Chap 26 to 38 Case Study Answers to Questions

7/25/2019 Chap 26 to 38 Case Study Answers to Questions

1/13

ANSWERS TO CASE STUDY QUESTIONS

Patient profile J.G.

1. Quantifying smoking habits in pack years is done by multiply-

ing the number of packs smoked per day by the number of yearssmoked. In this case, Mr. J.G. smoked an average of 3 packs peryear for 15 years. Te risks of lung cancer rise in direct proportionto the number of years smoked. Smoking is the most important riskfactor for COPD and lung cancer.

2. Observe for the following: unexplained restlessness or irritability,lethargy, rapid respiration, use of accessory muscles of breathing,and rapid heart rate. When interacting, also observe J.G.s capac-ity to answer oral questions, whether he stops to catch his breathwhile talking. Te data collected from the observation serves as aguide to nursing problem identification and prioritizing nursingintervention.

3. An elderly person is expected to have a less forceful cough andfewer and less functional cilia. Tus, he will use more energy whencoughing. Tese pathophysiologic changes may help explain easyfatigability, weakness, and shortness of breath. When assessing,evaluate the quality of the cough. For example, a loose-soundingcough indicates the presence of secretions. Ask the patient todescribe the pattern of coughing.

4. (1) Establishing rapport is a basic nursing function for nursepatient interaction. J.G. should be given respct and courtesies.Safety, comfort, and privacy during assessment should be providedfor. (2) Te expected findings from the general survey include thefollowing: easy fatigability, orthopnea, tachypnea, tachycardia, thepresence of sputum when coughing, and general weakness; headand neck: pursed lip breathing; thorax and lungs: barrel chested,hyperresonant lungs upon percussion, the use of accessory musclesupon breathing (intercostal retractions, the use of neck muscles inbreathing), and wheezes.

5. For objective physical examination: observe:respiratory rate andquality, pattern of breathing; inspect: neck for the position of tra-chea, chest wall shape, symmetry and movement; skin and nails forintegrity and color;palpate: chest and back for masses, symmetryof the chest, tenderness; auscultate: breath (lung) sounds. Makinga check-list of assessment parameters provides an easy frameworkfor the nurse on assessment that can be developed further overtime.

6. Te physician would probably order a complete blood cou

(CBC), arterial blood gas (ABG), chest X-ray, and pulmonafunction tests (PFs). CBC will help to determine whether theis an increase in RBCs, which is a compensatory mechanism fpersistently low-oxygen saturation; ABG will help to measure tamount of oxygen and carbon dioxide in the blood and asseoxygenation status. Along with other parameters, ABG helps thealth care providers in determining the adaptability of the bowith low-oxygen saturation; chest X-ray will help to visualize if tnormal lung markings are still present and determine the extentdamage the disease caused to the lungs; and pulmonary functitests (PFs) are used to determine the severity of the lung diseaWhen answering this question, you should be able to get mostthese.

7. In emphysema, the walls of the alveoli gradually get destroyed. Talveolar surface area in direct contact with the pulmonary cap

laries continually decreases, causing an increase in dead space aimpaired diffusion, which may lead to hypoxemia. o compensafor the increased airway resistance, the patient purses his lips prevent airway collapse as he slowly exhales. Tis describes tpuffing part. Patients with emphysema usually have flushed skhence the term pink puffers.

8. Te 6-minute walk test (6MW) is an exercise test. It is used diagnosis, in determining exercise capacity, and also for disabity evaluation. Tis is a common procedure prescribed as part pulmonary rehabilitation. Te six-minute walk test (6MW) mesures the distance an individual is able to walk over a total of sminutes on a hard, flat surface. Te goal is for the individual walk as far as possible in six minutes. Te individual is allowed self-pace and rest as needed as he traverses back and forth along

marked walkway.

Chapter 26


2/13


Patient profile C.J.

1. Te nose functions to protect the lower airways by warming and

humidifying the air and filtering small particles before air entersthe lungs. Te tonsils are located in the oropharynx. Air movesthrough the nose and then through the oropharynx to the laryn-gopharynx to the trachea.

2. Continuous high fever can be regarded harmful, but it is also animportant host defense mechanism. Steps are taken to lower thebody temperature to relieve the anxiety of the patient. Spongebaths are advised, as this procedure helps to increase the evapora-tive loss and lower the body temperature. But it has been recom-mended to combine sponge bath with the use of antipyretic drugs.

3. A throat swab for culture and sensitivity may also be indicated for

confirmatory diagnosis of patients with suspected streptococcalthroat infection. It is the gold standard in diagnosing streptococ-cal throat infection.

