Nursing Case Study

1. Suzanne Jones, 76-year-old patient with COPD is admitted to the ICU. Mrs. Jones is placed on mechanical ventilation to assist with her breathing. After 2 days on the ventilator, Mrs. Jones is extubated and then transferred to a medical-surgical unit. The medication regimen is adjusted during the hospitalization. Mrs. Jones is discharged home after 6 days. She and her family are pleased with the care she receive in the hospital. (Learning Objectives 3 and 6)

 

a. Describe the quality performance tools that may be used to demonstrate that the care and treatment rendered are both cost-efficient and of high quality.

b. Describe the quality performance tools that may be used to demonstrate that the nursing care utilized is evidence-based care and high quality, resulting in patient satisfaction and good patient outcomes.

 

2. The registered nurse working in the cardiac care clinic is tasked with implementing quality improvement measures. To educate the clinic staff, the nurse plans an in-service program to introduce concepts of quality improvement and evidence-based practice. Additionally, the role of the case manager will be included in the presentation. The nurse plans on using care of the patient with Congestive Heart Failure as a template, and prepares sample clinical pathways, care maps, and multidisciplinary action plans. (Learning Objective 3)

 

a. Describe how clinical pathways are used to coordinate care of caseloads of patients.

b. What is the role of the case manager in evaluating a patient’s progress?

c. What are examples of evidence-based practice tools used for planning patient care?

. Mr. Jones, who is 74 years of age, is being discharged home after having a right knee replacement. The discharge orders from the orthopedic surgeon include: continuous passive motion (CPM) at the current setting of 0-degrees extension worn when walking with crutches (nonweight-bearing postdischarge day 1, and may begin weight-bearing postdischarge day 2); and home nurse visits, as needed. Physical therapy should begin the day after discharge at an orthopedic center. The orders will be faxed to the center. The following medications with prescriptions attached include: Lovenox (enoxaparin) 70 mg subcutaneously once daily for 7 days, Vicodin (hydrocodone bitartrate) 10 mg every 4 hours PRN, and Colace (docusate sodium) 100 mg every day. The patient is to follow up with the orthopedic surgeon in 3 weeks. His daughter plans to stay with him for several weeks to assist him with meals and household chores, and take him to physical therapy and the orthopedic surgeon for follow-up. Mr. Jones has three other children who live in other states. He is a widower and attends a local church. (Learning Objective 4)

 

 

a. What preparations should the nurse make in advance before attaining necessary community resources and referrals before the patient is discharged?

 

1. What necessary community resources and referrals will the patient need?

 

 

2. Mrs. Johnson, a 67-year-old female patient, has recently been discharged from the hospital following an admission for COPD. She has a past medical history of a colon resection related to acute diverticulitis. She developed a surgical wound infection that requires daily wet to dry wound packing and IV Zosyn. Mrs. Johnson was discharged with home oxygen. To manage her care at home, home care visits were ordered. (Learning Objective 5)

 

 

a. What would be involved in setting up the first home care visit?

 

1. Describe the nursing assessments and management that would occur during the visit.

 

1. Mrs. Elle, 80 years of age, is a female patient who is diagnosed with end-stage cancer of the small intestine. She is currently receiving comfort measures only in hospice. She has gangrene of her right foot and has a history of diabetes controlled with oral agents. She is confused and the physician has determined that she is unable to make her own informed decisions. The hospice nurse, not realizing that the weekly order for CBC and renal profile had been discontinued, obtained the labs and sent them to the nearby laboratory for processing. The abnormal lab results obtained later that day revealed that the patient needed a blood transfusion. The hospice nurse updated the patient’s medical power of attorney who was distressed at the report. The patient’s wishes were to die peacefully and to not have to undergo an amputation of her right foot. But if the patient receives the blood transfusion, she may live long enough to need the amputation. The patient’s physician had previously informed the medical power of attorney that the patient would most likely not be able to survive the amputation. The patient’s medical power of attorney had made the request to cease all labs so that the patient would receive comfort measures until she died. The patient has no complaint of shortness of breath or discomfort. (Learning Objective 4)

 

 

a. What ethical dilemma exists?

 

1. Who are the stakeholders and what gains or losses do each have?

 

1. What strategies should the hospice nurse take to resolve the ethical dilemma?

 

 

2. The nurse receives a 12-year-old girl from the operating room after an emergent appendectomy due to ruptured appendix. Upon arrival to the postanesthesia care unit, the patient is drowsy, but arousable to voice; she was extubated in the operating room and is receiving oxygen by facemask at 40%. She has two peripheral IVs in her left arm that are infusing Lactated Ringers solution at 100 mL/hr. A nasogastric tube is attached to low constant suction, and a small amount of aspirate is noted. She has a urinary catheter that is draining clear, yellow urine. Her abdominal dressing is dry and intact. Upon arousal, she complains of abdominal pain. (Learning Objective 5)

 

 

a. What NANDA-approved nursing diagnoses may be relevant to this patient?

