Case study in medical surgical nursing

Clinical Reasoning Cases in Nursing

SEVENTH EDITION

Mariann Harding, PhD, RN, CNE Associate Professor, Department of Nursing, Kent State University at Tuscarawas, New Philadelphia, Ohio

Julie S. Snyder, MSN, RN-BC Lecturer, School of Nursing, Regent University, Virginia Beach, Virginia

Table of Contents

Cover image

Inside Front Cover

Brief Contents

Title page

Copyright

Contributors

Reviewers

Introduction

What Is Clinical Reasoning?

What Is New in This Edition

The “How To” of Case Studies

Acknowledgments

1: Perfusion

Case Study 1

Case Study 2

Case Study 3

Case Study 4

Case Study 5

Case Study 6

Case Study 7

Case Study 8

Case Study 9

Case Study 10

Case Study 11

Case Study 12

Case Study 13

Case Study 14

Case Study 15

Case Study 16

Case Study 17

Case Study 18

Case Study 19

Case Study 20

Case Study 21

Case Study 22

2: Gas Exchange

Case Study 23

Case Study 24

Case Study 25

Case Study 26

Case Study 27

Case Study 28

Case Study 29

Case Study 30

Case Study 31

Case Study 32

Case Study 33

Case Study 34

Case Study 35

Case Study 36

Case Study 37

Case Study 38

Case Study 39

Case Study 40

3: Mobility

Case Study 41

Case Study 42

Case Study 43

Case Study 44

Case Study 45

Case Study 46

Case Study 47

Case Study 48

Case Study 49

Case Study 50

Case Study 51

Case Study 52

Case Study 53

Case Study 54

4: Digestion

Case Study 55

Case Study 56

Case Study 57

Case Study 58

Case Study 59

Case Study 60

Case Study 61

Case Study 62

Case Study 63

Case Study 64

Case Study 65

Case Study 66

5: Urinary Elimination

Case Study 67

Case Study 68

Case Study 69

Case Study 70

Case Study 71

Case Study 72

Case Study 73

Case Study 74

Case Study 75

6: Intracranial Regulation

Case Study 76

Case Study 77

Case Study 78

Case Study 79

Case Study 80

Case Study 81

Case Study 82

Case Study 83

Case Study 84

Case Study 85

Case Study 86

Case Study 87

Case Study 88

7: Metabolism and Glucose Regulation

Case Study 89

Case Study 90

Case Study 91

Case Study 92

Case Study 93

Case Study 94

Case Study 95

Case Study 96

Case Study 97

Case Study 98

Case Study 99

Case Study 100

8: Immunity

Case Study 101

Case Study 102

Case Study 103

Case Study 104

Case Study 105

Case Study 106

9: Cellular Regulation

Case Study 107

Case Study 108

Case Study 109

Case Study 110

Case Study 111

Case Study 112

Case Study 113

Case Study 114

Case Study 115

10: Tissue Integrity

Case Study 116

Case Study 117

Case Study 118

Case Study 119

11: Cognition

Case Study 120

Case Study 121

Case Study 122

12: Infection and Inflammation

Case Study 123

Case Study 124

Case Study 125

Case Study 126

Case Study 127

Case Study 128

Case Study 129

Case Study 130

13: Developmental

Case Study 131

Case Study 132

Case Study 133

Case Study 134

Case Study 135

Case Study 136

14: Reproductive

Case Study 137

Case Study 138

Case Study 139

Case Study 140

Case Study 141

Case Study 142

Case Study 143

15: Mood, Stress, and Addiction

Case Study 144

Case Study 145

Case Study 146

Case Study 147

Case Study 148

Case Study 149

Case Study 150

Inside Front Cover

Brief Contents Chapter 1 Perfusion, 1 Chapter 2 Gas Exchange, 99 Chapter 3 Mobility, 187 Chapter 4 Digestion, 247 Chapter 5 Urinary Elimination, 301 Chapter 6 Intracranial Regulation, 339 Chapter 7 Metabolism and Glucose Regulation, 401 Chapter 8 Immunity, 455 Chapter 9 Cellular Regulation, 483

Chapter 10 Tissue Integrity, 527 Chapter 11 Cognition, 547 Chapter 12 Infection and Inflammation, 561 Chapter 13 Developmental, 593 Chapter 14 Reproductive, 615 Chapter 15 Mood, Stress, and Addiction, 645

Copyright

CLINICAL REASONING CASES IN NURSING, SEVENTH EDITION ISBN: 978-0-323-52736-1

Copyright © 2020 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or

http://www.elsevier.com/permissions
otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Previous editions copyrighted 2016, 2013, 2009, 2005, 2001, 1996.

