Copyright 2010 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. CLINICAL DECISION MAKING Case Studies in Medical-Surgical Nursing SECOND EDITION This page intentionally left blank CLINICAL DECISION MAKING Case Studies in Medical-Surgical Nursing SECOND EDITION Gina M. Ankner RN, MSN, ANP-BC Revisions and New Cases Contributed by Patricia M. Ahlschlager RN, BSN, MSEd and Tammy J. Hale RN, BSN Australia • Brazil • Japan • Korea • Mexico • Singapore • Spain • United Kingdom • United States This is an electronic version of the print textbook. 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Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Contents Reviewers . . . . . . . . . . . . . . . . . . . . . . . vii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . viii Comprehensive Table of Variables . . . . . . . . . . . . . . . . . . . . . . xii Part 1 The Cardiovascular System & the Blood . . . . . . . . . . . . . . . . . . . . . . . . . 1 Needle Stick Bethany Deep Vein Thrombosis Mr. Luke Digoxin Toxicity Mrs. Kidway Pernicious Anemia Mrs. Andersson HIV Mr. Thomas Rule out Myocardial Infarction Mrs. Darsana Heart Failure Mrs. Yates Sickle Cell Anemia Ms. Fox Cardiac Catheterization Mrs. O’Grady Part 2 The Respiratory System . . . . . . . . . . 25 Asthma Mrs. Hogan ABG Analysis William COPD Mr. Cohen Sleep Apnea Mr. Kaberry Part 3 27 29 31 35 The Nervous/Neurological System . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Bell’s Palsy Mrs. Seaborn Transient Ischemic Attack Mrs. Giammo Delirium versus Dementia Mr. Aponi Acute Change in Mental Status Mrs. Greene Alcohol Withdrawal Mrs. Perry ALS Mr. Cooper Part 4 3 5 7 9 11 13 17 21 23 39 41 45 47 49 51 The Sensory System . . . . . . . . . . . . . 55 Glaucoma 57 Mr. Evans v vi C ONTENT S Part 5 The Integumentary System . . . . . . . 59 Urinary Incontinence Mrs. Sweeney Herpes Zoster Mr. Dennis MRSA Mrs. Sims Melanoma Mr. Vincent Stevens Johnson Syndrome Mr. Lee Part 6 The Digestive System . . . . . . . . . . . . 73 Diverticulitis Mrs. Dolan (Part 1) Diverticulitis Mrs. Dolan (Part 2) Upper GI Bleed Ms. Winnie Crohn’s Disease Mr. Cummings Malabsorption Syndrome Mrs. Bennett Part 7 117 121 The Reproductive System . . . . . . . 123 Breast Cancer Part 12 109 111 113 The Muscular System . . . . . . . . . . . 115 Patient Fall Mr. O’Brien Fibromyalgia Mrs. Roberts Part 11 101 103 105 The Skeletal System . . . . . . . . . . . . 107 Leg Amputation Mr. Mendes Hip Fracture/Replacement Mrs. Damerae Osteomyelitis Mr. Lourde Part 10 91 93 97 The Endocrine/Metabolic System . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Acute Gout versus Cellulitis Mr. Rogers Hyperglycemia Mr. Jenaro Acute Pancreatitis Mrs. Miller Part 9 75 77 79 83 85 The Urinary System . . . . . . . . . . . . . . 89 Renal Calculi Mrs. Condiff Acute Renal Failure Ms. Jimenez (Part 1) Acute Renal Failure Ms. Jimenez (Part 2) Part 8 61 63 65 67 71 Mrs. Whitney 125 Multi-System Failure . . . . . . . . . . . . 127 Septic Shock Mrs. Bagent 129 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Reviewers Dee Adkins, MSN, RN Harrison College Indianapolis Indiana Patricia N. Allen, MSN, APRN-BC Clinical Assistant Professor Indiana University School of Nursing Bloomington, Indiana Bonita E. Broyles, RN, BSN, PhD Associate Degree Nursing Faculty Piedmont Community College Roxboro, North Carolina Joyce Campbell, MSN, APRN, BC, CCRN Associate Professor Chattanooga State Community College Chattanooga, Tennessee Fran Cherkis, MS, RN, CNE Farmingdale State College Farmingdale, New York Marianne Curia, MSN, RN Assistant Professor University of St. Francis Joliet, Illinois Karen K. Gerbasich, RN, MSN Faculty Assistant Professor Ivy Tech Community College South Bend, Indiana Amanda M. Reynolds, MSN Associate Professor Grambling State University Grambling, Louisiana vii Preface Delmar’s Case Study Series was created to encourage nurses to bridge the gap between content knowledge and clinical application. The products within the series represent the most innovative and comprehensive approach to nursing case studies ever developed. Each title has been authored by experienced nurse educators and clinicians who understand the complexity of nursing practice, as well as the challenges of teaching and learning. All the cases are based on reallife clinical scenarios and demand thought and “action” from the nurse. Each case brings the user into the clinical setting and invites the user to employ the nursing process while considering all the variables that influence the client’s condition and the care to be provided. Each case also represents a unique set of variables, to offer a breadth of learning experiences and to capture the reality of nursing practice. In order to gauge the progression of a user’s knowledge and critical thinking ability, the cases have been categorized by difficulty level. Every section begins with basic cases and proceeds to more advanced scenarios, thereby presenting opportunities for learning and practice for both students and professionals. All the cases have been reviewed by experts to ensure that as many variables as possible are represented in a truly realistic manner and that each case reflects consistency with realities of modern nursing practice. Praise for Delmar’s Case Study Series “[This text’s] strength is the large variety of case studies—it seemed to be all inclusive. Another strength is the extensiveness built into each case study. You can almost see this person as they enter the ED because of the descriptions that are given.” —Mary Beth Kiefner, RN, MS, Nursing Program Director/Nursing Faculty, Illinois Central College “The cases . . . reflect the complexity of nursing practice. They are an excellent way to refine critical-thinking skills.” —Darla R. Ura, MA, RN, APRN, BC, Clinical Associate Professor, Adult and Elder Health Department, School of Nursing, Emory University “The case studies are very comprehensive and allow the undergraduate student an opportunity to apply knowledge gained in the classroom to a potentially real clinical situation.” —Tamella Livengood, APRN, BC, MSN, FNP, Nursing Faculty, Northwestern Michigan College “These cases and how you have approached them definitely stimulate the students to use critical-thinking skills. I thought the questions asked really pushed the students to think deeply and thoroughly.” —Joanne Solchany, PhD, ARNP, RN, CS, Assistant Professor, Family & Child Nursing, University of Washington, Seattle viii P R E FAC E “The use of case studies is pedagogically sound and very appealing to students and instructors. I think that some instructors avoid them because of the challenge of case development. You have provided the material for them.” —Nancy L. Oldenburg, RN, MS, CPNP, Clinical Instructor, Northern Illinois University “[The author] has done an excellent job of assisting students to engage in critical thinking. I am very impressed with the cases, questions, and content. I rarely ask that students buy more than one . . . book . . . but, in this instance, I can’t wait until this book is published.” —Deborah J. Persell, MSN, RN, CPNP, Assistant Professor, Arkansas State University “This is a groundbreaking book. . . . This book should be a required text for all undergraduate and graduate nursing programs and should be well-received by faculty.” —Jane H. Barnsteiner, PhD, RN, FAAN, Professor of Pediatric Nursing, University of Pennsylvania School of Nursing How to Use This Book Every case begins with a table of variables that is encountered in practice, and that must be understood by the nurse in order to provide appropriate care to the client. Categories of variables include gender, age, setting, ethnicity, cultural considerations, preexisting conditions, coexisting conditions, communication considerations, disability considerations, socioeconomic considerations, spiritual/ religious considerations, pharmacologic considerations, legal considerations, ethical considerations, alternative therapy, prioritization considerations, and delegation considerations. If a case involves a variable that is considered to have a significant impact on care, the specific variable is included in the table. This allows the user an “at a glance” view of the issues that will need to be considered to provide care to the client in the scenario. The table of variables is followed by a presentation of the case, including the history of the client, current condition, clinical setting, and professionals involved. A series of questions follows each case that require the user to consider how she or he would handle the issues presented within the scenario. Suggested answers and rationales are provided in the accompanying Instructor’s Manual for remediation and discussion. Organization Cases are grouped according to body system and are reorganized in this edition for a head-to-toe approach. Within each part, cases are organized by difficulty level from easy, to moderate, to difficult. This classification is somewhat subjective, but it is based upon a developed standard. In general, the difficulty level has been determined by the number of variables that affect the case and the complexity of the client’s condition. Colored tabs are used to allow the user to distinguish the difficulty levels more easily. A comprehensive table of variables is also provided for reference to allow the user to quickly select cases containing a particular variable of care. While every effort has been made to group cases into the most applicable body system, the scope of many of the cases may include more than one body system. In such instances, the case will still only appear in the section for one of the body systems addressed. The cases are fictitious; however, they are based on actual problems and/or situations the nurse will encounter. ix x PR EFACE Features • Reflecting real-world practice, the cases are designed to help the user sharpen critical thinking skills and gain hands-on experience applying what the user has learned. • Providing comprehensive coverage, 43 detailed case studies cover a wide range of topics. • Case studies progress by difficulty level, from easy to moderate to difficult, which can be identified by colored tabs. • Written by nurses with modern clinical experience, these cutting-edge cases are relevant to the real-world challenges and pressures of practice—offering insight into the realities of today’s profession. • Cases include a wide assortment of variables related to client diversity, prioritization, and legal and ethical considerations. New to This Edition • Cases are completely updated, reflecting the latest practices in the field. • Four new case studies cover Bell’s Palsy, Glaucoma, Renal Calculi, and Septic Shock. • Body systems have been reorganized to follow a head-to-toe approach. • Nursing diagnoses are updated to reflect NANDA International’s Nursing Diagnoses: Definitions and Classifications 2009–2011. Also Available Instructor’s Manual to Accompany Clinical Decision Making: Case Studies in MedicalSurgical Nursing, Second Edition, by Gina M. Ankner ISBN-10: 1-111-13858-3 ISBN-13: 978-1-111-13858-5 This instructor’s manual provides suggested answers and rationales, with references, to each of the case studies in this book. Instructors can use this to evaluate and assess student responses to cases, or as a discussion tool in the classroom. Clinical Decision Making: Online Case Studies in Medical-Surgical Nursing, Second Edition A convenient way for you to use these popular case studies online, please visit www. cengagebrain.com for more information on