Critical Thinking Cases In Nursing Answer Key

Each patient is individual in his or her medical history and tolerance for specific medications, so M. may find that her friends are on different medications. 1 Cardiovascular 38 PART 1 MEDICALSURGICAL CASES 13. • Evaluate the effectiveness of his pain medication. Blood can pool inside the atria, and clot formation might occur. • Explore with him the possibility of sending an audiotaped or videotaped message from him to the newlyweds. When you perform your assessment, you find that his apical heart rhythm is regular and his peripheral pulses are strong.

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She is placed back on oral furosemide (Lasix) once her weight loss is deemed adequate to achieve a euvolemic state. Of all of his behaviors, which one is the most significant in promoting cardiac disease? According to the American Heart Association, a smoker’s risk of developing CAD is two to four times higher than that of nonsmokers. Identify the teaching strategy you would use with him. This helps cement their commitment to behavioral change. Inform him that cardiac rehabilitation will help him become more active and do it safely—he might even enjoy it! This is probably the biggest risk factor and affects not only him but also his wife and children’s health (children exposed to cigarette smoke are more likely to have asthma and other diseases). If the wife does the cooking, give her a few lowfat recipes that taste good, and encourage her to swap recipes with other people in cardiac rehab. Help him analyze whether his current techniques are healthy. • The history of his hip pain is consistent with osteoarthritis—the pain does not disappear promptly after exercise, may be associated with changes in the weather, and can vary in intensity. From his history, list two risk factors, and explain the reason they are risk factors. Brown discoloration of the skin and ankle edema are changes found with venous disease. Aspirin acts as a platelet aggregation inhibitor and is used to prevent thromboembolism. P.’s case, his history of CABG and CAD make him a higher risk for other cardiovascular events such as myocardial infarction (MI), cerebrovascular accident (CVA), and pulmonary embolism. His primary care provider discusses these results with him and decides to wait 2 months to see whether his symptoms improve with medication changes and risk factor modification before deciding about surgical intervention. For example, lipid-lowering agents, antihypertensives, and antiplatelet agents, such as clopidogrel (and the aspirin), all help decrease the patient’s risk for cardiovascular and cerebrovascular disease. Exercise will be started slowly and gradually increased. As collateral circulation improves, the distances walked will improve. In addition to risk factor modification, what other measures to improve tissue perfusion or to prevent skin damage should you recommend to S. • Ensure adequate hydration to prevent increased blood viscosity. • He should have called the anticoagulation clinic as soon as possible after the urgent care center visit and alerted his provider of the antibiotic. His provider will monitor him closely before and after surgery. The blood pressure and pulse are slightly elevated, with several possibilities, including worsening of his CAD, HTN, or possibly heart failure (HF). His Hgb and Hct are slightly decreased, and further testing is needed to determine whether an iron deficiency or vitamin B 12 deficiency exists. The biggest problem usually is not added table salt. (If so, have him describe the sputum.) What happens when you wake up at night, “gasping” for breath? How many pillows do you use at night when sleeping? Crackles/wheezes in lungs Assessment findings for left-sided heart failure: 1. Last, patients who are taking digoxin need to have potassium levels monitored as well as periodic digoxin levels. his medications, he looks at the potassium tablet, wrinkles his nose, and tells you he “hates those horse pills.” He tells you a friend of his said he could eat bananas instead. Tell him that sounds good, but to get as much potassium from a banana as he would from the potassium tablet, he would have to eat a 4 foot long bananas every day! would prefer, ask the physician for an order of a different formulation. • Gradually increase and pace your activities to decrease the work requirements and oxygen demand of the heart. He tells you that both his mother and father had coronary artery disease (CAD).

