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Please find in the following:
1. The Scenarios that were posted on the discussion board with Mrs. Wolfe’s input by reply
2. The questions that Mrs. Wolfe posted on the discussion board and John Stell’s answers
3. Mrs. Wolfe’s last follow up to address loose ends that needed clarification for the exam
Scenario One:
A female client, 57 years of age, is admitted to the emergency department (ED) with a diagnosis of heart
failure. 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
admission. She reports she has been gaining 1 to 2 lbs every day since her discharge.
1A) What error in teaching most likely occurred when the patient was discharged 10 days ago?
The patient should be on a diuretic along with the fluid and sodium restriction. The diuretic should be
taken at the same time every day, and not discontinued just because she "feels better". She may also be
on ACE inhibitors, Beta blockers, or CCB. Also pt. teaching over which foods are high in sodium, ie...
pickles, processed foods. Not to just avoid "table salt". Also patient should know that foods can increase
fluid intake as well, such as melons, grapes, and ice. Pt. should have been taught to notify her physician
of the weight gain or any swelling in her arms and legs, prior to becoming symptomatic. Also encourage
periods of rest between ADL's. Reporting her daily weight would have really helped out!! If she had
caught this a day or 2 after her discharge, she wouldn't be in such bad shape.
The client had been taking furosemide (Lasix) 40 mg PO daily. The doctor changes her dose to 80
mg IV push twice daily.
1B) Identify several strategies you would use to monitor effectiveness of this medication. Monitor
Strict I/O, Monitor patients weight daily at the same time everyday, monitor for peripheral edema,
Auscultate lung sounds for diminished crackles and decreased shortness of breath. Also you need to
monitor serum electrolytes of this patient during diuretic therapy, especially potassium
Scenario Two: Your client is a 70 yr-old retired bus driver who has just been admitted to your floor with a
right leg DVT. He has a 48-pack-year smoking history but states he quit 2 years ago. He has had
pneumonia several times and has frequent bouts of A-fib. His history includes two previous DVTs. Two
months ago he began experiencing shortness of breath on exertion and noticed swelling of his right lower
leg that became progressively worse until it involved his thigh to groin. His wife brought him in because
of complaints of increasingly severe leg pain. A Doppler study indicated probable thrombus of the
external iliac vein extending distally to the lower leg. He is admitted for bed rest and heparin therapy.
His lab values are PT 12.4 second and INR 1.11 (Both low: we prefer for the INR to be 2.5-3.0) PTT 25
seconds (also low) H/H 13.3 & 38.9, cholesterol 206 mg/dl. BMP is normal
2A) Identify problems in this client’s history that represent his personal risk for DVT. Increased
age, previous occupation, history of smoking, previous DVT’s, SOB, Swelling of lower right leg, history of
pneumonia and frequent bouts of A-fib
2B) Based on his history, this client should have been taking an important medication. What is it,
and why should he be on it? Coumadin as antiplatelet therapy, Digoxin to treat dysrhythmias and to
prevent clotting
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Mrs. Wolfe’s Reply
Exactly right! Another issue is his high cholesterol. We know his blood flow isn't good. So that will make
him at increased risk for stasis of blood.
He definitely needs to be on Coumadin. Once you have had more than one DVT, the physician most
likely will prescribe Coumadin for several years - life.
2C) Any signs of complications from anticoagulation therapy such as: Unusual bleeding (
nosebleed, bleeding gums, red or cola colored urine, black bowel movements, skin ulcers)
bruises. Lung sounds, pedal pulses, limb pain, swelling, redness, warmth, and difference in leg
circumference, tenderness to touch, respiratory rate, 02 sats and heart rate.
Mrs. Wolfe Reply
Yes! We are concerned about all the effects of Coumadin, worried about risk/side effects of the present
DVT, and really watching to make sure he doesn't develop a P.E.