Library of Congress Control Number: 2018954100

Executive Content Strategist: Lee Henderson Content Development Specialist: Laura Goodrich Publishing Services Manager: Julie Eddy Senior Project Manager: Tracey Schriefer Design Direction: Margaret Reid

Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1

Contributors

Meghan Davis, MSN-Ed, CCRN, RN Registered Nurse, Virginia Beach, Virginia

Jatifha C. Felton, MSN-Ed, APRN, ACNCP-AG, CCRN Critical Care Nurse Practitioner, Chesapeake Regional Healthcare, Chesapeake, Virginia

Sherry D. Ferki, RN, MSN Adjunct Faculty, School of Nursing, Old Dominion University, Norfolk, Virginia

Joanna Van Sant, MSN, RN Clinical Nurse Manager–Oncology Unit, Sentara Northern Virginia Medical Center, Woodbridge, Virginia

Reviewers

Heidi Matarasso Bakerman, RN, BA Nursing, MscN Nursing Instructor, Nursing Vanier College, Montreal, Quebec, Canada

Beverly Banks, MSN, BSN, RN Full Time Faculty, Nursing, Alpena Community College, Alpena, Michigan

Mitzi L. Bass, MPH, MSN, RN Assistant Professor of Nursing, School of Nursing and Health Professions, Baltimore City Community College, Baltimore, Maryland

Michelle Bayard, BSN, RN Teacher, Faculty of Careers and Technology: Nursing Vanier College, Montreal, Quebec, Canada

Diana Lynne Burgess, MSN, RN Nursing Faculty—ADN Program, St. Petersburg College of Nursing, St. Petersburg, Florida

Lacey M. Campbell, MSN, RN Program Coordinator Accelerated LPN to RN Program, Texas County Technical College, Houston, Missouri

Diane Cohen, MSN, RN Professor—Nursing, MassBay Community College, Framingham, Massachusetts

Nicola Eynon-Brown, RN(EC), BNSc, MN, NP, CPNP- PC Professor, School of Baccalaureate Nursing, St. Lawrence College, Brockville, Ontario, Canada

Melissa Marie Fischer, MSN, RN ADN Nursing Faculty, Nursing, Blackhawk Technical College, Janesville, Wisconsin

Victoria A. Greenwood, MSN, MSEd, RN-BC Assistant Professor, Nursing, The Sage Colleges, Troy, New York

Rose A. Harding, MSN, RN Coordinator, Standardized Test

Evaluation Committee, JoAnne Gay Dishman School of Nursing, Lamar University, Beaumont, Texas

Antonea Jackson, PhD (c), MSN, RN CNE Clinical Assistant Professor, Nursing, Prairie View A&M University, Houston, Texas

Llynne C. Kiernan, DNP, MSN, RN-BC Assistant Professor of Nursing, Nursing, Norwich University, Northfield, Vermont

Tonie Metheny, MS, RN, CNE Clinical Instructor, Nursing, Fran and Earl Ziegler College of Nursing, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma

Kathleen S. Murtaugh, MSN, RN, CNA Assistant Professor, Nursing, St. Elizabeth School of Nursing/University of Saint Francis, Lafayette, Indiana

Karen Noss, MSN, RN Professor, Nursing Department, Luzerne County Community College, Nanticoke, Pennsylvania

Alicia Powell, MSN, RNC Clinical Nurse Educator, Women’s Services, Chesapeake Regional Healthcare, Chesapeake, Virginia

Deborah J. Pumo, MS, RN, EdD Nursing Professor, Nursing Department, Illinois Valley Community College, Oglesby, Illinois

Sandra A. Ranck, MSN, RN Program Administrator, Auburn Practical Nursing Program, Auburn Career Center, Concord Township, Ohio

Cherie R. Rebar, PhD, MBA, RN, COI Professor of Nursing, Wittenberg University, Springfield, Ohio

Alicia N. Rose, ACNS-BC, PMHNP-BC, RN-BC, CSAC Psychiatric Nurse Practitioner, Meridian Psychotherapy, Virginia Beach, Virginia

Jane Tyerman, BA, RN, BScN, MScN, PhD Professor, Trent/Fleming School of Nursing, Trent University, Peterborough, Ontario, Canada

Introduction

To provide safe, quality care, nurses need to have well-developed clinical reasoning skills. As new graduates, you will make decisions and take actions of an increasingly sophisticated nature. You will encounter problems you have never seen or heard about during your classroom and clinical experiences. You will have to make complex decisions with little or no guidance and limited resources.

We want you to be exposed to as much as possible during your student days, but more importantly, we want you to learn to think. You cannot memorize your way out of any situation, but you can think your way out of any situation. We know that students often learn more and faster when they have the freedom to make mistakes. This book is designed to allow you to look at how to solve problems and find answers without the pressure of someone’s life hanging in the balance. We want you to do well. We want you to be the best. It is our wish for you to grow into confident, competent nursing professionals. We want you to be very, very good at what you do!