Digoxin level 1.6 ng/m L Answer: A Low potassium levels can increase the potential for digoxin toxicity. Potassium levels should be monitored carefully during digoxin therapy. 125mcg = 0.125mg 1 Cardiovascular 4 PART 1 MEDICALSURGICAL CASES 11. G.’s symptoms improve with IV diuretics and the digoxin. High risk for sudden cardiac death (multiple risk factors such as family history, male); smoking; inactivity (sedentary lifestyle); obesity; stressful lifestyle; HTN; hyperlipidemia; and a high-fat, lowfiber diet 7. and his wife are willing to work on, the one they identify as most important. Inform them that eating low-fat meals does not mean that they have to give up tasty foods. If the chest discomfort is not relieved, give another SL NTG tablet, and wait 5 minutes more. If the chest discomfort is not relieved, have someone else call 911, while you give B. These guidelines reflect the fact that angina pain that does not respond to NTG might indicate that an MI is occurring. It should be noted that patients with advanced or severe arterial occlusive disease would experience pain even at rest. Thick, brittle nails Answers: A, B, D, F Assessment findings for intermittent claudication (peripheral artery disease) include diminished or absent pulses below the level of stenosis; cool or cold extremity; shiny, thin, fragile skin that can be dry and scaly; diminished or loss of hair in a stocking pattern; loss of subcutaneous tissue; nail changes—thick, brittle, slow growing. • Popliteal disease would cause cramping pain in the lower third of his calf. What is the purpose of the daily aspirin listed in his current medication? In addition, instruct him to wear clothes that are easy to remove or pull up or down because blood pressure (BP) cuffs will be placed on both arms and legs. Inform him that the test is painless, takes about 30 minutes, and that he can eat before the test. P.’s ABI results showed 0.43 right (R) leg and 0.59 left (L) leg. receives a prescription for clopidogrel (Plavix) 75 mg daily and is told to discontinue the daily aspirin. It might be helpful to explain how each medication will help with the treatment of PVD. Exercise may improve collateral circulation to the limb. will be instructed to walk to the point of claudication, stop, rest, then resume to walk a little farther. 1 Cardiovascular 20 PART 1 MEDICALSURGICAL CASES 10. • He should have alerted the staff at the urgent care center that he was taking warfarin. The goal is to have him off oral anticoagulation for a minimum amount of time to prevent the possible risk of a clot formation and potential stroke. Holding extra pressure over the injection site might be needed to prevent excessive bleeding; K. You review his morning blood work and initial assessment. As you review these results, which ones are of possible concern, and why? However, the ACE inhibitor retains potassium and can lead to hyperkalemia. Before he leaves the clinic, you want to teach him about lifestyle modifications he can make and monitoring techniques he can use to prevent or minimize future problems. List five suggestions you might make and the rationale for each. Some patients might associate sodium with added salt only. He needs to limit daily sodium intake to 2 to 3 g, and limit daily fluid intake to 2 L. He states, “I just feel crappy all the time.” A cardiac catheterization done several years ago revealed 50% stenosis of the right coronary artery (RCA) and 50% stenosis of the left anterior descending (LAD) coronary artery.

Patients taking beta blockers cannot use normal exercise heart rate recommendations and require special guidelines. is instructed to return to the clinic in 1 week to have her blood work checked. had been complaining of dizziness, which may be caused by orthostatic hypotension. It is especially important to monitor potassium levels; the HCTZ can cause decreased levels, but ACE inhibitors, such as benazepril, can cause potassium levels to increase. • Remind her of the therapeutic goal you worked on with her. Therapeutic goals are individualized; however, these BP readings are improved and at the “prehypertensive” levels, according to the national guidelines. • Review her progress over the past months with her. • Remind her of the necessity of adhering to her treatment plan (because she is doing so well) and to keep checking her BP and taking her medications as directed. She continues to do well on her daily BP drug regimen, with average BP readings of 130/78 mm Hg. 1 Cardiovascular 35 CHAPTER 1 CARDIOVASCULAR DISORDERS CASE STUDY 8 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. His wife brought him to the hospital when he complained of increasingly severe pain in his leg. Venous compromise of affected leg: Assess warmth, redness, pain, edema, Homans’ sign, distal pulses, capillary refill, and baseline calf and thigh girth. Lungs: Assess breath sounds; assess for dyspnea and chest pain. Pulmonary embolism CASE STUDY PROGRESS Your assessment of L. reveals bibasilar crackles with moist cough; normal heart sounds; blood pressure (BP) 138/88 mm Hg; pulse 104 beats/min; 3 pitting edema of right lower extremity; mild erythema of right foot and calf; and severe right calf pain. Why can’t I just get a Coumadin pill to thin my blood? “Your physician prefers the injections over the pills.” d. • Keep right leg elevated without pressure under the knee to promote circulation.