This pt might need an IVC filter. He is on his third DVT and has so many risk factors. It sure wouldn't
hurt. I would really like ya'll to think about your antiplatelet and clot busting meds. Think about risks,
special considerations during care, and what can be done if a patient receives too much of a particular
drug.
Scenario 3
You are assigned a 76 year-old female client. Two nights before her admission to your cardiac unit, she
awoke with heavy substernal pressure accompanied by epigastric distress. The pain was reduced
somewhat when she rolled onto her side but did not completely subside for about 6 hours. The next night
she experienced the same chest pressure. The following morning her husband brought her to the ER
and she was hospitalized to rule out a myocardial infarction (MI).
3A) What steps will be taken to evaluate if her chest pain is due to a cardiac problem?
EKG, Lab work: Calcium, Magnesium and Potassium levels as well as CK levels, WBC and Triponin
levels. Check O2 sats. Auscultate heart sounds, Extensive health history including medication list and
previous cardiac issues. So if the ECG showed cardiac problems then from least invasive to most
invasive I think it would go: ECG--> Cardiac cath (to look for blockage and if blockage found)--> then a
PCI( percutaneous coronary intervention)of either a PTCA( percutaneous transluminal coronary
angioplasty) to balloon artery and grab plaque, and if plaque present then stent placed on the spot
(coronary artery stent).Then if artery very occluded -->CABG.
Mrs. Wolfe Reply
Yes, great answers. Now on question 3A) lets take it a step further. Let's say that all of these indicators
are pointing toward a cardiac problem. Going from least invasive to most invasive, what tests/procedures
can we anticipate??
3B) What interventions should we begin immediately?
Vital signs, Oxygen if needed, get order for aspirin or Nitro, blood tests: CK triponin and get
EKG. Morphine would also be given to promote vasoDILATION;) and reduce the workload of the heart.
The ASA should be enteric coated to prevent GI upset.
Mrs. Wolfe Reply
3B answers are right on the mark too. One other medication was left out. Think about the meds I
mentioned in class.
Also, would the aspirin be coated or non-coated?
Morphine would also be given to promote vasoDILATION;) and reduce the workload of the heart. The
ASA should be enteric coated to prevent GI upset
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A thorough assessment and health history are performed. Her vitals are 132/86, 88, 18, and 97.9.
She has moderate edema of both ankles and peripheral pulses are 1+. She has a soft systolic
murmur. She denies any discomfort at this time. She has no history of smoking or alcohol use,
good general health except for osteoarthritis of her hands, knees, and spine. She takes Protonix,
ibuprofen for joint and bone pain, and some “herbs”.
3C) Why are we concerned about her murmur and edema?
We are concerned that her murmur and edema are related due to the possiblity of mitral valve
dysfunction. This maybe the result of ischemia to the papillary muscles resulting in acute mitral
insufficiency. Which in turn could lead to congestive heart failure.
Mrs. Wolfe Reply
Additional possibility of symptoms could be aortic stenosis, the contributing factors could be her age. Her
age could cause calcific aortic stenosis, causing CHF and coronary symptoms.
3D) What other sources, besides cardiac ischemia, might be responsible for her chest
pain/abdominal discomfort? (think of a couple)
The herbal supplements maybe a contributory factor in her symptoms either masking them or
exererbating them. She might have a hiatal hernia in addition to her GERD. She may have been
misdiagnosed with GERD, since she was taking Protonix on admission. Her cardiac issues maybe worse
than orginally thought if her GERD was misdiagnosed and the cardiac portion of her disease was missed.
AT 76 yrs old, her peripheral pulses are at 1+, her edema is moderate (2+?), her ejection fracture may be
down or she could have PVD. In our 70's we start getting calicum deposits in our peripheral vasculature.
She takes very little medication and would be considered to be in good health with her age. Treatment
suggestions (not that we would offer one to a Dr. without being asked!) would be digixon and lasix to help
contractility and fluid retention.