this resource. Delmar’s Case Study Series: Medical-Surgical Nursing, Second Edition, by Gina M. Ankner ISBN-10: 1-111-13859-1 ISBN-13: 978-1-111-13859-2 Following the same general case study model, this resource provides an additional 22 case studies based on real-life clinical scenarios that demand critical thinking from the nurse. Suggested answers and rationales are provided immediately following each case to support remediation, review, and discussion. Acknowledgments Special thanks go to Patricia M. Ahlschlager and Tammy J. Hale for their hard work revising and updating these cases and contributing the new case studies. Thank you to the publishing team at Delmar Cengage Learning: Steven Helba, P R E FAC E Juliet Steiner, Jennifer Wheaton, Jack Pendleton, and Jim Zayicek. Many thanks to those individuals who willingly shared their personal stories so that future nurses could learn from them. The input from students, friends, and family was invaluable, especially the generosity of Kimberly Dodd, MD, and Kathleen Elliott, ANP, BC, whose contributions and support exemplify friendship and professional collaboration. With great appreciation, I wish to acknowledge the reviewers for the constructive comments and suggestions that helped to enhance the educational value of each case. About the Author Gina Ankner, RN, MSN, ANP-BC, is senior nurse coordinator and program director for the Specialty Care in Pregnancy Program (SCIPP) in the Department of Medicine at Women & Infants Hospital of Rhode Island. The only program of its kind in the United States, SCIPP brings a multidisciplinary team together to consult on cases of women whose pregnancy, or plan for pregnancy, is complicated by a medical condition. She is also responsible for outreach and new program development for the Department of Medicine. Prior to her current position at Women & Infants Hospital, she taught medical-surgical nursing for ten years at the University of Massachusetts Dartmouth College of Nursing. Ankner earned her bachelor’s and master’s degrees in nursing from Boston College. Note from the Author My students were the inspiration for this book. With rare exception, each case study is based on a client that a student cared for. Through the student’s eyes, I share stories of men and women who have turned to their nurses for care and support during their illness. Perhaps when reading a scenario, you will think, “It would not happen like that.” Please know that it did and that it will. The most enjoyable part of writing each case was the realization that another nursing student will learn from the experience of a peer. The intent was not only to provide the more common patient scenarios, but also to present actual cases that encourage critical thinking and prompt a student to ask “what if ?” The wonderful thing about a case study is that possibilities for learning abound! These cases provide a foundation upon which endless knowledge can be built. So be creative—change a client’s gender, age, or ethnicity, pose new questions, but, most importantly, enjoy the journey of becoming a better nurse. The author welcomes comments via e-mail at MedSurgCases@yahoo.com. xi X X X DELEGATION X PRIORITIZATION X ALTERNATIVE THERAPY X ETHICAL LEGAL X SPIRITUALITY PHARMACOLOGIC SOCIOECONOMIC STATUS DISABILITY COMMUNICATION COEXISTING CONDITIONS PREEXISTING CONDITIONS CULTURE ETHNICITY SETTING AGE GENDER CASE STUDY Comprehensive Table of Variables Part One: The Cardiovascular System & the Blood 1 F 20 Hospital Asian American 2 M 58 Rehabilitation unit Asian American 3 F 71 Hospital Russian 4 F 88 Primary care White American 5 M 42 Hospital White American 6 F 67 Hospital Black American X X 7 F 70 Home Black American X X X X 8 F 20 Hospital Black American X X X X 9 F 55 Hospital White American X X X X X X X X X X X X X X X X X X X X X X X X Part Two: The Respiratory System 1 F 38 Walk-in White American 2 M 25 Hospital Black American 3 M 75 Hospital Jewish American 4 M 67 Primary care White American X X X X X X X X X X X X X X X Part Three: The Nervous/Neurological System 1 F 43 Emergency department White American 2 F 59 Hospital Black American 3 M 85 Long-term care Native American 4 F 92 Hospital White American 5 F 35 Hospital White American 6 M 73 Home X X X X X X X X X X X X X X X X X X X White American X X X X X X X X X X X X X X Part Four: The Sensory System 1 M 73 Outpatient clinic Black American X X X X X X X X Part Five: The Integumentary System 1 F 70 Home White American 2 M 57 Hospital White American 3 F 72 Hospital White American 4 M 32 Primary care White American 5 M 55 Hospital Black American xii X X X X X X X X X X X X X X X X X X X X X X PRIORITIZATION DELEGATION ALTERNATIVE THERAPY ETHICAL LEGAL PHARMACOLOGIC SPIRITUALITY SOCIOECONOMIC STATUS DISABILITY COMMUNICATION COEXISTING CONDITIONS PREEXISTING CONDITIONS CULTURE ETHNICITY SETTING AGE GENDER CASE STUDY COMPREH ENSIVE TA BL E OF VAR IAB LE S X X Part Six: The Digestive System 1 F 46 Hospital White American X X 2 F 46 Hospital White American X X X X 3 F 33 Hospital White American X X X X 4 M 44 Hospital White American X X 5 F White American X X 63 Hospital X X X X X X X X X Part Seven: The Urinary System 1 F 35 Hospital Native American X X X 2 F 56 Hospital Hispanic X X X X X X X 3 F 56 Hospital Hispanic X X X X X X Part Eight: The Endocrine/Metabolic System 1 M 91 Long-term care White American 2 M 61 Hospital Mexican American 3 F White American 88 Hospital X X X X X X X X X X X X X X X X X X X Part Nine: The Skeletal System 1 M 81 Hospital Portuguese X X X 2 F 77 Hospital Black American X X X 3 M 73 Hospital White American X X X X X X X X X Part Ten: The Muscular System 1 M 81 Hospital White American X 2 F White American X 48 Primary care X X X X X X X X X X Part Eleven: The Reproductive System 1 F 45 Hospital Black American X X X White American X X X Part Twelve: Multi-System Failure 1 F 74 Intensive care unit X X xiii ONE © Getty Images/Photodisc PART The Cardiovascular System & the Blood This page intentionally left blank CASE STUDY 1 Bethany GENDER SPIRITUAL/RELIGIOUS Female PHARMACOLOGIC AGE (Epivir); didanosine (Videx); indinavir sulfate (Crixivan) SETTING ■ Hospital LEGAL ■ Blood-borne pathogen exposure; ETHNICITY incident (occurrence or variance) report ■ Asian American ETHICAL CULTURAL CONSIDERATIONS ALTERNATIVE THERAPY PREEXISTING CONDITION PRIORITIZATION COEXISTING CONDITION ■ Immediate assessment of injury is necessary COMMUNICATION DELEGATION DISABILITY SOCIOECONOMIC ■ Cost of needle stick injury testing, treatment, and follow-up THE CARDIOVASCULAR SYSTEM & THE BLOOD Level of difficulty: Easy Overview: This case requires that the student nurse recognize the appropriate interventions following a needle stick injury. Her risk of blood-borne pathogen exposure is considered. Testing, treatment, suggested follow-up, and the cost associated are discussed. An incident (occurrence or variance) report is completed. 3 EASY ■ Zidovudine (Retrovir); lamivudine 20 4 Part 1 ■ T H E CARDI OVASCU LAR SYSTEM & TH E BLOOD Client Profile Bethany is a 20-year-old nursing student. Although she has practiced the intramuscular injection technique in the nursing laboratory, she is nervous about giving her first intramuscular injection to a “real” client. Case Study Bethany has reviewed the procedure and the selected intramuscular site landmark technique. She follows all the proper steps, including donning gloves. The syringe was equipped with a safety device to cover the needle after injection, but after giving the injection, before the instructor can stop her, Bethany attempts to recap the needle and sticks herself with the needle through her glove. She is embarrassed to say anything in front of the client so she removes her gloves and washes her hands. Once outside the client’s room, Bethany shows the nursing instructor her finger. There is blood visible on her finger where she stuck herself. Questions 1. What should Bethany do first? 2. Discuss the appropriate interventions that the clinical agency should initiate following Bethany’s needle stick injury. 3. What is the recommended drug therapy based on the level of risk of HIV exposure? 4. Which form(s) of hepatitis is Bethany most at risk for contracting? Discuss her level of risk of the form(s) of hepatitis you identified, as well as the risk of infection with HIV resulting from this needle stick. 5. Can the client’s blood be tested for communicable diseases if the client does not give consent? 6. What will be the recommendations for Bethany’s follow-up antibody testing? 7. HIV test results are reported as positive, negative, or indeterminate. What does each result mean? 8. What is an incident (occurrence or variance) report, and why should Bethany and her nursing instructor complete one? 9. Discuss how Bethany could have prevented this needle stick injury. 10. Bethany’s nursing instructor decides to share information with the nursing students about OSHA’s Needlestick Safety and Prevention Act. Explain OSHA’s role and the safety and prevention act. 11. Discuss who is most likely responsible for the expense of Bethany’s care immediately following the needle stick and any follow-up care. What risks are presented if the expense is prohibitive? 12. Identify three potential nursing diagnoses appropriate for Bethany. CASE STUDY 2 Mr. Luke GENDER SOCIOECONOMIC Male ■ Smokes one pack of cigarettes per day AGE 58 PHARMACOLOGIC SETTING ■ Enoxaparin (Lovenox); dalteparin ■ Outpatient rehabilitation unit sodium (Fragmin); warfarin sodium (Coumadin); nicotine transdermal system (Nicoderm CQ); acetylsalicylic acid (aspirin, ASA); dextran (Macrodex, Gentran) ETHNICITY ■ Asian American CULTURAL CONSIDERATIONS LEGAL PREEXISTING CONDITION ETHICAL ■ Left total knee replacement (TKR) five days ago ALTERNATIVE THERAPY COEXISTING CONDITION PRIORITIZATION COMMUNICATION ■ Prevention of pulmonary embolism (PE) DELEGATION DISABILITY THE CARDIOVASCULAR SYSTEM & THE BLOOD Level of difficulty: Easy Overview: This case requires the nurse to recognize the symptoms of a deep vein thrombosis (DVT), understand the diagnostic tests used to confirm this diagnosis, and discuss the rationale for a treatment plan. Nursing diagnoses to include in the client’s plan of care are prioritized. 5 EASY SPIRITUAL/RELIGIOUS 6 Part 1 ■ T H E CARDI OVASCU LAR SYSTEM & TH E BLOOD Client Profile Mr. Luke is a 58-year-old man who is currently a client on an outpatient rehabilitation unit following a left total knee replacement (TKR) five days ago. This afternoon during physical therapy he complained that his left leg was unusually painful when walking. His left leg was noted to have increased swelling from the prior day. He was sent to the emergency department to be examined. Case Study Mr. Luke’s vital signs are temperature 98.1°F (36.7°C), blood pressure 110/50, pulse 65, and respiratory rate of 19. His oxygen saturation is 98% on room air. The result of a serum D-dimer is 7 μg/mL. Physical exam reveals that his left calf circumference measurement is ¾ of an inch larger than his right leg calf circumference. Mr. Luke’s left calf is warmer to the touch than his right. He will have a noninvasive compression/doppler flow study (doppler ultrasound) to rule out a DVT in his left leg. Questions 1. The health care provider in the emergency department chooses not to assess Mr. Luke for a positive Homan’s sign. What is a Homan’s sign and why did the health care provider defer this assessment? 