What Is Clinical Reasoning? Clinical reasoning is not memorizing lists of facts or the steps of procedures. Instead, clinical reasoning is an analytical process that can help you think about a patient care issue in an organized and efficient manner. Five steps are involved in clinical reasoning. Thinking about these steps may help you when you work through the questions in your cases. Here are the five steps with an explanation of what they mean.

1. Recognize and define the problem by asking the right questions:

Exactly what is it you need to know? What is the question asking?

2. Select the information or data necessary to solve the problem or answer the question: First you have to ask whether all the necessary information is there. If not, how and where can you get the additional information? What other resources are available? This is one of the most difficult steps. In real clinical experiences, you rarely have all of the information, so you have to learn where you can get necessary data. For instance, patient and family interviews, nursing charting, the patient medical chart, laboratory data on your computer, your observations, and your own physical assessment can help you identify important clues. Of course, information can rapidly become outdated. To make sure you are accessing the most current and accurate information, you will occasionally need to use the Internet to answer a question.

3. Recognize stated and unstated assumptions; that is, what do you think is or is not true? Sometimes answers or solutions seem obvious; just because something seems obvious does not mean it is correct. You may need to consider several possible answers or solutions. Consider all clues carefully and do not dismiss a possibility too quickly. Remember, “You never find an answer you don’t think of.”

4. Formulate and select relevant and/or potential decisions: Try to think of as many possibilities as you can. Consider the pros and cons of the consequences of making each decision. What is the best answer/solution? What could go wrong? This requires considering many different angles. In today’s health care settings, decision making often requires balancing the well- being needs of the patient, the preferences and concerns of the patient and caregiver, and financial limitations imposed by the reimbursement system. In making decisions, you need to take into account all relevant factors. Remember, you may need to explain why you rejected other options.

5. Draw a valid, informed conclusion: Consider all data; then

determine what is relevant and what makes the most sense. Only then should you draw your conclusion.

It may look as if this kind of reasoning comes naturally to your instructors and experienced nurses. You can be certain that even experienced nurses were once where you are now. The rapid and sound decision making that is essential to good nursing requires years of practice. The practice of good clinical reasoning leads to good thinking in clinical practice. This book will help you practice the important steps in making sound clinical judgments until the process starts to come naturally.

What Is New in This Edition The conceptual approach to nursing education is a new way to manage information and help students develop clinical reasoning skills. In this edition, we chose to reorganize the cases in each section by health-illness concepts. Within each section, you will see the basic principles of that concept applied in exemplars, or models of that concept, that cross care settings, the life span, and the health-illness continuum. For example, you may be enrolled in a course that focuses on gas exchange, including risk factors, physiologic mechanisms, assessment, and interventions to promote optimal oxygenation. Based on prevalence and incidence, exemplars such as pneumonia, influenza, and asthma, are used to show how to apply principles across ages and care settings. To ensure that there are cases that cover common exemplars you may see in class, we added over 20 new cases. Like the existing cases, each of these are adaptations of actual scenarios encountered in the clinical setting—there is no better way to learn than from real patients!

Because nurses play a vital role in improving the safety and quality of patient care, you need to learn interventions you will use to deliver safe care and enhance patient outcomes. To help you learn key principles, you will note questions marked with a

. These questions involve scenarios that typically include inherent

risks, such as medication administration, fall and pressure injury reduction protocols, and preventing health care–associated infections.

The “How To” of Case Studies When you begin each case, read through the whole story once, from start to finish, getting a general idea of what it is about. Write down things you have to look up. This will help you move through the case smoothly and get more out of it. How much you have to look up will depend on where you are in your program, what you know, and how much experience you already have. Preparing cases will become easier as you advance in your program.

Acknowledgments

We would like to express our appreciation to the editorial Elsevier staff, especially Laura Goodrich, Lee Henderson, and Tracey Schriefer for their professional support and contributions in guiding this text to publication. We extend a special thanks to our reviewers, who gave us helpful suggestions and insights as we developed this edition.

Mariann’s gratitude goes to those she loves most—her husband, Jeff, and her daughters, Kate and Sarah. She gives a special thanks to her students, colleagues, and patients; each inspire her passion for nursing and education. Lastly, Mariann praises God, who has graciously bestowed more blessings than could ever be imagined.

Julie thanks her husband, Jonathan, for his love, support, and patience during this project. She is grateful for the encouragement from daughter Emily, son-in-law Randy, and parents Willis and Jean Simmons. Julie appreciates the hard work of colleagues Sherry Ferki, Jatifha Felton, Meghan Davis, Joanna Van Sant, Alicia Rose, and Alicia Powell as contributors and reviewers for this edition. She is especially thankful to the students, whose eagerness to learn is an inspiration. Most importantly, Julie gives thanks to God, our source of hope and strength.