 

1. Once the nursing diagnoses are determined, what steps does the nurse take to complete the Planning Phase of the Nursing Process?

 

1. What is the difference between nursing diagnoses and collaborative problems?

Case Study, Chapter 4, Health Education and Health Promotion

 

 

1. Mr. Smith, a 57-year-old patient, presents at a health fair asking questions about the age-appropriate health maintenance and promotion considerations he should be concerned about. He stated that he only goes to his physician when he is sick and the last time he saw his physician was 2 years ago when he had a sinus infection. (Learning Objectives 7 to 9)

 

 

a. What further assessment does the nurse need to make before designing a teaching plan?

 

1. What topics does the nurse need to include for Mr. Smith based on current medical recommendations?

 

1. Design a teaching plan that covers the topics.

 

 

2. The community health nurse is planning a health promotion workshop for a high school PTSO (Parent-Teacher-Student Organization). The choice of topics was suggested by the high school’s registered nurse who has observed a gradual increase in student obesity. The two nurses have collaborated to develop this workshop to provide parents, students, and teachers with information about the importance of health promotion. (Learning Objectives 6, 8, and 9)

 

 

a. Describe the importance of a focus on health promotion.

 

1. According to the health promotion model developed by Becker (1993), what four variables influence the selection and use of health promotion behaviors?

 

1. Describe four components of health promotion.

 

Case Study, Chapter 5, Adult Health and Nutritional Assessment

 

 

1. Mrs. Jones, a 40-year-old female patient, is presenting for a history and physical. The nurse gathers a family history from the patient. She shares that her mother died at 70 years of age of colon cancer and had adult onset diabetes controlled with oral agents, hypercholesterolemia, and hypertension. She had a stroke before passing away. Her father died at 67 years of age from a stroke. He had a long history of alcoholism and smoked two packs per day of cigarettes for 50 years. He had hypertension, hypercholesterolemia, and two heart attacks; the first heart attack was at 30 years of age and the second at 52 years of age. He had adult onset diabetes controlled with oral agents since 50 years of age. He had renal stenosis that was unsuccessfully treated with a renal angioplasty and he developed end-stage renal failure requiring hemodialysis. Mrs. Jones has two brothers. One brother developed hypertension, hypercholesterolemia, and adult onset diabetes controlled with oral agents at 50 years of age. The second brother has no health problems. The maternal grandmother died at 88 years of age of a stroke and had hypertension. The maternal grandfather died at 70 years of age of a massive heart attack and had a history of hypertension. The paternal grandmother died at 80 years of age of a heart attack. The paternal grandfather died at 50 years of age from bleeding esophageal varices related to long-standing alcoholism. The patient shares that her mother’s first cousin, George, died at 52 years of age of Hodgkin lymphoma. She has another first cousin Mabel, 72 years of age, who is alive but has had cancer of the colon and had a recent stroke, and has a history of hypertension, hypercholesterolemia, and adult onset diabetes controlled with diet. Her mother’s sister, who is 68 years of age, is alive and has a history of hypertension and hypercholesterolemia. Her mother’s brother died at 68 years of age of renal cancer and had a history of hypertension, hypercholesterolemia, and adult onset diabetes controlled with oral agents. He also had a heart attack at 45 years of age and a coronary artery bypass graft operation of three vessels at 55 years of age. He smoked cigarettes for 50 years. The patient’s father was an only child and her father’s family all lived to be over 80 years of age. (Learning Objective 5)

 

 

a. What genetic-related diseases do the patient’s first-order relatives have?

 

1. What genetic-related diseases do the patient’s second-order relatives have?

 

1. Optional: Draw a genogram of the patient’s family’s health history using the example in the textbook (see Fig. 5-2) as a guide.

 

 

2. The registered nurse prepares to conduct a nutritional assessment on Mrs. Varner, a 52-year-old Caucasian female who describes herself as “overweight most of my adult life.” The client states that her health is good. She works part time as a receptionist and volunteers about 10 hours per week in her church. The nurse obtains Mrs. Varner’s height as 64 inches and her weight as 165 pounds. (Learning Objective 8)

 

 

a. What is the rationale for computing body mass index? What is Mrs. Varner’s BMI?