2. Discuss the diagnostic cues gathered during Mr. Luke’s examination in the emergency department that indicate a possible DVT. 3. Discuss Virchow’s triad and the physiological development of a DVT. 4. The nurse who cared for Mr. Luke immediately following his knee surgery, when writing the postoperative plan of care, included appropriate interventions to help prevent venous thromboembolism. Discuss five nonpharmacological interventions the nurse included in the plan. 5. Discuss the common pharmacologic therapy options for postsurgical clients to help reduce the risk of a DVT. 6. Mr. Luke’s noninvasive compression/doppler flow study (doppler ultrasound) shows a small thrombus located below the popliteal vein of his left leg. While a positive DVT is always of concern, why is the health care provider relieved that the thrombus is located there and not in the popliteal vein? 7. Mr. Luke was admitted to the hospital for observation overnight. He is being discharged back to the rehabilitation unit with the following prescribed discharge instructions: (a) bed rest with bathroom privileges (BRP) with elevation of left leg for 72 hours; (b) thromboembolic devices (TEDs); (c) continue with enoxaparin 75 mg subcutaneously (SQ) every 12 hours; (d) warfarin sodium 5 mg by mouth (PO) per day starting tomorrow; (e) nicotine transdermal system 21 mg per day for 6 weeks, then 14 mg per day for 2 weeks, and then 7 mg per day for 2 weeks; (f) acetylsalicylic acid 325 mg PO once daily; (g) prothrombin time (PT) and international normalized ratio (INR) daily; (h) occult blood (OB) test of stools; (i) have vitamin K available; and (j) vital signs every four hours. Provide a rationale for each of the prescribed discharge instructions. 9. Prioritize five nursing diagnoses to include in Mr. Luke’s plan of care when he returns to the rehabilitation unit. 10. What is an inferior vena cava (IVC) filter and for which clients is this filter indicated? 11. Discuss the symptoms the nurse at the rehabilitation center should watch for that could indicate that Mr. Luke has developed a pulmonary embolism (PE). 12. Because of the DVT, Mr. Luke is at risk for postphlebitic syndrome (also called post-thrombotic syndrome or PTS). Discuss the incidence, cause, symptoms, and prevention of this potential long-term complication. CASE STUDY 3 Mrs. Kidway GENDER DISABILITY Female SOCIOECONOMIC AGE SPIRITUAL/RELIGIOUS SETTING ■ Hospital PHARMACOLOGIC ETHNICITY ■ Digoxin (Lanoxin); potassium chloride (KCl); atropine sulfate (Atropine); digoxin immune fab (Digibind) ■ Russian CULTURAL CONSIDERATIONS LEGAL PREEXISTING CONDITIONS ■ Heart failure (HF, CHF); pneumonia; ETHICAL chronic obstructive pulmonary disease (COPD); gastroesophageal reflux disease (GERD) ALTERNATIVE THERAPY ■ Licorice (glycyrrhiza, licorice root) COEXISTING CONDITION PRIORITIZATION COMMUNICATION ■ Russian speaking only; daughter DELEGATION speaks English THE CARDIOVASCULAR SYSTEM & THE BLOOD Level of difficulty: Easy Overview: This case requires that the nurse be knowledgeable regarding the action and pharmacokinetics of digoxin. The nurse must recognize the symptoms of digoxin toxicity and discuss appropriate treatment. The interaction between digoxin and an herbal remedy is considered. Priority nursing diagnoses for this client are identified. 7 EASY ■ Lives with daughter’s family 71 8 Part 1 ■ T H E CARDI OVASCU LAR SYSTEM & TH E BLOOD Client Profile Mrs. Kidway is a 71-year-old woman who lives at home with her daughter’s family. Her daily medications prior to admission include digoxin 0.125 mg once a day. Case Study Mrs. Kidway arrives in the emergency room with her daughter who explains, “She was fine this morning but then this afternoon she developed terrible abdominal pain and got short of breath.” Mrs. Kidway is lethargic. Her physical examination is unremarkable except for facial grimacing when palpating her abdomen. She is afebrile with a blood pressure of 105/50, pulse 60, and respiratory rate 18. Blood work on admission reveals a digoxin level of 3.8 ng/mL. Questions 1. How does digoxin work in the body? 2. Why is Mrs. Kidway taking digoxin? 3. Given Mrs. Kidway’s digoxin level, briefly explain what electrolyte imbalance is of concern. 4. During a nursing assessment of Mrs. Kidway’s current medications, the nurse asks if Mrs. Kidway takes any over-the-counter medications or herbal remedies. Mrs. Kidway’s daughter says, “Is licorice considered an herbal remedy? My mother started taking licorice capsules about a month ago because we heard that licorice helps decrease heartburn.” Does licorice interact with digoxin? If so, explain. 5. Discuss what the terms loading dose and steady state indicate. 6. What are the onset, peak, and duration times of digoxin when it is taken orally? 7. If Mrs. Kidway was having difficulty swallowing her digoxin capsule and her health care provider changed her prescription to the elixir form of digoxin, theoretically would she still receive 0.125 mg? 8. What is a medication’s “half-life”? What is the half-life of digoxin? Theoretically, if Mrs. Kidway took her digoxin at 8:00 a.m. on a Monday, when will 75% of the digoxin be cleared from her body according to the half-life? Since the half-life of digoxin is prolonged in the elderly, use the high end of the range of digoxin’s half-life. 9. What is the normal therapeutic range of serum digoxin for a client taking this medication? 10. What symptoms may be noted when digoxin levels are at toxic levels? 11. At what serum digoxin range do cardiac dysrhythmias appear and what is the critical value for adults? 12. Mrs. Kidway’s heart rate drops to 50 beats per minute. Her potassium is 2.1 mEq/L. She is given four vials of intravenous digoxin immune fab (reconstituted with sterile water) and admitted to the intensive care unit for monitoring. Discuss how her digoxin toxicity will be treated. 13. What are the two highest priority nursing diagnoses appropriate for Mrs. Kidway’s plan of care? CASE STUDY 4 Mrs. Andersson GENDER SOCIOECONOMIC Female SPIRITUAL/RELIGIOUS AGE PHARMACOLOGIC SETTING ■ Cyanocobalamin (oral vitamin B ); 12 ■ Primary care cyanocobalamin crystalline (injectable vitamin B12); cyanocobalamin nasal gel (Nascobal); hydrochloric acid (HCI) ETHNICITY ■ White American LEGAL CULTURAL CONSIDERATIONS ■ Swedish; increased risk of pernicious ETHICAL anemia PREEXISTING CONDITIONS ALTERNATIVE THERAPY ■ Small bowel obstruction (SBO) with subsequent bowel resection; diverticulitis PRIORITIZATION ■ Client safety COEXISTING CONDITION DELEGATION COMMUNICATION DISABILITY THE CARDIOVASCULAR SYSTEM & THE BLOOD Level of difficulty: Easy Overview: This case requires the nurse to identify causes of vitamin B12 deficiency, define pernicious anemia, and discuss elements of treatment. Client education is provided regarding preventing injury when experiencing parathesias or peripheral neuropathy. 9 EASY 88 10 Part 1 ■ T H E CARDI OVASCU LA R SYSTEM & TH E BLOOD Client Profile Mrs. Andersson was diagnosed with pernicious anemia at the age of 70. She has monthly appointments with her primary health care provider for treatment with vitamin B12 injections. Case Study At the age of 70, Mrs. Andersson was exhibiting weakness, fatigue, and an unexplained weight loss. A complete blood count (CBC) was done as part of her diagnostic workup. The CBC revealed red blood cell count (RBC) 3.20 million/mm3, mean corpuscular volume (MCV) 130 μL, reticulocytes 0.4%, hematocrit (Hct) 25%, and hemoglobin (Hgb) 7.9 g/dL. Suspecting pernicious anemia, the health care provider prescribed a Shilling test. Mrs. Andersson was diagnosed with pernicious anemia and started on vitamin B12 injections. Questions 1. Briefly describe the pathophysiology of pernicious anemia. 2. Identify possible causes of vitamin B12 deficiency. 3. Identify the possible manifestations of pernicious anemia. 4. Identify the physical assessment findings that are characteristic of pernicious anemia. 5. What are the expected results of a complete blood count (CBC) and serum vitamin B12 level in a female client with pernicious anemia? 6. How does Mrs. Andersson’s ethnicity relate to pernicious anemia? 7. To help make a definitive diagnosis of pernicious anemia, a Schilling test may be performed. Describe the Schilling test. 8. Mrs. Andersson understands that including foods high in vitamin B12 in her diet is helpful in preventing vitamin B12 deficiency. Identify five foods rich in vitamin B12. 9. Discuss the standard dosing and desired effects of the vitamin B12 injections for the client with vitamin B12 deficiency. 10. When can Mrs. Andersson discontinue the vitamin B12 injections? 11. The nurse administers Mrs. Andersson’s vitamin B12 injections using the z-track injection method. Discuss why the nurse used this method and the steps of this injection technique. 12. Discuss other possible medications or supplements that may be indicated for the treatment of pernicious anemia. 13. During a routine visit, Mrs. Andersson tells the nurse that she has noticed a decreased sensation in her fingers. “I can pick up a cup, but I can’t really feel the cup in my hand. It is a tingling sensation of sorts.” What teaching should the nurse initiate to promote Mrs. Andersson’s safety at home? CASE STUDY 5 Mr. Thomas GENDER SOCIOECONOMIC Male ■ Married for seventeen years; two children (ages 14 and 11 years old); primary income provider for family AGE 42 SPIRITUAL/RELIGIOUS SETTING ■ Hospital PHARMACOLOGIC ETHNICITY LEGAL ■ White American ■ Infectious disease; client CULTURAL CONSIDERATIONS confidentiality; partner notification ETHICAL PREEXISTING CONDITIONS ■ Partner notification of exposure ■ Pneumonia last year; unexplained to HIV fifteen-pound weight loss over past six months ALTERNATIVE THERAPY PRIORITIZATION ■ Thrush; pneumonia; human immunodeficiency virus (HIV) DELEGATION COMMUNICATION DISABILITY ■ Potential disability resulting from chronic illness THE CARDIOVASCULAR SYSTEM & THE BLOOD Level of difficulty: Moderate Overview: The nurse in this case is caring for a client who has recently learned that he is positive for the human immunodeficiency virus (HIV). Laboratory testing to monitor the progression of HIV is reviewed. The ethical and legal concerns regarding the client’s decision not to disclose his HIV status to his wife or others are discussed. 11 M O D E R AT E COEXISTING CONDITIONS 12 Part 1 ■ T H E CARDI OVASCU LA R SYSTEM & TH E BLOOD Client Profile Mr. Thomas is a 42-year-old man admitted to the hospital with complaints of shortness of breath, fever, fatigue, and oral thrush. The health care provider reviews the laboratory and diagnostic tests with Mr. Thomas and informs him that he has pneumonia and is HIV positive. Mr. Thomas believes that he contracted HIV while involved in an affair with another woman three years ago. He is afraid to tell his wife, knowing she will be angry and that she may leave him. Case Study The nurse assigned to care for Mr. Thomas reads in the medical record (chart) that he learned two days ago that he is HIV positive. There is a note in the record that indicates that Mr. Thomas has not told his wife the diagnosis. To complete a functional health pattern assessment, the nurse asks Mr. Thomas if he may ask him a few questions. Mr. Thomas is willing and in the course of their conversation shares with the nurse that he believes that he contracted the HIV during an affair with another woman. He states, “How can I tell my wife about this? I am so ashamed. It is bad enough that I had an affair, but to have to tell her in this way—I just don’t think I can. She is not sick at all. I will just say I have pneumonia and take the medication my health care provider gave me. I do not want my wife or anyone else to know. If she begins to show signs of not feeling well, then I will tell her. I just can’t tell anyone. What will people think of me if they know I have AIDS?” Questions 1. Briefly discuss how HIV is transmitted and how it is not. How can Mr. Thomas prevent the transmission of HIV to his wife and others? 