Health history
Scenario Identify the Top 3 client areas for the nurse to assess….
| Scenario | Identify the Top 3 client areas for the nurse to assess. |
| 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” non-modifiable.
4. Based on the history you have so far, circle the modifiable and non-modifiable risk factors in Question 3 that apply to G.P.
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
5. Although the client has had a prescription for sublingual nitroglycerin (SL NTG) for a long time, the nurse wants to be certain he is using the medication correctly. Which actions are correct when taking SL NTG for chest pain? Select all that apply. What is the rationale for each answer- add comment in for each correct action?
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. The nurse reviews the use and storage of SL NTG with G.P. Which statement by G.P. indicates a need for further education? Explain your answer next to your answer selection.
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., the nurse places the client on telemetry and observes his cardiac rhythm. The rhythm has periods of faster rates than below.
8. Identify the rhythm: (6 second strip) after answering the questions below to analyze the rhythm.
- Rate: What is the rate?
- Regularity: Is the rate regular or irregular? Measure regularity using R waves.
- P-Wave examination: Is there a P wave before each QRS?
- P to R interval: Measure P to R interval, is it within normal limits? Is it consistent?
- QRS width: Is the QRS narrow or wide? Measure the duration of the QRS complex.
- What is the rhythm?
- What are the nurse’s top 3 responses once the rhythm is confirmed?
9. Explain the primary complication that could occur if this heart rhythm were not treated.
10. Review G.P.’s history. What conditions may have contributed to the development of this dysrhythmia?
11. The nurse reviews G.P.’s lab test results and notes that all of them are within normal range, including troponin and creatinine phosphokinase levels. His potassium level is 4.9 mEq/L. Given this and his current dysrhythmia, what is the likely cause of the symptoms he has been experiencing this past week?
Case Study Progress
Within the hour, G.P. converts with intravenous diltiazem (Cardizem) to sick sinus syndrome with long sinus pauses that cause lightheadedness and hypotension. Sick sinus syndrome is the inability of the heart’s natural pacemaker (sinus node) to create a heart rate that’s appropriate for the body’s needs. It causes irregular heart rhythms (dysthymias).
12. What risks does the new rhythm pose for G.P.? Explain the reasons for your answers
Case Study Progress
Because G.P.’s dysrhythmia is causing unacceptable symptoms, he is taken to surgery and a permanent DDDR pacemaker is placed and set at a rate of 70beats per minute (BPM).
13. What does the code DDDR mean?
14. What is the purpose of DDDR pacing?
15. The pacemaker insertion surgery places G.P. at risk for several serious complications. List 3 potential problems you would monitor when caring for him.
16. G.P. will need some education regarding his new pacemaker. What information will you give him before he leaves the hospital?
18. Describe the teach-back process and the top 3 priorities on living with a pacemaker?
19. G.P. and his wife tell the nurse they have heard that people with pacemakers can have their hearts stop because of microwave ovens and cell phones. Where can you help them find more information? Name 3 resources.
Case Study Progress
After discharge, G.P. is referred to a cardiac rehabilitation center to start an exercise program. He will be exercise tested, and an individualized exercise prescription will be developed for him, based on the results of the exercise test. (NG NCLEX What outcomes demonstrate interventions are working? (Reflecting)
20. What information will be obtained from a graded exercise (stress) test?
21. What is included in an exercise prescription?
Case Study Outcome
G.P. returns in 1 month for a pacemaker check. He reports that he and his wife go for a walk at least 3 times a week at the mall, and he is hoping to start volunteering soon. He has lost 8 lbs. (3.6 kg).
Reflecting/Analysis Compare and contrast the assessment and care among the dysrhythmias.
Using the information including this case, compare and contrast the findings, treatment and care among the dysrhythmias. (NG NCLEX What could it mean? (Noticing/Analyzing).
Example: Under sinus bradycardia, you would check off bradycardia because bradycardia is an assessment finding for this dysrhythmia.
| Client Assessment Findings (above) | Sinus bradycardia | Atrial fibrillation (AF) | Ventricular Tachycardia | |
| Bradycardia
Chest Pain Clammy skin Consciousness change Edema Hypotension Pulse +1 Tachycardia What else would you assess for each rhythm? |
☑
□ □ □ □ □ □ □ |
□
□ □ □ □ □ □ □ □ |
□
□ □ □ □ □ □ □ □ |
|
| Best treatment (medications) | 1. | 1. | 1.
|
|
| Name Top 2 nursing interventions for each
|
1.
2. |
1.
2. |
1.
2. |
| Scenario | Identify the Top 3 client areas for the nurse to assess. |
An 89-year-old female client is admitted to a telemetry unit with a diagnosis of heart failure exacerbation. She reports a medical history of osteoarthritis, chronic renal insufficiency, and coronary artery disease including a myocardial infarction and coronary artery bypass surgery 22 years ago. She is alert and her daughter is at her bedside. The nurse’s initial client assessment findings include:
|
|
| Nursing Action | Potential Heart Failure Complication | Appropriate Nursing Action for each potential heart failure complication |
|
Acute pulmonary edema | |
|
Fatigue | |
|
Hypokalemia | |
|
Cardiac dysrhythmia | |
|
Hypoxemia | |
|
||
|
||
|
||
|
||
|
||
| Example:
Complication |
Example:
Appropriate actions for complication: #3 |
Case Study Progress
The 80-year-old client will be discharged today and will move in with her daughter until she feels well enough to go home alone. Which of the following discharge instructions will the nurse provide the client and her daughter? Select all that apply
- “Weight yourself each day at the same time on the same scale to monitor for fluid retention”
- Contact your primary health care provider if you experience cold symptoms lasting more than 3 days.”
