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Clinical Reasoning Cases in Nursing

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

Cover image

Inside Front Cover

Brief Contents

Title page





What Is Clinical Reasoning?

What Is New in This Edition

The “How To” of Case Studies




1: Perfusion

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

3: Mobility

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

4: Digestion



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

8: Immunity

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

11: Cognition

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

13: Developmental

Case Study 131

Case Study 132

Case Study 133

Case Study 134

Case Study 135

Case Study 136

14: Reproductive

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





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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.

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 (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

renal tubules

Case Study Progress After reviewing M.G.’s medications, the cardiologist writes the following medication orders.

Chart View

Medication Orders

Enalapril (Vasotec) 5 mg PO bid

Carvedilol (Coreg) 3.125 mg PO twice daily



Metformin (Glucophage)

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.

Chart View

Family History



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



cardiovascular disease?

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?

Chart View

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

her success.

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.

Chart View

Laboratory Results

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)

HbA1C 5.9%



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.

Chart View

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)

Hct 37%

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

Chart View

Medication Orders

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

a year.”

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.

Chart View

General Assessment

Weight 261 lb (118.4 kg)

Height 5 ft, 10 in (178 cm)

BP 163/91

Pulse 82

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)

Current Medications



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?

Case Study Outcome K.N. is discharged to a rehabilitation facility, where he makes a quick recovery from the knee replacement surgery. He does not experience any thrombotic events or bleeding episodes during his recovery.

Case Study 8 Name _________________________________ Class/Group ______________________________ Date ___________

Scenario You are assigned to care for L.J., a 70-year-old retired bus driver who has just been admitted to your medical floor with right leg deep vein thrombosis (DVT). L.J. has a 48–pack-year smoking history, although he states he quit 2 years ago. He has had pneumonia several times and frequent episodes of atrial flutter or fibrillation. He has had 2 previous episodes of DVT and was diagnosed with rheumatoid arthritis 3 years



ago. Two months ago he began experiencing shortness of breath on exertion and noticed increasing swelling of his right lower leg that became progressively worse until it extended up to his groin. His wife brought him to the hospital when the pain in his leg became increasingly severe. After a Doppler study showed a probable thrombus of the external iliac vein extending distally to the lower leg, he was admitted for bed rest and to initiate heparin therapy. His basic metabolic panel was normal; other lab results were as follows.

Chart View

Laboratory Testing

PT 12.4 seconds

INR 1.11

aPTT 25 seconds

Hgb 13.3 g/dL (133 g/L)

Hct 38.9%

Cholesterol 206 mg/dL (5.34 mmol/L)

1. List 6 risk factors for DVT. 2. Identify at least 5 risk factors from L.J.’s history. 3. Something is missing from the scenario. Based on his history,

L.J. should have been taking an important medication. What is it, and why should he be taking it?

4. Keeping in mind L.J.’s health history and admitting diagnosis, outline the most important assessments you will make during your physical examination.

5. What is the most serious complication of DVT? 6. List at least 8 assessment findings you should monitor closely

for in the development of the complication identified in Question 5.



7. You review the literature for DVT and see the abbreviation VTE. What does VTE mean?

Case Study Progress Your assessment of L.J. reveals bibasilar crackles with moist cough, normal heart sounds, BP 138/88, pulse 104, 4 + pitting edema of right lower extremity, mild erythema of right foot and calf, and severe right calf pain. He is awake, alert, and oriented but a little restless. His Spo2 is 92% on room air. He denies chest pain but does have shortness of breath with exertion. He states he is anxious about missing his grandson’s wedding. He denies any voiding problems.

8. Your institution uses electronic charting. Based on the assessment noted previously, which of the following systems would you mark as “abnormal” as you document your findings? For abnormal findings provide a brief narrative note.

◻ Neurologic: ◻ Respiratory: ◻ Cardiovascular: ◻ Genitourinary: ◻ Skin: ◻ Psychosocial: ◻ Pain:

Case Study Progress L.J. is placed on 72-hour bed rest with bathroom privileges and given acetaminophen (Tylenol) for pain. The physician writes orders for enoxaparin (Lovenox) injections.