4. Te tonsils may enlarge suff iciently to threaten the patency of theairway. Te inf lamed tonsils may cause partial airway obstruction.Complete airway obstruction is a medical treatment.

5. Signs and symptoms of obstruction in the patency of the airwayinclude the following: stridor, the use of accessory muscles, supra-sternal and intercostal retractions, wheezing, restlessness, tachy-cardia, and even cyanosis.

6. Te goals for nursing and collaborative management are infe

tion control, symptomatic relief, and the prevention of secondainfection.7. Some nursing measures for self-care include the followin

Encourage C.J. to increase fluid intake. Advise him on diet annutrition to have cool, bland liquids, and gelatin for diet, to avoirritating the throat. Warm saline gargle is recommended to allviate throat discomfort. Having adequate rest can help to speup recovery and prevent relapse. Provide C.J. with informationthat he makes an informed decision about his health. Is taking texamination more important that regaining his health back firs

8. Te trachea bifurcates into the right and left mainstream broncat a point known as the carina. Its location on physical assessmecorresponds to the level of the manubriosternal junction, al

called the angle of Louis. Te carina is highly sensitive, and irrit

ing it during suctioning causes vigorous coughing.

Chapter 27


3/13

Chapter 28


Patient profile S.A.

1. Te defense mechanisms include filtration of air, warming, and

humidification of inspired air, epiglottis closure over the trachea,cough reflex, mucociliary escalator system, secretions of immu-noglobulin A, and alveolar macrophages.

2. Possible risk factors include the following: advancing age, air pol-lution, exposure to people with the infection, smoking, upperrespiratory tract infection, malnutrition, the presence of chronicillness, and immobility.

3. Te following signs and symptoms support the findings: fever,lethargy, tachypnea, nasal flaring, asymmetric chest movements,the use of accessory muscles of breathing, decreased breath soundson the right lung f ields, rusty and purulent sputum, and abnormalarterial blood gas.

4. Penumonia results when the lung defense mechanisms becomeincompetent or are overwhelmed by the infectious agents, whenthe cough mechanism is decreasing (in cases of elderly changes),or when the patients aspirate oropharyngeal contents into thelungs. Endotracheal intubation interferes with the normal coughreflex, and the mucociliary escalator mechanism, bypasses theupper airways, in which filtration and humidification normallytake place.

5. Te physician would probably order the following tests: arterialblood gas (ABG), complete blood count (CBC), sputum for cul-ture and sensitivity (CS), and chest X-ray.

6. Te overall goals for a patient with pneumonia include the follow-ing: clear breath sounds, normal breathing pattern, no signs onhypoxia, normal chest X-ray, no complications related to pneu-monia. Te need for health education for better self-care at homeis also important as it will help S.A. allay her anxieties and gainknowledge about the disease.

7. Nursing interventions should focus on improving gas exchan

and helping the airway clear secretions. Tis should be doby increasing oral fluid intake to liquefy bronchial secretionencouraging the patient to perform deep breathing exercise to ain adequate ventilation and increase efficiency of respiratory mucles; and performing nebulization to loosen thick secretions animprove ventilation, postural drainage to mobilize secretions, achest physiotherapy postnebulization to loosen thick secretiothat are difficult to cough up. In addition, the patient should instructed on the proper coughing technique to effectively expetorate bronchial secretions.

8. Te focus of the patients health promotion education encompasses the following: practice of good health habits in the commnity to prevent infection, such as frequent hand washing, eatina balanced diet, adequate rest, and exercise. Health-promotiactions such as the following should be emphasized: covering tmouth during coughing and sneezing and avoidance of cigaretsmoke. Seeking medical care early enough in the illness should advised. It is important to make S.A. aware of the different community and barangay resources that are available to her.


4/13

Chapter 29


Patient profile L.E.

1. L.E. is an elderly patient with a history o hypertension. Elderly

patients have more complicated health issues than youngerpatients with asthma. L.E.s need or the nurses bedside pres-ence and support is expressed by the patient holding on tightlyto the nurses hand.

2. Asthma is a chronic inflammatory disease o the airways thatcauses airway hyper-responsiveness, mucosal edema, andmucus production. Te inflammation leads to swelling o themembranes that line the airways, reducing the air diameter.Bronchial smooth muscles that encircle the airways contract,causing urther narrowing, leading to airway obstruction thatcauses inspiratory stridor, difficulty o breathing, distress,retractions upon breathing, and decreased breath sounds on theupper lung fields. Inflammation also causes increased mucusproduction that results in the presence o rhonchi upon aus-cultation. As a result, there is a ventilation/perusion mismatch

that leads to decreased oxygen saturation. Tus, the cells areinadequately oxygenated to compensate the heart pumps aster(tachycardia) and the lungs breathe in air aster (tachypnea).Due to increased cardiac workload, the blood pressure rises aswell. Eventually, cardiac cells become hypoxic, due to decreasedoxygenation and increased workload, which may result in chestdiscomort.

