Medical surgical case studies, nursing diagnoses and interventions

Case Study, Chapter 34, Management of Patients With Hematologic Neoplasms

1. John King, 60 years of age, is a male patient who is admitted with the diagnosis of multiple myeloma. He presents with a spinal fracture of the fifth lumbar vertebrae. The patient is scheduled for a vertebroplasty of the spinal fracture. The patient is to remain on bed rest and should be log rolled. Osteolytic lesions are seen in x-rays of the skull, vertebrae, and ribs. The patient has hypercalcemia. The patient’s uric acid level is elevated. The patient has orders for zoledronic acid (Zometa), thalidomide (Thalomid), allopurinol (Zyloprim), calcitonin, ibuprofen, and Vicodin. (Learning Objective 5)

a.  What nursing management should the nurse provide the patient?

1. Explain the indication and action of the various medications ordered to treat the patient’s symptoms.

2. Susan Clare, age 38, is admitted to the medical oncology unit with acute myeloid leukemia (AML). She has many areas of ecchymosis and petechiae on her skin, as well as generalized pallor. She states she has lost 15 pounds in the last 2 months, and often has a low-grade fever. On physical assessment, you find her liver and spleen to be enlarged on palpation. (Learning Objective 3)

a.  What laboratory results would you anticipate due to her ecchymosis and petechia?

1. Why would it be important to inspect her gums and teeth?

a.  Why is her liver enlarged?

Case Study, Chapter 37, Management of Patients With HIV Infection and AIDS

1. The nurse is planning to provide education on HIV infection transmission and prevention strategies at a local senior center. (Learning Objectives 1 and 4)

a.  What should the nurse include in the session considering the needs of the older population?

2. Sallie Jefferies, 28-year-old patient, is at the obstetric clinic for a pregnancy visit. The physician informs the patient that her HIV screen test is positive. The patient has no evidence of AIDS. The nurse provides patient education regarding what HIV is and what the clinical management entails. (Learning Objective 5)

a. What clinical management is recommended for the patient during the pregnancy to help decrease the risk of transmitting HIV to the unborn child?

1. The patient asks the nurse how zidovudine (Retrovir) will help her unborn child from getting HIV. How should the nurse respond?


2. What explanation about Retrovir should the nurse provide?


3. The patient asks the nurse if it will be safe to breast-feed her infant after the delivery. The nurse should provide what explanation?

a.  The patient asks the nurse what testing schedule for the HIV antibody is needed after her baby is born. How should the nurse respond?

Case Study, Chapter 31, Assessment and Management of Patients With Hypertension

1. 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?

1. 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. 

2. The community health nurse is preparing a program about hypertension for a local community center. The focus of the program is on the reduction of risk factors and compliance for those who have been diagnosed with high blood pressure. The target population includes older adults. (Learning Objectives 1 to 4) 

a.  The nurse focuses on primary hypertension because it accounts for 90% to 95% of hypertension in the United States. What risk factors does the nurse include for this population?

b.  The nurse prepares to discuss the changes in how the JNC 7 defines hypertension. What ranges and descriptions should the nurse include?

c.  Because this is a gerontologic audience, the nurse needs to review why blood pressure increases with age. Explain how the structural and functional changes of aging contribute to higher blood pressure in the older adult.

a.  What information does the nurse include about lifestyle modifications that may decrease risk of hypertension (or complications associated with diagnosed hypertension)?

Case Study, Chapter 23, Management of Patients With Chest and Lower Respiratory Tract Disorders

1. 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 101.5°F. 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, PaO2 55, PaCO250, 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?

1. What diagnostic findings support the diagnosis of pneumonia?


2. What NANDA nursing diagnoses should the nurse formulate for the patient?


3. What goals should the nurse develop for the patient?


4. What overall interventions should the nurse provide?

2. 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?

1. What risk factors does the patient have for a pulmonary embolus?


2. What measures are appropriate to manage a pulmonary embolism?


3. What measures are appropriate to help the patient in this case study prevent the reoccurrence of a pulmonary embolism?

Case Study, Chapter 29, Management of Patients With Complications From Heart Disease

1. George Brown, 72 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 88/50 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. 

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. 

1. What are the actions of furosemide that will help the patient? 


2. What nursing actions should be implemented when administering a diuretic?

2. 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. 

a.  Which of his medications might be contributing to his symptoms of generalized weakness and heart irregularities?

1.  For what clinical manifestations should you assess to correlate to his left-sided heart failure?


2. How do his medications treat his congestive heart failure?


3. How does the hypokalemia affect the effects of Digitalis?

Case Study, Chapter 39, Assessment and Management of Patients With Rheumatic Disorders

1. Ellie Long, a 55-year-old patient, presents to the pain clinic with the diagnosis of fibromyalgia syndrome. The nurse at the clinic obtains a history and physical assessment of the patient. (Learning Objective 2)

a.  On what areas should the nurse concentrate when interviewing the patient during the history process?