9. L.J. asks, “Why do I have to get these shots? Why can’t I just get a Coumadin pill to thin my blood?” What would be your response?” Explain your answer.

a. “Your physician prefers the injections over the pills.”

b. “The enoxaparin will work to dissolve the blood



clot in your leg.” c. “It would take the Coumadin pills several days to

become effective.” d. “Good idea! I will call and ask your physician to

switch medications.” 10. The order for the enoxaparin reads: Enoxaparin 70 mg

every 12 hours subQ. L.J. is 5 ft, 6 in tall and weighs 156 lb. Is this dose appropriate?

11. What special techniques do you use when giving the subcutaneous injection of enoxaparin? Select all that apply.

a. Rotate injection sites. b. Give the injection near the umbilicus. c. Massage the injection site gently after the injection

is given. d. After inserting the needle, do not aspirate before

giving the injection. e. Expel the bubble from the prefilled syringe before

giving the injection. 12. True or False? Enoxaparin dosage is directed by monitoring

aPTT levels. Explain your answer. 13. L.J. asks you how long it will take for the Lovenox injections to

dissolve his blood clot. What is your response to him? 14. After providing teaching about anticoagulant therapy,

you ask L.J. to teach back to you what he has learned. Which statements indicate a need for further education? Select all that apply.

a. “I will not blow my nose really hard.” b. “I will brush my teeth gently with a soft

toothbrush.” c. “I will take aspirin or ibuprofen if I have a

headache.” d. “I will shave very carefully with my disposable

razor.” e. “I will put lotion on my skin to keep it from getting



to dry.” f. “I will purchase and wear a medical alert necklace

for blood thinners.” g. “I will get help right away if I notice bleeding in my

stools or urine or if I have a bad headache or stomach pain.”

15. You identify pain as a key issue in the care of L.J. List 4 interventions you will choose for L.J. to address his pain.

16. What pertinent lab values and measurements would you expect the physician to order and the results of which you will monitor? Explain the reason for each test.

17. You evaluate L.J.’s electrocardiogram (ECG) strip. Name this rhythm, and explain what consequences it could have for L.J.

(Modified from Lilley LL, Rainforth Collins S, Harrington S, et al: Pharmacology and the Nursing Process, ed. 8, St. Louis, MO: Mosby; 2017.)

Case Study Progress A week has passed. L.J. responded to heparin therapy and was bridged to oral warfarin therapy. His heart dysrhythmia converted to sinus rhythm after he started taking cardiac medications, and he is being discharged to home with home care follow-up. “Good,” he says, “just in time to fly out west for my grandson’s wedding. His wife, who has come to pick him up, rolls her eyes and looks at the ceiling.

18. Although you are surprised at his comment, you realize he is serious about going to the wedding. What are you going to tell



him? 19. What discharge instructions about activity will you give L.J.?

Case Study Outcome L.J. listens to you, and his wife is quite relieved. They were able to watch the wedding ceremony via a live-stream connection, and he watches the recording daily and points out his favorite parts to the home care nurse every time she visits.

Case Study 9 Name _________________________________ Class/Group ______________________________ Date ___________

Scenario You are working at the local cardiac rehabilitation center, and R.M. is walking around the track. He summons you and asks if you could help him understand his recent lab report. He admits to being confused by the overwhelming data on the test and does not understand how the results relate to his recent heart attack and need for a stent. You take a moment to locate his lab reports and review his history. The findings are as follows.