 

1. Calculate her ideal body weight. What is your assessment of her BMI and weight?

 

1. Based on Mrs. Varner’s BMI and weight, the nurse measures her waist circumference. Describe the proper procedure for this assessment.

 

1. Mrs. Varner’s waist circumference is 38 inches. What is your assessment?

 

1. What laboratory values would the nurse review to evaluate Mrs. Varner’s protein levels?

 

Case Study, Chapter 6, Individual and Family Homeostasis, Stress, and Adaptation

 

 

1. Mr. Smith, a 52-year old patient, is admitted to the coronary care unit with the diagnosis of acute inferior myocardial infarction. The patient has a history of smoking two packs per day of cigarettes for 35 years, and he drinks a six-pack of beer on weekend nights, but does not drink the rest of the week. He is the sole financial support for his family. He is a consultant for a company and is out of town during week days. Over the past year, Mr. Smith has gained 20 pounds. He is 5 foot 6 inches, weighing 200 pounds. His diet consists mostly of fast food. He rarely exercises. His wife cares for their three teenage children. The eldest son, 17 years of age, totaled the family car when drinking and driving 2 days ago and he is in the local children’s hospital in the intensive care unit in critical condition. Mr. Smith developed chest pain and slumped over in his chair during an argument with his wife about their teenage daughter, who is 15 years of age and wanted to get birth control pills. The wife is in the waiting room while the nurses settle Mr. Smith into his room. The youngest son, 13 years of age, is at a friend’s house. The teenage daughter is staying at the bedside of the critically ill eldest son. The wife blames her eldest son for her husband’s heart attack and told the emergency department nurse that she does not care to see her son at all. (Learning Objectives 6, 10, and 11)

 

 

a. What maladaptive responses to stress may have contributed to Mr. Smith’s development of an illness?

 

1. Based on the case study, what family assessment data may be used to determine coping strategies being currently used by the family in crisis?

 

1. What nursing interventions should be used to promote effective coping for the patient and his family?

 

 

2. Mary Turner stepped on a nail 5 days ago and sustained a puncture about 1 inch deep. She immediately cleaned the area with soap and water and hydrogen peroxide, and applied triple antibiotic ointment to the site. Today she comes to the clinic with complaints of increased pain and swelling in her foot. On assessment, the nurse notes that the puncture site is red and edematous, and has a moderate amount of yellowish drainage. (Learning Objective 9)

 

 

a. Describe the sequence of events that caused the local inflammation seen in Mary’s foot.

 

1. What is the role of histamine and kinins in the inflammatory process?

 

1. Which of the five cardinal signs of inflammation does Mary exhibit?

 

1. Because Mary’s injury occurred 5 days ago, the nurse should assess for what systemic effects?

Case Study, Chapter 7, Overview of Transcultural Nursing

 

 

1. Mrs. Perez, 32 years of age, is a Hispanic patient who is admitted for early stage cancer of the uterus. The surgeon stated that in order to treat Mrs. Perez’s cancer successfully, the uterus will need to be removed surgically through a procedure called a simple hysterectomy leaving the ovaries, fallopian tubes, and vagina. The surgeon requests that the nurse make arrangements for an interpreter, so they can both use the interpreter’s services. The patient only speaks Spanish, but her mother and one of the patient’s sisters are bilingual. They are currently visiting the patient. Her husband is also visiting and he only speaks Spanish. The patient’s two children are with her sister Maria. The family stated they are devout Catholics and request to see a priest while in the hospital. Today is Ash Wednesday. (Learning Objective 4)

 

 

a. Which interpreter is the most appropriate choice to communicate with Mrs. Perez and why?

 

1. After critically analyzing the cultural influences, what nursing actions are appropriate for the patient?

 

 

2. The nurse manager of an ambulatory care clinic has noted an increased number of visits by patients from different countries and cultures, including patients from Mexico and other Latin American countries. Concerned about meeting the needs of this culturally diverse population, the nurse manager convenes a staff meeting to discuss this change in patient demographics, and to query the staff about any learning needs they have related to the care of these patients. (Learning Objective 3)

 

 

a. What strategy to avoid stereotyping clients from other cultures should the nurse include in this meeting?

 

1. Identify culturally sensitive issues to be discussed in the staff meeting.

 

1. One technician on the staff complains that some patients never make eye contact, and this makes it difficult for him to complete his work. How should the nurse respond?