Here are some rules of thumb for exercise: (1) If you are stiff, sore, or exhausted as a result of the exercise, you have done something wrong or have done too much; and (2) if you are out of breath during exercise, you are doing too much. • Interventions, like stress management, might work with some individuals, but studies on the efficacy of these interventions are less convincing. P.’s HCTZ dosage to 12.5 mg PO daily and adds a prescription for benazepril (Lotensin) 5 mg daily. She is also instructed to monitor her BP at least twice a week and return for a medication management appointment in 1 month with her list of BP readings. Why did the internist decrease the dose of the HCTZ? The elderly might be more sensitive to hypotensive effects, and dosage adjustments can help reduce this problem. Both drugs can cause decreased sodium and creatinine levels. She participates in a senior citizens group-walking program at the local mall. When a Doppler study indicated a probable thrombus of the external iliac vein extending distally to the lower leg, he was admitted for bed rest and to initiate heparin therapy. Mental status: Assess for confusion, restlessness, and lethargy. He is awake, alert, and oriented but a little restless. He denies chest pain but does have shortness of breath with exertion. List at least eight assessment findings you should monitor closely for in the development of the complication identified in Question 5. “The enoxaparin will work to dissolve the blood clot in your leg.” Answer: B Enoxaparin takes 3 to 5 hours to reach maximum antithrombotic activity; warfarin (Coumadin) takes 12 to 24 hours for onset and peaks in 1. It takes several days for warfarin to reach an effective anticoagulation level. • Avoid sudden muscle movement of affected limb, which could dislodge a thrombus. What pertinent laboratory values or test results would you expect the physician to order and you to monitor? • Platelet count: Enoxaparin might decrease the platelet count. • CXR: For evaluation of pulmonary and cardiac systems.

It is critical to provide the primary care provider with accurate, timely assessment data after the change from IV to oral diuretic therapy. The most essential aspect of teaching hospitalized patients is to focus on realistic key points. Laboratory Testing (Fasting) Total cholesterol 240 mg/d L HDL 35 mg/d L LDL 112 mg/d L Triglycerides 178 mg/d L 1 Cardiovascular 13 CHAPTER 1 CARDIOVASCULAR DISORDERS CASE STUDY 3 5. ” Which is considered the “good cholesterol,” and why? The HDL (high density lipoprotein) cholesterol is considered the “good” cholesterol because it has protective properties. • Praise his wife for being supportive in helping both of them live a healthier lifestyle. There are many excellent books and magazines available on tasty, low-fat healthy eating. If necessary, teach positive relaxation techniques that he can use when he is on the road. I grew up in a really dysfunctional family where there was a lot of violence. I find myself suddenly awakening at night just to see if he’s breathing.” How are you going to respond? Acknowledge that heart disease in a loved one can be a very frightening thing. stop any activity and sit or lie down because you want to decrease the workload on his heart and decrease his body’s need for oxygen. The pain is related to posture and is not made worse with exertion or relieved with rest. In addition, cigarette smoking can cause transient arterial constriction. P.’s primary care provider has seen him and wants you to schedule the patient for an ankle-brachial index (ABI) test to determine the presence of arterial blood flow obstruction. • Do not use heating pads and hot water bottles—the skin has poor circulation and is subject to injury. Vital Signs Temperature 97.9° F (36.6° C) Blood pressure 142/83 mm Hg Heart rate 105 beats/min Respiratory rate 18 breaths/min Difficulty: Intermediate Setting: Outpatient clinic Index Words: coronary artery disease (CAD), heart failure (HF), laboratory values, medications, therapeutic nutrition Case Study 6 Coronary Artery Disease and Heart Failure 1 Cardiovascular 26 PART 1 MEDICALSURGICAL CASES 2. Also ask about microwave meals, lunch meats, canned foods, fast foods or restaurant foods, and Do you wake up during the night with shortness of breath? Does your heart race at times or flutter, skip beats, pause, or thump? stopped smoking 10 years ago.) Occupational history: This question is critical with respect to smoking history. Digoxin levels must be monitored carefully because digoxin toxicity can lead to serious complications. • Avoid hot or cold environments; both increase cardiac demand. • Are they accompanied by other signs and symptoms (S/S), such as nausea/vomiting (N/V), diaphoresis, shortness of breath, dizziness, weakness, palpitations, or anxiety? Answers: A, C, F SL NTG should be placed under the tongue and allowed to dissolve naturally and not swallowed until the drug is entirely dissolved.