R.M. is an active 61-year-old married man who works full time for the postal service. He spends most of his day in a mail truck, and admits he does not eat a “perfect diet.” He enjoys 2 or 3 beers every night, uses stick margarine, eats red meat 2 or 3 times per week, and is a self-professed “sweet eater.” He has tried to quit smoking and is down to 1 pack per day. Cardiac history includes a recent inferior myocardial infarction (MI) and a heart catheterization revealing three- vessel disease: in the left anterior descending (LAD) coronary artery, a proximal 60% lesion; in the right coronary artery (RCA), proximal 100% occlusion with thrombus; and a circumflex artery with 40% to 60% diffuse dilated lesions. A stent was deployed to the RCA and



reduced the lesion to 0% residual stenosis. He has had no need for sublingual nitroglycerin (NTG). He was discharged on enteric-coated aspirin 325 mg daily, clopidogrel (Plavix) 75 mg daily, atorvastatin (Lipitor) 10 mg at bedtime, and ramipril (Altace) 10 mg/day. Six weeks after his MI and stent placement, he had a fasting advanced lipid profile with other blood work.

Chart View

Six-Week Postprocedure Laboratory Work (Fasting)

Total cholesterol 188 mg/dL (4.87 mmol/L)

HDL 34 mg/dL (0.88 mmol/L)

LDL 98 mg/dL (2.54 mmol/L)

Triglycerides 176 mg/dL (1.99 mmol/L)

Homocysteine 18 mmol/L

C-reactive protein (CRP) 8 mg/dL (80 mg/L)

FBG 99 mg/dL (5.5 mmol/L)

TSH 1.04 mU/L

1. When you start to discuss R.M.’s lab values with him, he is pleased about his results. “My cholesterol level is below 200!— and my ‘bad cholesterol’ is good! That’s good news, right?” What would you say to him?

2. Which lab test is considered the “good cholesterol,” and why? 3. Discuss the significance of R.M.’s CRP level. 4. Discuss the significance of the homocysteine test and R.M.’s

results. 5. What else in R.M.’s history might be contributing to his

elevated homocysteine levels? 6. Identify R.M.’s health-related problems. List the problem that



is potentially life-threatening first.

Case Study Progress

7. R.M.’s physician adds niacin, a vitamin preparation (folic acid, vitamin B6, and vitamin B12 [Foltx]) daily with food, and omega-3 fatty acids to his list of medications. How do these medications affect lipids? R.M. states, “But I already take Lipitor. What do all these medications do?” How do you answer him?

8. You are teaching R.M. about the side effects of niacin. Which effects will you include in your teaching? Select all that apply.

a. Pruritus b. Dizziness c. Headache d. Flushed skin e. Gastrointestinal distress

9. R.M. tells you that he really does not want to “put up with” the side effects of the niacin. Is there an alternative to niacin?

10. You review his other medications, including atorvastatin (Lipitor). Which statement by R.M. indicates a need for further teaching about atorvastatin?

a. “I will take this drug at night.” b. “I will try to exercise more each week.” c. “I like to take my medicines with grapefruit juice.” d. “I will call my doctor right away if I experience

muscle pain.”

Case Study Progress You enter R.M.’s room and hear the physician say, “There are many options for changing your LDL and triglyceride levels. You need to continue modifying your diet and exercise to enhance your medication regimen. And stop smoking!” The physician asks R.M. whether he has any questions, and he responds, “No.”



11. After the physician leaves the room, R.M. tells you he really did not understand what the physician said. Explain the need for lifestyle changes to R.M.

12. You review the DASH diet with R.M. and his wife. Which food choices would follow the DASH diet? Select all that apply.

a. Fish and chips b. Fresh fruit salad c. Apples fried in butter and brown sugar d. Fat-free yogurt with tablespoon of almonds e. Grilled chicken sandwich on whole wheat bun

13. R.M. tells you that he knows exercise will help him to lose weight, which is good, but he does not understand how exercise helps his cholesterol levels. How do you answer him?

14. Of all of R.M.’s behaviors, which one is the most

significant in promoting cardiac disease and why? 15. Develop a comprehensive teaching plan directed toward

helping R.M. with addressing this behavior.

Case Study Outcome R.M. tells you that he is determined to stop smoking. At his next checkup 3 months later, he proudly shows off his 15 lb (6.8 kg) weight loss and tells you that he has not had a cigarette for 10 weeks.

