Discussion 1.1 – Case Study One

Discussion 1.1 – Case Study One

A 39 year-old woman is brought to the emergency department by her husband. She is conscious but confused and keeps repeating that her head hurts so much she feels it might “explode.” The husband tells you that she has no health problems and takes no medications other than aspirin for occasional pain. He also tells you that she entered a contest earlier today to try and drink the most water in 1 hour. She drank 10 glasses but did not win the contest and came home. Her confusion and headache started about an hour later.

What type of fluid or electrolyte imbalance is she likely to have and from what cause? Explain your answer.

What physical assessment data are the priority to obtain? Explain.

What laboratory data would you expect to be ordered?

Is this patient at risk for heart failure or pulmonary edema? Why or why not?

For details regarding grading criteria and posting requirements, please see the grading rubric. Contact your instructor if you have issues or concerns.

Discussion 1.2 – Case Study Two

The patient is a 29 year old woman admitted 20 hours ago for an acute exacerbation of Crohn’s disease with intense abdominal pain. She is NPO and receiving normal saline intravenously at 175 mL per minute. She was last given hydromorphone (Dilaudid) 4 mg IV 30 minutes ago. Because she did have an episode of hypotension earlier after Dilaudid, you now take her vital signs. On inflating the blood pressure cuff, she develops palmar flexion. The flexion remains after the cuff is deflated.

What is most likely the cause of this problem?

What electrolytes are most likely to be out of balance and why?

What is your best first action?Should the Rapid Response Team be called? Why or why not?

What additional assessment data are most important to collect? Explain your answer.

For details regarding grading criteria and posting requirements, please see the grading rubric. Contact your instructor if you have issues or concerns.

Discussion 2.1 – Case Study One

The patient is a 21 year old college student brought to the emergency department by his friends when he was found unconscious during a fraternity party. He was seen drinking heavily at the party and had not eaten for 2 days before the event. He takes no prescription drugs, and his current vital signs are T = 97.8, P = 48, slightly irregular and thread; R = 28, deep and regular; B/P = 88/50; His arterial blood gas results are pH = 7.31, HCO 3 = 25 mEq/L; PaCo2= 28 mm Hg; PaO2 = 99 mm Hg.

What specific type of acid-base problem does this patient have? Explain.

What is the most probable origin of the acid-base imbalance?

Should oxygen be applied? Why or why not?

What nursing interventions for safety are most appropriate for this patient?

What additional laboratory and assessment data should be performed? Provide a rationale for your answer.

For details regarding grading criteria and posting requirements, please see the grading rubric. Contact your instructor if you have issues or concerns.

Discussion 3.1 – Case Study One Options Menu: Forum

At the start of the shift, you are assessing an 86 year old patient who is awaiting surgery for a hip repair after a fall 12 hours ago at home. You are collecting a clean-catch urine specimen, using a bedpan, as part of the preoperative preparation. You observe that when she voids, the urine odor is foul and the urine is cloudy and full of sediment. She reports some urgency but notes that she had urgency before her fall.

What assessment information will you document in the chart?

What additional information should you ask the patient and what else should you consider?

Organize your thoughts into a SBAR communication.

Who should you notify and why?

For details regarding grading criteria and posting requirements, please see the grading rubric. Contact your instructor if you have issues or concerns.

Discussion 3.2 – Case Study Two

The patient is a 52-year old perimenopausal woman who reports a small loss of urine with coughing, laughing, and occasionally bending over. Recently she has started to leak urine just as she arrives in the bathroom but before she sits on the toilet. She stated her mother has had a continuing problem with incontinence for years and seldom leaves her home. The patient wants to continue to lead an active lifestyle and wants to discuss options for preventing progression of this embarrassing condition.

What other information should you obtain from this patient?

What type or types of incontinence is she most likely to have from the information she has provided thus far?

Is this problem likely to be genetic? Why or why not?

What will you tell her regarding options for care?

She asks if there is anything she can do now to help reduce her urine leakage. How do you respond?

For details regarding grading criteria and posting requirements, please see the grading rubric. Contact your instructor if you have issues or concerns.

Discussion 4.1 – Case Study One

The 56 year old African-American woman is admitted for treatment of newly diagnosed renal cell carcinoma. You find her daughter in the hallway crying. She has heard that her mother has undergone genetic testing related to her cancer diagnosis and wonders if she is at increased risk for the same condition. She was with her mother during the renal scan before admission and is also worried that this exposure to a radioactive isotope will cause cancer in her.

Is renal cell carcinoma commonly inherited, and why is genetic testing done?

Do renal scan radioisotopes require radiation precautions? Why or why not?

What risk factors are associated with renal cell carcinoma?

How can you evaluate whether your information was understood by the daughter and if follow-up is needed?

