Cardiovascular Disorders



Cardiovascular Disorders



Case Study 1


Name______________________Class/Group_____________Date___________


Group Members_______________________________________________


INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.




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 every day since her discharge.




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 20 mEq/day PO




Case Study Progress


After reviewing M.G.’s medications, the physician writes these medication orders:



Chart View


Medication Orders


Enalapril (Vasotec) 5 mg PO bid


Carvedilol (Coreg) 100 mg PO every morning


Glipizide (Glucotrol) 10 mg PO every morning


Furosemide (Lasix) 80 mg IV push (IVP) now, then 40 mg/day IVP


Potassium chloride (K-Dur) 20 mEq/day PO




Case Study Progress


The next day, M.G. has shown only slight improvement, and digoxin (Lanoxin) 125 mcg PO daily is added to her orders.



8. What is the action of the digoxin? Digoxin:



9. Which findings from M.G.’s assessment would indicate an increased possibility of digoxin toxicity? Explain your answer.



10. When you go to give the digoxin, you notice that it is available in milligrams (mg) not micrograms (mcg). Convert 125 mcg to mg.


11. M.G.’s symptoms improve with IV diuretics and the digoxin. She is placed back on oral furosemide (Lasix) once her weight loss is deemed adequate to achieve a euvolemic state. What will determine whether the oral dose will be adequate to consider her for discharge?


12. M.G. is ready for discharge. Using the mnemonic MAWDS, what key management concepts should be taught to prevent relapse and another admission?



Case Study 2


Name______________________Class/Group_____________Date___________


Group Members_______________________________________________


INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.



Scenario


M.P. is a 65-year-old African-American woman who comes to your 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 cerebrovascular accident (CVA, stroke) at her 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 on 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, HTN, type II diabetes mellitus (DM)








Case Study Progress


The internist decreases M.P.’s HCTZ dosage 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 also 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 internist decrease the dose of the HCTZ?


8. You provide M.P. with education about the common side effects of benazepril, which can include which conditions? (Select all that apply.)



9. It is sometimes difficult to remember whether you’ve taken your medication. What techniques might you teach M.P. to help her remember to take her medication each day? (Name at least two.)


10. After the teaching session, which statement by M.P. indicates a need for further instructions?




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 136/78 to 82 mm Hg.




Chart View


Laboratory Test Results (Fasting)




























Potassium 3.6 mEq/L
Sodium 138 mEq/L
Chloride 100 mEq/L
CO2 28 mEq/L
Glucose 112 mEq/L
Creatinine 0.7 mg/dL
BUN 18 mg/dL
Magnesium 1.9 mEq/L




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 mm Hg. She participates in a senior citizens group-walking program at the local mall. She admits she has not done as well with decreasing her salt intake but that she is trying. She tells you she was recently at a luncheon with her garden club and that most of those women take different BP pills than she does. She asks why their pills are different shapes and colors.




Case Study 3


Name______________________Class/Group_____________Date___________


Group Members_______________________________________________


INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.



Scenario


You are a nurse at a freestanding cardiac prevention and rehabilitation center. Your new patient in risk-factor modification is B.T., a 41-year-old traveling salesman, who is married and has three children. He tells you that his work does not let him slow down. During a recent evaluation for chest pain, he underwent a cardiac catheterization procedure that showed moderate single-vessel disease with a 50% stenosis in the mid right coronary artery (RCA). He was given a prescription for sublingual (SL) nitroglycerin (NTG), told how to use it, and referred to your cardiac rehabilitation program for sessions of 3 days a week. B.T.’s wife comes along to help him with healthy lifestyle changes. You take a nursing history, as indicated in the following.



Chart View


Family History


Father died suddenly at age 42 of a myocardial infarction (MI)


Mother (still living) had a quadruple coronary artery bypass graft (CABG × 4) at age 52








Case Study Progress


B.T. laughingly tells you he believes in the five all-American food groups: salt, sugar, fat, chocolate, and caffeine.



6. Identify health-related problems in this case description; the problem that is potentially life threatening should be listed first.


7. Of all of his behaviors, which one is the most significant in promoting cardiac disease?


8. What is the highest priority problem that you need to address with B.T.? How will you determine this? Identify the teaching strategy you would use with him.


9. What is the second problem you would work with B.T. to change? Identify an appropriate strategy to resolve the problem.


10. B.T.’s wife takes you aside and tells you, “I’m so worried for B. I grew up in a really dysfunctional family where there was a lot of violence. B. has been so good to the kids and me. I’m so worried I’ll lose him that I have nightmares about his heart stopping. I find myself suddenly awakening at night just to see if he’s breathing.” How are you going to respond?



Case Study Progress


Six weeks after you start working with B.T., he admits that he has been under a lot of stress. He is walking on the treadmill and rubs his chest and says, “It feels really heavy on my chest right now.” You feel his pulse and note that his skin is slightly diaphoretic and that he is agitated and appears to be anxious.



11. What is the first action you are going to do? What other information will you obtain? Explain.


12. B.T. is still uncomfortable, and he has an unopened bottle of sublingual nitroglycerin (SL NTG) tablets. You decide to give him one tablet. After 5 minutes, which is the appropriate action to take?



13. What other actions will you take at this time?


14. Five minutes after the first NTG tablet, B.T. states that the discomfort is still there and only slightly relieved. Explain what you can expect to be doing while waiting for emergency medical system (EMS) to arrive.




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 two city blocks before having to stop because of leg pain. Today, he can barely walk across the yard. S.P. has smoked two to three packs of cigarettes per day (PPD) for the past 45 years. He has a history of coronary artery disease (CAD), hypertension (HTN), peripheral vascular disease (PVD), and osteoarthritis. Surgical history includes quadruple coronary artery bypass graft (CABG × 4) 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, he continues to eat anything he wants, and continues to smoke two to three PPD. Other surgical history includes open reduction internal fixation of the 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, besides the calf pain, he is experiencing right hip pain that gets worse with exercise, the pain doesn’t 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
Height 5 ft, 10 in.
Blood pressure 163/91 mm Hg
Pulse 82 beats/min
Respiratory rate 16 breaths/min
Temperature 98.4° F (36.9° C)







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 medication 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. received a consult for physical therapy.





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 irregularly irregular heartbeat (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.





Case Study Progress


The health care provider does a brief focused history and physical examination, orders additional lab tests, and determines that there are no signs of bleeding other than the nosebleed, which has stopped. The provider discovers that K.N. recently went to the local urgent care center for a sinus infection and had received a prescription for the antibiotic co-trimoxazole (sulfamethoxazole-trimethoprim) (Septra).




Case Study Progress


K.N.’s INR the next day is 3.7, and the health care provider made no further medication changes. K.N. is instructed to finish the remaining 2 days of antibiotics and return again in 7 days to have another PT/INR drawn.







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) showed cardiomegaly, and a 12-lead electrocardiogram (ECG) showed sinus tachycardia with left bundle branch block (LBBB). You review his morning blood work and initial assessment.



Chart View


Laboratory Testing







Case Study Progress


J.M. tells you he becomes exhausted and has shortness of breath climbing the stairs to his bedroom and has to lie down and rest (“put my feet up”) at least an hour twice a day. He has been sleeping on two pillows for the past 2 weeks. He has not salted his food since the physician told him not to because of his high blood pressure, but he admits having had ham and a whole bag of salted peanuts 3 days 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 heart failure (L) or right-sided heart failure (R).


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Jan 16, 2017 | Posted by in NURSING | Comments Off on Cardiovascular Disorders

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