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Fibrillation/Heart Failure (2/4)
Bill Hill, 71 years old
Primary Concept
Perfusion Gas
Exchange
Interrelated Concepts (In order of emphasis)
NCLEX Client Need Categories Covered^ in^ Case
Study
NCSBN Clinical
Judgment Model
Covered in Case
Study
Safe and Effective Care Environment Step 1: Recognize Cues (^) ✓
- Management of Care ✓ Step 2: Analyze Cues ✓
- Safety and Infection Control Step 3: Prioritize Hypotheses ✓ Health Promotion and Maintenance ✓ Step 4: Generate Solutions ✓ Psychosocial Integrity ✓ Step 5: Take Action ✓ Physiological Integrity Step 6: Evaluate Outcomes ✓
- Basic Care and Comfort ✓
- Pharmacological and Parenteral Therapies
- Reduction of Risk Potential ✓
- Physiological Adaptation ✓
Case study NextGen UNFOLDING Reasoning Atrial
Fibrillation/Heart Failure (2/4)
Problem:
Part I: Initial Nursing Assessment Present
Bill Hill is a 71-year old male with a past medical history of benign prostatic hyperplasia (BPH), peripheral vascular disease and myelodysplastic syndrome MDS) two months ago after a bone marrow biopsy. Six weeks ago, Bill was admitted because he had a syncopal episode. He was diagnosed with paroxysmal atrial fibrillation and acute anemia with a Hgb of 6.9 and received a transfusion of one unit of PRBCs. Bill presents to the emergency department today with increasing weakness, fatigue, sinus congestion, fever, and chills the past week. He was around grandchildren with colds two weeks ago. Bill woke up at 6 a.m. today feeling short of breath, and coughing harshly with clear sputum. He had difficulty walking back to bed after getting up to the bathroom. His wife, who is a retired nurse, noted that he was much paler, took his vital signs, which were BP: 96/62, HR: 140 irreg, RR: 24. Bill admits to losing 15 lb (6.8 kg) over the last 2-3 months.
Personal/Social History:
Mr. Hill is retired and lives at home with his wife in a rural area. His two adult children live out of state. He has been an active, healthy male who enjoys gardening, hunting, and splits wood to heat his home in the winter. Since he has been dealing with changes in his health he has not been able to participate in these activities as much. In the past, he has been employed as a minister who has a strong Christian faith. He denies smoking, alcohol use, and illicit drug use.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential)
RELEVANT Data from Present Problem: Clinical Significance:
- Peripheral vascular disease
- A-fib and acute anemia, HGB
- Weakness, fatigue, congestion, fever, chills
- SOB, harsh coughing, clear sputum
- BP: 96/62, HR: 140 irreg. RR:
- Weight loss 15lbs 2-3 months
- R/F heart problems
- Anemia & a-fib can cause many of these symptoms
- Could be infection
- Respiratory issues possibly related to cardiac issues.
- BP: hypotensive. HR: TACHY. RR: tachypnea
- Abnormal must be looked into
RELEVANT Data from Social History: Clinical Significance:
- Enjoys the outdoors such as hunting, gardening, and chopping wood
- Christian faith
- In now less active in these roles due to declining health and can cause emotional response and make treating difficult.
- This can play an effect in how the patient gets treatment and what kind of care to give as well as certain advanced directives.
Case study NextGen UNFOLDING Reasoning Atrial
Fibrillation/Heart Failure (2/4)
ABDOMEN: Abdomen round, soft, and nontender. BS + in all 4 quadrants.
GU: Voiding frequently with hesitancy, urine clear/dark amber
INTEGUMENTARY: Skin warm, dry, intact. No clubbing of nails, cap refill <3 seconds, pale nailbeds.
Skin integrity intact, skin turgor with mild tenting present.
What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse?
(NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential/Promotion & Maintenance)
RELEVANT Assessment Data: Clinical Significance:
Looks ill, is weak and barely able to stand, and appetite is decreased, conjunctiva, lips, tongue, and oral mucosa are all pale and dry. Respiratory: breathe sounds diminished and crackles heard in both lower lobes.
- The patient can have an electrolyte imbalance or be going into shock.
- This can be an indicator od anemia, should assess the Hgb lab results
- Because the patient doesn’t have aa history of COPD this would lead me to believe the cause is a pleural effusion or congestive HF.
Cardiac Telemetry Strip:
Regular/Irregular: irregular
Interpretation: A-fin with RVR
P wave present? None PR: None QRS: QT :
Clinical Significance:
Prior history of paroxysmal A-fib and been admitted with a rapid HR and a low BP, greatly reducing
cardiac output.
1. Interpreting relevant clinical data, identify potential problems. What additional data is needed to identify the priority problem and nursing priorities? (NCSBN: Step 2 Analyze cues/NCLEX Management of Care/Physiologic Adaptation)
Likely Problems: Additional Clinical Data Needed:
Case study NextGen UNFOLDING Reasoning Atrial
Fibrillation/Heart Failure (2/4)
- Infection
- A-fib w/ RVR
- CBC, sputum & urine analysis
- 12 lead EKG
Caring and the “Art” of Nursing
2. What is the patient likely experiencing/feeling right now in this situation? What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person? ( Psychosocial Integrity)
What Patient is Experiencing: How to Engage:
- The patient is most likely feeling fear and anxiousness, he doesn’t know what is happening to him and it’s all happening in a small-time frame to a man who has otherwise been healthy his whole life, - Discuss his fears and anxiety with him. Answer any and all questions he has but try not to increase fear. Investigate what religious comforts may help him. Include his wife as much as possible. Build a trusting friendship.
