The Cardiovascular System and The Blood Case Study Essay

A comprehensive analysis of the Ms. Fox Case Study: The Cardiovascular System and the Blood.

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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
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Clinical Decision Making: Case Studies
in Medical-Surgical Nursing, Second Edition
Gina M. Ankner, RN, MSN, ANP-BC
Vice President, Career Education and Training
Solutions: Dave Garza
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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?
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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
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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
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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…