Case Study, Chapter 8, Overview of Genetics and Genomics in Nursing

 

 

1. A patient who is 38 years of age is diagnosed with autosomal dominant polycystic kidney disease, a hereditary disease that results in fluid-filled cysts occupying space in the kidneys. The cysts can interfere with the function of the kidney and may burst and cause bleeding inside the kidney. The patient with polycystic kidney disease may or may not have a berry aneurysm of a blood vessel in the brain that could lead to bleeding and death, cysts on the ovaries, and a mitral valve prolapse (in females) that can lead to dysrhythmias (irregular heart rhythms), or diverticula (outpouching of the bowel) that are susceptible to infection and inflammation and may lead to gastrointestinal bleeding. The patient is susceptible to retaining fluid in the abdomen so the abdomen is large to constipation, and to hypertension. There is no cure for the disease. The patient receives supportive care for the various symptoms or complications the patient may have. (Learning Objectives 1 to 3)

 

 

a. When explaining to the patient and family about polycystic kidney disease, the nurse should explain what characteristics about an autosomal dominant genetic disease?

 

1. How does variable expression of genetic characteristics play a role in the course of polycystic kidney disease and how can the nurse further predict the level of the disease?

 

1. Identify the roles of the nurse in integrating genetics in the nursing care provided for the patient.

 

 

2. Mr. Wayne is a 38-year-old man with a significant family history of elevated cholesterol levels. His father died at age 42 from a massive heart attack secondary to elevated cholesterol and triglycerides, and two of his older siblings are currently taking medications to lower their cholesterol levels. Mr. Wayne makes an appointment to discuss his risk for hypercholesterolemia. The nurse recognizes that Mr. Wayne is at risk for familial hypercholesterolemia because this is an autosomal dominant inherited condition. (Learning Objective 2)

 

 

a. Describe the pattern of autosomal dominant inheritance.

 

1. Mr. Wayne asks what chance his children have of developing familial hypercholesterolemia. How should the nurse respond?

 

1. Explain the phenomenon of penetrance observed in autosomal dominant inheritance.

Case Study, Chapter 9, Chronic Illness and Disability

 

 

1. Mr. Edwards is 20-year-old male patient who is admitted for treatment of recurring pyelonephritis (kidney infection) and surgical treatment of a urinary stricture, which has decreased the urinary stream. Mr. Edwards has paraplegia; he is paralyzed from the waist down secondary to an automobile accident when he was 16. He came by ambulance to the hospital, leaving his wheelchair and wheelchair pressure-relieving cushion at home. According to the nursing history, the patient is a nonsmoker and he does not drink alcohol or take any illegal drugs. (Learning Objective 5)

 

 

a. What nursing considerations should be made for Mr. Edwards related to his disability?

 

1. What health promotion and prevention education does Mr. Edwards need?

 

 

2. Ms. Fulton is a 38-year-old mother who was recently diagnosed with myasthenia gravis, a chronic disease of the neuromuscular system. Management of this disease process requires strict adherence to a medication regimen. The disease also affects ADLs for the patient and her family. Additionally, because myasthenia gravis is characterized by exacerbations that may require hospitalizations, Ms. Fulton has had to resign from her position as president of a marketing firm. She has remained as an employee of the same company, but now serves as a consultant with more flexible work hours. (Learning Objective 3)

 

 

a. In discussing management of her chronic disease, the nurse focuses on what types of strategies?

 

1. Describe supportive nursing care that may be helpful to Ms. Fulton.

Case Study, Chapter 10, Principles and Practices of Rehabilitation

 

 

1. Mrs. Adams, 72 years of age, is admitted to the rehab unit with the diagnosis of stroke. The stroke affected the limbic area in the brain, which has caused the patient to have emotional labiality (her mood changes rapidly because she misinterprets situations). As a result of the emotional labiality, she sometimes refuses to be repositioned or to participate in physical or occupational therapy. She sometimes also refuses to eat and drink. The patient’s right side is paralyzed and flaccid. She has no feeling on her right side. She has reddened areas on her coccyx and both heels at least 1 cm in diameter that do not go away with repositioning. She is incontinent of urine and stool. She has problems with communication called global aphasia (difficulties understanding speech and the written word and difficulties with speaking and writing). She is 5 feet tall and weighs 178 pounds. She has a tendency to develop skin tears because her skin is thin, and she has several bandages on her arms. The family states they are concerned because the staff on the previous medical-surgical unit would drag their mother up in bed when she slid down. The staff would chart when their mother refused to be repositioned and then would not reposition her for hours. (Learning Objectives 2 and 4)

 

 

a. Explain the pathophysiology of the risk factors that predispose Mrs. Adams to developing pressure ulcers?