1

Perfusion

Case Study 1 Name_________________________________ Class/Group ______________________________ Date ___________

Scenario M.G., a “frequent flier,” is admitted to the emergency department (ED) with a diagnosis of heart failure (HF). She was discharged from the hospital 10 days ago and comes in today stating, “I just had to come to the hospital today because I can’t catch my breath and my legs are as big as tree trunks.” After further questioning, you learn she is strictly following the fluid and salt restriction ordered during her last hospital admission. She reports gaining 1 to 2 pounds (0.5 to 1 kg) every day since her discharge.

1. What error in discharge teaching most likely occurred? 2. An echocardiogram revealed that her ejection fraction (EF) is

30%, but it was 40% a month ago. What is EF, and what does the decreased number indicate?

Case Study Progress During the admission interview, the nurse makes a list of the medications M.G. took at home.

Chart View

Nursing Assessment: Medications Taken at Home

Enalapril (Vasotec) 5 mg PO bid

Pioglitazone (Actos) 45 mg PO every morning

Furosemide (Lasix) 40 mg/day PO

Potassium chloride (K-Dur) 20 mEq/day PO

3. Which of these medications may have contributed to M.G.’s HF? Explain.

4. How do angiotensin-converting enzyme (ACE) inhibitors, such as enalapril (Vasotec), work to reduce HF? Select all that apply.

a. Cause systemic vasodilation b. Increase cardiac contractility c. Reduce preload and afterload d. Prevent the conversion of angiotensin I to

angiotensin II e. Block sympathetic nervous system stimulation to

the heart f. Promote the excretion of sodium and water in the

renal tubules

Case Study Progress After reviewing M.G.’s medications, the cardiologist writes the following medication orders.

Chart View

Medication Orders

Enalapril (Vasotec) 5 mg PO bid

Carvedilol (Coreg) 3.125 mg PO twice daily

Metformin (Glucophage)

500 mg twice daily

Furosemide (Lasix) 80 mg intravenous push (IVP) now, then 40 mg/day IVP

Potassium chloride (K- Dur)

20 mEq/day PO

5. What is the rationale for changing the route of the furosemide (Lasix)?

6. You give furosemide (Lasix) 80 mg IVP. Identify at least 4 parameters you would use to monitor the effectiveness of this medication.

7. What lab tests should be ordered for M.G. related to the order for furosemide (Lasix)? Select all that apply.

a. Sodium level b. Potassium level c. Magnesium level d. Coagulation studies e. Serum glucose level f. Complete blood count

8. What is the reason for ordering the beta blocker carvedilol? a. Increase urine output b. Cause peripheral vasodilation c. Increase the contractility of the heart d. Reduce cardiac stimulation from catecholamines

9. You assess M.G. for conditions that may be a

contraindication to carvedilol. Which condition, if present, may cause serious problems if she takes this medication?

a. Angina b. Asthma c. Glaucoma d. Hypertension

Case Study Progress One day later, M.G. has shown only slight improvement, and digoxin (Lanoxin) 125 mcg PO daily is added to her orders.

10. What is the mechanism of action of digoxin? a. Causes systemic vasodilation b. Increases cardiac contractility and cardiac output c. Blocks sympathetic nervous system stimulation to

the heart d. Promotes the excretion of sodium and water in the

renal tubules 11. Which findings from M.G.’s assessment would indicate an

increased possibility of digoxin toxicity? Explain your answer. a. Digoxin level 1.6 ng/mL (2.05 mmol/L) b. Serum sodium level of 139 mEq/L (138 mmol/L) c. Apical heart rate of 64 d. Serum potassium level of 2.2 mEq/L (2.2 mmol/L)

12. When preparing to give the digoxin, you notice that it is

available in milligrams (mg) not micrograms (mcg). Convert 125 mcg to mg.

13. After 2 days, M.G.’s symptoms improve with intravenous diuretics and digoxin. She is placed back on oral furosemide (Lasix) once her weight loss is deemed adequate for achievement of a euvolemic state. What will determine whether the oral dose will be adequate for discharge to be considered?

14. M.G. is ready for discharge. According to the mnemonic MAWDS, what key management concepts should be taught to prevent relapse and another admission?

15. After the teaching session, the nurse asks M.G. to “teach back” one important concept of care at home. Which statement by M.G. indicates a need for further education? Explain your answer.

a. “I will not add salt when I am cooking.”

b. “I will use a weekly pill calendar box to remind me to take my medicine.”

c. “I will weigh myself daily and tell the doctor at my next visit if I am gaining weight.”

d. “I will try to take a short walk around the block with my husband three times a week.”

Case Study Outcome After M.G. has been at home for 2 days, the STOP Heart Failure Nurse Navigator calls to ask about her progress. M.G. reports that her weight has not increased since she has been home and she is breathing more easily.