Case Study 10 Name _________________________________ Class/Group ______________________________ Date ___________

Scenario The wife of C.W., a 70-year-old man, brought him to the emergency department (ED) at 0430. She told the ED triage nurse that he had diarrhea for the past 2 days and that last night he had a lot of “dark



red” diarrhea. When he became very dizzy, disoriented, and weak this morning, she decided to bring him to the hospital. C.W.’s vital signs (VS) in the ED were 70/− (systolic blood pressure [SBP] 70, diastolic blood pressure [DBP] inaudible), pulse rate 110, respirations 22, oral temperature 99.1° F (37.3° C). A 16-gauge IV catheter was inserted and a lactated Ringer’s infusion was started. The triage nurse learned C.W. has had idiopathic dilated cardiomyopathy for several years. The onset was insidious, but the cardiomyopathy is now severe. His last cardiac catheterization showed an ejection fraction of 13%. He has frequent problems with heart failure (HF) because of the cardiomyopathy. Two years ago, he had a cardiac arrest that was attributed to hypokalemia. He has a long history of hypertension and arthritis. He had atrial fibrillation in the past, but it has been under control recently. Fifteen years ago he had a peptic ulcer.

Endoscopy showed a 25- × 15-mm duodenal ulcer with adherent clot. The ulcer was cauterized, and C.W. was admitted to the medical intensive care unit (MICU) for treatment of his volume deficit. You are his admitting nurse. As you are making him comfortable, Mrs. W. gives you a paper sack filled with the bottles of medications he has been taking: enalapril (Vasotec) 5 mg PO bid, warfarin (Coumadin) 5 mg/day PO, digoxin (Lanoxin) 0.125 mg/day PO, potassium chloride 20 mEq PO bid, and diclofenac (Voltaren) 50 mg PO tid. As you connect him to the cardiac monitor, you note he is in sinus tachycardia. Doing a quick assessment, you find a pale man who is sleepy but arousable and slightly disoriented. He states he is still dizzy and feels weak and anxious overall. His BP is 98/52, pulse is 118, and respiratory rate 26. You hear S3 and S4 heart sounds and a grade II/VI systolic murmur. Peripheral pulses are all 2 +, and trace pedal edema is present. Capillary refill is slightly prolonged. Lungs are clear. Bowel sounds are present, mid-epigastric tenderness is noted, and the liver margin is 4 cm below the costal margin. Has not yet voided since admission. Rates his pain level as “2.” A Swan-Ganz pulmonary artery catheter and a peripheral arterial line are inserted.

1. What may have precipitated C.W.’s gastrointestinal (GI)



bleeding? 2. From his history and assessment, identify 5 signs and

symptoms of GI bleeding and loss of blood volume, and explain the pathophysiology for each one listed.

3. What is the most serious potential complication of C.W.’s bleeding?

4. Your institution uses electronic charting. Based on the assessment just described, which of the following systems would you mark as “abnormal” as you document your findings? Mark abnormal findings with an X and provide a brief narrative note.

☐ Neurologic: ☐ Respiratory: ☐ Cardiovascular: ☐ GI: ☐ Genitourinary: ☐ Musculoskeletal: ☐ Skin: ☐ Psychosocial: ☐ Pain:

5. What intervention is required to assess his renal function? 6. Calculate C.W’s mean arterial pressure (MAP) and explain

why this measure is important.

Case Study Progress As soon as you get a chance, you review C.W.’s admission lab results.

Chart View

Laboratory Results

Sodium 138 mEq/L (138 mmol/L)

Potassium 6.9 mEq/L (6.9 mmol/L)

BUN 90 mg/dL (32.1 mmol/L)



Creatinine 2.1 mg/dL (185.6 mcmol/L)

WBC 16,000/mm3 (16 x 109/L)

Hgb 8.4 g/dL (84 g/L)