 

1. What nursing measures need to be instituted for Mrs. Adams based on the information presented in the case study?

 

 

2. You are assigned to care for David Ramsey, a 22-year-old male patient who sustained a back injury secondary to being thrown from a motorcycle. He did not damage the spinal cord, but the computed tomography revealed a compression fracture at L-2 (lumbar area). David complains of severe lower back pain with numbness and tingling in the lower extremities. You identify the following nursing diagnosis: Impaired Physical Mobility.

(Learning Objective 4)

 

 

a. What assessments are indicated based on this nursing diagnosis?

 

1. List other major nursing diagnoses based on David’s clinical presentation.

 

Case Study, Chapter 11, Health Care of the Older Adult

 

 

1. The nurse working at the senior center notices Mrs. Jones, a 78-year-old, crying. The nurse approaches Mrs. Jones and asks if she needs help. Mrs. Jones states “I am so embarrassed. I had another accident and my pants are all wet. It’s like I’m a baby. I never should have come to the senior center.” (Learning Objectives 3 and 4)

 

 

a. What factors may be contributing to the urinary incontinence?

 

1. How should the nurse respond to Mrs. Jones?

 

 

2. The nurse is completing the admission assessment for a patient scheduled for cataract surgery in the outpatient center. Because the patient is over the age of 70 and has several chronic conditions, including hypertension and congestive heart failure, the nurse focuses on completing a thorough medication history. (Learning Objective 4)

 

 

a. What questions should the nurse include in the medication history?

 

1. The patient states that she stopped taking one of her medications due to cost, since her health insurance would not reimburse for the medication. What are other reasons that older adults may be noncompliant with ordered medications?

 

1. How does aging affect drug absorption, metabolism, distribution, and excretion?

 

Case Study, Chapter 12, Pain Management

 

 

1. Mr. Will, a 67-year-old patient, is postoperative day 2 after a coronary artery bypass graft operation to revascularize his coronary arteries that were significantly blocked. He has a midline incision of his chest and a 7-inch incision on the inner aspect of his right thigh where a saphenous vein graft was harvested and used to vascularize the blocked coronary artery. The surgeon ordered Oxycodone 5 mg every 4 hours PRN for moderate pain and Oxycodone 10 mg every 4 hours PRN for severe pain. (Learning Objectives 7 and 8)

 

 

a. Considering the patient’s age, what medication administration considerations should the nurse incorporate into the pain management plan and why?

 

1. What measures should the nurse provide the patient to prevent adverse effects of analgesic agents from occurring?

 

1. What nonpharmacologic pain management methods should the nurse teach to Mr. Will to assist with pain management?

 

 

2. Mr. Rogers is 2 days postoperative of a thoracotomy for removal of a malignant mass in his left chest. His pain is being managed via an epidural catheter with morphine (an opioid analgesic). As the nurse assumes care of Mr. Rogers, he is alert and fully oriented, and states that his current pain is 2 on a 1-to-10 scale. His vital signs are 37.8 – 92 – 12, 138/82. (Learning Objective 6)

 

 

a. What are benefits of epidural versus systemic administration of opioids?

 

1. The nurse monitors Mr. Rogers’ respiratory status and vital signs every 2 hours. What is the rationale for these frequent assessments?

 

1. The nurse monitors Mr. Rogers for what other complications of epidural analgesia?

 

1. Mr. Rogers complains of a severe headache. What should the nurse do?

 

1. Mr. Rogers’ epidural morphine and decreased mobility increase his chances of constipation. What interventions should be included in his plan of care to minimize constipation?

 

Case Study, Chapter 13, Fluid and Electrolytes: Balance and Disturbance

 

 

1. Mrs. Dean is 75-year-old woman admitted to the hospital for a small bowel obstruction. Her medical history includes hypertension. Mrs. Dean is NPO. She has a nasogastric (NG) tube to low continuous suction. She has an IV of 0.9% NS at 83 mL/hr. Current medications include furosemide 20 mg daily and hydromorphone 0.2 mg every 4 hours, as needed for pain. The morning electrolytes reveal serum potassium of 3.2 mEq/L. (Learning Objective 4)

 

 

a. What are possible causes of a low potassium level?