Case Study 2 Name _________________________________ Class/Group _____________________________ Date _____________

Scenario M.P. is a 65-year-old African American woman who comes to the clinic for a follow-up visit. She was diagnosed with hypertension (HTN) 2 months ago and was given a prescription for a thiazide diuretic but stopped taking it 2 weeks ago because “it made me dizzy and I kept getting up during the night to empty my bladder.” During today’s clinic visit, she expresses fear because her mother died of a stroke (cerebrovascular accident [CVA]) at M.P.’s age, and M.P. is afraid she will suffer the same fate. She states, “I’ve never smoked and I don’t drink, but I am so afraid of this high blood pressure.” You review the data from her past clinic visits.

Chart View

Family History

Mother, died at age 65 years of CVA Father, died at age 67 years of myocardial infarction (MI) Sister, alive and well, age 62 years Brother, alive, age 70 years, has coronary artery disease (CAD),

HTN, type 2 diabetes mellitus (DM)

Patient Past History

Married for 45 years, 2 children, alive and well, 6 grandchildren Cholecystectomy, age 42 years Hysterectomy, age 48 years

Blood Pressure Assessments

January 2: 150/92 January 31: 156/94 (given prescription for hydrochlorothiazide

[HCTZ] 25 mg PO every morning) February 28: 140/90

1. According to the most recent guidelines from the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, M.P.’s blood pressure (BP) falls under which classification?

2. What could M.P. be doing that is causing her nocturia?

Case Study Progress During today’s visit, M.P.’s vital signs are as follows: BP: 162/102; P: 78; R: 16; T: 98.2°F (36.8 ° C). Her most recent basic metabolic panel (BMP) and fasting lipids are within normal limits. Her height is 5 ft, 4 in (163 cm), and she weighs 110 lb (50 kg). She tells you that she tries to go on walks but does not like to walk alone and so has done so only occasionally.

3. What risk factors does M.P. have that increase her risk for

cardiovascular disease?

Case Study Progress Because M.P.’s BP continues to be high, the provider decides to start another antihypertensive drug and recommends that she try again with the HCTZ, taken in the mornings.

4. According to the JNC 8 national guidelines, describe the drug therapy recommended for M.P. at this time.

5. M.P. goes on to ask whether there is anything else she should do to help with her HTN. She asks, “Do I need to lose weight?” Look up her height and weight for her age on a body mass index (BMI) chart. Is she considered overweight?

6. What nonpharmacologic lifestyle alteration measures might help M.P. control her BP? List 2 examples and explain.

Case Study Progress The provider decreases M.P.’s HCTZ dose to 12.5 mg PO daily and adds a prescription for benazepril (Lotensin) 5 mg daily. M.P. is instructed to return to the clinic in 1 week to have her blood work checked. She is instructed to monitor her BP at least twice a week and return for a medication management appointment in 1 month with her list of BP readings.

7. Why did the provider decrease the dose of the HCTZ? 8. You provide M.P. with education about the common side

effects of benazepril, which can include which of these? Select all that apply.

a. Cough b. Dizziness c. Headache d. Constipation e. Shortness of breath

9. It is sometimes difficult to remember whether one has

taken one’s medication. What techniques might you teach M.P. to help her remember to take her medicines each day? Name at least 2.

10. After the teaching session about her medicines, which statement by M.P. indicates a need for further instructions?

a. “I need to rise up slowly when I get out of bed or out of a chair.”

b. “I will leave the salt shaker off the table and not salt my food when I cook.”

c. “I will call if I feel very dizzy, weak, or short of breath while on this medicine.”

d. “It’s okay to skip a few doses if I am feeling bad as long as it’s just for a few days.”

11. Describe 3 priority problems that will guide M.P.’s nursing care.

Case Study Progress M.P. returns in 1 month for her medication management appointment. She tells you she is feeling fine and does not have any side effects from her new medication. Her BP, checked twice a week at the senior center, ranges from 132 to 136 systolic, and 78 to 82 diastolic.

12. When someone is taking HCTZ and an angiotensin-converting enzyme (ACE) inhibitor, such as benazepril, what lab test results would you expect to be monitored?

Chart View

Laboratory Test Results (Fasting)

Potassium 3.6 mEq/L (3.6 mmol/L)

Sodium 138 mEq/L (138 mmol/L)

Chloride 100 mEq/L (100 mmol/L)

CO2 28 mEq/L (28 mmol/L)

Glucose 112 mEq/L (6.2 mmol/L)

Creatinine 0.7 mg/dL (61.9 mcmol/L)

Blood urea nitrogen (BUN) 18 mg/dL (6.4 mmol/L)

Magnesium 1.9 mEq/L (0.95 mmol/L)

13. What lab test results, if any, are of concern at this time? 14. You take M.P.’s BP and get 138/88. She asks whether these BP

readings are okay. On what do you base your response? 15. List at least 3 important ways you might help M.P. maintain

her success.