- Exertion can cause another episode of heart failure, so help your mother by assisting her with daily activities.”
- Notify your primary health care provider if you experience shortness of breath or chest pain while resting.”
- “Do not use table salt, avoid salty foods, and read labels on all food items to ensure your diet is low in sodium.”
- “Do not take metoprolol if your heart rate is less than 60 beats per minute.”
- “Heart failure is a chronic condition, so you don’t need to be alarmed when you experience heart palpitations.”
Case Study Progress
The client was discharged 2 weeks ago and is with her daughter for her follow up primary health care provider visit. For each assessment finding, use an X to indicate whether the interventions are Effective (helped to meet expected outcomes), Ineffective (did not help to meet expected outcomes), or Unrelated (not related to the expected outcomes).
| Assessment finding | Effective | Ineffective | Unrelated |
| States that she has had no shortness of breath since hospital discharge | |||
| Has 2+ pitting edema in both ankles and feet | |||
| Blood pressure of 134.76 mm Hg | |||
| Has had no chest pain since hospital discharge | |||
| Reports feeling like she has more energy now when compared with before her hospital stay | |||
| Has new onset fungal skin infection |
| Scenario | Identify the Top 3 client areas for the nurse to assess. |
| A 72-year-old male client is admitted to a telemetry unit after a fall at home. The clients is experiencing severe weakness in his lower extremities and states, “I got out of bed at 0430 this morning, my legs gave out on my way to the bathroom, and I was unable to get up.” Emergency medical services transported the client to the hospital. Past medical history provided by the client includes high cholesterol, aortic valve stenosis, and residual lower extremity muscle pain and weakness secondary to poliomyelitis as a child. He saw his cardiologist and had an echocardiogram completed 3 weeks ago. He also received his influenza and pneumococcal vaccines this year. The client is married and has two adult children. He lives in a single-story home, ambulates with a cane, and completes ADLs independently. His echocardiogram reports moderate heart failure with an ejection fraction (EF) of 38%. The client’s wife provides a list of his current medications, but the list is not complete. Choose the most likely options for the information missing from the paragraph by selecting from the lists of options provided. |
Next GEN NCLEX: What matters most? Noticing, Tanner’s Clinical Judgement model |
| Medication | Dose, Route, Frequency | Drug Class | Indication |
| aspirin | 1 | Salicylate | Prevention of platelet aggregation |
| Atorvastatin | 20 mg orally once a day | Statin | 2 |
| 3 | 12.5 mg orally twice a day | Beta-adrenergic blocker | Management of hypertension and heart failure |
| Ibuprofen | 400 mg orally every 6-8 hr as needed | Nonsteroidal anti-inflammatory drug | 4 |
| 5 | 0.125 mg orally once a day | Cardiac glycoside | Increase myocardial contractile force |
| lisinopril | 2.5 mg orally once a day | 6 | Management of heart failure |
| Options for 1 | Options for 2 | Options for 3 |
| 0.25 mg orally twice a day | Management of angina | carvedilol |
| 81 mg orally every 4-5 hr as needed for pain | Treatment of bronchospasm | hydrochlorothiazide |
| 200 mg subcutaneously every 8 hours | Management of heart failure | furosemide |
| 325 mg orally once a day | Management of hyperlipidemia | nesiritide |
| 1000 mg transdermal patch every 2 days | Prevention of pulmonary hypertension | verapamil |
| Options for 4 | Option for 5 | Option for 6 |
| Treatment for decreased cardiac output | enalapril | Aldosterone antagonist |
| Prevention of dyspnea | spironolactone | Angiotensin-converting enzyme inhibitor |
| Management of extremity pain | digoxin | Calcium channel blocker |
| Treatment of pyrexia | losartan | Histamine blocker |
| Prevention of tachycardia | metroprolol | Thiazide diuretic |
Case Study Progress
After completing the medication reconciliation with the patient’s wife, the nurse completed the initial assessment. The nurse’s findings include:
- Alert and oriented
- Blurred vision
- Reports lower extremity stiffness; Ambulates with crutches
- Sinus rhythm with preventricular contractions (PVCs); Cardiac murmur
- Reports dyspnea on exertion; Bilateral basilar crackles
- Blood urea nitrogen (BUN) = 11 mg/dL and Creatinine kinases 1200 U/L
- Potassium 5.3 mg/dL
Case Study Progress
The provider arrives to the telemetry unit to discuss the diagnosis and plan with the patient and wife. The client is diagnosed with rhabdomyolysis. Prescriptions to place a large-bore intravenous catheter and administer normal saline 0.9% at 125 mL/hr are received. Choose the most likely options for the information missing from the paragraph by selecting from the lists of options provided.
When caring for a client who has left ventricular dysfunction, the nurse assesses for _____1_____ related to inadequate cerebral perfusion, _____2______ related to inadequate myocardium perfusion, and _____3______
related to inadequate renal perfusion. The nurse monitors a client who has heart failure closely for complications of pulmonary congestion when administering intravenous fluids. Manifestations of pulmonary congestion include _____4_____, _____5_____, and _____6_____. If the client experiences acute pulmonary edema, the nurse would place the client in a sitting position and administer _____7_____ and _____8_____.
| Options for 1, 2, and 3 | Options for 4, 5, and 6 | Options for 7 and 8 |
| Confusion | Crackles | Albuterol nebulizer |
| Chest pain | Dyspnea | chest percussion |
| nausea | Fatigue | Lorazepam orally |
| oliguria | Jugular vein distention | Morphine intravenous push |
| orthopnea | Stridor | Nitroglycerin sublingual |
| pallor | Tachypnea | Supplemental oxygen |
| polyuria | Weight gain | Furosemide intravenous push |
Leave a Reply
Want to join the discussion?Feel free to contribute!