3. Te priority nursing diagnoses are impaired gas exchangerelated to ventilation/perusion mismatch; ineffective airwayclearance related to increased airway resistance/airway obstruc-tion, and anxiety related to difficulty in breathing and eelingso helplessness. Te nurse considered allaying L.E.s anxieties bystaying with her and providing inormation about her currentcondition and treatment plan.

4. Te ollowing explanation was provided. Te peak flow meteris a device that measures how well air moves in and out o thelungs. Peak flow meters are used to check asthma, the way thatblood pressure cuffs are used to check blood pressure. Duringan asthma episode, the airways o the lungs usually begin tonarrow slowly. Te peak flow meter may tell you i there is nar-rowing in the airways beore the patient experiences asthmasymptoms. Ten, explain how to use the peak flow meter.

5. Tere are combination medications that have both bronchodi-lator and expectorant unctions that are sold over-the-counter(OC). Tey can come in the orm o cough syrups. Tese med-ications should be used with caution as they may cause stimula-

tion o the cardiovascular system and may produce effects

heart palpitations, tremors, and insomnia. Warn the patieabout the dangers associated with non-prescription combintion drugs. Tese drugs are especially dangerous to patienwith underlying cardiac problems because elevated blood presure and tachycardia ofen occur.

6. Te overall goals include the attainment o asthma controlevidenced by the ollowing: minimal symptoms during tday and night, acceptable activtity levels (including exercand other physical activity), maintenance o greater than 80o personal best peak expiratory flow rate, ew or no advereffects o therapy, no recurrent exacerbations o asthma, anadequate knowledge to participate in and carry out managment.

7. In planning nursing interventions, the nurse should considthat the patient is elderly, with a history o hypertension, wh

also uses OC drugs to control her asthma symptoms. Furththe chest discomort will be examined. Priority nursing inteventions should include making sure that the airway is patent positioning the patient correctly, using oxygen therapy, manaing secretions, and ensuring that the patients ear and anxieare addressed. Being with the patient or presence at the bedsican provide reassurance early in the stage o acute attack. prescribed, administration o ast-acting bronchodilators ananti-inflammatory drugs can be part o the collaborative untion. Te nurse perorm continuously and closely monitor L.Ecardiorespiratory status.

8. Given the home situation o L.E. in a barangay community, tollowing discharge plan and patient education instructiomay be provided. Identiy and avoid possible asthma triggesuch as personal triggers (cigarette smoke, animal dander ropets, and house dust mites) and irritants (air pollutants, liexhaust umes, indoor air pollution, and aerosol sprays). Tuse o special dust covers on mattresses and pillows, washibed clothes in hot water, with the use o detergent and bleamay help control triggers. Avoid public places. Adequate nuttional intake must be emphasized. Healthy liestyle guides oadequate physical activity are important. Adequate instructito identiy asthma attack, use o peak flow meter, and correinstructions on the use o medications are necessary. L.E. anher daughter may also benefit rom keeping a diary o daiactivities.


5/13

Chapter 30


Patient profile J.C.

1. Te following concepts are important in understanding the role

of the hematologic system: (a) blood as a transport mechanism,transporting oxygen, nutrients, hormones, and waste productsaround the body; (b) role of blood in regulation of fluid, elec-trolyte, and acidbase balance, and (c) bloods protective roleand its ability to clot and combat invasion of pathogens andother foreign substances. An understanding of these conceptsenhances the nurses ability to link signs and symptoms withpathophysiology, and pathophysiology with treatments andinterventions.

2. Iron is obtained from food and dietary supplements and is pres-ent in all RBCs as heme in hemoglobin. Te heme in hemo-

globin accounts for two-thirds of the bodys iron. Te otherone-third is stored as ferritin and hemosiderin in the bone mar-row, spleen, liver, and macrophages. When the stored iron is not

replaced, hemoglobin production is reduced. 3. Te four components that contribute to normal hemostasis: (a)

vascular response, (b) platelet plug formation, (c) plasma clot-ting factors, and (d) lysis of clot.