Case Study Progress M.P. tells you she was recently at a luncheon with her garden club and that most of those women take BP pills different from the ones she does. She asks why their pills are different shapes and colors.

16. How can you explain the difference to M.P.? 17. During the visit, you ask M.P., “When was your last eye

examination?” She answers, “I’m not sure, probably about 2 years ago. What does that have to do with my blood pressure?” What is your response?

Case Study Outcome M.P. comes in for a routine follow-up visit 3 months later. She continues to do well on her daily BP drug regimen, with average BP readings of 130/78. She participates in group walking program for senior citizens at the local mall. She admits she has not done as well with decreasing her salt intake but says she is trying. She visited an ophthalmologist last week and had no problems except for a slight cataract in one eye.

Case Study 3 Name _________________________________ Class/Group _____________________________ Date _____________

Scenario A.M. is a 52-year-old woman who has gained over 75 lbs (32 kg) over the past 30 years, after the birth of her 3 children. She has a sedentary job that requires sitting at a desk for most hours of the work day. When she is at home, she stays inside because she is afraid to walk by herself in her neighborhood. She lives alone, but her children live in the same city. She has a history of hypertension and states that she does not take her medications regularly. She came to the clinic today stating that she thinks she might have a urinary tract infection. Her weight is 255 lbs (102.5 kg). She is 5 feet, 4 inches tall (162.5 cm) and has a waist circumference of 41 inches (104 cm). Her abdomen is large, nontender, soft, and round. Her blood pressure is 160/104. You review fasting labs results that were drawn a week ago.

Chart View

Laboratory Results

Glucose 170 mg/dL (9.4 mmol/L)

Total cholesterol 215 mg/dL (5.6 mmol/L)

Triglycerides 267 mg/dL (3.0 mmol/L)

HDL 60 mg/dL (1.56 mmol/L)

LDL 116 mg/dL (3.0 mmol/L)

HbA1C 5.9%

1. What is BMI? Calculate A.M.’s BMI and identify her classification based on the results.

2. Does A.M. have type 2 diabetes mellitus? Explain your answer.

Case Study Progress A.M.’s urinalysis is clear, and upon examination she is diagnosed with a vaginal yeast infection. The health care provider discusses A.M.’s condition with her and tells her that in addition to the yeast infection, she has metabolic syndrome and reviews some treatment goals with her. In addition, the HCP reinforces the need for A.M. to take her blood pressure medication regularly. A.M. is visibly upset and has many questions.

3. What is metabolic syndrome? 4. Review A.M.’s history and assessment. What criteria for

metabolic syndrome does A.M. have, if any? 5. What other lifestyle habits will you ask A.M. about during

your assessment? 6. What health problems may result if metabolic syndrome

remains untreated? Select all that apply. a. Stroke b. Diabetes c. Breast cancer d. Heart disease e. Renal disease

Case Study Progress A.M. is given the following prescriptions:

Metformin (Glucophage), 500 mg BID Atorvastatin (Lipitor), 10 mg PO at bedtime Lisinopril (Zestril) 5 mg PO, 1 tablet every morning Fluconazole (Diflucan) 150 mg tablet × 1 dose

7. Explain the purpose of each medication ordered.

8. Which are potential side effects of metformin? Select all that apply.

a. Nausea b. Diarrhea c. Dizziness d. Constipation e. Abdominal bloating

Case Study Progress You take the time to talk to A.M. about her concerns and provide health promotion teaching that includes increasing regular physical activity, weight reduction, and eating a diet low in saturated fats. A.M. tells you she is willing to make changes but that this is a lot of information to take in at this time.

9. She asks, “Why do I have to take a drug for diabetes if I don’t have diabetes?” What is the appropriate answer?

a. “Metformin will prevent you from ever developing diabetes.”

b. “Metformin provides the insulin your body is no longer making.”

c. “Metformin allows you to eat whatever you want and your glucose levels won’t increase.”

d. “Metformin helps your cells to be less resistant to insulin, and, as a result, your glucose levels will decrease.”

10. Explain the role of insulin resistance with metabolic syndrome and metformin’s effect on insulin resistance.

11. Is A.M. at greater risk for coronary artery disease? Explain your answer.

12. A.M. asks you, “Won’t all these pills help me? Why do I need to change how I eat and exercise?” Explain the role of reducing risk factors as part of the treatment for metabolic syndrome.