Hct 25%

PT 23.4 seconds

INR 4.8

7. After examination of the lab results, do you have any concerns with C.W.’s electrolyte levels? Explain your answer.

8. In view of the previous lab results, what diagnostic test will be performed and why?

9. Evaluate this electrocardiogram (ECG) strip and note the effect of any electrolyte imbalances.

10. Why do you think the BUN and creatinine are elevated? 11. What do the low Hgb and Hct levels indicate about the

rapidity of C.W.’s blood loss? 12. What is the explanation for the prolonged PT/INR? 13. What will be your response to the prolonged PT/INR? Select

all that apply. a. Hold the warfarin dose. b. Avoid injections as much as possible. c. Obtain an order for aspirin if needed for pain.



d. Monitor C.W. for signs and symptoms of bleeding. e. Prepare to administer a STAT dose of protamine

sulfate. 14. What safety precautions should you initiate in light of his

prolonged PT and INR? 15. How do you explain the elevated WBC count?

Case Study Progress C.W. receives a total of 4 units of packed red blood cells (PRBCs), 5 units of fresh frozen plasma (FFP), and several liters of crystalloids to keep his mean BP above 60. On the second day in the MICU, his total fluid intake is 8.498 L and output is 3.66 L. His hemodynamic parameters after fluid resuscitation are pulmonary capillary wedge pressure (PCWP) 30 mm Hg and cardiac output (CO) 4.5 L/min.

16. Calculate his fluid balance and identify whether it is positive or negative.

17. Why will you want to monitor his fluid status very carefully? 18. List at least 6 things you will monitor to assess C.W.’s fluid

balance. 19. Explain the purpose of the FFP for C.W.

Case Study Progress Mrs. W. has been with her husband since he arrived at the emergency department and is worried about his condition and his care.

20. List 5 things you might do to make her more comfortable while her husband is in the MICU.

Case Study Outcome After the transfusions, C.W.’s BP is 110/78, his pulse is 94, and his respirations are 18. His urine output is now 60 mL/hour. He seems more alert and asks you, “What happened?” He is transferred to a step-down unit the next day and is eventually transferred to a



rehabilitation facility for a week of physical therapy before returning home.

Case Study 11 Name _________________________________ Class/Group ______________________________ Date ___________

Scenario J.F. is a 50-year-old married woman with a genetic autoimmune deficiency; she has had recurrent infective endocarditis. The most recent episodes were a Staphylococcus aureus infection of the mitral valve 16 months ago and a Streptococcus viridans infection of the aortic valve 1 month ago. During the latter hospitalization, an echocardiogram showed moderate aortic stenosis, moderate aortic insufficiency, chronic valvular vegetations, and moderate left atrial enlargement. Two years ago, J.F. received an 18-month course of parenteral nutrition (PN) for malnutrition caused by idiopathic, relentless nausea and vomiting (N/V). She has had coronary artery disease (CAD) for several years and 2 years ago had an acute anterior wall myocardial infarction (MI). In addition, she has a history of chronic joint pain.

Now, after having been home for only a week, J.F. has been readmitted to your floor with infective endocarditis (IE), N/V, and renal failure. Since yesterday, she has been vomiting and retching constantly. She also

Chart View

Admission Orders

STAT blood cultures (aerobic and anaerobic) × 2, 30 minutes apart



STAT CMP & CBC Begin PN at 85 mL/hr Piperacillin sodium/tazobactam sodium (Zosyn) 2.25 g q6hr Vancomycin (Vancocin), renal dosing per pharmacy, IVPB

q12hr Furosemide (Lasix) 80 mg PO daily Amlodipine (Norvasc) 5 mg PO daily Potassium chloride (K-Dur) 40 mEq PO daily Metoprolol (Lopressor) 25 mg PO bid Ondansetron 4 mg IV every 6 hours PRN Transesophageal echocardiogram ASAP

Admission Assessment

Oriented × 3 to person, place, and time, but drowsy Grade II/VI holosystolic murmur and a grade III/VI diastolic

murmur Lungs clear bilaterally Abdomen soft with slight left upper quadrant tenderness Multiple petechiae on skin of arms, legs, and chest; splinter

hemorrhages under the fingernails; hematuria noted in voided urine

Blood pressure 152/48 (supine) and 100/40 (sitting)

Pulse rate 116

Respiratory rate 22

Temperature 100.2° F (37.9° C)

has had chills, fever, fatigue, joint pain, and headache. As you go through the admission process with her, you note that she wears glasses and has dentures. Intravenous (IV) access is obtained with a double-lumen peripherally inserted central catheter (PICC) line. Other orders and your assessment are shown in the box.