4. Objective assessment may include measurement of weight,palpation for swelling in the armpits, neck, or groin, andinspection for skin petechiae, or bleeding of the gums. For theinterview questions, you should focus on dietary history suchas intake of meat, eggs, leafy green vegetables, dried fruits, andlegumes. Local eating patterns and common sources of dietaryiron should also be assessed.

5. Te activityexercise pattern is closely associated with fun

tional ability. Questions to assess this pattern include: feelinof tiredness, weakness, complaints of heavy extremities, bo

malaise, dyspnea, and palpitations. Fatigue is a prominesymptom in many hematologic disorders.

6. J.C. may report that she has feelings of increased heart beats afluttering of pounding of the chest. Rapid heartbeat means theart rate is above 100 beats/min. Palpitations may be felt ascompensatory mechanism of anemia, in an attempt by the heato increase cardiac output.

7. Hemoglobin normal values: male = 13.217.3 g/dl (1321g/L); female = 11.716.0 g/dl (117160 g/L). J.C.s values aabnormally low, confirming the diagnosis of anemia, anexplaining the patients signs and symptoms.

8. Te following indicators are important to assess: knowledge

concepts in hematology, related functional health patterns assessment, common related diagnostic tests, and normal vues, and skills in physical examination procedures and assistiwith common diagnostic procedures. Atttitude competencrelate to the demonstration of good rapport, respect durinexamination procedures, privacy when needed, and presenwhen anxiety situation arises.


6/13

Chapter 31


Iron-deficiency anemia

1. MDGs are a set of social objectives that need to be responded to

by 2015 as part of the countrys global commitment to attain betterhealth outcomes. 2. Department of Health (National Objectives for Health 20112016)

data on the prevalence of iron-deficiency anemia among differentdemographic groups 19982008) are as follows:

AGE GROUP 1998 2003 2008

6 to 1 year 56.6 66.2 55.7

1 5 years old 29.6 29.6 20.8

612 years old 35.6 37.4 19.8

Pregnant women 50.7 43.9 42.5

Lactating women 45.7 42.2 31.4

Source: Department of Health, National Objectives for Health,

20112016, p. 80

3. Anemia is not a specific disease, it is a manifestation of a patho-logic process. It is a deficiency in the number of erythrocytes orred blood cells (RBCs), the quantity of hemoglobin, and/or thevolume of packed RBCs (hematocrit). It is a prevalent condi-tion with many causes such as blood loss, impaired productionof erythrocytes, or increased destruction of erythrocytes. RBCstransport oxygen, thus erythrocyte disorders can lead to tissuehypoxia.

4. Subjective data included the following: dietary history, generaldietary patterns, intake of vegetables and fruits. Objective dataare elicited from the general survey, like easy fatigability, lethargy,apathy; assessment of the integumentary to include paleness of theskin and mucous membrane, poor skin turgor, presence of pete-chiae, nose or gingival bleeding, dryness of the hair; rapid respi-ratory rate, increased heart rate, low blood pressure; oocasionalheadache, anxiety; and diagnostic tests showing decreased hemo-globin levels.

5. Signs and symptoms of anemia in older persons may go unnticed, because of the changes in aging and the presence of oth

health problems, and that nutritional type of anemia (folate aniron) is reported as common in older persons. Terefore, foassessment is important.

6. Te nursing interventions that were recommended includcollaborating with the nutritionist/dietician on the type nutrients needed to meet nutritional requirements, diet teachinwith emphasis on iron-rich food, maintaining a food diary, an

providing medications that are prescribed.7. Data for 1998 and 2003 showed that intake of vegetables sligh

decreased, and the intake of fruits decreased drastically. 8. Community-based information and education campaigns shou

include information on how to improve consumption of vegetbles and fruits. Health information should include the followininformation:

Nutrients Needed for Erythrocytes

ROLE IN ERYTHROPOIESIS FOOD SOURCE

Cobalamin (vitamin B12) RBC maturation

Red meat, liver, eggs,enriched grains

Folic acid RBCmaturation

Green leafy vegetables,liver, meat, sh, legumes,whole grains

Iron hemoglobinsynthesis

Liver and muscle meat,eggs, dried fruits,legumes, dark greenleafy vegetables, cereals,potatoes

Ascorbic acid (vitamin C) conversion of folic acidto its active forms aids iniron absorption

Citrus fruits, green leafyvegetables, cantaloupes


7/13

Chapter 32


Patient profile C.R.

1. Te aorta is the origin o the two major coronary arteries. Blood

flow to the myocardium occurs during diastole (when the myo-cardium relaxes). Te two major coronaries are the right coronaryartery and the lef main coronary artery.