What will determine whether the oral dose will be adequate to consider her for discharge? Using the mnemonic MAWDS, what key management concepts should be taught to prevent relapse and another admission? For those at risk for CAD, the fasting total cholesterol should be below 200 mg/d L, the HDL should be above 40 mg/d L, the LDL should be less than 100 mg/d L, and the triglycerides should be less than 150 mg/d L for men. asks you, “So, how is my ‘good cholesterol’ doing today? Those who smoke a pack of cigarettes per day have more than twice the risk of MI than nonsmokers. What is the highest priority problem that you need to address with B. You may help him change his outlook because this is something he thinks is important. • The American Heart Association, the American Lung Association, and the American Cancer Society all have excellent literature and programs on smoking cessation. Focus your teaching around a low-fat diet to decrease obesity and hyperlipidemia risks. For example, drinking a lot of beer is not a healthy technique. T.’s wife takes you aside and tells you, “I’m so worried for B. I’m so worried I’ll lose him that I have nightmares about his heart stopping. is still uncomfortable, and he has an unopened bottle of sublingual nitroglycerin (SL NTG) tablets. After 5 minutes, which is the appropriate action to take? • Another possible source of hip pain could be pseudoclaudication—this pain is due to neurospinal canal compression. Tobacco use: Smoking is associated with increased serum concentrations of cholesterol. The changes put the individual at increased risk for atherosclerosis and heart disease. 1 Cardiovascular 19 CHAPTER 1 CARDIOVASCULAR DISORDERS CASE STUDY 4 CASE STUDY PROGRESS S. • Avoid exposing the right leg to temperatures less than 70Åã F (21.1Åã C) to prevent vasoconstriction and subsequent reduction of arterial blood flow. 1 Cardiovascular 24 PART 1 MEDICALSURGICAL CASES Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Laboratory Testing Chemistry Sodium 142 m Eq/L Chloride 95 m Eq/L Potassium 3.9 m Eq/L Creatinine 0.8 mg/d L Glucose 82 mg/d L BUN 19 mg/d L CBC WBC 5400/mm 3 Hgb 13 g/d L Hct 41% Platelets 229,000/mm 3 Initial Assessment Complains of increased fatigue and shortness of breath, especially with activity, and “waking up gasping for breath” at night, for the past 2 days. Do you sometimes feel like you can’t get your breath (shortness of breath)? Many foods like chips, peanuts, pizza, pickles, canned soups, turkey dressing, and ham (fill in local or ethnic salt-rich favorites) contain salt. Try to relate salt intake to symptoms that started 2 days ago. Cardiac rhythm: Are you having any strange feelings in your chest (palpitations)? If potassium levels get low, the hypokalemia can make the patient more susceptible to digoxin toxicity. He says he would rather eat a banana every day than take one of those pills. • Tell him there are other ways the physician can order the potassium, such as in a liquid form or a powder form that is dissolved in liquid. • Minimize stress to reduce sympathetic nervous system response to increased workload of the heart. He is currently taking amlodipine (Norvasc), metoprolol (Lopressor), atorvastatin (Lipitor), and aspirin 81 mg/day. What other information are you going to ask about his episodes of chest pain?

HCTZ can increase serum glucose levels and decrease serum magnesium levels. What lab results, if any, are of concern at this time? The serum glucose is slightly elevated over 110 m Eq/L, but note that the elderly can have an increase in the normal range of glucose levels after age 50. She admits she has not done as well with decreasing her salt intake but that she is trying. These are personal characteristics that cannot be altered or controlled. His basic metabolic panel was normal; other laboratory results are listed as follows: ■ Chart View 1. Most risk factors fall within the three categories of Virchow’s triad: Venous stasis: lengthy surgery, immobility, older than age 40, pregnancy, atrial fibrillation, heart failure, obesity, stroke, denervated limb, hip or knee replacement Venous endothelial injury: previous DVT, IV catheter, fractures, chemical injury (e.g., cigarette or tobacco products, elevated glucose), trauma, varicose veins, hypertension Hypercoagulability: malignant neoplasms, dehydration, oral contraceptives, estrogen therapy, sepsis, blood dyscrasias, burns, genetic predisposition (i.e., antiphospholipid syndrome, activated protein C resistance, protein C deficiency, protein S deficiency, antithrombin III deficiency, and factor V Leiden) 2. J.’s history that represent his personal risk factors. • Crackles • Cough • Tachycardia • Restlessness • Dyspnea and tachypnea (occur in 85% of cases) • Sudden pleuritic chest pain (occurs in 74% of cases) • Apprehension • Hemoptysis • Fever • Nausea and vomiting • Cyanosis CASE STUDY PROGRESS L. is placed on 72-hour bed rest with bathroom privileges and given acetaminophen (Tylenol) for pain. 1 Cardiovascular 37 CHAPTER 1 CARDIOVASCULAR DISORDERS CASE STUDY 8 8. • CBC: Used to monitor for blood loss from bleeding that might or might not be evident while L. • D-dimer assay: High levels are associated with thrombotic problems, such as DVT. • Get specific information on the symptoms; verify with the patient the location, quality, intensity, onset, duration, and expression of pain. doesn’t seem to have realistic expectations associated with his recovery, so you explain the following: • He is going to require daily follow-up visits to monitor his status. J.’s son arranges to record the wedding ceremony, and guests at the reception record special greetings for him. He watches the recording daily and points out his favorite parts to the home care nurse every time she visits.