1. On what areas should the nurse concentrate when assessing the patient?


2. What diagnostic tests are used with fibromyalgia syndrome?

2. Julie Walker, a 22-year-old patient, is newly diagnosed with systemic lupus erythematosus (SLE). She presented with extreme fatigue; muscle and joint aching and swelling; a butterfly-shaped, flat, red rash across the bridge of the nose; patchy alopecia; a low-grade fever; and loss of appetite. Further workup revealed a positive antinuclear antibodies (ANA) titer, anemia, leucopenia, and mild thrombocytopenia. She has an abnormal lipid profile, proteinuria, and hypertension. The liver and renal profiles are within normal range. The physician ordered over-the-counter ibuprofen as needed for joint discomfort, but not to exceed 1,200 mg/day; hydroxychloroquine sulfate (Plaquenil) before meals at the same time each day; and prednisone in tapering doses over the next month. The physician also started the patient on lisinopril, an ACE inhibitor for the hypertension and a statin for the elevated lipids. The clinic nurse is asked by the physician to provide patient and family education. (Learning Objective 5) 

a.  What teaching-plan topics should the nurse provide for the patient?

HOW TO WRITE:  YOU ARE TO CREATE A PICTURE OF YOUR PATIENT

These are topics for you to consider documenting as applies to your client.

General appearance:

• Affect/behaviour/anxiety


• Level of hygiene


• Body position


• Patient mobility


• Speech pattern and articulation

This is not a specific step. Evaluating the skin, hair, and nails is an ongoing element of a full  body assessment as you work through steps 3-9.

2. Skin, hair, and nails:

• Inspect for lesions, bruising, and rashes.


• Palpate skin for temperature, moisture, and texture.


• Inspect for pressure areas.


• Inspect skin for edema.


• Inspect scalp for lesions and hair and scalp for presence of lice and/or nits.


• Inspect nails for consistency, colour, and capillary refill.

Head and neck:

• Inspect eyes for drainage.


• Inspect eyes for pupillary reaction to light.


• Inspect mouth, tongue, and teeth for moisture, colour, dentures.


• Inspect for facial symmetry.

4. Chest:

• Inspect:
  
  
  
  • Expansion/retraction of chest wall/work of breathing and/or accessory muscle use
  
  
  • Jugular distension
  
  
  
  


• Auscultate:
  
  
  
  • For breath sounds anteriorly and posteriorly
  
  
  • Apices and bases for any adventitious sounds
  
  
  • Apical heart rate/rhythm
  
  
  
  


• Palpate:
  
  
  
  • For symmetrical lung expansion
  
  
  
  


• Breasts

Abdomen/GI:

• Inspect:
  
  
  
  • Abdomen for distension, asymmetry
  
  
  
  


• Auscultate:
  
  
  
  • Bowel sounds (RLQ)
  
  
  
  


• Palpate:
  
  
  
  • Four quadrants for pain and bladder/bowel distension (light palpation only)
  
  
  
  


• Check urine output for frequency, colour, odour.


• Determine frequency and type of bowel movements.

Genitourinary:

    Check urine output for frequency, colour, odour.

    Female: vaginal discharge

    Male: circumcision, discharge

Musculoskeletal:

• Check if full or partial weight-bearing.


• Determine gait/balance.


• Determine need for and use of assistive devices.

Inspect:

• Arms and legs for pain, deformity, edema, pressure areas, bruises


• Compare bilaterally


• Palpate:
  
  
  
  • Radial pulses
  
  
  • Pedal pulses: dorsalis pedis and posterior tibial
  
  
  • CWMS and capillary refill (hands and feet)
  
  
  
  


• Assess handgrip strength and equality.


• Assess dorsiflex and plantarflex feet against resistance (note strength and equality).

Back area (turn patient to side or ask to sit up or lean forward):

• Inspect back and spine.


• Inspect coccyx/buttocks.

Tubes, drains, dressings, and IVs:

• Inspect for drainage, position, and function.


• Assess wounds for unusual drainage.

Sample format for documentation:

General Status

Vital signs

Head, Ears, Eyes, Nose, Throat

Neck

Respiratory 

Cardiac 

Abdomen/GI

GU

Pulses

Extremities

Skin

Neurological 

NURSING CARE PLAN RUBRIC

Include the case study in your document.

Do not write the NCP using a grid format… use an essay format/ bullet point using the numbers of this rubric.

All NCP will be graded according to the following rubric.

1) Definition of the medical diagnosis                        __________10

    etiology/pathophysiology

2) Common signs and symptoms                        ___________5

3) Potential complications                            ___________5

4) Head to toe physical assessment    you are to write one….use the data in the case if there is none you create it as if this was your patient.                                                                                                                                                                                   ____________10

5) Diagnostic and lab studies                            ___________5

    normal values

    expected abnormalities

6) ALL NANDA Nursing diagnoses                                __________10

    www.deanza.edu/faculty/hrycykcatherine/NANDA_2015-2017_list__November_2014.pdf

7) Develop 3 NANDA priority nursing diagnoses                __________10

8) State a patient plan/goal for each of the                     __________10

 priority nursing diagnosis

9) Write interventions for each of                         __________10

    priority nursing diagnosis

10) Write scientific rationales for you you                     ___________5

interventions

11) Write evaluation of your interventions                    __________10

    or make changes

12) List of typical medications                        __________10

    category

    usual dosage

    side effects

    patient teaching