2. Te slow HR (30/min) was identified as the most immediate con-cern. Te possible reason or the slow HR (bradycardia) may ariserom the conduction system o the heart. Te pacemaker o theheart is the sinoatrial (SA) node. Each impulse generated rom theSA node travels through the atria, the atrioventricular (AV) nodedown the bundle o His to depolarize the Purkinje fibers in theventricles. Te normal HR ranges about 60100/min.

3. Te CO reers to the amount o blood pumped by each ventricle o

the heart in one minute. It is calculated by multiplying the strokevolume (SV) with the heart rate (HR). Tus, CO= SV HR. Strokevolume is the amount o blood ejected rom the ventricle with

each heart beat. C.F. s reported HR is 30 beats/min. His slow HRis not adequate to support good CO, and thus, less circulation tothe brain may contribute to the dizziness and ainting spells.

4. Te stimulation o the parasympathetic system, which is mediatedby the vagus nerve, causes the decrease inHR. Tis is due to theSA node rate, and so the conduction down the conduction systemslows down.

5. wo patterns will be assessed or C.R.s unctional capacity: healt

perception sel-management pattern and activityexercise patter 6. Te objective data or physical examination should include tollowing: patients general appearance; vital signs (blood presure, HR, respiratory rate, body temperature, and chest pain,any); data on the peripheral vascular system by doing inspectiopalpation, and auscultation; and assessment o the pulses.

7. Te electrocardiogram can help identiy conduction abnormaties. Deviations rom the normal sinus rhythm will potentiaindicate the ocus or nursing problems. Cardiac monitoring irequired nursing competency in the care o patients with oxygention problems.

8. Te inormation will include the ollowing: exercise or stress teing, which is a method to evaluate the cardiovascular responsephysical stress, such as work, or prolonged walking. Te test hel

to assess cardiovascular disease and define limits or exercise prgrams.


8/13

Chapter 33


Patient profile A.L.

1. Hypertension prevention measures include: maintaining a healthy

weight; reducing salt and sodium intake; increasing the level ophysical exercise; moderate alcohol consumption; monitoringblood pressure periodically to know whether it is increasing; andtaking medication to control BP, when prescribed by physician.

2. Te ollowing are sources o inormation about hypertensionprevalence in the Philippines: the Department o Health, the Foodand Nutrition Research Institute (FNRI) o the Department oScience and echnology, and specialty organizations, such as thePhilippine Society o Hypertension and Philippine Heart Associa-tion.

3. Te known risk actors or the development o hypertensioninclude increasing age, alcohol consumption, cigarette smoking,diabetes mellitus, elevated serum lipids, excess dietary sodium,gender, amily history, obesity, sedentary liestyle, and socioeco-nomic status.

4. Awareness o risk actors will help the nurse to plan patient andamily education on the prevention and control o hyperten-sion. In the case o A.L., the ollowing actors contributed to risk:increasing age, alcohol consumption, elevated serum lipids, excessdietary salt, obesity, and socioeconomic status. In this case, it isalso significant to note that the amily livelihood involves thepreparation o salted fish.

5. Te amily approach to patient and amily education is the appr

priate paradigm or helping A.L. and his amily members. Teducation on the prevention and control o hypertension worwell or all members o the amily.

6. Hypertensive emergency, a type o hypertensive crisis, is a sitation that develops over hours to days in which the patients Bis severely elevated (ofen above 220/140 mmHg). It can causevere complications, and thus the patients should be monitorregularly. Te rate o increase in BP is more important than thabsolute value in determining the need or emergency treatmenHypertensive crisis occurs most commonly in patients with a htory o hypertension who have ailed to comply with their prscribed medication.

7. It is important or the nurse to consider the age-related actors thwill affect the blood pressure in elderly persons. Blood pressushould be determined careully to avoid the occurrence o auscutatory gaps.

8. When treating hypertensive crisis, such as IV administration drugs, the mean arterial blood pressure (MAP) is ofen used guide and evaluate therapy. Te MAP is calculated as ollowMAP = (SBP + 2DBP)/3.


9/13

Chapter 34


Patient profile E.D.

1. In the case of E.D., the nonmodifiable risk factors to be considered

include the following: age, gender, and being postmenopausal;family history since diabetes is also present. For the modifiablerisk factors, look into the elevation of serum lipid levels, bloodpressure elevation, diabetes, obesity, physical inactivity, anddegree of stress.

2. Te two leading causes of death in the Philippines are diseases ofthe heart and cerebrovascular diseases.

3. Te nurse should ask about the history of GI bleeding. Tis infor-mation will alert her of the contraindication of GI bleeding.