In addition, remember that the HCTZ can cause an increase in glucose levels. She tells you she was recently at a luncheon with her garden club and that most of those women take different BP pills than she does. • Smoking history • Decrease in mobility related to shortness of breath and rheumatoid arthritis • History of atrial flutter/fibrillation • Previous DVT • 70 years of age • Lifetime history of sedentary jobs Laboratory Testing PT 12.4 sec INR 1.11 a PTT 25 sec Hgb 13.3 g/d L Hct 38.9% Cholesterol 206 mg/d L Difficulty: Intermediate Setting: Hospital Index Words: deep vein thrombosis (DVT), atrial fibrillation, atrial flutter, laboratory values, medications, assessment, diagnostic tests, patient education, electrocardiogram (ECG) strip Case Study 8 Deep Vein Thrombosis 1 Cardiovascular 36 PART 1 MEDICALSURGICAL CASES 3. The physician also writes orders for enoxaparin (Lovenox) injections. The order for the enoxaparin reads: Enoxaparin 70 mg every 12 hours subcut . • V/Q scan (ventilation/perfusion lung scan): Used to test for the presence of pulmonary embolism. • Assess and monitor those factors that increase or decrease pain. • Sitting on a plane for several hours, along with the vigorous activity required to make plane changes, is not safe for him at this time. 1 Cardiovascular 39 CHAPTER 1 CARDIOVASCULAR DISORDERS CASE STUDY 9 􀁘 Scenario A. is a 70-year-old retired construction worker who has experienced lumbosacral pain, nausea, and upset stomach for the past 6 months.

You take a nursing history, as indicated in the following. Pack-year is calculated by taking the average number of packs smoked per day times the number of years smoked. Chest pain: If perfusion to the myocardium is decreased, the heart can become ischemic. What is the most serious, life-threatening complication of AAA, and why?

■ Chart View Family History Father died suddenly at age 42 of a myocardial infarction (MI) Mother (still living) had a quadruple coronary artery bypass graft (CABG Å~ 4) at age 52 Past History and Current Medications Metoprolol (Lopressor) 25 mg PO every 12 hours Aspirin (ASA) 325 mg per day PO Simvastatin (Zocor) 20 mg PO every evening Lifestyle Habits Smokes an average of 1ó packs of cigarettes per day (PPD) for the past 20 years Drinks an “occasional” beer, and “a 6-pack every weekend when watching football” Dietary history: High in fried and fast foods because of his traveling Exercise: “I don’t have time to take walks.” General Assessment White Male Weight 235 lb Height 5 ft, 8 in. Blood pressure 148/88 mm Hg Pulse 82 beats/min Respiratory rate 18 breaths/min Temperature 98.4 ° F (36.9 ° C) Difficulty: Beginning Setting: Outpatient cardiac rehabilitation center Index Words: coronary artery disease (CAD), hypertension (HTN), angina, substance abuse, risk factors, family history, obesity assessment, family counseling, crisis management Case Study 3 Coronary Artery Disease: Prevention and Rehabilitation 1 Cardiovascular 12 PART 1 MEDICALSURGICAL CASES 1. In this example, it is 1.5 packs Å~ 20 years = 30 pack-years. There are several risk factors for coronary artery disease (CAD). VS: Hypotension, tachycardia, and tachypnea are signs of hypovolemia or hemorrhagic shock. Rupture of the aneurysm: A ruptured aneurysm (as opposed to one with a slow leak) is usually rapidly fatal. What single problem mentioned in the first paragraph of this case study presents a risk for AAA rupture? • Risk for AAA rupture is evident in the statement, “He hasn’t had a bowel movement for 3 days.” • Straining to have a bowel movement (Valsalva’s maneuver) can cause a profound increase in intra-abdominal pressure that could result in rupture. During your assessment, you notice a pulsation in A.


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