2. Mr. Thomas stated, “What will people think of me if they know I have AIDS?” How can the nurse explain the difference between being HIV positive and having AIDS? 3. Discuss the ethical dilemmas inherent in this case. 4. Does the health care provider have a legal obligation to tell anyone other than Mr. Thomas that he is HIV positive? If so, discuss. 5. Any loss, such as the loss of one’s health, results in a grief response. Describe the stages of grief according to Kubler-Ross. 6. Discuss which stage of grief Mr. Thomas is most likely experiencing. Provide examples of Mr. Thomas’s behavior that support your decision. 7. What are the laboratory tests used to confirm the diagnosis of HIV infection in an adult? 8. Discuss the function of CD4+ T cells and provide an example of how the CD4+ T-cell count guides the management of HIV. 9. Briefly explain the purpose of viral load blood tests in monitoring the progression of HIV. 10. Mr. Thomas expresses a readiness to learn more about HIV. Discuss the nurse’s initial intervention when beginning client teaching, and then discuss the progression of the HIV disease, including an explanation of primary infection, categories (groups) A, B, and C, and four main types of opportunistic infections. 11. Following the nurse’s teaching, Mr. Thomas states, “How stupid I was to have that affair. Not only could it ruin my marriage, but it gave me a death sentence.” Share with Mr. Thomas what you know about long-term survivors, long-term nonprogressors, and Highly Active Antiretroviral Therapy (HAART). 12. Discuss how the nurse should respond if Mr. Thomas’s wife approaches him in the hall and asks, “Did the test results come back yet? Do you know what is wrong with my husband?” 13. List five possible nursing diagnoses appropriate to consider for Mr. Thomas. CASE STUDY 6 Mrs. Darsana GENDER SOCIOECONOMIC Female SPIRITUAL/RELIGIOUS AGE 67 PHARMACOLOGIC SETTING ■ Acetylsalicylic acid (aspirin); ■ Hospital enoxaparin (Lovenox); GPIIb/IIIa agents; heparin sodium; morphine sulfate; nitroglycerin; tissue plasminogen activator (tPA) ETHNICITY ■ Black American LEGAL CULTURAL CONSIDERATIONS ■ Risk of hypertension and heart ETHICAL disease PREEXISTING CONDITION ALTERNATIVE THERAPY ■ Hypertension (HTN) ■ Minimizing cardiac damage COMMUNICATION DELEGATION DISABILITY THE CARDIOVASCULAR SYSTEM & THE BLOOD Level of difficulty: Moderate Overview: This case requires the nurse to recognize the signs and symptoms of an acute myocardial infarction (MI). The nurse must anticipate appropriate interventions to minimize cardiac damage and preserve myocardial function. Serum laboratory tests and electrocardiogram findings used to diagnose a myocardial infarction are discussed. Criteria to assess when considering reperfusion using a thrombolytic agent are reviewed. The nurse is asked to prioritize the client’s nursing diagnoses. 13 M O D E R AT E PRIORITIZATION COEXISTING CONDITION 14 Part 1 ■ T H E CARDI OVASCU LA R SYSTEM & TH E BLOOD Client Profile Mrs. Darsana was sitting at a family cookout at approximately 2:00 p.m. when she experienced what she later describes to the nurse as “nausea with some heartburn.” Assuming the discomfort was because of something she ate, she dismissed the discomfort and took Tums. After about two hours, she explains, “My heartburn was not much better and it was now more of a dull pain that seemed to spread to my shoulders. I also noticed that I was a little short of breath.” Mrs. Darsana told her son what she was feeling. Concerned, her son called emergency medical services. Case Study En route to the hospital, emergency medical personnel established an intravenous access. Mrs. Darsana was given four children’s chewable aspirins and three sublingual nitroglycerin tablets without relief of her chest pain. She was placed on oxygen 2 liters via nasal cannula. Upon arrival in the emergency department, Mrs. Darsana is very restless. She states, “It feels like an elephant is sitting on my chest.” Her vital signs are blood pressure 160/84, pulse 118, respiratory rate 28, and temperature 99.38F (37.48C). Her oxygen saturation is 98% on 2 liters of oxygen. A 12-lead electrocardiogram (ECG, EKG) shows sinus tachycardia with a heart rate of 120 beats per minute. An occasional premature ventricular contraction (PVC), T wave inversion, and ST segment elevation are noted. A chest X-ray is within normal limits with no signs of pulmonary edema. Mrs. Darsana’s laboratory results include potassium (K1) 4.0 mEq/L, magnesium (Mg) 1.9 mg/dL, total creatine kinase (CK) 157 μ/L, CK-MB 7.6 ng/mL, relative index 4.8%, and troponin I 2.8 ng/mL. Her stool tests negative for occult blood. Questions 1. What are the components of the initial nursing assessment of Mrs. Darsana when she arrives in the emergency department? 2. Mrs. Darsana has a history of unstable angina. Explain what this is. 3. Briefly discuss what causes an MI. Include in the discussion the other terms used for this diagnosis. 4. The nurse listens to Mrs. Darsana’s heart sounds to see if S3, S4, or a murmur can be heard. What would the nurse suspect if these heart sounds were heard? 5. What factors are considered when diagnosing an acute myocardial infarction (AMI)? 6. Besides her unstable angina, what factors increased Mrs. Darsana’s risk for an MI? 7. Identify which of Mrs. Darsana’s presenting symptoms are consistent with the profile of a client who is having an MI. 8. The nurse overhears Mrs. Darsana’s son asking his mother sternly, “Mom. Why didn’t you tell me that you were having chest pain sooner? You should have never ignored this. You could have died right there at my house.” How might the nurse explain Mrs. Darsana’s actions to the son? 9. Provide a rationale for why Mrs. Darsana was given sublingual nitroglycerin and aspirin en route to the hospital. 10. Briefly discuss the laboratory tests that are significant in the determination of an acute myocardial infarction (AMI). 11. Laboratory results follow: April 1 at 1645: Total CK 5 216 units/L April 2 at 0045: Total CK 5 242 units/L CK-MB 5 5.6 ng/mL relative index 5 2.2% Troponin I 5 2.8 ng/mL CK-MB 5 8.1 ng/mL relative index 5 3.3% Troponin I 5 5.2 ng/mL CASE STUDY 6 ■ MR S . DAR SAN A Questions (continued) April 2 at 0615: Total CK 5 298 units/L April 3 at 0615: Total CK 5 203 units/L CK-MB 5 9.2 ng/mL relative index 5 3.0% Troponin I 5 4.1 ng/mL CK-MB 5 6.1 ng/mL relative index 5 3.0% Troponin I 5 1.7 ng/mL Are Mrs. Darsana’s laboratory results consistent with those expected for a client having an acute myocardial infarction? 12. Describe four pharmacologic interventions you anticipate will be initiated/considered during an acute MI. 13. Identify five criteria that could exclude an individual as a candidate for thrombolytic therapy with a tissue plasminogen activator (tPA). 14. An echocardiogram reveals that Mrs. Darsana has an ejection fraction of 50%. How could the nurse explain the meaning of this result to Mrs. Darsana? 15. Identify three appropriate nursing diagnoses for the client experiencing an AMI. 16. Rank the following five nursing diagnoses for Mrs. Darsana in priority order. • Decreased Cardiac Output related to (r/t) ineffective cardiac tissue perfusion secondary to ventricular damage, ischemia, dysrhythmia. • Deficient Knowledge (condition, treatment, prognosis) r/t lack of exposure, unfamiliarity with information resources. • Risk for Injury r/t adverse effect of pharmacologic therapy. • Acute Pain r/t myocardial tissue damage from inadequate blood supply. • Fear r/t threat to well-being. 15 This page intentionally left blank CASE STUDY 7 Mrs. Yates GENDER DISABILITY Female SOCIOECONOMIC AGE ■ Widow; lives alone; able to care for 70 self independently; nonsmoker SETTING SPIRITUAL/RELIGIOUS ■ Home ETHNICITY PHARMACOLOGIC ■ Black American ■ Aspirin (acetylsalicylic acid, ASA); clopidogrel bisulfate (Plavix); lisinopril (Prinivil, Zestril); carvedilol (Coreg); furosemide (Lasix); potassium chloride (KCl) CULTURAL CONSIDERATIONS ■ The impact of diet on heart failure PREEXISTING CONDITIONS LEGAL ■ Hypertension (HTN); heart failure (HF, CHF); coronary artery disease (CAD); myocardial infarction (MI) five years ago; ejection fraction (EF) of 55% ETHICAL COEXISTING CONDITION PRIORITIZATION COMMUNICATION DELEGATION THE CARDIOVASCULAR SYSTEM & THE BLOOD Level of difficulty: Moderate Overview: This case requires the nurse to recognize the symptoms of heart failure and collaborate with the primary care provider to initiate treatment. The pathophysiology of heart failure is reviewed. Several heart failure classification systems are defined. Rationales for prescribed diagnostic tests and medications are provided. The nurse must consider the impact of the client’s diet on the exacerbation of symptoms and provide teaching. Nursing diagnoses are prioritized to guide care. 17 M O D E R AT E ALTERNATIVE THERAPY 18 Part 1 ■ T H E CARDI OVASCU LA R SYSTEM & TH E BLOOD Client Profile Jeraldine Yates is a 70-year-old woman originally from Alabama. She lives alone and is able to manage herself independently. She is active in her community and church. Mrs. Yates was admitted to the hospital two months ago with heart failure. Since her discharge, a visiting nurse visits every other week to assess for symptoms of heart failure and see that Mrs. Yates is continuing to manage well on her own. Case Study The visiting nurse stops in to see Mrs. Yates today. The nurse immediately notices that Mrs. Yates’s legs are very swollen. Mrs. Yates states, “I noticed they were getting a bit bigger. They are achy, too.” The nurse asks Mrs. Yates if she has been weighing herself daily to which Mrs. Yates replies, “I got on that scale the last time you were here, remember?” The nurse weighs Mrs. Yates and she has gained 10 pounds. Additional assessment findings indicate that Mrs. Yates gets short of breath when ambulating from one room to the other (approximately 20 feet) and must sit down to catch her breath. Her oxygen saturation is 95% on room air. Bibasilar crackles are heard when auscultating her lung sounds. The nurse asks Mrs. Yates if she is currently or has in the past few days experienced any chest, arm, or jaw pain or become nauseous or sweaty. Mrs. Yates states, “No, I didn’t have any of that. I would know another heart attack. I didn’t have one of those.” The nurse asks about any back pain, stomach pain, confusion, dizziness, or a feeling that Mrs. Yates might faint. Mrs. Yates denies these symptoms stating, “No. None of that. Just a little more tired than usual lately.” Her vital signs are temperature 97.6ºF (36.4ºC), blood pressure 140/70, pulse 93, and respirations 22. The nurse reviews Mrs. Yates’s list of current medications. Mrs. Yates is taking aspirin, clopidogrel bisulfate, lisinopril, and carvedilol. The nurse calls the health care provider who asks the nurse to draw blood for a complete blood count (CBC), basic metabolic panel (BMP), brain natriuretic peptide (B-type natriuretic peptide assay or BNP), troponin, creatine kinase (CPK), creatine kinase-MB (CKMB), and albumin. The health care provider also prescribes oral (PO) furosemide and asks the nurse to arrange an outpatient electrocardiogram (ECG, EKG), chest X-ray, and echocardiogram. Questions 1. Which assessment findings during the nurse’s visit are consistent with heart failure? 