4. An important memory aid for pain assessment is PQRS. Pstands for precipitating factors, Q for quality of pain, R for radia-tion of pain, S for severity of chest pain, and for timing of chestpain.

5. Myocardial infarction is a disease process where areas of myo-

cardial cells in the heart are destroyed permanently. It is usuallycaused by decreased blood flow in a coronary artery because ofatherosclerosis or occlusion by thrombus or embolus. In the caseof E.D., coronary branches supplying the anterior portion of theheart are blocked. As the cells are deprived of oxygen, ischemiadevelops, cellular injury occurs, and over time, the lack of oxygenresults in infarction, or the death of cells. Te chest pain expe-rienced by patients experiencing MI is caused by the build-upof lactic acid, which is a by-product of anaerobic metabolismby myocardial cells. Dyspnea and shortness of breath are atypi-cal symptoms usually seen in female patients with MI. Terefore,accurate and prompt diagnosis is important in treating this life-threatening condition.

6. Initial management for E.D. include the following:

a.

Emergency care for chest pain. b. Establish an IV route for the access of emergency IV therapy. c. Provide oxygen by nasal cannula at a rate of 24 L/minute.

d. Cardiac monitoring for dysrhythmias, pulse oximetry, and co

tinuous vital signs assessment for changes in condition. e. Provide comfortable positioning, initial bed rest, and impment limitation of activity.

f. Allay E.D.s anxiety by constant presence at the bedside aexplaining procedures to be done.

7. Te goal for collaborative management of myocardial infarctiis to salvage as much myocardial muscle as possible. Nurses ne

to provide emotional care. Te nurses role is to understand whthe patient is currently experiencing, to assist the patient in copiwith the illness. Patients like E.D. may have experienced deniaand manifest behavior such as ignoring the signs and symptomrelated to heart disease as well as anxiety and fear, such as feaof undertaking physical activity or fear of long-term disabiliTe nurse becomes an important support system while in t

hospital and helps patients accept the event through constanursepatient interaction. Te nurses role include engaging tcaregivers in the care, informing them of the patients progreand encouraging the patient and caregiver to interact as necsary during confinement. It is also beneficial for nurses to identadditional support systems.

8. Tere are three phases of cardiac rehabilitation: Phase 1, hosptal; Phase II, early recovery; and Phase III, late recovery. Phasoccurs while the patient is still in the hospital. Te nurse neeto continuously assess the level of chest pain occurrence, anxiedysrhythmias, and other possible complications. Te findinwill serve as guide for decision-making especially with regarto activities that can be provided. E.D., may be helped to initiasit-up in bed or chair, perform range of motion exercises, a

self-care activities, such as washing her face, performing simpgrooming activities, and progressing to ambulation, once clearmedically. During this time, the nurse interacts with E.D. on dcharge planning.


10/13

Chapter 35


Patient profile P.C.

1. Heart ailure is an abnormal clinical syndrome characterized by

impaired cardiac pumping and/or cardiac filling. It was ormerlycalled congestive heart ailure. Heart ailure is the preerred ter-minology since not all patients experience pulmonary congestionand volume overload.

2. Te ollowing actors regulate cardiac output: (1) preload, (2)aferload, (3) myocardial contractility, and (4) heart rate.

3. Lef-side ailure results rom lef ventricular dysunction, whichprevents normal blood flow thus causing blood to flow back up inthe lef atrium and into the pulmonary veins. Tus, the increas-ing pulmonary pressure causes fluid extravasation rom the pul-monary capillary bed into the interstitium, and then the alveoli,which maniests as pulmonary congestion, and edema. In the caseo P.C., there were findings o crackles on the lung bases.

4. Right-side heart ailure causes back up o the blood into the rightatrium and venous circulation. Venous congestion in the systemic

circulation results in jugular venous distention, hepatomegaly,splenomegaly, vascular congestion o the gastrointestinal tract,and peripheral edema.

5. Te ollowing should be considered: history o uncontrolledhypertension, increasing atigue and decreasing capacity orwork, complaints o not being able to walk as beore, and increas-ing need or assistance. Te situation may cause emotional prob-lems o anxiety relating to the inability to work or his livelihood.

Immediate reerral or admission to a general hospital is the reommended action.

6. Priority findings include: BP = 90/60 (low), apical HR = 109/m(slightly tachycardic), with occasional skip beats; respiratory ra= 28/ min, ast and shallow, cannot tolerate the supine positioaccessory muscles are used or breathing, pronounced crackles both lower lung fields; cool and clammy skin; and edema o thands and eet. Te cues support impaired cardiac output.