Discussion 4.2 – Case Study Two

At the start of the shift, you are assessing an 86 year old patient who is awaiting surgery for a hip repair after a fall 12 hours ago at home. You are collecting a clean catch urine specimen, using a bedpan, as part of the preoperative preparation. You observe that when she voids, the urine odor is foul and the urine is cloudy and full of sediment. She reports some urgency but notes that she had urgency before her fall.

What assessment information will you document in the chart?

What additional information should you ask the patient and what else should you consider?

Organize your thoughts into SBAR communication

Who should you notify and why?

Discussion 5.1 – Case Study One

The patient just completed a vascular “mapping” procedure with an angiogram to plan the site of an AV fistula for hemodialysis. You are considering the care priorities for the patient’s return when the AV fistula is formed.

What are important teaching points for the period immediately following AV fistula formation?

The patient asks if there is anything she can do to make this AV fistula last a long time. How should you respond to promote best practices in AV fistula self-management?

What else should this patient know about AV fistula care?

Discussion 6.1 – Case Study One

The patient is a 68 year old man who has had shortness of breath for the past 2 to 3 days. His past medical history includes a 40 years of smoking a pack as day – history, COPD, and heart failure. He reports that he became concerned when he woke from sleep because he could not breathe. Your physical assessment reveals crackles in the lower lobes bilaterally. His oxygen saturation is 84% without supplement oxygen.

What are some areas of focus to assess as part of this patient’s current history?

Whom should you contact and why?

What are some factors that may affect gas exchange for this patient?

What additional referrals might be appropriate for this patient?

Discussion 6.2 – Case Study Two

Your patient is the 68 year old man from the previous challenge who had shortness of breath for the past 2 to 3 days. His clinical condition deteriorated further, requiring intubation. The health care provider orders a CT scan of the chest.

What are responsivities when preparing the patient for the CT scan?

Why is it important to monitor your patient using capnography?

A large fluid collection on the left side is found during the CT scan and a thoracentesis is planned. What are your responsibilities in preparing for and assisting with this procedure?

Your patient was extubated after the left thoracentesis. Withing 12 hours he again develops respiratory distress, decreased breath sounds and a trachea that appears deviated to the right. What is your assessment?

Discussion 6.3 – Case Study Three

Your patient is a 41 year old woman with a significant closed head injury CHI from a motor vehicle crash MVC. She is not anticipated to be able to be weaned from the ventilator, and the physicians have asked the patient’s family for permission to create a tracheostomy. The family is concerned that the patient will not be able to speak again.

What is your response?

What are some possible concerns for patient care in the immediate postoperative period?

What can you do to minimize tracheal damage?

The patient’s family is concerned that the tracheostomy will be permanent and they are worried about her image. How do you respond?

Discussion 7.1 – Case Study One

A patient who had a supraglottic partial laryngectomy with a right sided radical neck dissection 4 weeks ago is now receiving radiation therapy. He has lost 24 pounds since his surgery, which makes him 15 pounds less than his ideal weight. He tells you that he has no appetite and that what food he does eat “has no taste”. In addition although he expresses that he is glad to be alive he does not want friends to visit because it takes so much energy to interact with them. He also says that he can no longer play the piano because of difficulty moving his right arm and shoulder.

What factors are contributing to his fatigue?

Is the weight loss a concern? If so, what should you do about it?

Should you further press the issue of not wanting to visit with friends? Why or why not?

What other health care professionals or resources would be appropriate at this time?

Discussion 7.2 – Case Study Two

The patient is a 64 year old man with COPD who lives with his wife of 35 years. He retired 2 years ago when his disease interfered with his job as a carpenter. He also quit smoking about a year ago. Since then, his disease has remained stable; however, he now reports that he thinks his wife is preparing for widowhood by taking over all the home chores that he always performed including driving and bill paying. Limiting his interaction with friends, and making all decisions. He is angry and depressed. Routine assessment with pulmonary function testing show his FEV to be 40% of his predicted value, which is an improvement over the 32% value of FEV last year.

What severity classification is his COPD? Provide a rationale for your choice.

How should you respond to his statement about the wife probably preparing for widowhood?

Should he continue to drive and pay bills? Why or why not?

What psychosocial assessment of this patient and his situation should you make?

Should you include the wife in any part of this discussion? Why or why not?

Discussion 7.3 – Case Study Three

The patient is a 60 year old man who has just been diagnosed with non-small cell lung cancer. He smoked cigarettes for about 25 years starting when he was 16 years old and quit when he was 41 years old. His lung cancer is at stage I in the left lower lobe. He is distraught, saying that he can’t die now because he has one child in college and two in high school. He also fears chemotherapy and seems bitter that he quit smoking and got lung cancer anyway. His next statement is; “Why couldn’t I get prostate cancer like most men? At least they survive. No one beats lung cancer.”

