Perfusion Case Study(1) PDF

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Perfusion Case Study: Dr. Vinesky NURS 2000 Fall 2021

CASE STUDY

Case Presentation Joe Jenkins is a 69-year-old male who has arrived in the Emergency Department @ approximately 1000 complaining of moderate chest pain and severe shortness of breath. He reports his chest pain started at approximately 0930 at a 6 on a 1-10 scale and was improved by (now pain is a 2). He reports taking three 81 mg baby aspirin at home per his doctor’s order. He describes his pain as a heavy feeling on his chest. He states the shortness of breath has been worsening over the last 2-3 days and he was having difficulty climbing stairs and completing simple tasks around his home. His skin is moist and clammy, and he is mildly anxious. He is sitting in a tripod position using his accessory muscles to breathe and is having difficulty speaking in complete sentences. His vital signs are as follows: temperature 99 F, blood pressure 102/68 mm Hg, AP 112 beats/minute and rhythm slightly irregular, radial pulse 99, respiratory rate 32 breaths per minute and slightly shallow. Pulse oximeter is 86% on room air. Immediate respiratory assessment reveals scattered rales and rhonchi and an occasional expiratory wheeze. Patient is alert and oriented times three, color is pale. Skin clammy and moist. Pitting edema is noted in his lower extremities +2 knees to ankles bilaterally but worse on the right. Capillary refill fingers and toes is >3 seconds and sluggish. Joe is slightly overweight but has been trying in the last six months to eat healthier and cut back on his salt intake (he has lost approximately 20 pounds). He has a remote history of smoking and quit 30 years ago after a 20-year history of smoking one pack of cigarettes per day. He has a history of congestive heart failure, mild hypertension, osteoarthritis, and last year was diagnosed with cardiomyopathy. Joe lives with his daughter and two granddaughters.

You are the nurse in the ER, and then in the ICU where Joe will initially be admitted after

he leaves the ER. Now let’s take care of Joe! Case Analysis Questions 1. Does this case exemplify an impairment of local perfusion, central perfusion, or both? What is the difference? Joe Jenkins case exemplified both impaired perfusion local/tissue and central perfusion. The difference is that central perfusion propels blood to all organs and their tissues from arteries through capillaries and returns the blood to the heart. Whereas tissue perfusion refers to the volume of blood that flows through target tissues. This perfusion is supplied by blood flowing from arteries to capillaries. 2. Please prioritize your care starting with a focused assessment. Document your assessment. You bring Joe back to an empty room and get him onto a cart. What will you do first, second, third? Explain your prioritization of care. Be very specific. Prioritization of patient care is built on the nursing process. The focused assessment is a detailed nursing assessment of specific body systems related to the presenting problem or other current concerns; therefore, I will be focusing on the lower level needs when prioritizing care for Joe. Because he has a respiratory distress, I will address this problem first because his pulse oxygen is 86% on room air and respiratory assessment reveals scattered rales and rhonchi and an occasional expiratory wheeze. After that, I will assess and then work on his circulatory problem because of his SOB, chest pain, elevated HR, and pitting edema. And then, I will address his temperature and other health issues. 3. Complete a pain assessment on Joe. What did he do prior to his arrival to alleviate the pain? His pain level is now low 2out of 10. He took three nitroglycerine 0.4 mg sublingual tablets taken five minutes apart which was a correct action. Nitroglycerine cause coronary and generalized vascular vasodilation, which increase blood flow through the coronary arteries to myocardial cell and relive chest pain. 4. Joe has osteoarthritis. Does this limit his mobility, and to what degree? Is Joe at risk for problems related to immobility at this time? If so, which potential problems and why? Osteoarthritis can degrade cartilage, change bone shape and cause inflammation, resulting in pain, stiffness and loss of mobility. Yes, Joe at risk for problems related to immobility at this time because he is overweight and has a lot of