7. Priority actions should ocus on the alleviation or relie o symtoms, such as shortness o breath, eeling o atigue, and anxieTe patient is positioned in the position o comort, usually thigh Fowlers to help decrease venous return to the heart, asupplemental oxygen therapy, as ordered. o decrease anxiety, tnurse should apply the concept o constant presence at the beside. Te overall goals o care include the ollowing: preventioncomplications, compliance to medical regimen and interventioincrease in physical tolerance, and improvement in activities daily living.

8. Patient and amily education on the detection and control hypertension may serve as a ocal point in the community settitoward prevention o heart ailure.


11/13

Chapter 36


Patient profile FC.

1. Te ollowing cues were considered by the nurse as priority con-

cerns: (1) history o loose stools and vomiting, since F.C., an agingperson, may have fluid and electrolyte problems, and this couldtrigger development o dysrhythmias. Tere is a need to monitorthe electrolyte studies and correlate these with ECG findings, (2)chest heaviness, increased dyspnea, and palpitations; and (3) ECGfindings o requent multiocal premature ventricular contractions(PVCs) and S- segment elevations in L II, III, and aVF.

2. Te nurse who works in a coronary care unit needs to be com-petent in telemetry monitoring to provide sae care. elemetrymonitoring reers to the observation o the patients heart rateand rhythm at a site distant rom the patient. Tere are generallytwo types o systems: (1) the centralized monitoring systemcontinuous observation o a group o patients ECG rhythms at acentral location, and (2) systems that are capable o detecting and

storing data, including sophisticated alarm systems or differentlevels o detection o dysrhythmias, ischemia, or inarction.

3. Te nurse should aim or accurate interpretation to help identiyF.C.s immediate problems. Te approaches include: immediatelyevaluating the consequences o the findings or the individualpatient, assessing the patients hemodynamic response to anychange in the rhythm, selecting appropriate therapeutic inter-ventions, and at all times, monitoring the patient, F.C., not themonitor.

4. F.C. is an older person who experiences symptoms and verbalizsigns that caused her to be anxious. She was earul that she m

die soon. Te nurse showed compassion and provided reassuranto F.C. by explaining events, equipment, treatments, and the en

ronment in a manner that was easily understood by the patient 5. During myocardial injury, the typical pattern observed is S- se

ment elevation, usually occurring with chest pain and suggestio worsening o the patients condition. In F.C.s case, these finings were reported. Tis may suggest worsening o the conditioTe goal is to restore oxygen to the myocardium and avoid inartion.

6. Te instructions include the ollowing: (1) monitor the pulse raand inorm the primary care provider i it drops below the predtermined heart rate, (the nurse teaches the patient and the carin the home how to check the pulse rate); (2) report any sigo inection in the incision site; (3) avoid lifing the arm on t

pacemaker site above the shoulder until clearance has been give(4) avoid close proximity to high-output electric generators, large magnets, such as the MRI scanner (these devices can inteere with the unction o the pacemaker); and (5) carry pacemakinormation card and a current list o medications, at all the tim


12/13

Chapter 37


Patient profile S.A.

1. S.A.s throat culture was positive. She also has a history o Group A streptococcal inection. Her previous diagnostic test resu

showed increased levels o antistreptolysin O titer.2. Te structural deormities cause obstruction o blood flow and create a pressure difference between the lef atrium and lef vetricle during diastole. Te lef atrial pressure and volume increase. Tis event results in higher pulmonary vasculature pressuand then hypertrophy o the pulmonary vessels. In chronic mitral stenosis, as in the case o S.A., pressure overload occursthe lef atrium, the pulmonary bed, and the right ventricle.

3. Mitral regurgitation allows blood to flow backward, rom the lef ventricle to the lef atrium, due to the incomplete valve closuduring systole. Te lef ventricle and the lef atrium both work hard to preserve the cardiac output. In situations when theresudden increase in pressure and volume transmitted to the pulmonary bed, pulmonary edema and cardiogenic shock result

4. Te stenosed mitral valve is not able to open sufficiently during atrial asystole, preventing the filling o the lef ventricle.

CLINICAL MANIFESTATIONS POSSIBLE PATHOPHYSIOLOGIC REASONING

Exertional dyspnea Due to reduced lung compliance

Fatigue and palpitations Due to atrial brillation, irregular rhythm is produced, and withincreased HR, there is no adequate ventricular lling.

Heart sounds: accentuated heart sounds,the presence of murmur

There is an increased level of pressure to push blood througha stenosed mitral valve, and with mitral regurgitation, bloodbackows to the left atrium.