2. Why did the visiting nurse ask Mrs. Yates about back pain, stomach pain, confusion, dizziness, or a feeling that she might faint? 3. Discuss anything else the nurse should assess during her visit with Mrs. Yates. 4. Explain what the following terms indicate and include the normal values: cardiac output, stroke volume, afterload, preload, ejection fraction, and central venous pressure. 5. Discuss the body’s compensatory mechanisms during heart failure. Include an explanation of the Frank-Starling law and the neurohormonal model in your discussion. 6. Heart failure can be classified as left or right ventricular failure, systolic versus diastolic, according to the New York Heart Association (NYHA) and using the ACC/AHA (American Heart Association) guidelines. Explain these four classification systems and the signs and symptoms that characterize each. 7. According to each classification system discussed above in question #6, how would you label the type of heart failure Mrs. Yates is experiencing? 8. Discuss Mrs. Yates’s predisposing risk factors for heart failure. Is her age, gender, or ethnicity significant? 9. Provide a rationale for why each of the following medications are included in Mrs. Yates’s medication regimen: aspirin, clopidogrel bisulfate, lisinopril, and carvedilol. 10. The nurse is teaching Mrs. Yates about her newly prescribed furosemide. Explain the rationale for adding furosemide to Mrs. Yates’s medication regimen, when she should expect to see the therapeutic results (urination), and instructions regarding the administration of furosemide. CASE STUDY 7 ■ MR S . YAT E S Questions (continued) 11. The visiting nurse asks the primary health care provider if he/she will prescribe potassium chloride for Mrs. Yates. Why has the nurse suggested this? 12. What information will each of the following blood tests provide: CBC, BMP, BNP, troponin, CPK, CK-MB, and albumin? 13. What will the health care provider look for on the electrocardiogram, chest X-ray, and echocardiogram? What will each diagnostic test tell the physician? 14. Mrs. Yates’s son comes to stay with his mother so she will not be alone. What should the nurse tell Mr. Yates about when he should bring his mother to the hospital? 15. The visiting nurse returns the next day. Mrs. Yates does not seem to be diuresing as well as the nurse anticipated. Mrs. Yates is not worse, but the swelling in her legs is still considerable and there is no change in her weight. When asked about her frequency of voiding, Mrs. Yates does not seem to have noticed much difference. While the nurse is unpacking her stethoscope to assess lung sounds, Mrs. Yates says, “Honey, I was just making myself a ham salad sandwich. Would you like one?” The nurse declines and becomes concerned because of this offer. Why is the nurse concerned? 16. The nurse asks Mrs. Yates to tell her more about how she cooks. Specifically, the nurse asks Mrs. Yates about the types of foods and food preparation. With great pride, Mrs. Yates leads the nurse to the kitchen and explains, “Honey. I am from the South and we cook soul food. Today I am cooking my famous pea soup for the church dinner tonight. I use ham hocks. Have you ever had those? My son says they are not good for me. He has been trying to get me to eat healthier foods. Last week he brought me turkey sausage to try instead of my pork sausage in the morning. I know he means well but some foods are tradition and you don’t break soul food tradition.” What information has the nurse gathered that is of concern? 17. The nurse arranges for Mrs. Yates’s son to be present at the next home visit so that the nurse can teach them both about proper dietary choices and fluid restrictions. List five points of information that the nurse should include in the teaching. 18. During the dietary teaching, the nurse asks Mrs. Yates to describe a typical day of meals and snacks. Mrs. Yates lists coffee with whole milk, eggs and sausage for breakfast, a sandwich or soup for lunch, fried chicken with vegetables for dinner, and fruit, pretzels, or rice pudding for snacks. Which of these foods will the nurse instruct Mrs. Yates to limit and are there alternatives that the nurse can suggest? 19. Since changing her diet, Mrs. Yates has responded to her outpatient treatment plan and has noticed marked improvement in how she feels. The nurse wants to make sure that Mrs. Yates understands the importance of monitoring her weight. What instructions should the nurse give Mrs. Yates regarding how often to weigh herself, and what weight change should be reported to her health care provider or the nurse? 20. Prioritize five nursing diagnoses that the visiting nurse should consider for the recent events regarding Mrs. Yates’s care. 19 This page intentionally left blank CASE STUDY 8 Ms. Fox GENDER SPIRITUAL/RELIGIOUS Female PHARMACOLOGIC AGE ■ Acetaminophen (Tylenol); 20 hydroxyurea (Droxia); morphine sulfate (MS contin); ibuprofen (Advil, Motrin); acetaminophen 300 mg/ codeine 30 mg (Tylenol with codeine No. 3); meperidine hydrochloride (Demerol); hydromorphone hydrochloride (Dilaudid) SETTING ■ Hospital ETHNICITY ■ Black American LEGAL CULTURAL CONSIDERATIONS ■ Increased risk for sickle cell disease ETHICAL PREEXISTING CONDITION ■ Sickle cell disease ALTERNATIVE THERAPY ■ Breathing techniques; relaxation; COEXISTING CONDITION distraction; transcutaneous nerve stimulation (TENS) COMMUNICATION PRIORITIZATION DISABILITY DELEGATION SOCIOECONOMIC ■ Risk for substance abuse Level of difficulty: Difficult Overview: This case requires the nurse to define different types of anemia, recognize the symptoms of a sickle cell crisis, and discuss short- and long-term management of sickle cell disease. Nursing diagnoses appropriate for the client are prioritized. 21 D I F F I C U LT THE CARDIOVASCULAR SYSTEM & THE BLOOD 22 Part 1 ■ T H E CARDI OVASCU LA R SYSTEM & TH E BLOOD Client Profile Ms. Fox is a 20-year-old black American who presents to the emergency department with complaints of chest pain and some shortness of breath. Ms. Fox indicates that she has had a nonproductive cough and low-grade fever for the past two days. She recognizes these symptoms as typical of her sickle cell crisis episodes and knew it was important she come in to get treatment. Case Study Ms. Fox was diagnosed with sickle cell anemia as a child and has had multiple crises requiring hospitalization. Ms. Fox states that the pain in her chest is an “8” on a 0 to 10 pain scale. She describes the pain as a “constant burning pain.” Her vital signs are temperature of 100.8ºF (38.2ºC), blood pressure 120/76, pulse 96, and respiratory rate of 22. Her oxygen saturation on room air is 94%. She is having some difficulty breathing and is placed on 2 liters of oxygen by nasal cannula. Ms. Fox explains that she took Extra Strength Tylenol for the past two days in an effort to manage the pain, but when this did not work and the pain got worse, she came in for a stronger pain medication. She explains that in the past she has been given morphine for the pain and prefers to use the patient-controlled analgesia (PCA) pump. Blood work reveals the following values: white blood cell count (WBC) 18,000 cells/mm3, red blood cell count (RBC) 3 3 106, mean corpuscular volume (MCV) 70 μm3, red cell distribution width (RDW) 20.4%, hemoglobin (Hgb) 7.5 g/dL, hematocrit (Hct) 21.8%, and reticulocyte count 23%. Ms. Fox is admitted for pain management, antibiotic treatment, and respiratory support. Questions 1. Three types of anemia are hypoproliferative, bleeding, and hemolytic. Provide a basic definition of the etiology of each type and one example of each type. 2. Discuss how Ms. Fox’s laboratory results are consistent with clients who have sickle cell anemia. 3. Describe the structure and function of normal red blood cells in the body. 4. Describe the structure and effects of red blood cells (RBCs) that contain sickle cell hemoglobin molecules. 5. Is sickle cell anemia an inherited anemia or an acquired anemia? Explain. 6. Discuss the relationship between sickle cell anemia and Ms. Fox’s ethnicity. 7. Discuss the characteristic signs and symptoms of sickle cell anemia. 8. Discuss the potential complications associated with sickle cell anemia. 9. Describe the pharmacologic management for a client with sickle cell anemia. Include a discussion of the potential adverse effects of the medication. 10. Describe the use of transfusion therapy for management of sickle cell anemia. Include a discussion of the potential complications of chronic red blood cell transfusions. 11. Bone marrow transplantation (BMT) offers a potential cure for sickle cell disease. Why is BMT a treatment option available to only a small number of clients with sickle cell disease? 12. In the adult, three types of sickle cell crisis are possible: sickle crisis, aplastic crisis, and sequestration crisis. Briefly describe the pathophysiological changes that lead to each type. 13. There are four common patterns of an acute vaso-occlusive sickle cell crisis: bone crisis, acute chest syndrome, abdominal crisis, and joint crisis. Briefly describe the characteristic symptoms of each pattern. 14. Which pattern discussed in question number 13 is most congruent with Ms. Fox’s presenting signs and symptoms? 15. Discuss the symptoms the nurse should look for while completing an assessment of a client in potential sickle cell (vaso-occlusive) crisis. 16. Briefly discuss the factors that can trigger a sickle cell crisis. 17. Prioritize three potential nursing diagnoses appropriate for Ms. Fox. 18. Describe the nursing management goals during the acute phase of a sickle cell crisis. 19. Explain why individuals with sickle cell disease may be at risk for substance abuse. 20. Discuss the long-term prognosis for Ms. Fox. CASE STUDY 9 Mrs. O’Grady GENDER DISABILITY Female SOCIOECONOMIC AGE 55 SPIRITUAL/RELIGIOUS SETTING ■ Hospital PHARMACOLOGIC ETHNICITY ■ Dipyridamole (Persantine); atenolol (Tenormin); atorvastatin calcium (Lipitor); conjugated estrogen, oral (Premarin) ■ White American CULTURAL CONSIDERATIONS LEGAL PREEXISTING CONDITIONS ■ Informed consent ■ Hypertension (HTN); angina; total ETHICAL abdominal hysterectomy six months ago; allergy to shellfish ALTERNATIVE THERAPY COEXISTING CONDITION ■ Positive myocardial perfusion PRIORITIZATION imaging study (stress test) COMMUNICATION DELEGATION Level of difficulty: Difficult Overview: This case requires the nurse to convey an understanding of the cardiac catheterization procedure. Appropriate client care pre- and postcardiac catheterization is discussed. The client’s current medications are reviewed. Discharge teaching is provided. 23 D I F F I C U LT THE CARDIOVASCULAR SYSTEM & THE BLOOD 24 Part 1 ■ T H E CARDI OVASCU LA R SYSTEM & TH E BLOOD Client Profile Mrs. O’Grady is a 55-year-old female with a history of angina and recent hospital admission for complaints of chest pain and shortness of breath. It is determined that she did not suffer a myocardial infarction. Mrs. O’Grady’s health care provider has scheduled her for a cardiac catheterization after learning that the results of her dipyridamole (Persantine) myocardial perfusion imaging study (stress test) were abnormal. Case Study Mrs. O’Grady is having a cardiac catheterization today. The cardiac catheterization lab nurse assigned to care for Mrs. O’Grady will provide teaching, check to see that there are no contraindications for Mrs. O’Grady consenting to the procedure, and provide pre- and postprocedure care. Questions 1. Why has Mrs. O’Grady’s health care provider prescribed a cardiac catheterization? What information will this procedure provide? 