 

1. What action should the nurse take in relation to the serum potassium level?

 

1. What clinical manifestations might the nurse assess in Mrs. Dean?

 

 

2. Conrad Jackson is a 28-year-old man who presents to the emergency department with severe fatigue and dehydration secondary to a 4-day history of vomiting. During the interview, he describes attending a family reunion and states that perhaps he “ate something bad.” Upon admission his vital signs are a temperature of 102.7°F, heart rate of 116 bpm, respiratory rate of 18 breaths/min, and blood pressure of 86/54 mm Hg. The nurse also notes the patient has dry mucous membranes and tenting of skin. The physician orders an IV to be started with 0.45% normal saline, and orders a serum electrolytes and an arterial blood gas. (Learning Objective 7)

 

The following results are returned from the laboratory:

 

Sodium (Na+)             150

Potassium (K+)           5.5

Chloride (Cl¯)             110

BUN                           42

Creatinine                    0.8

Glucose                       86

pH                               7.32

PaCO2                         35

HCO3¯                        20

PaO2                            90

O2 Sat                          98%

 

 

a. What is your interpretation of this arterial blood gas sample?

 

1. Explain the high potassium in this patient.

 

1. Calculate the patient’s anion gap:

 

1. What is the interpretation of this anion gap?

Case Study, Chapter 14, Shock and Multiple Organ Dysfunction Syndrome

 

 

1. Adam Smith, 77 years of age, is a male patient who was admitted from a nursing home to the intensive care unit with septic shock secondary to urosepsis. The patient has a Foley catheter in place from the nursing home with cloudy greenish, yellow-colored urine with sediments. The nurse removes the catheter after obtaining a urine culture and replaces it with a condom catheter attached to a drainage bag since the patient has a history of urinary and bowel incontinence. The patient is confused, afebrile, and hypotensive with a blood pressure of 82/44 mm Hg. His respiratory rate is 28 breaths/min and the pulse oximeter reading is at 88% room air, so the physician ordered 2 to 4 L of oxygen per nasal cannula titrated to keep SaO2 greater than 90%. The patient responded to 2 L of oxygen per nasal cannula with a SaO2 of 92%. The patient has diarrhea. His blood glucose level is elevated at 160 mg/dL. The white blood count is 15,000 and the C-reactive protein, a marker for inflammation, is elevated. The patient is being treated with broad-spectrum antibiotics and norepinephrine (Levophed) beginning at 2 mcg/min and titrated to keep systolic blood pressure greater than 100 mm Hg. A subclavian triple lumen catheter was inserted and verified by chest x-ray for correct placement. An arterial line was placed in the right radial artery to closely monitor the patient’s blood pressure during the usage of the vasopressor therapy. (Learning Objectives 6 and 7)

 

 

a. What predisposed the patient to develop septic shock?

 

1. What potential findings would suggest that the patient’s septic shock is worsening from the point of admission?

 

1. The norepinephrine concentration is 16 mg in 250 mL of normal saline (NS). Explain how the nurse should administer the medication. What nursing implications are related to the usage of a vasoactive medication?

 

1. Explain why the effectiveness of a vasoactive medication decreases as the septic shock worsens. What treatment should the nurse anticipate to be obtained to help the patient?

 

1. Explain the importance for nutritional support for this patient and which type of nutritional support should be provided?

 

 

2. Carlos Adams was involved in a motor vehicle accident and suffered blunt trauma to his abdomen. Upon presentation to the emergency department, his vital signs are as follows: temperature, 100.9°F; heart rate, 120 bpm; respiratory rate, 20 breaths/min; and blood pressure, 90/54 mm Hg. His abdomen is firm, with bruising around the umbilicus. He is alert and oriented, but complains of dizziness when changing positions. The patient is admitted for management of suspected hypovolemic shock.

 

The following orders are written for the patient:

 

Place two large-bore IVs and infuse 0.9% NS at 125 mL/hr/line

Obtain complete blood count, serum electrolytes

Oxygen at 2 L/min via nasal cannula

Type and cross for 4 units of blood

Flat plate of the abdomen STAT

(Learning Objectives 1, 4, and5)

 

 

a. Describe the pathophysiologic sequence of events seen with hypovolemic shock.

 

1. What are the major goals of medical management in this patient?

 

1. What is the rationale for placing two large-bore IVs?

 

1. What are advantages of using 0.9% NS in this patient?

 

1. What is the rationale for placing the patient in a modified Trendelenburg position?

 

ase Study, Chapter 15, Oncology: Nursing Management in Cancer Care

 

 

