Download Cardiac Case Studies Due: Jan. 22 Scenario #1 (15 questions) M.G.

Cardiac Case Studies
Due: Jan. 22
Scenario #1 (15 questions)
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 every day since her discharge.
1. What error in teaching most likely occurred when M.G. was discharged 10 days
ago?
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 20 mEq/day PO
2. Which of these medications may have contributed to M.G.'s heart failure?
Explain.
3. How do angiotensin-converting enzyme (ACE) inhibitors, such as enalapril
(Vasotec), work to reduce heart failure?
Medication Orders
Enalapril (Vasotec) 5 mg PO bid
Carvedilol (Coreg) 100 mg PO every morning
Glipizide (Glucotrol) 10 mg PO every morning
Furosemide (Lasix) 80 mg IV push (IVP) now, then 40 mg/day IVP
Potassium chloride (K-Dur) 20 mEq/day PO
4. What is the rationale for changing the route of the furosemide (Lasix)?
5. You administer furosemide (Lasix) 80 mg IVP. Identify three parameters you
would use to monitor the effectiveness of this medication.
6. What laboratory tests should be ordered for M.G. related to the order for
furosemide (Lasix)? (Select all that apply.)
a. Magnesium level
b. Sodium level
c. Complete blood count (CBC)
d. Serum glucose levels
e. Potassium level
f. Coagulation studies
7. What is the purpose of the beta-blocker carvedilol? It is given to:
a. Increase the contractility of the heart
b. Cause peripheral vasodilation
c. Increase urine output
d. Reduce cardiac stimulation by catecholamines
The next day, M.G. has shown only slight improvement, and digoxin (Lanoxin) 125
mcg PO daily is added to her orders.
8. What is the action of the digoxin? Digoxin:
a. Causes systemic vasodilation.
b. Promotes the excretion of sodium and water in the renal tubules.
c. Increases cardiac contractility and cardiac output.
d. Blocks sympathetic nervous system stimulation to the heart.
9. Which findings from M.G.'s assessment would indicate an increased possibility
of digoxin toxicity? Explain your answer.
a. Serum potassium level of 2.2 mEq/L
b. Serum sodium level of 139 mEq/L
c. Apical heart rate of 64 beats/minute
d. Digoxin level 1.6 ng/mL
10. When you go to give the digoxin, you notice that it is available in milligrams
(mg) not micrograms (mcg). Convert 125 mcg to mg.
11. M.G.'s symptoms improve with IV diuretics and the digoxin. She is placed back
on oral furosemide (Lasix) once her weight loss is deemed adequate to achieve
a euvolemic state. What will determine whether the oral dose will be adequate
to consider her for discharge?
12. M.G. is ready for discharge. Using the mnemonic MAWDS, what key
management concepts should be taught to prevent relapse and another
admission?
13. MG asks you how beta-blockers work. How would you answer her in a way
that is factual yet understandable?
14. MG next asks you why she can take an ace inhibitor but her sister developed a
cough. How would you answer her in a way that is factual yet understandable?
15. Your professor asks you to explain to the class (in your own words) the
difference between systolic and diastolic HF.
Scenario #2 (16 Questions)
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 three grown children.
As you take his health history, he tells you that he began feeling changes in his chest
about 10 days ago. He was diagnosed with hypertension (HTN) 8 years ago and a 5-year
history of angina pectoris. Other risk factors include his smoking history of a pack/day
X40 years and he mentions that his father suffered a myocardial infarction when he was
65.
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 (SL) 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 (RCA) and 50% stenosis of the left
anterior descending (LAD) coronary artery. He also tells you that both his mother and
father had coronary artery disease (CAD). He is currently taking amlodipine (Norvasc),
metoprolol (Lopressor), atorvastatin (Lipitor), and aspirin 81 mg/day.
1. Why do you think that these medications are ordered? What are the actions of
each of these medications?
2. Explain how you would complete an efficient, thorough cardiac assessment.
3. What are common sites for radiation of ischemic cardiac pain?
4. What are less common sites for ischemic cardiac pain?
G.P.’s provider told him that he is at risk for developing Acute Coronary Syndrome
(ACS).
5. Describe the pathophysiology of ACS?
6. How do men and women differ in c/o cardiac chest pain?
7. You know that G.P. has atherosclerosis of the coronary arteries. You need to
know his risk factors for CAD in order to plan teaching for lifestyle
modifications. What will you ask him about?
8. G.P asks you to explain the difference between stable angina and unstable angina.
How would you explain this to him?
9. Although he has been taking 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. Stop the activity and lie or sit down.
b. Call 911 immediately.
c. Call 911 if the pain is not relieved after taking one SL tablet.
d. Call 911 if the pain is not relieved after taking three SL tablets, 5 minutes apart.
e. Chew the tablet slowly then swallow.
f. Place the NTG tablet under the tongue.
10. What other information would you need to ensure in order to determine if he
understands the side effects and storage of SL NTG?
CASE STUDY PROGRESS
When you first admitted G.P., you placed him on telemetry and observed this cardiac
rhythm.
11. You identify the rhythm as ___________
12. Based on your above interpretation of this rhythm strip, prioritize your actions (be
specific).
The provider orders Cardiac biomarkers to be drawn on G.P.