2. What are the potential contraindications that can prevent someone from being able to have a cardiac catheterization? What is the contraindication that must be considered in Mrs. O’Grady’s case? Why is this of concern? 3. Discuss the preprocedure assessments the nurse will complete prior to Mrs. O’Grady’s cardiac catheterization. 4. Discuss interventions the nurse will complete prior to Mrs. O’Grady’s cardiac catheterization. 5. Provide a brief rationale for why each of the following medications have been prescribed for Mrs. O’Grady: atenolol (Tenormin); atorvastatin calcium (Lipitor); conjugated estrogen, oral (Premarin). 6. What are two appropriate nursing diagnoses to consider for Mrs. O’Grady prior to her having the cardiac catheterization? 7. Mrs. O’Grady asks the nurse, “What are they going to do to me today?” Explain what a cardiac catheterization involves and how long Mrs. O’Grady can expect the procedure to last. Briefly describe the difference between a left-sided and right-sided catheterization. 8. What are the risks of having a cardiac catheterization? What are the two most common complications during the procedure? 9. List at least five manifestations of an adverse reaction to the contrast dye the nurse will watch for. 10. How should the nurse respond when Mrs. O’Grady asks, “How soon will I know if something is wrong with me?” 11. What is “informed consent”? Is consent required prior to a cardiac catheterization? Why or why not? 12. Immediately following the cardiac catheterization procedure, what is the nurse’s responsibility to help minimize bleeding at the femoral puncture site, and what will be Mrs. O’Grady’s prescribed activity? 13. Discuss the priorities of the nursing assessment following a femoral cardiac catheterization. Be sure to note in your discussion when the health care provider should be notified. 14. What are two nursing diagnoses to consider for Mrs. O’Grady following the cardiac catheterization? 15. Mrs. O’Grady has a left groin puncture site. She needs to go to the bathroom, but is still on bed rest. What is the proper way for the nurse to assist her? 16. The results of Mrs. O’Grady’s cardiac catheterization indicate that she does not have any significant heart disease and her coronary arteries are patent. The health care provider discharges her. Her husband has been called to bring her home. What instructions should the nurse provide regarding activity, diet, and medications? © Getty Images/Photodisc PART TWO The Respiratory System This page intentionally left blank CASE STUDY 1 Mrs. Hogan GENDER SOCIOECONOMIC Female ■ Husband employed in asbestos removal AGE SETTING PHARMACOLOGIC ■ Walk-in health care center ■ Albuterol (Proventil, Ventolin); beclomethasone dipropionate (Beconase) ETHNICITY ■ White American LEGAL CULTURAL CONSIDERATIONS ETHICAL PREEXISTING CONDITION ■ Mild persistent asthma ALTERNATIVE THERAPY COEXISTING CONDITION PRIORITIZATION COMMUNICATION ■ Ensuring a patent airway; monitoring for status asthmaticus DISABILITY DELEGATION THE RESPIRATORY SYSTEM Level of difficulty: Easy Overview: This case requires that the nurse recognize appropriate interventions for an asthma attack and understand the actions of respiratory medications. The nurse must assess the triggers specific to this patient and provide teaching to reduce the patient’s risk of another exacerbation. Priority nursing diagnoses and outcome goals are identified. 27 EASY SPIRITUAL/RELIGIOUS 38 28 Part 2 ■ T H E RE SP I RATO RY SYST E M Client Profile Mrs. Hogan is a 38-year-old woman brought to a walk-in health care center by her neighbor. Mrs. Hogan is in obvious respiratory distress. She is having difficulty breathing with audible high-pitched wheezing and is having difficulty speaking. Pausing after every few words to catch her breath, she tells the nurse, “I am having a really bad asthma attack. My chest feels very tight and I cannot catch my breath. I took my albuterol and Vanceril, but they are not helping.” Mrs. Hogan hands her neighbor her cell phone and asks the neighbor to dial a telephone number. “That number is my husband’s boss. My husband just started working for an asbestos removal company about a month ago. He is usually on the road somewhere. Can you ask his boss to get a message to him that I am here?” Case Study While auscultating Mrs. Hogan’s lung sounds, the nurse hears expiratory wheezes and scattered rhonchi throughout. Mrs. Hogan is afebrile. Her vital signs are blood pressure 142/96, pulse 88, and respiratory rate 34. Her oxygen saturation on room air is 86%. Arterial blood gases (ABGs) are drawn. Mrs. Hogan is placed on 2 liters of humidified oxygen via nasal cannula. She is started on intravenous (IV) fluids and receives an albuterol nebulizer treatment. Questions 1. What other signs and symptoms might the nurse note during assessment of Mrs. Hogan? 2. In what position should the nurse place Mrs. Hogan and why? 3. Identify at least five signs and symptoms that indicate that Mrs. Hogan is not responding to treatment and may be developing status asthmaticus (a life-threatening condition). 4. Mrs. Hogan states that she took her albuterol and beclomethasone prior to coming to the walk-in health care center. How do these medications work? 5. Briefly discuss the common adverse effects Mrs. Hogan may experience with the albuterol nebulizer treatment. 6. Physiologically, what is happening in Mrs. Hogan’s lungs during an asthma attack? 7. In order of priority, identify three nursing diagnoses that are appropriate during Mrs. Hogan’s asthma exacerbation. 8. Write three outcome goals for Mrs. Hogan’s diagnosis of Ineffective Breathing Pattern. 9. Mrs. Hogan has responded well to the albuterol nebulizer treatment. Her breathing is less labored and she appears less anxious. The nurse asks Mrs. Hogan what she was doing when the asthma attack began. Mrs. Hogan says, “Nothing special. I was doing the laundry.” What other questions might the nurse ask (and why) to assess the cause of Mrs. Hogan’s asthma exacerbation? 10. What are some other questions the nurse might ask to get a better sense of Mrs. Hogan’s asthma? 11. The nurse asks Mrs. Hogan to describe step-bystep how she uses her inhalers. Mrs. Hogan describes the following steps: “First I shake the inhaler well. Then I breathe out normally and place the mouthpiece in my mouth. I take a few breaths and then while breathing in slowly and deeply with my lips tight around the mouthpiece, I give myself a puff. I hold my breath for a count of five and breathe out slowly as if I am blowing out a candle. I wait a minute or two and then I repeat those steps all over again for my second puff.” Which step(s) is/are of concern to the nurse and why? 12. Briefly discuss three nursing interventions to help decrease Mrs. Hogan’s risk of another asthma exacerbation. CASE STUDY 2 William GENDER SOCIOECONOMIC Male SPIRITUAL/RELIGIOUS AGE PHARMACOLOGIC SETTING ■ Heparin; lidocaine (Xylocaine) ■ Hospital LEGAL ETHNICITY ■ Black American ETHICAL CULTURAL CONSIDERATIONS ALTERNATIVE THERAPY PREEXISTING CONDITION PRIORITIZATION ■ Critical arterial blood gases COEXISTING CONDITION DELEGATION COMMUNICATION DISABILITY THE RESPIRATORY SYSTEM Level of difficulty: Easy Overview: This case provides the nurse with an opportunity to convey an understanding of the arterial blood gas testing method and practice the skill of acid-base analysis/arterial blood gas results interpretation. 29 EASY 25 30 Part 2 ■ T H E RE SP I RATO RY SYST E M Client Profile William is a newly graduated registered nurse. He will begin working on a respiratory nursing unit next week. During orientation to his role, he will learn how to collect an arterial blood gas (ABG) sample. He is given five sets of ABG results to practice acid-base analysis/arterial blood gas results interpretation. William must determine acid-base balance, determine if there is compensation, and decide whether each client is hypoxic. Case Study The five sets of arterial blood gas results are: 1. pH 6.95 PaCO2 48 mm Hg 2. pH 7.48 PaCO2 44 mm Hg 3. pH 7.48 PaCO2 31 mm Hg 4. pH 7.35 PaCO2 42 mm Hg 5. pH 7.53 PaCO2 31 mm Hg HCO32 23 mEq/L HCO32 30 mEq/L HCO32 19 mEq/L HCO32 26 mEq/L HCO32 35 mEq/L SaO2 95% SaO2 88% SaO2 93% SaO2 95% SaO2 90% PaO2 79 mm Hg PaO2 70 mm Hg PaO2 82 mm Hg PaO2 83 mm Hg PaO2 57 mm Hg Questions 1. Describe the purpose of the arterial blood gas (ABG) test. 2. Describe the client preparation that is necessary prior to drawing an ABG sample. Is written client consent (a consent form) required prior to drawing the blood sample? 3. List the equipment the nurse must gather prior to collecting the ABG sample. 4. List the steps for obtaining an ABG sample from a radial artery. 5. What are the potential complications of the ABG collection procedure? 6. Discuss the nursing responsibilities after the ABG sample is obtained. 7. Explain how an ABG sample should be transported to the laboratory for processing. 8. How long does it take to obtain ABG results? 9. Briefly discuss at least five factors that can cause false ABG results. 10. What are the normal ranges for each of the ABG components in an adult: pH, partial pressure of carbon dioxide (PaCO2), bicarbonate (HCO32), oxygen saturation (SaO2), and partial pressure of oxygen (PaO2)? 11. What are the critical/panic values for each of the ABG components in an adult: pH, PaCO2, HCO32, SaO2, and PaO2? 12. Help William analyze each set of ABG results. Determine whether each value is high, low, or within normal limits; interpret the acid-base balance; determine if there is compensation; and indicate whether the client is hypoxic. 1. 2. 3. 4. 5. pH 6.95 pH 7.48 pH 7.48 pH 7.35 pH 7.53 PaCO2 48 mm Hg HCO3– 23 mEq/L SaO2 95% PaO2 79 mm Hg PaCO2 44 mm Hg PaCO2 31 mm Hg PaCO2 42 mm Hg PaCO2 31 mm Hg HCO3– HCO3– HCO3– HCO3– 30 mEq/L 19 mEq/L 26 mEq/L 35 mEq/L SaO2 88% SaO2 93% SaO2 96% SaO2 90% PaO2 70 mm Hg PaO2 82 mm Hg PaO2 83 mm Hg PaO2 57 mm Hg 13. Identify three appropriate nursing diagnoses for a client having an ABG sample obtained. CASE STUDY 3 Mr. Cohen GENDER SOCIOECONOMIC Male SPIRITUAL/RELIGIOUS AGE ■ Judaism 75 PHARMACOLOGIC SETTING ■ Acetaminophen (Tylenol); albuterol ■ Hospital (AccuNeb, Proventil, Ventolin); enalapril (Vasotec); oxycodone/ acetaminophen (Percocet) ETHNICITY ■ Jewish American LEGAL CULTURAL CONSIDERATIONS ■ Perception and expression of pain ETHICAL PREEXISTING CONDITIONS ALTERNATIVE THERAPY ■ Chronic obstructive pulmonary disease (COPD) (emphysema); hypertension (HTN) well controlled by enalapril (Vasotec) ■ Nonpharmacologic interventions COEXISTING CONDITION PRIORITIZATION ■ Lower back pain ■ Difficulty breathing; pain management COMMUNICATION DELEGATION DISABILITY ■ Needs assistance of one person while ambulating due to unsteady gait and dyspnea on exertion THE RESPIRATORY SYSTEM Level of difficulty: Moderate Overview: This case requires that the nurse recognize the signs and symptoms of activity intolerance and respiratory distress and how symptoms differ in the client who has COPD. The nurse considers both pharmacologic and nonpharmacologic interventions to manage respiratory distress and pain. Cultural/spiritual perceptions of pain and pain management are discussed. The nurse must provide discharge teaching regarding safe use of oxygen in the home. 31 M O D E R AT E for respiratory distress and pain management 32 Part 2 ■ T H E RE SP I RATO RY SYST E M Client Profile Mr. Cohen is a 75-year-old