Mrs. Wolfe’s Reply
Given her age the murmur and edema are warning signs for heart failure.
The chest pain could definitely be due to GI distress itself or possibly d/t her chronic use of NSAID
medications. They can really irritate the GI lining! Another consideration could be that she is having bone
pain in her rib or sternal area. She does have a history of osteoarthritis.
Scenario Four:
A 46 year old male client with a history of familial hyperlipidemia presents to the medical clinic. He states
he used to smoke 2 packs of cigarettes a day but has cut back to 1 pack a day over the past 2 months.
He has recently begun walking his dog twice a day because “it’s good for the dog and my doctor says it’s
good for me too.” However, he states he cannot make it as far as he used to. He complains of pain to
his right calf that starts after only a couple minutes of walking. Once he goes inside and sits down the
pain goes away.
4A. What is the medical term for this symptom?
- Peripheral Arterial Disease: Intermittent Claudication
4B What disease process is this an indicator of?
- This may reflect femoral or popliteal artery ischemia
4C Name some symptoms of progression of this disease?
- Cyanosis, gangrenous changes, loss of hair, ulcerations and with severe ischemia pain persists at rest.
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Scenario Five:
A 68 year old female client is three days post-op bypass. She has done well today by walking in the hall
twice, showering, and sitting up in the chair for meals. She has had no arrhythmias and is 98% on
2LNC. She has had very few complaints.
At 1430 you are called to her room. She complains "I can't catch my breath." You note that her
respirations are labored and she is tachypnic with a rate of 32.
5A) What should you do next?
Apply oxygen
You note an irregular rhythm with absence of a P-wave on the monitor. Her heart rate is 143
beats per minute. She states "My heart is racing. I'm scared."
5B) What rhythm do you believe she is in?
Atrial Fibrillation
5C) What complications may arise if she maintains this rhythm?
If the heart is in atrial fibrillation then the blood can pool in the left atrium which can form a clot. The clot
can then be pumped into the left ventrical and travel out of the heart and into other areas of the body,
such as the brain. The clot could then get stuck and cause a stroke.
Mrs. Wolfe’s reply
Yes, definitely apply O2. But what else??
She is in atrial fibrillation.
She is at risk for mural thrombi and therefore a stroke. What are our other concerns/complications of this
rhythm??
5D) What interventions can be used to alleviate this rhythm?
-Apply O2
-Check ALL Vitals and Pulses
-Call Doctor to inform of situation
-Suggest: EKG, Labs (Mg,K,Ca,PT/INR)
-Ask about meds for:
1)Cordarone or Digoxin to convert back to a regular rhythm
2)Beta-Blockers and CCB
3)Coumadin (to prevent clot formation along the wall of the atria)
AFTER 24 HOURS:
-Cardiovert
-Pacemaker (Extreme)
5E) What do you tell your patient? Explain to her that her heart rate is irregular (HR 143), -Tell her you
are going to call the Doctor
-Keep her informed to help with anxiety b/c the increased HR will be making her feel bad.
Continued….
Mrs. Wolfe’s reply
..
We have to be sure she is resting quietly in bed, get that O2 on her, and start investigating/gathering
assessment data.
Once we get an EKG to confirm the A-fib we will indeed call the Dr. to make him/her aware and seek out
orders. It makes a big difference if a nurse knows what to anticipate. Ya'll have it right. We expect
Cordarone or digoxin immediately. They may add a beta-blocker or CA blocker to decrease the rate. Plus
the B blocker will assist contractility.
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Coumadin will usually be prescribed once we determine the client will not convert. Remember, some
clients live with chronic a-fib. We will just be sure they stay on Coumadin to prevent mural thrombi/stroke.
We will also have to watch them closely. We know that their cardiac output is greatly hindered and
therefore they will suffer all the side effects.