underlying circulatory problem, which cause him to have difficulty climbing stairs and completing simple tasks around his home, dyspnea on exertion. Eventually he may stop moving around because simply of difficulty which will mostly effect his cardiovascular system (reduce cardiac capacity, decrease CO, venous stasis, DVT), respiratory system( lung expansion, atelectasis, pooling of secretion)and other problems such as bone demineralization, constipation, infection, renal calculi, skin breakdown. 5. What nursing interventions can be done prophylactically to prevent potential problems? Encourage or perform active or passive range of motion exercises as prescribed by the physical therapist. Minimize underling conditions which can cause immobility. 6. Assess Joe’s need for oxygen? How will you make that assessment? How will you determine if Joe needs more or less oxygen? How will you determine if Joe’s respiratory assessment is improving or declining? Be very specific. I will assess his lung on presence of adventitious sounds, check his pulse oximeter, RR, ask if he has SOB, assess if he uses accessory muscles to breathe, observe his skin color and mucous membrane color, general appearance, level of consciousness. Also, I will check cap refill and if clubbing is present that may indicate prolonged oxygen deficiency. So, Joe’s oxygen is 86% on room air by pulse oximeter, his respiratory rate 32 breaths per minute and slightly shallow, he uses accessory muscles. Immediate respiratory assessment reveals scattered rales and rhonchi and an occasional expiratory wheeze. Joe is alert and oriented times three, color is pale. Capillary refill fingers and toes is >3 seconds and sluggish. He states SOB. According to the assessment I will administer at least 2 litter of oxygen by NC, and by monitoring his pulse oximeter I will know if his respiratory status is improving or declining. Also, I will watching his breathing pattern and if he uses his accessory muscle and what position his in for breathing. All this will help me to evaluate and access his condition. 7. Discuss color of your patient regarding an improvement or a decline in their condition? Describe their nail beds and capillary refill. How do you assess for clubbing? If the patient has improvement in his condition, the skin color will become more pink, warm. With declining of his condition, his skin may become cyanotic or bluetinged, dusky, cold to touch. Clubbing of the fingers and toes is caused by chronic oxygen deprivation in the body tissue. It is common in patient with advanced chronic pulmonary disease and congenital heart defect. By looking on the angel of nail bed I can assess for clubbing. The normal nail bed is 160degrees.With clubbing, the nail straightens out to the angle of 180 degrees and the base of the nail becomes spongy.

8. Joe’s AP differs from his radial pulse, what do we call this and why might this be happening? It is called apical-radial deficit. The presence of a pulse deficit indicates that there may be an issue with cardiac function or efficiency. When a pulse deficit is detected, it means that the volume of blood pumped from the heart may not be sufficient to meet the needs of your body's tissues. 9. Are we concerned about Joe’s blood pressure? Yes or no and why? Explain your answer. Yes, Joe’s BP is on the lower end. He has a history of CHF and recently diagnose with cardiomyopathy meaning that systolic function is impaired. According to the signs and symptoms he already got decreased CO from inadequate pumping of the heart to the rest of the body organs that we should be concern all the time. 10. Why does Joe have pitting edema in the lower extremities? Why is it potentially worse on the right leg? Joe has a history of congestive heart failure and cardiomyopathy. Pitting edema is a common finding in patients with cardiovascular problem. The problem can be the result of venous obstruction or lymphatic blockage, HF. 11. Based on the above information in question 10, should Joe be assessed for a DVT? What diagnostic test would provide a definitive diagnosis for DVT? Where can a DVT travel and what are potential ramifications? Explain your answers. Yes, the pitting edema on the right leg can be a result of venous obstruction or thrombosis and needs to be diagnosed further to rule out it or catch it earlier. Venous thrombosis can lead to pulmonary embolism which is a life-threatening complication. The preferred diagnostic test for DVT is venous duplex ultrasonography, addition to the US a d-dimer test can be performed to diagnose DVT. 12. Joe presents alert and oriented times three. What if Joe becomes drowsy, or somnolent and more difficult to arouse? What might we attribute this to and what will we do about it? If blood gases were drawn on Joe, what information might they provide? ABG values often reveals hypoxemia -low blood oxygen level (low Pao2 and high PCO2). Joe’s lungs sound positive for crackles and wheezes which indicate presents of fluids in the lungs. Therefore, there is not adequate gas exchange going on, because oxygen does not diffuse easily though fluid filled alveoli. The low oxygen leads to respiratory acidosis that can cause drowsiness, dizziness, disorientation. Usually, we treat respiratory acidosis with oxygen therapy, drug therapy and pulmonary hygiene. 13. Explain the relationship between central perfusion and cognition.