13. Identify and explain what biomarkers are and why they are measured in all
patients who present with chest discomfort consistent with acute coronary
syndrome (ACS).
The doctor orders the medication diltiazem [Cardizem] 15 mg IV over 2-minutes
followed by a diltiazem drip between 5 to 15 mg per hour - titrated to keep the
ventricular rate < 90.
14. What type of medication is diltiazem and why was it ordered?
15. After several days, G.P. was taken off the diltiazem drip, placed on oral diltiazem
SR 60mg twice a day. G.P.’s rate is “controlled” at a rate of 66 beats/min,
irregular and has been ordered to begin anti-coagulant therapy (warfarin) prior to
discharge. His cardiac biomarkers were negative. What medications would you
anticipate G.P. going home on?
16. What are the important teaching aspects and follow up care prior to discharge for
G.P.?
NCLEX Questions:
1. A nurse is assessing an electrocardiogram rhythm strip. The P waves and QRS
complexes are regular. The PR interval is 0.16 second, and QRS complexes
measure 0.06 second. The overall heart rate is 64 beats per minute. The nurse
assesses the cardiac rhythm as:
a.
b.
c.
d.
Normal sinus rhythm
Sinus bradycardia
Sick sinus syndrome
First-degree heart block
2. A nurse notices frequent artifact on the ECG monitor for a client whose leads are
connected by cable to a console at the bedside. The nurse examines the client to
determine the cause. Which of the following items is unlikely to be responsible
for the artifact?
a.
b.
c.
d.
Frequent movement of the client
Tightly secured cable connections
Leads applied over hairy areas
Leads applied to the limbs
3. A nurse is watching the cardiac monitor and notices that the rhythm suddenly
changes. There are no P waves, the QRS complexes are wide, and the ventricular
rate is regular but over 100. The nurse determines that the client is experiencing:
a.
b.
c.
d.
Premature ventricular contractions
Ventricular tachycardia
Ventricular fibrillation
Sinus tachycardia
4. A nurse is caring for a client with unstable ventricular tachycardia. The nurse
instructs the client to do which of the following, if prescribed, during an episode
of ventricular tachycardia?
a.
b.
c.
d.
Breathe deeply, regularly, and easily.
Inhale deeply and cough forcefully every 1 to 3 seconds.
Lie down flat in bed
Remove any metal jewelry
5. A client is having frequent premature ventricular contractions. A nurse would
place priority on assessment of which of the following items?
a.
b.
c.
d.
Blood pressure and peripheral perfusion
Sensation of palpitations
Causative factors such as caffeine
Precipitating factors such as infection
6. A client has developed atrial fibrillation, which a ventricular rate of 150 beats per
minute. A nurse assesses the client for:
a.
b.
c.
d.
Hypotension and dizziness
Nausea and vomiting
Hypertension and headache
Flat neck veins
7. A nurse is watching the cardiac monitor, and a client’s rhythm suddenly changes.
There are no P waves; instead there are wavy lines. The QRS complexes measure
0.08 second, but they are irregular, with a rate of 120 beats a minute. The nurse
interprets this rhythm as:
a. Sinus tachycardia
b. Atrial fibrillation
c. Ventricular tachycardia
d. Ventricular fibrillation
8. A client with rapid rate atrial fibrillation asks a nurse why the physician is going
to perform carotid massage. The nurse responds that this procedure may stimulate
the:
a.
b.
c.
d.
Vagus nerve to slow the heart rate
Vagus nerve to increase the heart rate; overdriving the rhythm.
Diaphragmic nerve to slow the heart rate
Diaphragmic nerve to overdrive the rhythm
9. A nurse notes that a client with sinus rhythm has a premature ventricular
contraction that falls on the T wave of the preceding beat. The client’s rhythm
suddenly changes to one with no P waves or definable QRS complexes. Instead
there are coarse wavy lines of varying amplitude. The nurse assesses this rhythm
to be:
a.
b.
c.
d.
Ventricular tachycardia
Ventricular fibrillation
Atrial fibrillation
Asystole
10. While caring for a client who has sustained an MI, the nurse notes eight PVCs in
one minute on the cardiac monitor. The client is receiving an IV infusion of D5W
and oxygen at 2 L/minute. The nurse’s first course of action should be to:
a. Increase the IV infusion rate
b. Call the RRT
c. Increase the oxygen concentration
d. Administer a prescribed analgesic
11. When ventricular fibrillation occurs in a CCU, the first person reaching the client
should:
a.
b.
c.
d.
Administer oxygen
Defibrillate the client
Initiate CPR
Administer sodium bicarbonate intravenously
12. What criteria should the nurse use to determine normal sinus rhythm for a client
on a cardiac monitor? Select all that apply.
a.
b.
c.
d.
e.
The RR intervals are relatively consistent
One P wave precedes each QRS complex
Four to eight complexes occur in a 6 second strip
The ST segment is higher than the PR interval
The QRS complex ranges from 0.12 to 0.20 second.
13. When auscultating the apical pulse of a client who has atrial fibrillation, the nurse
would expect to hear a rhythm that is characterized by:
a.
b.
c.
d.
The presence of occasional coupled beats
Long pauses in an otherwise regular rhythm
A continuous and totally unpredictable irregularity
Slow but strong and regular beats