Questions John Stell answered on the Discussion Board that Mrs. Wolfe posted
What are the primary sign and primary symptom of pericarditis? Muffled heart sounds upon
auscultation, JVD, narrowing pulse pressure.
What is pulse pressure? Difference between the systolic pressure and diastolic pressure.
Name some clients who would be at risk for developing a-fib/a-flutter?...previous hx of CAD, cardiac
arrhythmias, post-op CABG...probably more?
What is a common sign of a cardiovascular event in the elderly? Dyspnea; atypical s/sx due to
degeneration of nerve fibers.
What are the major side effects of thrombolytics? Increased bleeding risk, absolute contraindication in
those with concurrent hemorrhagic CVA or hx of the same.
How does morphine decrease preload? Decreases pain and anxiety...relaxes vessels causing
vasodilation and subsequent decrease in preload??
What do you need to assess in a patient that has just had a cardiac cath?...bleeding at the site of the
catheterization, increase the pt's fluid intake to flush out dye.
What are the risk factors of PTCA? Not sure :/...cardiac irritability? Risk of embolus if unable to
"capture" any debris that may be inadvertently dislodged during procedures...I think. Need to read up on it
more.
Do you elevate or dangle legs for peripheral arterial disease? peripheral venous disease? Dangle
for PAD - gravity assists in circulating the poor arterial circulation; elevate for PVD, which will also
facilitate gravity to help blood flow back to the heart.
What is involved in the care of a client immediately following pacemaker placement?....hmm, also
need to read up on it. Monitor for dysrhythmias?
A client with ascites is more likely to have ________ heart failure? Right sided heart failure...back up
of fluid into systemic circulation (including ascites) is the hallmark sign.
From Mrs. Wolfe, her posting for clarification
I've been going over things and found a few points I would like to bring up. I may find even more as the
next couple of days go on and ya'll start to ask me questions.
First off, I hope you kind of got a feel for what questions will be like. They will be similar to those from the
first test. You will be asked to prioritize, meaning: which intervention should be performed first, which
patient should you go take care of first, what assessment are you most concerned about, etc.
Ok, I know AAA was the last thing we covered and we were so, so ready to go. Just realize that we are
concerned when a person's pain is worsening. That makes us fear that the aneurysm is expanding and
rupture may be near. We are going to watch the H/H, BP, mental status, skin tone, etc. very closely. If
we see a drop in the H/H and BP we fear that there is a leak and immediate surgery is our only hope.
On a similar note, I feel like I covered how we care for surgical patients while they are still in the hospital.
However, I don't think I emphasized home care very well at all. This pretty much goes for all the
surgeries we talked about CABG, Valve Replacement, Peripheral Bypasses, AAA, and even Cardiac
Cath to some extent. We really have to teach these people to continue their ambulation and I.S. Really
want to avoid blood clots and pneumonia/atelectasis. They will be restricted on how soon they can drive.
One reason is because they will be on pain meds and won't be with it enough to drive. But, maybe even
more than that, they don't want to be at risk of having and accident and the steering wheel or airbag goes
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flying into their incision. They could suffer major, major damage. Another thing is that they have to watch
lifting. With open hearts, our fear is that they will pull those sternal wires apart. With AAAs and peripheral
bypasses we are worried that the stress of lifting and straining will pop their incision, or even worse, their
new graft open.
Also, I don't remember how much I said about restrictions for those people who have permanent
pacemakers. I remember talking about welding, using a chainsaw, jack-hammer etc. Did I talk about
avoiding heavy magnetic fields. One big issue is that they WILL NOT be able to have MRIs anymore.
We definitely don't want to run the risk of the pacemaker getting sucked out of their chest. As far as
airport security goes, they will need to have a card showing that they have a pacemaker. They will set
off the airport security. I don't believe that it will affect the pacemaker function as long as the wand isn't
held over the pacemaker site for an extended period of time.
I am ready and willing to clear things up for ya'll if you need it. Just let me know!!
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