male admitted with an exacerbation of chronic obstructive pulmonary disease (emphysema). He has been keeping the head of the bed up for most of the day and night to facilitate his breathing which has resulted in lower back pain. Acetaminophen (Tylenol) was not effective in reducing his pain, so the health care provider has prescribed oxycodone/acetaminophen (Percocet) one to two tablets PO every four to six hours as needed for pain. Mr. Cohen is on 2 liters of oxygen by nasal cannula. He can receive respiratory treatments of albuterol (AccuNeb, Proventil, Ventolin) every six hours as needed. Mr. Cohen needs someone to walk beside him when he ambulates because he has an unsteady gait and often needs to stop to catch his breath. Case Study The nurse enters the room and finds Mr. Cohen hunched over his bedside table watching television. He says this position helps his breathing. His lung sounds are clear but diminished bilaterally. Capillary refill is four seconds and slight clubbing of his fingers is noted. His oxygen saturation is being assessed every two hours to monitor for hypoxia. Each assessment reveals oxygen saturation at rest of 90% to 94% on 2 liters of oxygen by nasal cannula. After breakfast, Mr. Cohen complains of lower back pain that caused him increased discomfort while ambulating to the bathroom. He describes the pain as a dull ache and rates the pain a “6” on a 0–10 pain scale. He requests two Percocet tablets. The nurse assesses Mr. Cohen’s vital signs (blood pressure 150/78, pulse 90, respiratory rate 26) and gives the Percocet as prescribed. Forty-five minutes later, Mr. Cohen states the Percocet has helped relieve his back pain to a “2” on a 0–10 pain scale and he would like to take a walk in the hall. The nurse checks his oxygen saturation before they leave his room, and it is 92%. Using a portable oxygen tank, the nurse walks with Mr. Cohen from his room to the nurse’s station (approximately 60 feet). Mr. Cohen stops to rest at the nurse’s station because he is short of breath. His oxygen saturation at the nurse’s station is 86%. After a few deep breaths and rest, his oxygen saturation rises to 91%. Mr. Cohen walks back to his room where he sits in his recliner to wait for lunch. His oxygen saturation is initially 87% when he returns and then 91% after a few minutes of rest. Expiratory wheezes are heard bilaterally when the nurse assesses his lung sounds. While Mr. Cohen waits for lunch to arrive, the nurse calls respiratory therapy to give Mr. Cohen his albuterol treatment. The respiratory treatment and rest relieves his acute shortness of breath. His oxygen saturation is now 93%, and his lung sounds are clear but diminished bilaterally. Questions 1. Briefly define chronic obstructive pulmonary disease (COPD). What pathophysiology is occurring in the lungs of a client with emphysema? 2. What are five signs and symptoms of respiratory distress the nurse may observe in a client with COPD? 3. Describe the physical appearance characteristics of a client with emphysema. 4. Are Mr. Cohen’s oxygen saturation readings normal? Explain your answer. 5. Explain the effects that acute pain can have on an individual’s respiratory pattern and cardiovascular system. 6. List five nonpharmacologic interventions that the nurse could implement to help decrease Mr. Cohen’s difficulty breathing. 7. How would the nurse measure the effectiveness of the interventions suggested in question number 6? 8. Explain why the nurse did not increase Mr. Cohen’s oxygen to help ease his shortness of breath. CASE STUDY 3 ■ MR . C O HE N Questions (continued) 9. Discuss the cultural/spiritual considerations the nurse should keep in mind while creating a plan of care for Mr. Cohen’s pain management. 10. What are three nonpharmacologic nursing interventions to help manage Mr. Cohen’s pain? 11. How would the nurse measure the effectiveness of the interventions suggested in question number 10? 12. Should the nurse be concerned about the adverse effects of respiratory depression and hypotension when giving oxycodone/acetaminophen (Percocet) to Mr. Cohen? Why or why not? 13. What are three nursing diagnoses that address physical and/or physiological safety concerns for Mr. Cohen? 14. Mr. Cohen will be returning home with oxygen. List at least five safety considerations the nurse should include in discharge teaching regarding the use of oxygen in the home. 33 This page intentionally left blank CASE STUDY 4 Mr. Kaberry GENDER SOCIOECONOMIC Male ■ Smokes a half pack of cigarettes per day for past forty years; wife accompanied client to office visit AGE 67 SPIRITUAL/RELIGIOUS SETTING ■ Primary care PHARMACOLOGIC ETHNICITY LEGAL ■ White American CULTURAL CONSIDERATIONS ETHICAL PREEXISTING CONDITION ALTERNATIVE THERAPY COEXISTING CONDITION PRIORITIZATION DELEGATION COMMUNICATION DISABILITY THE RESPIRATORY SYSTEM Level of difficulty: Moderate Overview: This case reviews the normal sleep cycle of an adult. The nurse must identify the symptoms of sleep apnea syndrome. Potential long-term complications of obstructive sleep apnea syndrome are discussed and treatment options are considered. 35 M O D E R AT E ■ Obesity 36 Part 2 ■ T H E RE SP I RATO RY SYST E M Client Profile Mr. Kaberry is a 67-year-old man. He is 5 feet, 10 inches tall. Over the past five years, Mr. Kaberry has gained 50 pounds and currently weighs 260 pounds (118.2 kg). He smokes a half pack of cigarettes each day and has been a smoker for the past forty years. In the past three months, he has noticed that, despite sleeping for at least seven hours a night, he is very tired during the day. He is afraid he is ill and has made an appointment with his primary health care provider. Case Study While conducting an initial assessment, the nurse asks Mr. Kaberry what brought him to the provider’s office. Mr. Kaberry states, “I have been so tired during the day. I realize I have put on weight over the last few years, but I am so exhausted. I work in a bank and sometimes I wish I could just put my head on my desk at and catch a quick nap. That is not like me. I usually feel rested in the morning and I never take naps during the day. There must be something wrong with me.” Mrs. Kaberry adds, “If anyone should be tired it is me. He keeps me up most of the night with his snoring. I hope you can find out what is wrong with him because living with him has been unbearable lately.” The nurse asks Mrs. Kaberry to explain what she means by “unbearable.” Mrs. Kaberry explains that Mr. Kaberry has been short with her, “Very irritable, I guess you could say.” Questions 1. Describe the five stages of sleep and the normal sleep cycle of an adult. 2. How is sleep apnea syndrome defined and what are the three types of sleep apnea? 3. How does Mr. Kaberry fit the profile of the “typical” client who has sleep apnea? 4. The nurse continues the assessment of Mr. Kaberry’s symptoms. List at least five other manifestations of sleep apnea the nurse should ask if he has experienced. 5. Briefly discuss Mr. Kaberry’s predisposing risk factors for sleep apnea syndrome. How common is sleep apnea in the United States? 6. Discuss the anatomy and physiology that causes obstructive sleep apnea syndrome. 7. Explain how sleep apnea syndrome is diagnosed. 8. What are the potential complications associated with sleep apnea syndrome? 9. Discuss the interventions to consider when planning the medical management of Mr. Kaberry’s obstructive sleep apnea. Include a discussion of positive airway pressure therapy. 10. How will the nurse respond when Mrs. Kaberry asks “Do we really need that machine? Isn’t there a medication he could take to help this problem?” 11. Mr. and Mrs. Kaberry are learning how to use the CPAP machine. What are two potential side effects experienced by people using CPAP therapy and what are two interventions that can help decrease the side effects? 12. When teaching Mr. and Mrs. Kaberry how to use the CPAP machine, what relationship and body image concerns should be acknowledged? 13. Surgery may be an option for Mr. Kaberry if the symptoms of his obstructive sleep apnea do not improve with nonsurgical interventions. What surgical procedures are used to treat obstructive sleep apnea? 14. Help the nurse generate three appropriate nursing diagnoses for Mr. Kaberry. 15. Until Mr. Kaberry’s sleep apnea responds to treatment and his fatigue resolves, what safety precaution(s) should the nurse suggest? © Getty Images/Photodisc PART THREE The Nervous/ Neurological System This page intentionally left blank CASE STUDY 1 Mrs. Seaborn GENDER DISABILITY Female SOCIOECONOMIC AGE SPIRITUAL/RELIGIOUS SETTING ■ Emergency department PHARMACOLOGIC ETHNICITY ■ Acyclovir; Prednisone ■ White American LEGAL CULTURAL CONSIDERATIONS ETHICAL PREEXISTING CONDITION ALTERNATIVE THERAPY COEXISTING CONDITION ■ Acupuncture ■ Herpes Simplex virus type 1 PRIORITIZATION COMMUNICATION DELEGATION THE NERVOUS/NEUROLOGICAL SYSTEM Level of difficulty: Easy Overview: This case requires the nurse to discuss Bell’s palsy. An understanding of pharmacological treatments and cranial nerve testing is needed. Nursing diagnoses for priority care are identified. 39 EASY ■ Married 43 40 Part 3 ■ T H E N E RVO U S/ N E U RO LO G ICA L SYSTEM Client Profile Mrs. Seaborn is a 43-year-old woman who presents to the emergency department with complaints of weakness of the left side of her face. She is married and is an interior decorator who owns her own business. Earlier today she was working at a client’s home when she started to have increased facial weakness and was unable to taste her lunch. She states a history of two days of numbness in her forehead. Case Study Mrs. Seaborn’s vital signs are temperature 98.2°F, blood pressure 148/60, pulse 83, and respiratory rate of 26. She is fearful, crying, and states, “My mother died of a stroke, I am sure that is what is going on. Am I going to die?” She complains of pain behind and in front of her left ear. She is exhibiting unilateral facial paralysis. Her left eye is drooping and she says it feels dry. Her inability to raise her eyebrow, puff out her cheeks, frown, smile or wrinkle her forehead is suspicious for Bell’s palsy. A healing cold sore is observed on her lower lip. Questions 1. Define Bell’s palsy and identify two conditions that could mimic it. 2. What is the main cranial nerve involved with Bell’s palsy? How is testing done for this nerve? 3. What significance does Mrs. Seaborn’s current cold sore on her lip have with Bell’s palsy? 4. What other tests may be needed to rule out other causes of Bell’s palsy? 5. What other symptoms would you expect to occur for Mrs. Seaborn? 6. What are three priority nursing diagnoses for Mrs. Seaborn? 7. Discuss the nonsurgical management for Bell’s palsy. 8. Discuss further complications of Bell’s palsy. 9. What is the normal expected recovery time for Mrs. Seaborn? CASE STUDY 2 Mrs. Giammo GENDER SPIRITUAL/RELIGIOUS Female PHARMACOLOGIC AGE Sodium); atorvastatin (Lipitor) SETTING LEGAL ■ Hospital ETHICAL ETHNICITY ■ Black American ALTERNATIVE THERAPY CULTURAL CONSIDERATIONS ■ Lifestyle modification PRIORITIZATION PREEXISTING CONDITION ■ Hypertension (HTN) DELEGATION COEXISTING CONDITION ■ Hypercholesterolemia COMMUNICATION DISABILITY SOCIOECONOMIC ■ History of tobacco use for twenty-five years—quit ten years ago; husband smokes one pack per day; positive family history of heart disease; occasionally takes walks in the neighborhood with friends but does not have a regular exercise regimen THE NERVOUS/NEUROLOGICAL SYSTEM Level of difficulty: Easy Overview: This case requires the nurse to recognize the signs and symptoms of a transient ischemic attack (TIA) and define the difference between a cerebrovascular accident (CVA, stroke) and a TIA. The nurse must recognize the risk factors for a possible stroke and suggest lifestyle modifications to decrease risk. Explanations of test results and physical assessment findings are offered. Appropriate nursing diagnoses for this client are prioritized. 