13. After visiting with the dietitian, you review what A.M. has

learned. You ask her to tell you what food choices would be good for a low-fat diet. Which answer reflects a need for further education?

a. “I will eat more fruits and vegetables.” b. “I will try to eat more chicken and fish.” c. “I can eat red meat as long as I don’t fry it.” d. “I will eat more whole grains, such as whole wheat

bread.”

Case Progress A.M. is referred to a registered dietitian for nutrition education and decides to join the local YMCA for exercise. You teach her how to monitor blood glucose levels at home. She has an appointment to return to the clinic in one month. However, A.M. does not return to the clinic for her appointment. When you call to follow up with her, she agrees to come in a week later. At that time, she tells you that she did not do well with the exercise because it “hurts too much.” She said she tried eating a low-fat diet but that it was difficult to stick to it. She did not check her blood glucose regularly, but told you that when she did check them, her fasting levels were in the “140s to 160s.” Her weight is now 250 lbs (113 kg). She tells you that she feels so discouraged and that she will “never get better.”

14. What resources do you suggest for A.M. at this time?

Case Study Outcome During the next year, A.M. continued to miss appointments, and her weight increased to 272 lbs (123 kg). She was eventually diagnosed with type 2 diabetes mellitus, and at her last visit she asked her HCP about having weight loss surgery.

Case Study 4 Name _________________________________ Class/Group

______________________________ Date ___________

Scenario You are working in the internal medicine clinic of a large teaching hospital. Today your first patient is 70-year-old J.M., a man who has been coming to the clinic for several years for management of coronary artery disease (CAD) and hypertension (HTN). A cardiac catheterization done a year ago showed 50% stenosis of the circumflex coronary artery. He has had episodes of dizziness for the past 6 months and orthostatic hypotension, shoulder discomfort, and decreased exercise tolerance for the past 2 months. On his last clinic visit 3 weeks ago, a chest x-ray (CXR) examination revealed cardiomegaly and a 12-lead electrocardiogram (ECG) showed sinus tachycardia with left bundle branch block. You review J.M.’s morning blood work and initial assessment.

Chart View

Laboratory Results Chemistry

Sodium 142 mEq/L (142 mmol/L)

Chloride 95 mEq/L (95 mmol/L)

Potassium 3.9 mEq/L (3.9 mmol/L)

Creatinine 0.8 mg/dL (70.7 mcmol/L)

Glucose 82 mg/dL (4.6 mmol/L)

BUN 19 mg/dL (6.8 mmol/L)

Complete Blood Count

WBC 5400/mm3 (5.4 x 109/L)

Hgb 11.5 g/dL (115 g/L)

Hct 37%

Platelets 229,000/mm3 (229 x 109/L)

Initial Assessment J.M. reports increased fatigue and shortness of breath, especially with activity, and “waking up gasping for breath” at night, for the past 2 days. Vital Signs

Temperature 97.9° F (36.6° C)

Blood pressure 142/83

Heart rate 105

Respiratory rate 18

1. As you review these results, which ones are of possible concern, and why?

2. Knowing his history and seeing his condition this morning, what further questions are you going to ask J.M. and his daughter?

Case Study Progress J.M. tells you he becomes exhausted and has shortness of breath climbing the stairs to his bedroom and must lie down and rest (“put my feet up”) at least an hour twice a day. He has been sleeping on 2 pillows for the past 2 weeks. He has not salted his food since the provider told him not to because of his high blood pressure, but he admits having had ham and a small bag of salted peanuts 3 days ago. He states that he stopped smoking 10 years ago. He denies having palpitations but has had a constant, irritating, nonproductive cough lately.

3. You think it’s likely that J.M. has heart failure (HF). From his history, what do you identify as probable causes for his HF?

4. You are now ready to do your physical assessment. For each potential assessment finding for HF, indicate whether the finding indicates left-sided HF (L) or right-sided HF (R).

1. Weakness 2. Jugular (neck) vein distention 3. Dependent edema (legs and sacrum) 4. Hacking cough, worse at night 5. Enlarged liver and spleen 6. Exertional dyspnea 7. Distended abdomen 8. Weight gain 9. S3/S4 gallop

10. Crackles and wheezes in lungs

Chart View

Medication Orders

Enalapril (Vasotec) 10 mg PO twice a day Furosemide (Lasix) 20 mg PO every morning Carvedilol (Coreg) 6.25 mg PO twice a day Digoxin (Lanoxin) 0.5 mg PO now, then 0.125 mg PO daily Potassium chloride (K-Dur) 10 mEq tablet PO once a day

Case Study Progress The provider confirms your suspicions and indicates that J.M. is experiencing symptoms of early left-sided heart failure. A two- dimensional (2D) echocardiogram is ordered. Medication orders are written.

5. For each medication listed, identify its class and describe its purpose in treating HF.

6. When you go to remove the medications from the

automated dispensing machine, you see that carvedilol (Coreg CR) is stocked. Will you give it to J.M.? Explain.

