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High-Acuity Nursing, 7th Edition Class Notes

  • Nursing
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    DECISION - MAKING CASE SUMMARIES CASE NAME OVERVIEW MAJOR CASE DECISIONS Nils Rasmussen Mr. Nils Rasmussen is a 72 - year - old man with a long history of peripheral atherosclerotic vascular disease. He has a five - year history of abdominal aortic aneurysm (AAA) that has been treated medically with periodic monitoring and drug therapy. Several da ys ago, after undergoing his periodic physical examination and abdominal CT scan, Mr. Rasmussen’s cardiovascular healthcare provider informed him that the aneurysm had significantly increased in size when compared to the previous scan. Interventional repai r of the aneurysm was recommended. 1. Identifying and responding to abnormal test results , vital signs, or symptoms 2. Asking appropriate patient history questions to identify risk factors 3. Prioritizing medication administration 4. Monitoring for side effects of treatments 5. Responding to patient questions 6. Recognizing a need for additional patient teaching Estimated Case Length: Difficulty Level: High Learning Objectives: • Apply knowledge of risk factors associated with aortic aneurysms to care of the patient with aortic aneurysm. • Describe the pathophysiologic basis of aortic aneurysm. • Apply knowledge of the pathophysiologic basis of aortic aneurysm to care of the patient with aortic aneurysm. • 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 . • Describe the 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 has undergone aortic aneurysm repair. Questions Correct Answers 1. You have just received Mr. Rasmussen into Room E and have connected him to the hemodynamic monitor Inform the intensivist that the patient’s blood pressure is significantly elevated. HIGH ACUITY NURSING # 1 : AORTIC ANEURYSM

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    and a pulse oximeter. You are performing your initial assessment , which includes: Oral temp: 97.2  F BPM: 90/min Respiratory rate: 14/min BP of 194/92 (MAP 126 mmHg) O 2 saturation of 88% Pain: abdominal discomfort rated at 2 out of 10 What is the appropriate response to these findings? 2. You are obtaining a nursing history on Mr. Rasmussen. Which of the following interview questions should you ask him to specifically target risk factors for development of aortic aneurysm? (Select all that 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 aortic aneurysm? 3. Mr. Rasmussen’s medication orders include: • atorvastatin (Lipitor) • esm olol (Brevibloc) • fentanyl • a lbuterol (Proventil) • Fluticasone/salmeterol (Advair) Which of his medication order should you initiate first? Esmolol 4. You would alert the health care provider immediately if Mr. Rasmussen develops which of the following clinical findings? ( Select all that apply.) Rapid onset of severe flank or back pain Complaints of numbness in legs Sudden drop in arterial blood pressure.

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    5. You note that the esmolol (Brevibloc) bolus and infusion are quickly reducing Mr. Rasmussen’s heart rate and blood pressure. Based on his medical history, which of the following drug - related problems should you closely monitor him for? Acute kidney injury 6. While you are charting at Mr. Rasmussen’s bedside, he says, “I don’t understand what all of the fuss is about. I have had this aneurysm for years, and it has never caused me any problems. Why do I suddenly need surgery?” How should you respond? “Your aneurysm has significantly enlarged, putting too much pressure on the artery wall. This increases your risk for rupture.” 7. Mr. Rasmussen’s aortic aneurysm is growing according to LaPlace’s law. Which of the following statements correctly reflects the relationship among arterial wall pressure (P), radius (R), and tension (T)? (Select all that apply.) The relationship is expressed as T = P × R. Increased pressure exerted against the arterial wall increases wall radius and tension. 8. You enter Mr. Rasmussen’s room, and he tells you, “The doctor just talked with my wife and me about tomorrow’s EVAR procedure and showed us drawings of what will happen. We are still confused about what “Once the graft has been placed, your arterial blood flows directly through the graft rather than touching the aneurysm wall. The graft protects the damaged portion of your artery and prevents it from growing any larger.”

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    the graft does.” How should you answer? 9. Mr. Rasmussen’s aortic aneurysm repair can be one of two types: open surgical repair (OSR) or endovascular aneurysm repair (EVAR). Which of the following statements are correct regarding these two procedures? (Select all that apply.) EVAR is a lower risk procedure than OSR. Both procedures leave the aneurysm in place. OSR has a longer recovery time than EVAR. 10. Mr. Rasmussen returns to his room following the EVAR drowsy but responsive. His 5% dextrose and 0.45 NS infusion is infusing at 50 mL/h and his IV esmolol (Brevibloc) is infusing at a rate of 0.2 mg/kg/min. You take his vital signs and note that his HR is now 52 and BP is 100/62. How should you respond? Decrease the esmolol infusion rate. 11. Mr. Rasmussen has no additional post - procedure problems. His esmolol (Brevibloc) drip is discontinued as ordered and he has started on an oral beta blocking agent. While conducting discharge teaching, Mr. Rasmussen’s wife says, “I am a little worried about taking him home so soon after his procedure. Can you talk a little about when Presence of any signs of incision site infection Any signs of unusual bleeding A fever greater than 101  F Problems urinating

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    we should contact the doctor’s office?” What information should you include on when to seek medical attention? (Select all that apply). 12. You have been teaching Mr. Rasmussen and his wife about post - EVAR discharge activities. Which statement, if made by Mr. Rasmussen, would indicate the need for additional teaching? “I can sit up in my recliner as much as I want as long as I keep my legs elevated.”

