High-Acuity Nursing, 7th Edition Class Notes

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DECISION-MAKINGCASE SUMMARIESCASENAMEOVERVIEWMAJOR CASEDECISIONSNilsRasmussenMr. Nils Rasmussen is a 72-year-old man with a long historyof peripheral atheroscleroticvascular disease. He has a five-year history of abdominal aorticaneurysm (AAA) that has beentreated medically with periodicmonitoring and drug therapy.Several days ago, afterundergoing his periodic physicalexamination and abdominal CTscan, Mr. Rasmussen’scardiovascular healthcareprovider informed him that theaneurysm had significantlyincreased in size whencompared to the previous scan.Interventional repair of theaneurysm was recommended.1.Identifying and responding toabnormal test results, vitalsigns, or symptoms2.Asking appropriate patienthistory questions to identify riskfactors3.Prioritizing medicationadministration4.Monitoring for sideeffects oftreatments5.Responding to patientquestions6.Recognizing a need foradditional patient teachingEstimated Case Length:Difficulty Level:HighLearning Objectives:•Apply knowledge ofrisk factors associated with aortic aneurysms to care of the patientwith aortic aneurysm.•Describe the pathophysiologic basis of aortic aneurysm.•Apply knowledge of the pathophysiologic basis of aortic aneurysm to care of thepatient with aorticaneurysm.•Assess the patient for clinical manifestations of aortic aneurysm, aneurysm rupture,and aneurysm dissection.•Identify potential complications of drug therapy in a patient with aortic aneurysm.•Describethe interventional management choices for aortic aneurysm repair.•Demonstrate understanding of management priorities of with aortic aneurysm.•Apply knowledge of patient/family teaching pertaining to the patient who hasundergone aortic aneurysm repair.QuestionsCorrect Answers1.You have just receivedMr. Rasmusseninto Room Eand have connected him tothe hemodynamic monitorInform the intensivist that the patient’s blood pressure issignificantly elevated.HIGH ACUITY NURSING#1:AORTIC ANEURYSM

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and a pulse oximeter. Youare performing your initialassessment, which includes:Oral temp:97.2FBPM: 90/minRespiratory rate: 14/minBP of 194/92 (MAP 126mmHg) O2saturation of88%Pain: abdominaldiscomfort rated at 2 out of10What is the appropriateresponse to these findings?2.You are obtaining anursing history on Mr.Rasmussen. Which of thefollowing interviewquestions should you askhim to specifically targetrisk factors fordevelopment of aorticaneurysm?(Select allthat apply)Do you have a history of high blood pressure?Do you use tobacco products such as cigarettes or cigars?Has anyone in your family ever been diagnosed with aorticaneurysm?3.Mr. Rasmussen’smedication orders include:•atorvastatin (Lipitor)•esmolol(Brevibloc)•fentanyl•albuterol(Proventil)•Fluticasone/salmeterol(Advair)Which of his medicationordershould you initiatefirst?Esmolol4.You would alert thehealth care providerimmediately if Mr.Rasmussen developswhich of the followingclinical findings? (Selectallthat apply.)Rapid onset of severe flank or back painComplaints of numbness in legsSudden drop in arterial blood pressure.

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5.You note that theesmolol (Brevibloc) bolusand infusion are quicklyreducing Mr.Rasmussen’s heart rateand blood pressure.Based on his medicalhistory, which of thefollowing drug-relatedproblems should youclosely monitor him for?Acute kidneyinjury6.While you are chartingat Mr. Rasmussen’sbedside, he says, “I don’tunderstand what all of thefuss is about. I have hadthis aneurysm for years,and it has never causedme any problems. Why doI suddenly need surgery?”How should you respond?“Your aneurysm has significantly enlarged, putting toomuch pressure on the artery wall. This increases your riskfor rupture.”7.Mr. Rasmussen’s aorticaneurysm is growingaccording to LaPlace’slaw. Which of the followingstatements correctlyreflects the relationshipamong arterial wallpressure (P), radius (R),and tension (T)?(Selectall that apply.)The relationship is expressed as T = P × R.Increased pressure exerted against the arterial wallincreases wall radius and tension.8.You enter Mr.Rasmussen’s room, andhe tells you, “The doctorjust talked with my wifeand me about tomorrow’sEVAR procedure andshowed us drawings ofwhat will happen. We arestill confused about what“Once the graft has been placed, your arterial blood flowsdirectly through the graft rather than touching theaneurysm wall. The graft protects the damaged portion ofyour artery and prevents it from growing any larger.”

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the graft does.” Howshould you answer?9.Mr. Rasmussen’s aorticaneurysm repair can beone of two types: opensurgical repair (OSR) orendovascular aneurysmrepair (EVAR). Which ofthe following statementsare correct regardingthese two procedures?(Select all that apply.)EVAR is a lower risk procedure than OSR.Bothprocedures leave the aneurysm in place.OSR has a longer recovery time than EVAR.10.Mr. Rasmussenreturns to his roomfollowing the EVARdrowsy but responsive.His5% dextrose and 0.45NS infusion is infusing at50 mL/h and hisIVesmolol(Brevibloc)isinfusing at a rate of 0.2mg/kg/min. You take hisvital signs and note thathis HR is now 52 and BPis 100/62. How should yourespond?Decrease the esmololinfusion rate.11.Mr. Rasmussen hasno additional post-procedure problems. Hisesmolol (Brevibloc) drip isdiscontinued as orderedand he has started on anoral beta blocking agent.While conductingdischarge teaching, Mr.Rasmussen’s wife says, “Iam a little worried abouttaking him home so soonafter his procedure. Canyou talk a little about whenPresence of any signs of incision site infectionAny signs of unusual bleedingA fever greater than 101FProblems urinating

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we should contact thedoctor’s office?”What information shouldyou include on when toseek medical attention?(Select all that apply).12.You have beenteaching Mr. Rasmussenand his wife about post-EVAR discharge activities.Which statement, if madeby Mr. Rasmussen, wouldindicate the need foradditional teaching?“I can sit up in my recliner as much as I want as long as Ikeep my legs elevated.”