7. As you remove the digoxin tablet from the automated

medication dispensing machine, you note that the dose on the tablet label is 250 mcg. How many tablets would you give?

8. Based on the new medication orders, which blood test or tests should be monitored carefully? Explain your answer.

9. When you give J.M. his medications, he looks at the potassium tablet, wrinkles his nose, and tells you he “hates those horse pills.” He tells you a friend of his said he could eat bananas instead. He says he would rather eat a banana every day than take one of those pills. How will you respond?

10. The 2D echocardiogram shows that J.M.’s left ventricular ejection fraction (EF) is 49%. Explain what this test result means with regard to J.M.’s heart function.

Case Study Progress This is J.M.’s first episode of significant HF. Before he leaves the clinic, you want to teach him about lifestyle modifications he can make and monitoring techniques he can use to prevent or minimize future problems.

11. List 5 suggestions you might make and the rationale for each. 12. You tell J.M. that the combination of high-sodium foods he

had during the past several days might have contributed to his present episode of HF. He looks surprised. J.M. says, “But I didn’t add any salt to them!” To what health care professional could J.M. be referred to help him understand how to prevent future crises? State your rationale.

13. After visiting with the cardiac dietitian, you review potential food choices with J.M. Which foods are high in sodium and must be avoided? Select all that apply.

a. Canned soups

b. Cheddar cheese c. Processed meats d. Whole wheat bread e. Fat-free fruit yogurt

14. You also include teaching about digoxin toxicity. When teaching J.M. about the signs and symptoms of digoxin toxicity, which should be included? Select all that apply.

a. Diarrhea b. Visual changes c. Increased urine output d. Loss of appetite or nausea e. Dizziness when standing up

Case Study Outcome J.M.’s condition improves after 5 days of treatment, and he is discharged to home. He has a follow-up appointment with a cardiologist in 2 weeks. He is enrolled in the clinic’s STOP Heart Failure program, and a heart failure nurse navigator will contact him in a few days to check his progress.

Case Study 5 Name _________________________________ Class/Group ______________________________ Date ___________

Scenario It is midmorning on the cardiac unit where you work, and you are getting a new patient. G.P. is a 60-year-old retired businessman who is married and has 3 grown children. As you take his health history, he tells you that he began feeling changes in his chest about 10 days ago. He has hypertension (HTN) and a 3-year history of angina pectoris. During the past week, he has had frequent episodes of mid-chest discomfort. The chest pain responds to nitroglycerin (NTG), which he

has taken sublingually about 8 to 10 times over the past week. During the week, he has also experienced increased fatigue. He states, “I just feel crappy all the time.” A cardiac catheterization done several years ago revealed 50% stenosis of the right coronary artery and 50% stenosis of the left anterior descending coronary artery. He tells you that both his mother and his father had coronary artery disease (CAD). He is currently taking amlodipine (Norvasc), metoprolol (Lopressor), atorvastatin (Lipitor), and aspirin 81 mg/day. He is retired and says that he spends his days watching television, with some occasional yard work. He has gained 25 lb (11.3 kg) since retiring and admits that he is overweight.

1. What other information are you going to obtain about his episodes of chest pain?

2. What are common sites for radiation of ischemic cardiac pain? 3. There are several risk factors for coronary artery disease. For

each risk factor listed, mark whether it is “M” modifiable or “N” nonmodifiable.

a. ___ Age b. ___ Stress c. ___ Gender d. ___ Obesity e. ___ Smoking f. ___ Hypertension g. ___ Hyperlipidemia h. ___ Diabetes mellitus i. ___ Physical inactivity j. ___ Ethnic background k. ___ Excessive alcohol use l. ___ Family history of CAD

4. Based on the history you have so far, circle the modifiable and nonmodifiable risk factors in Question 3 that apply to G.P.

5. Although he has had a prescription for sublingual nitroglycerin (SL NTG) for a long time, you want to be certain he is using it correctly. Which actions are correct when taking SL NTG for

chest pain? Select all that apply. a. Call 911 immediately. b. Stop the activity and lie or sit down. c. Chew the tablet slowly then swallow. d. Place the NTG tablet under the tongue. e. Call 911 if the pain is not relieved after taking 1 SL

tablet. f. Call 911 if the pain is not relieved after taking 3 SL

tablets, 5 minutes apart. 6. You review the use and storage of SL NTG with G.P. Which

statement by G.P. indicates a need for further education? Explain your answer.

a. “I carry the tablets with me at all times.” b. “I will keep the pills in their original brown bottle.” c. “I will not store other pills in the nitroglycerin

bottle.” d. “I will discard any open bottle of nitroglycerin after

a year.”

Case Study Progress When you first admit G.P., you place him on telemetry and observe his cardiac rhythm.

7. Identify the rhythm: