- George Brown, 12 years of age, is a male patient who is admitted with the diagnosis of acute pulmonary edema secondary to acute left ventricular heart failure. The patient has a history of coronary artery disease that has been treated medically. The patient is anxious, pale, cold, clammy, and dyspneic. The vital signs are: blood pressure 88150 mm Hg, heart rate 110 bpm, respiratory rate 32 breaths/min, and temperature 97°F. There are bubbling crackles and wheezing throughout the lung fields and the patient is raising frothy blood-tinged clear sputum. The patient’s admission weight is 100 kg. (Learning Objective 4)
a. What first actions should the nurse take and what are the rationales for these actions? The physician ordered furosemide (Lasix) 40 mg IVP STAT. b. What are the actions of furosemide that will help the patient? c. What nursing actions should be implemented when administering a diuretic? - Carl Edwards is a 75-year-old man with congestive heart failure. Having sustained three myocardial infarctions in the last 10 years, he has decreased left ventricular function. Mr. Edwards takes Digoxin. Capoten, Coreg, and Lasix for management of this disease. Today he presents to the emergency department with fatigue, generalized weakness, and feelings of “skipping” heartbeats. Upon arrival, he is placed on the cardiac monitor, his vital signs are assessed, and an IV is inserted. He currently denies chest pain, but is experiencing some shortness of breath, and is placed on 2 L of oxygen via nasal cannula. (Learning Objective 1)
a. Which of his medications might be contributing to his symptoms of generalized weakness and heart irregularities - Carl Edwards is a 75-year-old man with congestive heart failure. Having sustained three myocardial infarctions in the last 10 years, he has decreased left ventricular function. Mr. Edwards takes Digoxin, Capoten, Coreg, and Lasix for management of this disease. Today he presents to the emergency department with fatigue, generalized weakness, and feelings of ‘skipping’ heartbeats. Upon arrival, he is placed on the cardiac monitor. his vital signs are assessed, and an IV is inserted. He currently denies chest pain, but is experiencing some shortness of breath, and is placed on 2 L of oxygen via nasal cannula. (Learning Objective 1)
a. Which of his medications might be contributing to his symptoms of generalized weakness and heart irregularities?
b. For what clinical manifestations should you assess to correlate to his left-sided heart failure? c. How do his medications treat his congestive heart failure? d. How does the hypokalemia affect the effects of Digitalis? Case Study, Chapter 23. Management of Patients With Chest and Lower Respiratory Tract Disorders - Harry Smith, 70 years of age, is a male patient who is admitted to the medical-surgical unit with acute community-acquired pneumonia. He was diagnosed with paraseptal emphysema 3 years ago. The patient smoked cigarettes one pack per day for 55 years and quit 3 years ago. The patient has a history of hypertension, and diabetes controlled with oral diabetic agents. The patient presents with confusion as to time and place. The family stated that this is a new change for the patient. The admission vital signs are as follows: blood pressure 90/50 mm Hg, heart rate 101 bpm, respiratory rate 28 breaths/min, and temperature 101.57. The pulse oximeter on room air is 85%. The CBC is as follows: WBC 12,500, platelets 350,000, HCT 30%, and Hgb 10 g/dL. ABGs on room air are pH 7.30, Pa02 55, PaCO2 50, HCO3 25. Chest x-ray results reveal right lower lobe consolidation, presence of apical bullae, flattened diaphragm, and a small pleural effusion in the right lower lobe. Lung auscultation reveals severely diminished breath sounds in the right lower lobe and absence of breath sounds at the base. The breath sounds in the rest of the lungs are slightly decreased. The patient complains of fatigue and shortness of breath and cannot finish a short sentence before the respiratory rate increases above the baseline and his nail beds and lips turn a bluish tinge and the pulse oximetry decreases to 82%. The patient is diaphoretic and is using accessory muscles. The patient coughs weakly, but he does not raise any sputum. (Learning Objective 3)
a. What nursing assessment findings support the diagnosis of pneumonia? b. What diagnostic findings support the diagnosis of pneumonia? c. What NANDA nursing diagnoses should the nurse formulate for the patient? d. What goals should the nurse develop for the patient? e. What overall interventions should the nurse provide? - Marie Perez, a 53-year-old patient, is day 1 after a gastric bypass. She complains of shortness of breath; her respiratory rate is 30 breaths/min, heart rate is 110 bpm, pulse oximetry 89% on room air, temperature is 100°F, and her blood pressure is 90/50 mm Hg. She complains of feeling anxious and having stabbing chest pain which gets worse with inspiration. She complains that she feels like she is going to pass out or possibly die. (Learning Objective 7)
a. What could possibly be going on with the patient and what measures should the nurse provide immediately? b. What risk factors does the patient have for a pulmonary embolus? c. What measures are appropriate to manage a pulmonary embolism?
d. What measures are appropriate to help the patient in this case study prevent the reoccurrence of a pulmonary embolism? Case Study, Chapter 31. Assessment and Management of Patients With Hypertension - Joan Smith, 55 years of age, is a female patient who presents to the intensive care unit with the diagnosis of intracranial hemorrhage. The patient stopped taking her antihypertensives suddenly because of the cost of the medications and she recently lost her job to outsourcing. The patient is slightly drowsy and complains of a headache and blurred vision. The patient’s blood pressure is 220/130 mm Hg upon presentation. (Learning Objective 6)
a. According to the definitions set by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7), which type of hypertensive crisis is the patient currently experiencing?
b. Describe the treatment goals for handling the hypertensive crisis and apply the goals to the case study. Determine the current mean arterial pressure (MAP) and the goals for treatment.
The physician orders nicardipine hydrochloride (Cardene) 25 mg/250 mL, NS for peripheral IV starting at 2.5 mg/hr, and titrate by 2.5 mg/hr every 15 minutes to reach the goal for the first hour, which is to achieve 25% reduction of the initial MAP. • Call the physician if the dosing range of 15 mg/hr has been reached and the MAP is still not at target goal for the first hour of treatment, or up to four dose increases. • Lower the BP within 6 hours to 160/100 mm Hg. • Adjust the IV rate so that the IV fluids plus the nicardipine IV drip are equal to 100 mL/hr. in total. Call the physician if the IV fluids must go above 100 mL/hr to provide the nicardipine.
c. Explain what rate to set initially for both the nicardipine drip and the NS maintenance fluids.
d. Explain the process of titrating the nicardipine drip for the first hour to achieve the final MAP goal of 25% reduction of the original MAP.
Sample Solution