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DECISION-MAKINGCASE SUMMARIESCASENAMEOVERVIEWMAJOR CASEDECISIONSGrace PotterGrace Potter is a 74-year-oldwoman who was admitted fourdays ago to the Medical ICU inacute respiratoryfailure withsevere pneumococcuspneumonia. A conservativeinitial treatment plan wasinitiated. Ms. Potter was orallyintubated and mechanicallyventilated 12 hours postadmission when her respiratorystatus deteriorated. Sheresponded well to antibiotictherapy and was extubated 36hours post admission.On day 4post admission, Ms. Potterbeganto show signs ofneurological changes.1.Identifying and responding toabnormal test results, vitalsigns, or symptoms2.Selecting appropriatediagnostictests3.Interpreting test results4.Identifying risk factors forcognitive dysfunction5.Responding to patientandfamilyquestions6.Setting patient managementgoals7.Selecting interventions for theplan of careEstimated Case Length:Difficulty Level:HighLearning Objectives:•Assess the patient for the presence of a cognitive dysfunction.•Demonstrate knowledge of the clinical significance of abnormal laboratory values.•Identify risk factors for development of delirium cognitive dysfunction.•Demonstrate an understanding of the confusional cognitive disorders.•Select management goals for the patient with a confusional cognitive disorder.•Demonstrate understanding of evidence-based management of a confusionalcognitive disorder.•Determine evidence-based actions to prevent reoccurrence of cognitive dysfunction.QuestionsCorrect Answers1.It is now 1930 and youare performing your initialshift bedside assessmenton Ms. Potter. You assessher Glasgow Coma ScaleTake her vital signs.Check heroxygenation status.Perform an abbreviated neurologic assessment.HIGH ACUITY NURSING#2:COGNITIVEDYSFUNCTION

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score as 13 (E=4, M=5,V=4). While shemomentarily looks directlyat you when you speak,she does not focus on youfor any length of time anddoes not appear to beattending to what you areasking her. She seemsagitated, frequentlymoving around in bed.Based on these findings,what initial actions shouldyou take?Select all thatapply.2.Ms. Potter’s 1800 ABGresults are now availableand you review them toverify her oxygenationstatus. The results are asfollows:•pH of 7.44•PaCO2of 33mmHg•PaO2of 92 mmHg•HCO3of 22 mEq/L,and•SaO2of 96%Her most current vitalsigns includeBP of134/74, HR of 92, and RRof 22. How should yourespond to these newABG values?Make note of the results and continue with your patientcare.3.You discuss yourconcerns regarding Ms.Potter’s changing level ofconsciousness with thePerform a Letters Attention Test.Obtain a RASS score.

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intensivist, who agreesthat further investigation iswarranted. You review herEHR and prepare toperform the CAM-ICU.Which tests and scoreswill you include tocomplete the CAM-ICU?(Select all that apply)Perform a Command test.Perform a Yes/No Question test.Review Ms. Potter’s EHR to check for mental statuschanges.4.You have completedthe CAM-ICU on Ms.Potter and review theworksheet results, whichinclude:•3 errors whenattempting to correctlyidentify the letter A•RASS score of +1.•Lifted 3 fingers on righthand none on left whencommanded to do so.•Answered 2 of 4 yes/noquestions correctly.•Her baseline GCS was15 and is now 13.Based on these data,which conclusion can youdraw?She meets the CAM-ICU criteria for delirium.5.You are reviewing Ms.Potter’s EHR to check forpossible risk factors thatcould have precipitatedher delirium. Which of thefollowing of Ms. Potter’sEHR data place her at riskfor an acute confusionalcognitive disorder?Select all that apply.Age of 74 yearsHer recent severe pneumococcal pneumonia.ICU patient statusRecent mechanical ventilation support

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6.You are aware thatcertain drugs have beenassociated withdevelopment of delirium.For this reason, you arereviewing Ms. Potter’sprescribed medications.Which of her medicationshave been associated withincreased risk fordelirium?Select all thatapply.alprazolam (Xanax)ranitidine (Zantac)acetaminophen (Tylenol)7.You are talking with Ms.Potter’s daughter,Rebecca, about hermother’s altered cognitivestatus and the CAM-ICUresults. During yourconversation she states,“I’m really confused aboutthe difference betweendelirium and dementia.We hear a lot aboutdementia, but I’ve neverreally learned aboutdelirium. Can you explainthem to me?” Whichstatements accuratelyreflect dementia anddelirium.Select all thatapply.“Delirium is an acute onset problem, meaning that thesymptoms develop quickly.”“Peoplewith dementia develop symptoms slowly overmonths to years.”“People with delirium usually alternate between beinghypoactive and hyperactive.”8.You are currentlyreporting on Ms. Potter’smental status changesduring interdisciplinaryrounds. Thecontents ofyour verbal report shouldinclude patient data thathelp achieve whatessential managementgoal specific to Ms.Potter’s changed cognitivestatus?Identification of underlying cause

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