Perfusion depends on how much oxygen from arterial blood perfuses to tissue. Some areas can adjust to changes in perfusion such as skin or skeletal muscles; other organ does not tolerate hypoxia (low levels of tissue oxygen) like the CNS, heart, and kidneys. Reduced cerebral perfusion associated with poorer cognition and LOC. With low perfusion we should assess the patient’s level of consciousness and orientation, which are sensitive to cerebral hypoxia. In the initial and nonprogressive stages of hypoxia, patient may be restless or agitated and be anxious. As hypoxia progress or perfusion decreases, confusion and lethargy can occur. 14. Joe presents with scattered rales and rhonchi and expiratory wheezing on auscultation. What diagnostic test should Joe have? The crackles and wheezes may indicate left side heart failure or pulmonary edema. Joe should have an echocardiography and/or CXR and d-dimer test for PE. 15. Joe came in with chest pain, which could be indicative of an MI. What noninvasive procedure and blood tests should be done immediately to rule out an MI? ECG and troponin test, CK(creatine kinase). 16. Describe the appearance of Joe’s lower extremities and what they might look like. Joe’s low extremities are clammy and moist with pitting 2+ edema bilaterally with right leg more swollen. They may look tighten, puffy and shiny, and be cool to touch. 17. What medications may be ordered immediately for Joe and why? Milrinone. it is indicated for the short-term (48 hours or less) treatment of patients with acute decompensated heart failure. Diuretics. They are the first line drug of choice in older adults with HF and fluid overload. ACE inhibitors or ARB they suppress the renin-angiotensin system that resulting in atrial dilation and increase stroke volume. Also, these drugs block aldosterone which prevents sodium and water retention, thus decreasing fluid overload. 18. We talk about collaboration of care. What department may be called to Joe’s bedside upon arrival to the ER and why? How might they assist the nurse? Cardiologist or cardio team to assess the patient’s circulatory status, respiratory therapist to address respiratory issues, nephrologist to assess renal function and possible complications, ultrasound technician to perform echocardiography, phlebotomist to start and draw blood for tests, radiologist to perform needed tests. Collaborate with interprofessional team will help the nurse individualize care based on the patient’s needs, clinical experiences of interprofessional team.

19. How will we evaluate Joe’s elimination status? What nursing interventions will we perform? What blood work will be drawn and why? Why are we concerned with Joe’s fluid and electrolyte status at this time? Why is this a priority? Joe’s elimination status should be evaluated my measuring I&O. One of the nursing interventions would be a bladder scanning as well as the insertion of Foley catheter if the patient has problem with elimination. Also control the weight gain to monitor for fluid retention. Yes, we are concerned about Joe’s fluid and electrolyte status, because electrolyte imbalance may occur from complication of HF or a side effect of drug therapy, specialty diuretic therapy. Either way it can greatly affect the patients’ condition if not be fixed. The blood work for serum creatinine level should be draw because it is a good indicator of kidney function and BUN / creatine ratio indicate fluid overload with decreased ration or fluid excess with increased ration, BNP. 20. How often will we check Joe’s vital signs and why? How often would we perform a focused assessment on him and why? What are some early red flags that would indicate a deterioration in his condition is imminent? Mr. Jenkins VS should be monitoring every 1 to 4 hours. Auscultate breath sound every 4hours. After any nursing interventions we should perform a focused assessment to ensure that there is a change in patient condition. The red flags would be changes in his VS, chest pains that’s not relief with meds, frothy, pink-tinged sputum. Decreased LOC, cough, changes in ECG. 21. Based on Joe’s history and presentation, do you think he is experiencing Acute Decompensated Heart Failure? Why? Based on his past medical history and presentation I would assume that he is experiencing an exacerbation of congestive heart failure which is acute decompensated heart failure. The cardinal manifestations of ADHF are dyspnea, fluid retention, and fatigue. Fluid retention, commonly leads to pulmonary congestion and peripheral edema, increasing dyspnea on exertion or at rest. All these symptoms were experienced by Mr. Jenkins. Success! Your submission appears on this page. The submission confirmation number is dcffc2ee-21f0-4adc-bef8-e3ecb30eb1b9. Copy and save this number as proof of your submission. View all of your submission receipts in My Grade...