1. Emanuel Jones, 60 years of age, is male patient diagnosed with small cell carcinoma. He underwent surgery in the past to remove the left lower lobe of his lung. He is receiving chemotherapy. Two weeks before a round of chemotherapy, a complete blood count with differential, and a renal and metabolic profile are obtained for the patient. The patient presents to the oncology clinic for chemotherapy with a temperature of 101°F. Further assessment reveals decreased breath sounds in the right base of the right lung, and a productive cough expectorating green colored mucus. The patient is short of breath and has a pulse oximetry reading that is SaO2 of 85% on room air. The patient has a history of benign prostate hypertrophy (BPH) and has complaints of urinary frequency and burning upon urination. The patient is admitted to the oncology unit in the hospital. The oncologist orders the following: blood, sputum, and urine cultures; and a chest x-ray. An x-ray of the kidneys, ureters, bladder (KUB) is ordered. An arterial blood gas (ABG) on room air, CBC with differential, and renal and metabolic profile are ordered. Oxygen is ordered to begin with nasal cannula at 2 L/min and titrate to keep SaO2 greater than 90%. A broad-spectrum antibiotic, levofloxacin 500 mg in 100 mL of NS is ordered to be administered IV over 60 minutes once daily. (Learning Objective 8)

 

 

a. After examining the physician orders, in what sequence should the nurse provide the care to the patient admitted to the hospital? Give the rationale for the sequence chosen.

 

1. On what areas should the nurse focus the assessment to detect potential complications for Mr. Jones?

 

1. What patient education does Mr. Jones need from the nurse to help prevent the reoccurrence of an infection and to get treatment for an infection promptly?

 

 

2. The oncology clinical nurse specialist (CNS) is asked to develop a staff development program for registered nurses who will be administering chemotherapeutic agents. Because the nurses will be administering a variety of chemotherapeutic drugs to oncology patients, the CNS plans on presenting an overview of agents, classifications, and special precautions related to the safe handling and administration of these drugs. (Learning Objectives 6 and 8)

 

 

a. What does the CNS describe as the goals of chemotherapy?

 

1. How should the CNS respond to the following question: “Why do patients require rounds of chemotherapeutic drugs, including different drugs and varying intervals?”

 

1. In teaching about the administration of chemotherapeutic agents, what signs of extravasation should the nurse include?

 

1. What clinical manifestations of myelosuppression, secondary to chemotherapy administration, should the CNS include in this program?

Case Study, Chapter 16, End-of-Life Care

 

 

1. Joe Clark, 79 years of age, is a male patient who is receiving hospice care for his terminal illnesses that include lung cancer and chronic obstructive pulmonary disease (COPD). He developed bilateral pleural effusion (fluid that accumulates in the pleural space of each lung), which has compromised his lung expansion. He states that he is short of breath and feels anxious that the next breath will be his last. The patient is admitted to the hospital for a thoracentesis (an invasive procedure used to drain the fluid from the pleural space so the lung can expand). The thoracentesis is being used as a palliative measure to relieve the discomfort he is experiencing. Low dose morphine is ordered to provide relief from dyspnea or discomfort. The patient is prescribed Proventil (albuterol) inhaler 2 puffs per day, as needed, and Flovent (fluticasone propionate) inhaler 2 puffs twice a day. The patient has 2 L/min of oxygen ordered per nasal cannula as needed for comfort. (Learning Objective 9)

 

 

a. What nursing measures should the nurse use to manage the patient’s dyspnea?

 

1. The patient complains that he has no appetite and struggles to eat and breathe. What nursing measures should the nurse implement to manage this physiologic response to the terminal illnesses?

 

 

2. Ms. Williams underwent a lobectomy for lung cancer 6 months ago, followed by treatment with radiation therapy and chemotherapy. On her most recent visit to the oncologist, she is told that despite the treatments, there is evidence of metastatic disease in her spine. The physician explains that there are no further treatment options, and refers Ms. Rogers to Hospice for continuing care. (Learning Objective 4)

 

 

a. What are the underlying principles of hospice?

 

1. To be eligible for Medicare and Medicaid Hospice benefits, what information needs to be provided by Ms. Williams’ physician?

 

1. Ms. Williams has severe back pain and is concerned whether the hospice will assist with her pain management.

 

Case Study, Chapter 17, Preoperative Nursing Management

 

 

1. Joan Arnold, 67 years of age, is a female patient who underwent a coronary angiogram that diagnosed severe coronary artery disease in three of her coronary arteries, the left anterior descending, the left circumflex, and the right coronary artery. She is scheduled for a coronary artery bypass graft operation tomorrow. The nurse provides patient education for Mrs. Arnold and her husband, which includes watching a hospital video on the operation, the intensive care environment, what to expect after the surgery, the recovery period, and cardiac rehabilitation. The video also covered the importance of coughing and deep breathing, using an incentive spirometer, splinting, early ambulation, pain medication, and how to position oneself safely. The video stressed the importance of not rolling onto the side that the chest tube may be in place postoperatively. The video also discussed the preoperative preparation. The nurse also provided a booklet on the subject material. The nurse had a session with the patient and her husband to assess their understanding and to answer any questions they may have had. (Learning Objectives 6 to 8)

 

 

a. What specific preoperative nursing measures should the nurse review with the patient to help decrease the risk for postoperative complications?

