Clinical Reasoning Cases in Nursing
Mariann Harding, PhD, RN, CNE Associate Professor, Department of Nursing, Kent State University at Tuscarawas, New Philadelphia, Ohio
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Julie S. Snyder, MSN, RN-BC Lecturer, School of Nursing, Regent University, Virginia Beach, Virginia
Table of Contents
Inside Front Cover
What Is Clinical Reasoning?
What Is New in This Edition
The “How To” of Case Studies
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
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
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
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
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
Case Study 131
Case Study 132
Case Study 133
Case Study 134
Case Study 135
Case Study 136
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
CLINICAL REASONING CASES IN NURSING, SEVENTH EDITION ISBN: 978-0-323-52736-1
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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
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
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.
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.
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.
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
Case Study Progress After reviewing M.G.’s medications, the cardiologist writes the following medication orders.
Enalapril (Vasotec) 5 mg PO bid
Carvedilol (Coreg) 3.125 mg PO twice daily
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.
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
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?
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
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.
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)
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
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.
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)
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
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
Case Study Progress When you first admit G.P., you place him on telemetry and observe his cardiac rhythm.
7. Identify the rhythm:
(From Ignatavicius DD, Workman ML. Medical-Surgical Nursing, ed. 6, St. Louis, MO: Saunders; 2010.)
8. Explain the primary complication that could occur if this heart rhythm were not treated.
9. Review G.P.’s history. What conditions may have contributed to the development of this dysrhythmia?
10. You review G.P.’s lab test results and note that all of them are within normal range, including troponin and creatinine phosphokinase levels. His potassium level is 4.7 mEq/L (4.7 mmol/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.
11. 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 70.
12. What does the code DDDR mean? 13. What is the purpose of DDDR pacing? 14. The pacemaker insertion surgery places G.P. at risk for several
serious complications. List 3 potential problems you would monitor for as you care for him.
15. G.P. will need some education regarding his new pacemaker. What information will you give him before he leaves the hospital?
16. G.P. and his wife tell you 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?
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.
17. What information will be obtained from a graded exercise (stress) test?
18. 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).
Case Study 6 Name _________________________________ Class/Group ______________________________ Date ___________
Scenario S.P. is a 68-year-old retired painter who is experiencing right leg calf pain. The pain began approximately 2 years ago but has become significantly worse in the past 4 months. The pain is precipitated by exercise and is relieved with rest. Two years ago, S.P. could walk 2 city blocks before having to stop because of leg pain. Today, he can barely walk across the yard. S.P. has smoked 2 to 3 packs of cigarettes per day (PPD) for the past 45 years. He has a history of coronary artery disease (CAD), hypertension (HTN), peripheral artery disease (PAD), and osteoarthritis. Surgical history includes quadruple
coronary artery bypass graft 3 years ago. He has had no further symptoms of cardiopulmonary disease since that time, even though he has not been compliant with the exercise regimen his cardiologist prescribed, continues to eat anything he wants, and continues to smoke 2 to 3 PPD. Other surgical history includes open reduction and internal fixation of a right femoral fracture 20 years ago.
S.P. is in the clinic today for a routine semiannual follow-up appointment with his primary care provider. As you take his vital signs, he tells you that in addition to the calf pain, he is experiencing right hip pain that gets worse with exercise, the pain does not go away promptly with rest, some days are worse than others, and his condition is not affected by a resting position.
Weight 261 lb (118.4 kg)
Height 5 ft, 10 in (178 cm)
Respiratory rate 16
Temperature 98.4° F (36.9° C)
Laboratory Testing (Fasting)
Cholesterol 239 mg/dL (6.2 mmol/L)
Triglycerides 150 mg/dL (1.69 mmol/L)
HDL 28 mg/dL (0.73 mmol/L)
LDL 181 mg/dL (4.69 mmol/L)
Ramipril (Altace) 10 mg daily
Metoprolol (Lopressor) 25 mg twice a day
Aspirin 81 mg daily
Atorvastatin (Lipitor) 20 mg daily
1. What are the likely sources of his calf pain and hip pain? 2. S.P. has several risk factors for PAD. From his history, list 2
risk factors, and explain the reason they are risk factors. 3. You decide to look at S.P.’s lower extremities. What signs do
you expect to find with PAD? Select all that apply. a. Ankle edema b. Thick, brittle nails c. Cool or cold extremity d. Thin, shiny, and taut skin e. Brown discoloration of the skin f. Decreased or absent pedal pulses
4. You ask further questions about the clinical manifestations of PAD. Which of these would you expect S.P. to have, given the diagnosis of PAD? Select all that apply.
a. Paresthesia b. Elevation pallor c. Dependent rubor d. Rest pain at night e. Pruritus of the lower legs f. Constant, dull ache in his calf or thigh
5. What is the purpose of the daily aspirin listed in S.P.’s current medication?
Case Study Progress S.P.’s primary care provider has seen him and wants you to schedule him for an ankle-brachial index (ABI) test to determine the presence of arterial blood flow obstruction. You confirm the time and date of the procedure and then call S.P. at home.
6. What will you tell S.P. to do to prepare for the tests?
Case Study Progress S.P.’s ABI results showed 0.43 right (R) leg and 0.59 left (L) leg. His primary care provider discusses these results with him and decides to wait 2 months to see whether his symptoms improve with drug changes and risk factor modification before deciding about surgical intervention. S.P. receives a prescription for clopidogrel (Plavix) 75 mg daily and is told to discontinue the daily aspirin. In addition, S.P. receives a consultation for physical therapy.