41 EASY ■ Atenolol (Tenormin); heparin (Heparin 59 42 Part 3 ■ T H E N E RVO U S/ N E U RO LO G ICA L SYSTEM Client Profile Mrs. Giammo is a 59-year-old woman who was brought to the emergency department by her husband. Mr. Giammo noticed that all of a sudden his wife “was slurring her speech and her face was drooping on one side.” Mrs. Giammo told her husband that she felt some numbness on the right side of her face and in her right arm. Mr. Giammo was afraid his wife was having a stroke so he brought her to the hospital. Case Study In the emergency department, Mrs. Giammo is alert and oriented. Her vital signs are temperature 98.28F (36.78C), blood pressure 148/97, pulse 81, and respiratory rate 14. An electrocardiogram (ECG, EKG) monitor shows a normal sinus rhythm. Mrs. Giammo is still complaining of “numbness” of the right side of her face and down her right arm. Her mouth is noted to divert to the right side with a slight facial droop when she smiles. Her speech is clear. She is able to move all of her extremities and follow commands. Her pupils are round, equal, and reactive to light (4 mm to 2 mm) and accommodation. There is no nystagmus noted. Her right hand grasp is weaker than her left. Mrs. Giammo does not have a headache and denies any nausea, vomiting, chest pain, diaphoresis, or visual complaints. She is not experiencing any significant weakness, has a steady gait, and is able to swallow without difficulty. Laboratory blood test results are as follows: white blood cell count (WBC) 8,000 cells/mm3, hemoglobin (Hgb) 14 g/dL, hematocrit (Hct) 44%, platelets = 294,000 mm3, erythrocyte sedimentation rate (ESR) 15 mm/hr, prothrombin time (PT) 12.9 seconds, international normalized ratio (INR) 1.10, sodium (Na2+) 149 mEq/L, potassium (K+) 4.5 mEq/L, glucose 105 mg/dL, calcium (Ca2+) 9.5 mg/dL, blood urea nitrogen (BUN) 15 mg/dL, and creatinine (creat) 0.8 mg/dL. A head computed tomography (CT) scan is done which shows no acute intracranial change and a magnetic resonance imagery (MRI) is within normal limits. Mrs. Giammo is started on an intravenous heparin drip of 25,000 units in 500 cc of D5W at 18 mL per hour (900 units per hour). Mrs. Giammo is admitted for a neurology evaluation, magnetic resonance angiography (MRA) of the brain, a fasting serum cholesterol, and blood pressure monitoring. Upon admission to the nursing unit, her symptoms have resolved. There is no facial asymmetry and her complaint of numbness has subsided. Questions 1. The neurologist’s consult report states, “At no time during the episode of numbness did the client ever develop any scotoma, amaurosis, ataxia, or diplopia.” Explain what these terms mean. 2. The neurology consult report includes the following statement: “Client’s diet is notable for moderate amounts of aspartame and no significant glutamate.” What are aspartame and glutamate? Why did the neurologist assess Mrs. Giammo’s intake of aspartame and glutamate? 3. Discuss the pathophysiology of a transient ischemic attack (TIA). Include in your discussion what causes a TIA and the natural course of a TIA. 4. Mrs. Giammo asks, “How is what I had different from a stroke?” Provide a simple explanation of how a transient ischemic attack (TIA) differs from a cerebrovascular accident (CVA, stroke). 5. Discuss the defining characteristics of a transient ischemic attack (TIA). 6. How does Mrs. Giammo’s case fit the profile of the “typical” client with a TIA? 7. Mrs. Giammo has her fasting cholesterol levels checked. How long must Mrs. Giammo fast before the test? 8. Mrs. Giammo’s cholesterol lab work reveals total cholesterol 5 242 mg/dL, low-density lipoprotein (LDL) 5 165 mg/dL, high-density lipoprotein (HDL) 5 30 mg/dL. Discuss the normal values of each and which of her results are of concern and why. CASE STUDY 2 ■ MR S . GI AM M O Questions (continued) 9. When told that her cholesterol levels are elevated, Mrs. Giammo asks, “I always see commercials on television saying you should lower your cholesterol. What is cholesterol anyway?” How could the nurse explain what cholesterol is and why it increases the risk of heart disease and stroke? 10. Identify Mrs. Giammo’s predisposing risk factors for a TIA and possible stroke. Which factors can she change and which factors are beyond her control? 11. Mrs. Giammo takes atenolol at home. What is the most likely reason why she has been prescribed this medication? 12. The nurse hears a carotid bruit on physical assessment. What is a bruit and why is this of concern to the nurse? What would be likely diagnostic procedures ordered by the health care provider because of this assessment finding? 13. If a carotid ultrasound, carotid duplex, and/ or MRA reveals carotid artery stenosis, what surgical procedure can resolve the stenosis? 14. Provide a simple rationale for including intravenous heparin in Mrs. Giammo’s treatment plan. 15. Identify the potential life-threatening adverse effects/complications of heparin therapy and the treatment of heparin toxicity or overdose. 16. To assess for bleeding and possible hemorrhage, explain what the nurse monitors while Mrs. Giammo is on heparin therapy. 17. What is the major complication associated with a TIA? 18. Identify six nursing diagnoses in order of priority appropriate for Mrs. Giammo. 19. Atorvastatin 10 mg PO per day is prescribed for Mrs. Giammo. Explain the therapeutic effects of atorvastatin. 20. What type of lifestyle modifications should the nurse discuss with Mrs. Giammo (and her husband) prior to discharge? 43 This page intentionally left blank CASE STUDY 3 Mr. Aponi GENDER DISABILITY Male ■ Unable to care for himself 85 SOCIOECONOMIC SETTING ■ Lives in a long-term care facility; wife passed away five years ago; he has no children ■ Long-term care ETHNICITY SPIRITUAL/RELIGIOUS ■ Native American CULTURAL CONSIDERATIONS PHARMACOLOGIC ■ Touch; nonverbal behavior LEGAL PREEXISTING CONDITION ■ Progressive dementia over the ETHICAL past seven years COEXISTING CONDITION ALTERNATIVE THERAPY ■ Urinary incontinence PRIORITIZATION COMMUNICATION ■ Impaired communication secondary DELEGATION to altered mental status THE NERVOUS/NEUROLOGICAL SYSTEM Level of difficulty: Easy Overview: This case requires the nurse to distinguish the difference between dementia and delirium and plan nursing care accordingly. How the client’s cultural beliefs impact care is considered. 45 EASY independently due to cognitive decline AGE 46 Part 3 ■ T H E N E RVO U S/ N E U RO LO G ICA L SYSTEM Client Profile Mr. Aponi has a history of dementia. His dementia limits his ability to respond appropriately to questions and at times Mr. Aponi is easily agitated and resistant to nursing care. He refuses to take his medications, spitting them back out, gripping the bedside rail when the nurse tries to turn him, and yelling out for his wife to save him. Case Study Mr. Aponi is an 85-year-old man with a history of dementia. He is a resident of a long-term facility. Mr. Aponi’s frequent incontinence necessitates the development of therapeutic communication to facilitate activities of daily living (ADL) care and frequent skin hygiene. The nurse caring for Mr. Aponi for the first time soon learns that talking slowly and softly is the most effective way of focusing the client’s attention and prompting him to follow basic instructions such as turning side to side. The nurse feels uneasy about speaking to Mr. Aponi as if he were a child in some ways. However, the nurse finds that this manner of speech keeps Mr. Aponi calm and that he responds well to praise and compliments and that he is very helpful to the nurse in assisting with his own care. On the second day of caring for him, the nurse notes that Mr. Aponi is more agitated and needs frequent reorientation regarding where he is. The nurse needs the assistance of another person to hold Mr. Aponi’s arm steady while assessing his blood pressure since Mr. Aponi keeps pulling his arm away yelling “no.” At one point in the day, Mr. Aponi tells the nurse, “There was a little boy in the room a minute ago. Where did he go?” The nurse knows there was not a little boy in the room, but does not know how to respond. The nurse ignores Mr. Aponi’s comment and redirects his attention to what is on television. When saying good-bye to Mr. Aponi at the end of the second day, the nurse is disappointed that Mr. Aponi does not seem to recognize the nurse or remember that the nurse has been caring for him for the past two days. The nurse is saddened to see him so confused and is emotionally exhausted after two days of responding to his frequent changes in behavior. Questions 1. The nurse caring for Mr. Aponi overhears another nurse state, “Well, of course he is confused. He is 85 years old.” How should Mr. Aponi’s nurse respond? 2. Discuss the characteristics that define delirium and dementia. What is the principal difference between the diagnoses of delirium and dementia? 3. Describe the following strategies for caring for a confused client: validation, redirection, and reminiscence. 4. Explain why Mr. Aponi may state, “There was a little boy in the room a minute ago. Where did he go?” Which of the above strategies (in question 3) would be most effective in responding to his statement? 5. What are three nursing diagnoses appropriate for Mr. Aponi’s plan of care? 6. Discuss the importance of nonverbal communication when communicating with a person who is confused and agitated. Consider Mr. Aponi’s ethnicity. CASE STUDY 4 Mrs. Greene GENDER DISABILITY Female SOCIOECONOMIC AGE SPIRITUAL/RELIGIOUS SETTING ■ Hospital PHARMACOLOGIC ETHNICITY ■ Levofloxacin (Levaquin) ■ White American LEGAL CULTURAL CONSIDERATIONS ■ Restraints ETHICAL PREEXISTING CONDITION ALTERNATIVE THERAPY COEXISTING CONDITION ■ Urinary tract infection (UTI) PRIORITIZATION COMMUNICATION DELEGATION ■ Impaired communication secondary to altered mental status THE NERVOUS/NEUROLOGICAL SYSTEM Level of difficulty: Easy Overview: This case requires the nurse to recognize the most likely etiology of an acute change in mental status. Appropriate nursing interventions for a client requiring a physical restraint are considered. 47 EASY 92 48 Part 3 ■ T H E N E RVO U S/ N E U RO LO G ICA L SYSTEM Client Profile Mrs. Greene is a 92-year-old woman who presents to the emergency room with an acute change in mental status and generalized weakness. Her past medical history is unremarkable. She has not had episodes of confusion in the past. Case Study It is determined that Mrs. Greene has a urinary tract infection (UTI) for which she is started on intravenous (IV) levofloxacin (Levaquin). Mrs. Greene’s confusion escalates to visual hallucinations, the pulling out of two IV sites, and restless nights of little sleep. Bilateral soft wrist restraints are prescribed to maintain her safety, the integrity of the IV site, and the Foley catheter. While the nurse is providing care for Mrs. Greene, Mrs. Greene’s son visits. He is very distraught over Mrs. Greene’s state of confusion and her inability to recognize him. Mrs. Greene is unable to answer her son’s questions appropriately and frequently…
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