Chest pain Decreased cardiac output and coronary perfusion.

6. Te possible nursing diagnoses include the ollowing: Decreased cardiac output related to valve dysfunction ( in this case mitral stenosis), or possibly heart failure (if complic

tions set in) Activity intolerance related to pain, or dyspnea, or heart failure Ineective self-health management related to lack of knowledge concerning need for long-term care and possible complic

tions 7. Te type o surgery can either be valve repair or valve replacement. In valve repair, the ollowing are possible options: mit

commissurotomy (valvulotomy) and minimally invasive valvuloplasty, which involves mini-sternotomy and may involrobotic surgical systems. In valve replacements, prosthetic valves are used. Valves can be mechanical (from articial materiasuch as metal alloys) and biologic valves (from bovine, porcine, and human cadaver tissue).

8. Mechanical valves have been reported to last longer than biologic valves. However, they have increased risk o thromboemblism and require long-term anticoagulant therapy. During these procedures, the nurse applies perioperative principles of car

9. Te ollowing outcomes o care should be included: ability to perorm activities o daily living with minimum atigue and paiadherence to treatment regimen, prevention of complications, and condence in managing self. Discharge and home cainstructions should be planned or S.A..Te nurse should aim to increase sel-care capabilities, increasing S.A.s confidence her ability to carry out a normal lie, especially as a mother.

5.


13/13

Chapter 38


Patient profile M.S.

1. Te three types o clients are the individual, the population group, and the community. In this case, M.S. is an individual clie

because o the unique complaint o pain in his legs. Te population group covers, or example, all patients in the communiwith elevated blood pressure. I the nurses ocus is the health needs o all the people in a specific community, then, the community is her client.

2. Te small town where M.S. lives has a local health unit where population and community data are kept. Te reports showed ththe town had an increased number o people who had elevated blood pressures and increased asting blood sugar levels. Frothese data, the nurse may plan to start a blood pressure screening program targeting assessment or chronic illness.

3. Assessments o the individual client and his amily, the population groups o hypertensives and those with chronic illness, anthe community all need to be done.

4. Te students made the ollowing differentiation.

CHARACTERISTICS PERIPHERAL ARTERY DISEASE VENOUS DISEASE

Pain in the legs Intermittent c laudication or rest pain in foot; ulcer

may have pain

Dull ache or heaviness in calf or thigh;

ulcer often painful

Peripheral pulses Decreased or absent Present, but may be difcult to palpate,

with edema

Capillary rell >3 sec. < 3 sec.

Skin color Dependent rubor, redness. With elevation- pallor Brownish; varicose veins may be visible

Skin temperature Cold Warm

Edema Not present, not

unless leg is always in dependent position

Lower leg edema

Ulceration, if any Location: tips of toes, foot or lateral malleolus

Margin: rounded, smooth

Tissue: black eschar, or pale pink granulation

Drainage: minimal

Location: near medial malleolus

Margin: irregular shaped

Tissue: yellow slough or dark red

Drainage: moderate to large amount

5. Intermittent claudication is consistent with increasing pain with work or exercise and resolution with rest. Te ischemic pais the result o the accumulation o the end products o metabolism, such as lactic acid. Once the patient stops the exercise,

work, the metabolites are cleared and the pain subsides. 6. Rest pain occurs when there is insufficient blood flow to meet basic metabolic requirements o the distal tissues. Rest pain moofen occurs in the oreoot o toes and is aggravated when the limb is elevated and blood flow is impaired. M.S. claims that halso experiences rest pain at night. Rest pain occurs at night because cardiac output tends to decrease during sleep, and the limare at the level o the heart.

7. Peripheral vascular disease leads to several complications. Prolonged ischemia leads to atrophy o the skin and the underlyimuscles. Te decrease in arterial flow may result in delayed healing and wound inection., and tissue necrosis, especially i tpatient is diabetic. Nonhealing arterial ulcers and gangrene are the most serious complications.

8. Te nursing care plan or M.S. includes risk actor modification strategies to prevent ischemic stroke, myocardial inarction, aCVD-related emergencies. Te strategies include liestyle changes on the part o the patient, his carer, and the patients riendSmoking cessation is important and all must be assured accessibility to health education and smoking cessation interventionTe collaborative therapy should include the ollowing: regular physical activity (structured walking activity or the intermitteclaudication), achievement o ideal body weight, control o hypertension and diabetes, nutrition therapy (increase ruits an

vegetables, whole grains, low saturated at, low salt), and good oot care.

Documents

Chap 26 to 38 Case Study Answers to Questions