 

1. Explain the role of the nurse when implementing the immediate preoperative preparation the day before surgery and the morning of the surgery?

 

 

2. The nurse in a gynecology clinic is completing preoperative teaching for a patient scheduled for an abdominal hysterectomy next week. The patient states that she is currently taking 325 mg of aspirin daily for chronic joint pain, along with a multivitamin. The patient has type 2 diabetes; she closely monitors her blood glucose levels. Currently, she is taking an oral hypoglycemic agent. The nurse advises her to ask the anesthesiologist whether she should take this medication the morning of surgery. (Learning Objectives 2 and 4)

 

 

a. The nurse instructs the patient to stop taking the aspirin. What is the rationale for this action?

 

1. Why is it important to assess the patient for use of herbal products prior to surgery?

 

c.The patient asks how surgery could affect her blood glucose; how should the nurse respond?

 

Case Study, Chapter 18, Intraoperative Nursing Management

 

 

1. Pearl Richards, 69 years of age, is a female patient who is in the operating room for a repair of an abdominal aortic aneurysm. The patient has a history of hypertension controlled with medications, osteoporosis, chronic obstructive pulmonary disease, and has smoked two packs of cigarettes per day for 40 years. (Learning Objectives 2, 6, and 9)

 

 

a. What nursing interventions are instituted to reduce the surgical risk factors related to the patient’s age?

 

1. Explain the role of the nurse in providing patient safety measures during the intraoperative period.

 

 

2. Mr. Bond is a 32-year-old Caucasian man who plays professional football. He was admitted for repair of a rotator cuff injury sustained in a game. In excellent shape, Mr. Bond has a muscular build and his body fat is 18%. Mr. Bond is transferred to the operating room, and the anesthesiologist begins to administer general anesthesia. During the induction of anesthesia, Mr. Bond develops tachycardia and dysrhythmias. His condition continues to deteriorate and he becomes severely hypotensive and exhibits decreased cardiac output. The anesthesiologist states that Mr. Bond is developing malignant hyperthermia. (Learning Objective 5)

 

 

a. What risk factor does Mr. Bond have for malignant hyperthermia?

 

1. What clinical manifestations of malignant hyperthermia does Mr. Bond demonstrate?

 

1. Based on the patient’s condition, the surgical procedure is stopped and 100% oxygen is started. Additionally, a muscle relaxant and sodium bicarbonate are administered. What are the rationales for these medications?

 

Case Study, Chapter 19, Postoperative Nursing Management

 

 

1. Rita Schmidt, 74 years of age, is a female patient who was admitted to the surgical unit after undergoing removal of a section of the colon for colorectal cancer. The patient does not have a colostomy. The patient has several small abdominal incisions and a clear dressing over each site. The incisions are well approximated and the staples are dry and intact. There is a Jackson-Pratt drain intact with minimal serous sanguineous drainage present. The patient has a Salem sump tube connected to low continuous wall suction that is draining a small amount of brown liquid. The patient has no bowel sounds. The Foley catheter has a small amount of dark amber-colored urine without sediments. The patient has sequential compression device (SCD) in place. The nurse performs an assessment and notes that the patient’s breath sounds are decreased bilaterally in the bases and the patient has inspiratory crackles. The patient’s cardiac assessment is within normal limits. The patient is receiving O2 at 2 L per nasal cannula with a pulse oximetry reading of 95%. The vital signs include: blood pressure, 100/50 mm Hg; heart rate 110 bpm; respiratory rate 16 breaths/min; and the patient is afebrile. The patient is confused as to place and time. (Learning Objectives 4 and 7)

 

 

a. Explain the assessment parameters used to provide clues to detect postoperative problems early and the interventions needed.

 

1. What gerontological postoperative considerations should the nurse make?

 

 

2. Mr. John Smith is admitted to the hospital for surgical incision and drainage (I&D) of an abscess on his right calf, which resulted from a farm machinery accident. The right calf has an area 3 cm × 2.5 cm, which is red, warm and hard to touch, and edematous. (Learning Objective 5)

 

 

a. Explain the wound healing process according to the phase of Mr. Smith’s wound?

 

1. The surgeon orders for wet-to-dry sterile saline dressing twice a day with iodoform gauze to the wound, covered with the wet-to-dry dressing. Explain how to perform this dressing change.