7. What do these ABI results indicate? 8. You counsel S.P. on risk factor modification. What would you
address, and why? 9. You provide teaching on proper care of his feet and lower
extremities, then use “teach-back” to assess S.P.’s learning. Which statements by S.P. indicate a need for further instruction? Select all that apply.
a. “I can go barefoot in the house, but not outside.” b. “I will wear shoes that are roomy and protective.” c. “I will avoid exposing my feet to extremes of heat
and cold.” d. “I will soak my feet in water once a day to make
sure they are clean.” e. “I will put lotion on my feet and lower legs, but not
in between the toes.” 10. How will the physical therapy help? 11. In addition to risk factor modification, what other measures to
improve tissue perfusion or prevent skin damage should you recommend to S.P.?
12. S.P. tells you his neighbor told him to keep his legs elevated higher than his heart and asks for compression stockings to keep swelling down in his legs. How should you respond?
13. S.P. has been on aspirin therapy but now will be taking
clopidogrel instead. What is the most important aspect of patient teaching that you will emphasize with this drug?
Case Study Outcome S.P. asks for nicotine patches to assist with smoking cessation and makes an appointment for a physical therapy evaluation and a nutritional assessment. He assures you he does not want to lose his leg and will be more careful in the future.
Case Study 7 Name _________________________________ Class/Group ______________________________ Date ___________
Scenario You are the nurse working in an anticoagulation clinic. One of your patients is K.N., who has a long-standing history of an irregular heartbeat, known as atrial fibrillation or A-fib, for which he takes the oral anticoagulant warfarin (Coumadin). Recently K.N. had his mitral heart valve replaced with a mechanical valve.
1. How does atrial fibrillation differ from a normal heart rhythm? 2. What is the purpose of the warfarin (Coumadin) in K.N.’s case?
Case Study Progress K.N. calls your anticoagulation clinic to report a nosebleed that is hard to stop. You ask him to come into the office to check his coagulation levels. The lab technician draws a PT/INR test.
3. What is a PT/INR test, and what are the expected levels for K.N.? What is the purpose of the INR?
4. When you get the results, his INR is critical at 7.2. What is
the danger of this INR level?
Case Study Progress The health care provider does a brief focused history and physical examination, orders additional lab tests, and determines there are no signs of bleeding other than the nosebleed, which has stopped. The provider discovers that K.N. recently started to take daily doses of an over-the-counter proton pump inhibitor (PPI), omeprazole (Prilosec OTC), for heartburn.
5. What happened when K.N. began taking the PPI? 6. What should K.N. have done to prevent this problem? 7. The provider gives K.N. a low dose of vitamin K orally, asks
him to hold his warfarin dose that evening, and asks him to come back tomorrow for another prothrombin time (PT) and INR blood draw. Why is K.N. instructed to take the vitamin K?
8. You want to make certain K.N. knows what “hold the next dose” means. What should you tell him?
9. K.N. asks you why his PT/INR has to be checked so soon. How will you respond?
Case Study Progress K.N.’s INR the next day is 3.7, and the health care provider makes no further medication changes. K.N. is instructed to return again in 7 days to have another PT/INR drawn.
10. Why should the INR be checked again so soon instead of the usual monthly follow-up?
11. K.N. grumbles about all of the lab tests but agrees to follow through. You provide patient education to K.N. and start with reviewing the signs and symptoms (S/S) of bleeding. What are potential S/S of bleeding that should be taught to K.N.? Select all that apply.
a. Insomnia b. Black, tarry stool
c. New onset of dizziness d. Stool that is pale in color e. New joint pain or swelling f. Unexplained abdominal pain
12. Identify 2 other patient education needs you will stress at this time.
13. K.N. tells you that he has had a lot of pain in his knee and wants to take ibuprofen (Advil) because it is an over-the- counter product. How do you reply to his request?
14. Four months later, K.N. informs you that he is going to have a knee replacement next month. What will you do with this information?
Case Study Progress You know that sometimes the only needed action is to stop the warfarin (Coumadin) several days before the surgery. Other times, the provider initiates “bridging therapy,” or stops the warfarin and provides anticoagulation protection by initiating low-molecular- weight heparin. After reviewing all of his anticoagulation information, the provider decides that K.N. will need to stop the warfarin (Coumadin) 1 week before the surgery and in its place be started on enoxaparin (Lovenox) therapy.
15. Compare the duration of action of warfarin (Coumadin) and enoxaparin (Lovenox) and explain the reason the provider switched to enoxaparin at this time.
Case Study Progress K.N. is in the office and ready for his first enoxaparin (Lovenox) injection.
16. Which nursing interventions are appropriate when administering enoxaparin? Select all that apply.
a. Massage the area after the injection has been given. b. Hold extra pressure over the site after the injection.
c. Monitor activated partial thromboplastin time (aPTT) levels.
d. The preferred site of injection is the lateral abdominal fatty tissue.
e. Administer via intramuscular (IM) injection into the deltoid muscle.
Case Study Progress K.N. undergoes knee surgery without complications. Just before his discharge, his physician reviews the instructions and gives him a new prescription for warfarin (Coumadin). K.N. tells his doctor, “I saw this commercial for a new blood thinner called Xarelto. I’d like to take that instead because I wouldn’t need to have all this blood work done.”
17. How do you expect the physician to respond?