What can you tell him about lung cancer survival?

What can you tell him about the benefits of having quit smoking?

For this cancer stage and type, what is/are the most likely therapy/therapies?

What resources could you recommend to help him at this time?

Discussion 8.1 – Case Study One

The nurse is caring for a frail, older patient in the hospital after surgery to repair a bowel obstruction. The patient has a nasogastric NG tube, through which all her scheduled drugs are given, oxygen at 1 liter/nasal cannula at night, an indwelling urinary caterer, and a saline lock. The patient is weak and fatigued, has pain not relieved by IV opioids, and is reluctant to participate in any activities.

What risk factors does this patient have for developing pneumonia?

What actions does the nurse take to decrease the patient’s risk for pneumonia?

Two days later, the NG tube is removed and the patient is started on ice chips and other clear liquids. The patient swallows repeatedly when given sips of water. What action does the nurse perform?

The nurse does hourly rounds on the patient, and the patient’s daughter states, “Something is just not right with mom” What action should the nurse take first? What other actions should the nurse perform?

The physician orders a chest x-ray, and the results show pneumonia. What actions by the nurse are most important?

Discussion 8.2 – Case Study Two

A 50 year old patient is admitted to the medical-surgical floor from the emergency department with severe abdominal pain thought to be from acute pancreatitis. He case a history of drinking at least a case of beer a day. He also smokes and appears cachectic. His old chart indicates a history of COPD, but he does not take drugs for this. He does have a new productive cough. At chage of shift, the nurse finds the patient dyspneic and slight confused. Lung sounds have wheezes, and he is mildly febrile. Pulse is 120 beats per minute, respirations are 32 breaths per minute, and blood pressure is 118/64. Oximetry shows a SpO2 of 91%.

What risk factors for ARDS does this patient have?

Explain the relationship between the lung sounds and the oximetry reading

What diagnostic testing should you be prepared to obtain? Two hours after applying oxygen at 3 liters/nasal cannula, the patient’s Spo2 is now 89%4. What additional measures do you anticipate for this patient?

Discussion 9.1 – Case Study One

A 72 year old woman is transported to the ED with a diagnosis of chest pain to rule out myocardial infarction MI. During the initial assessment the nurse notes the cardiac rhythm changes from sinus tachycardia to ventricular tachycardia VT with a pulse. Her vital signs are 84/40, pulse 154 and respirations 30.

What is the initial treatment for this patient at this time?

What drugs should you anticipate administering to this patient? Why are they indicated?

What evidence-based precautions must be taken to promote safety for both the patient and the ACLS team?

If this rhythm deteriorates to ventricular fibrillation or VT without a pulse, what steps should you take? Why?

Discussion 9.2 – Case Study Two

At a recent staff meeting, the medical-surgical nurse manager reports that the rate of repeated hospitalizations for patients with chronic heart failure has increased 50% in the past 3 months. As a staff nurse you agree to be part of the unit quality improvement team to examine the causes of the increase and make evidence-based recommendations for improving the outcomes for this patient population. Specific patient data and summaries are available for the team to review as needed.

Where will your team begin with this process during the first meeting of the team?

What internet sites will your team use to determine best practices for decreasing repeated hospital stays and why?

How will you know if the plan of action to improve care was effective?

See Chapter 5 for assistance for answering above questions.

Discussion 10.1 – Case Study One

Discuss what you would teach a patient receiving treatment for hypertension and the importance of continuing to take prescribed drugs. What signs and symptoms do promptly need to report to the health care provider?

Discussion 10.2 – Case Study Two

Your patient is a 40 year old woman who is returned to your ambulatory care unit after having a cholecystectomy performed as minimally invasive surgery by laparoscopy. After moving her from the stretcher to her bed, you take her VS pulse is 118 and therady, blood pressure is 88/72 respiratory rate is 28 and pulse oximetry is 88%. When you call her name she opens her eyes but does not answer any questions.

What should you do first?

What manifestations of shock are present based on the information you currently have?3. How would you classify this stage of shock? Provide a rationale for your evaluation.

What other assessment data should you obtain?

Given the type of surgery she has undergone, where would you expect bleeding to occur and what manifestations would indicate possible bleeding?

Discussion 10.3 – Case Study Three

An 82 year old man living alone at home had a sudden onset of chest pain. He called 911 and was taken to the emergency department.

As his ED nurse what is your first action in response to his report of chest pain?

The physician prescribes IV nitroglycerin for the pain. What assessment will you perform prior to administering this drug and why?

The physician prescribed oxygen at 3L via nasal cannula. What is the purpose of this intervention for managing chest pain?

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