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    DECISION - MAKING CASE SUMMARIES CASE NAME OVERVIEW MAJOR CASE DECISIONS Grace Potter Grace Potter is a 74 - year - old woman who was admitted four days ago to the Medical ICU in acute respiratory failure with severe pneumococcus pneumonia. A conservative initial treatment plan was initiated. Ms. Potter was orally intubated and mechanically ventilated 12 hours post admission when her respiratory status deteriorated. She responded well to antibiotic therapy and was extubated 36 hours post admission. On day 4 post admission, Ms. Potter began to show signs of neurological changes. 1. Identifying and responding to abnormal test results , vital signs, or symptoms 2. Selecting appropriate diagnostic tests 3. Interpreting test results 4. Identifying risk factors for cognitive dysfunction 5. Responding to patient and family questions 6. Setting patient management goals 7. Selecting interventions for the plan of care Estimated Case Length: Difficulty Level: High Learning 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 confusional cognitive disorder. • Determine evidence - based actions to prevent reoccurrence of cognitive dysfunction. Questions Correct Answers 1. It is now 1930 and you are performing your initial shift bedside assessment on Ms. Potter. You assess her Glasgow Coma Scale Take her vital signs. Check her oxygenation status. Perform an abbreviated neurologic assessment. HIGH ACUITY NURSING # 2 : COGNITIVE DYSFUNCTION

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    score as 13 (E=4, M=5, V=4). While she momentarily looks directly at you when you speak, she does not focus on you for any length of time and does not appear to be attending to what you are asking her. She seems agitated, frequently moving around in bed. Based on these findings, what initial actions should you take? Select all that apply. 2. Ms. Potter’s 1800 ABG results are now available and you review them to verify her oxygenation status. The results are as follows: • pH of 7.44 • PaCO 2 of 33 mmHg • PaO 2 of 92 mmHg • HCO 3 of 22 mEq/L, and • SaO 2 of 96% Her mo st current vital signs include BP of 134/74, HR of 92, and RR of 22 . How should you respond to these new ABG values? Make note of the results and continue with your patient care. 3. You discuss your concerns regarding Ms. Potter’s changing level of consciousness with the Perform a Letters Attention Test. Obtain a RASS score.

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    intensivist, who agrees that further investigation is warranted. You review her EHR and prepare to perform the CAM - ICU. Which tests and scores will you include to complete 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 status changes. 4. You have completed the CAM - ICU on Ms. Potter and review the worksheet results, which include: • 3 errors when attempting to correctly identify the letter A • RASS score of +1. • Lifted 3 fingers on right hand none on left when commanded to do so. • Answered 2 of 4 yes/no questions correctly. • Her baseline GCS was 15 and is now 13. Based on these data, which conclusion can you draw? She meets the CAM - ICU criteria for delirium. 5. You are reviewing Ms. Potter’s EHR to check for possible risk factors that could have precipitated her delirium. Which of the following of Ms. Potter’s EHR data place her at risk for an acute confusional cognitive disorder? Select all that apply. Age of 74 years Her recent severe pneumococcal pneumonia. ICU patient status Recent mechanical ventilation support

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    6. You are aware that certain drugs have been associated with development of delirium. For this reason, you are reviewing Ms. Potter’s prescribed medications. Which of her medications have been associated with increased risk for delirium? Select all that apply. alprazolam (Xanax) ranitidine (Zantac) acetaminophen (Tylenol) 7. You are talking with Ms. Potter’s daughter, Rebecca, about her mother’s altered cognitive status and the CAM - ICU results. During your conversation she states, “I’m really confused about the difference between delirium and dementia. We hear a lot about deme ntia, but I’ve never really learned about delirium. Can you explain them to me?” Which statements accurately reflect dementia and delirium. Select all that apply. “Delirium is an acute onset problem, meaning that the symptoms develop quickly.” “People with dementia develop symptoms slowly over months to years.” “People with delirium usually alternate between being hypoactive and hyperactive.” 8. You are currently reporting on Ms. Potter’s mental status changes during interdisciplinary rounds. The contents of your verbal report should include patient data that help achieve what essential management goal specific to Ms. Potter’s changed cognitive status? Identification of underlying cause

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