RR 28

Sats 90 % RA

Brought in by wife per private vehicle. Alert and oriented x 3. Crackles bilaterally anteriorly & posteriorly. Moist cough. Some nasal flaring. States feeling like he cannot catch his breath. 8.

The nurse discusses the situation with the emergency department provider. Which prescription(s) should the nurse question? Select all that apply. A. IV 0.9% sodium chloride at 100 mL/hr. B. Delivery of sodium nitroprusside intravenously. C. Portable chest x-ray. D. Furosemide 5 mg intravenously.

E. Oxygen at 15 L by non-rebreather mask. ANSWER: A, D, E Lab Report

9.

Arterial Blood Gas

Normal Range

pH PO2 PCO2 HCO3 SaO2 O2 Delivery

7.35-7.45 80-100 mm Hg 35-45 mm Hg 22-28 mEq/L Above 95 1-4 L/NC

Admission Values (indicate if High or Low) 7.28 65 52 26 91 2 L/NC

The nurse receives the arterial blood gas results above. What conclusions should the nurse make about the client’s situation? A. In metabolic acidosis and has impaired renal function. B. In respiratory acidosis and needs more oxygen. C. Needs more oxygen and to breathe into a paper bag. D. Needs a bronchodilator and intubation. ANSWER: B

Hand-off Report to ICU: Mr. Jones is a 69 y.o. with a history of hypertension, DM type 2, and knee pain from a war injury. He came to the E.D. via private vehicle this morning after feeling severely short of breath. Upon admission to the E.D., he was found to be severely hypertensive and short of breath. His blood gases showed respiratory acidosis with hypoxemia and chest x-ray confirmed he is in acute cardiogenic heart failure. He’s on 4 L/NC and his saturations are 93%. We gave him the “now” dose of furosemide 40 mg IV about 10 minutes ago and started him on sodium nitroprusside IV at 0.1 mcg/kg/minute 15 minutes ago and his last BP was 211/115 (147) mmHg, HR is 120 in a sinus tachycardia, with rare premature ventricular contraction (PVC), respirations are 24 breaths per minute. His wife is in in the intensive care unit waiting room.

Orders August 13 1300

1. O2 to maintain sats >94% 2. Labs: Complete blood count (CBC), Comprehensive Metabolic Panel (CMP), Brain Natriuretic Peptide (BNP) stat 3. Chest X-Ray in the morning

4. Blood glucose monitoring before meals (AC) and at bedtime (HS) 5. Sodium Nitroprusside titrate for systolic BP...