1. Which of these statements about IE are true? Select all that apply.

a. IE may affect the heart valves. b. IE is an inflammation of the pericardial sac. c. IE is an infection of the innermost layer of the heart. d. Cardiac tamponade is a common complication of

IE. e. Heart failure, sepsis, and dysrhythmias may occur

with IE. 2. What is the significance of the orthostatic hypotension and

tachycardia? 3. What is the significance of the abdominal tenderness,

hematuria, joint pain, and petechiae? 4. What are splinter hemorrhages, and how are they related to IE? 5. Mark the area on the accompanying diagram where you would

place the stethoscope to auscultate an aortic valve murmur.



(From Jarvis C. Physical Examination and Health Assessment. 6th ed. St. Louis, MO: Saunders; 2012.)

6. As you monitor J.F. throughout the day, what other signs and symptoms of embolization will you watch for?

7. Explain the diagnostic criteria for infectious endocarditis.

Case Study Progress The next day, you review J.F.’s lab test results.

Chart View

Laboratory Test Results



Na 138 mEq/L (138 mmol/L)

K 3.9 mEq/L (3.9 mmol/L)

Cl 103 mEq/L (103 mmol/L)

BUN 85 mg/dL (30.3 mmol/L)

Creatinine 3.9 mg/dL (345 mcmol/L)

Glucose 165 mg/dL (9.2 mmol/L)

WBC 6700/mm3 (6.7 x 109/L)

Hct 27%

Hgb 9.0 g/dL (90 g/L)

8. Identify the values that are not within normal ranges and explain the reason for each abnormality.

9. You note that a new intern writes an order for “Fasting blood glucose levels daily.” Is this order appropriate for J.F.? Explain.

10. What is the greatest risk for J.F. during the process of

rehydration, and what would you monitor to detect its development?

Case Study Progress You were aware that as soon as J.F. became stable, she would be going home on parenteral nutrition (PN) and IV antibiotics. As part of the discharge preparations, you contact the home care agency that will be providing her care

11. List 5 important questions in assessing her home health care needs.

Case Study Progress Fortunately, J.F. has a supportive husband and 2 daughters who live nearby who can function as caregivers when J.F. is discharged. They,



along with J.F., will need teaching about endocarditis. Although J.F. has been ill for several years, you discover that she and her family have received little education about the disease. You prepare a teaching plan for the family.

12. Develop a teaching plan for J.F. and her family. 13. J.F.’s daughter tells you that she thinks her mother will have to

stay in bed until the infection is cured. How will you respond, and what measures can be implemented to prevent problems related to decreased mobility?

14. After you have taught J.F. about oral hygiene, which statement by J.F. reflects a need for further education?

a. “I will use a soft toothbrush to brush my teeth.” b. “I will use a water irrigation device to clean my

teeth and gums.” c. “I will rinse my mouth thoroughly with water after

brushing my teeth.” d. “I will remove my dentures after every meal and

clean them thoroughly before replacing them.”

Case Study Progress Your hospital discharge planner facilitates J.F.’s transition to home care. During the initial home visit, the home health nurse evaluates J.F.’s IV site for implementation of the IV therapy program. The nurse interviews the family members to determine their willingness to be caregivers and their level of understanding and enlists the patient’s and family’s assistance to identify goals.

15. The home health nurse also writes short- and long-term goals for J.F. and her family. Identify 2 short-term and 3 long-term goals.

Case Study Outcome Mr. F. and his 2 daughters learned to administer J.F.’s antibiotic and 8- month treatment of PN. J.F.’s endocarditis eventually resolves with no



worsening of her cardiac condition.

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