Part II: Interpreting Diagnostic Data
The primary care provider orders the following diagnostic tests and the
results just posted in the electronic health record:
Radiology Reports: What diagnostic results are RELEVANT and must be NOTICED as clinically
significant by the nurse?
(NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential/Reduction of Risk Potential/Physiologic Adaptation)
Radiology: Chest X-ray
Results: Clinical Significance:
Case study NextGen UNFOLDING Reasoning Atrial
Fibrillation/Heart Failure (2/4)
- Sodium: 135
- Potassium: 4.
- Glucose: 141
- Creatinine: 0.
- Always relevant in HF
- Cardiac electrical conduction
- If high or low can cause dysrhythmias
- Kidney function
- Stable
- Stable
- Stable
- Stable
Liver Panel
Albumin Total Bili Alk. Phos. ALT AST
Case study NextGen UNFOLDING Reasoning Atrial
Fibrillation/Heart Failure (2/4)
Current: 3.1 0.8 272 171 144
6 weeks ago: 3.5 0.7 45 22 28
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
(NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
- Albumin
- Bilirubin
- Alkaline phosphate
- ALT
- AST
- Can be caused by malnutrition
- Liver function
- Can be High due to HF
- Liver function test (specific)
- Liver function test (specific)
- Worsening
- worsening
- worsening
- worsening
- worsening
Trop. BNP Mg Current: Less than 0.04 475 2. 6 weeks ago: n/a n/a 1.
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
(NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Lab(s): Clinical Significance: TREND:
Improve/Worsening/Stable:
- Troponin
- BNP
- Magnesium
- Shows no signs of cardiac myocardial infarction
- Key indicator of heart failure
- Cardiac electrical conduction
Part III: Put it All Together to Think Like a Nurse
1. Interpreting all clinical data collected, what are the most likely problems? Rank by priority. Which problem is most serious? Why? (NCSBN: Step 2: Analyze Cues/Step 3 Prioritize hypotheses/NCLEX Management of Care )
Likely Problems: Rank by Priority: Rationale:
Case study NextGen UNFOLDING Reasoning Atrial
Fibrillation/Heart Failure (2/4)
- Elevate head of bed
- Continuous pulse oximeter
- Place on 2/L o2 NC
- Monitor respirations, O2, breath sounds. - To reduce work of breathing - Continually access O2 sat and S/S of hypoxia - Need to improve oxygenation to minimum of 92% - Focus on ABC’s the priority is airway and breathing - Breathing - Early changes In O2 levels detected - O2 above 92% - Identify changes in oxygen early. 5. What is the worst possible/most likely complication(s) to anticipate based on the primary problem? (NCLEX: Reduction of Risk Potential/Physiologic Adaptation) Worst Possible/Most Likely Complication to Anticipate: Nursing Interventions to PREVENT this Complication: Assessments to Identify Problem EARLY: Nursing Interventions to Rescue:
- Access cardiac rhythm continually to identify change in HR - Assess the BP, HR, color, & S/S of stroke - Medications - Electrical cardio inversion - Head CT
Collaborative Care: Medical Management
6. State the rationale and expected outcomes for the medical plan of care. (NCLEX Pharm. and Parenteral Therapies) Care Provider Orders: Rationale: Expected Outcome: Establish peripheral IV 1. Start patient on antibiotics 2. Identify infection 1. Obtain IV access 2. Identify infection 3. Identify infection 4. Blood type 5. Increase hgb levels 6. Treat infection 7. Treat infection 8. Decrease HR 9. Decrease HR Blood cultures x2 sites (^) 3. Patient is anemic/blood transfusion UA/UC 4. Patient is anemic/blood transfusion 5. Kill present bacteria Type and crossmatch 6. Fight infection 7. Help control HR PRBC 1 unit IV 8. Decreasing the contractility of the heart will reduce HR Cefepime IV 1 g every 12 hrs. over 30 minutes Vancomycin IV 1 g. every 12 hrs. over 60 minutes
Case study NextGen UNFOLDING Reasoning Atrial
Fibrillation/Heart Failure (2/4)
Diltiazem 10 mg IV x Diltiazem 5-15 mg IV gtt to keep HR <
7. Which orders do you implement first? Why? (NCLEX Management of Care) Care Provider Orders: Order of Priority: Rationale: - Establish peripheral IV - PRBC 1 unit IV - Cefepime IV 1 g every 12
Establish IV Cefepime Vancomycin
- To administer meds
- Fight infection
- Fight infection
- Control HR
- Control anemia hrs. over 30 minutes 4- Diltiazem
- Vancomycin IV 1 g. every 5-^ PRBC 12 hrs. over 60 minutes
- Diltiazem 10 mg IV x Diltiazem 5-15 mg IV gtt
Case study NextGen UNFOLDING Reasoning Atrial
Fibrillation/Heart Failure (2/4)
Resp. rate: 20/minute x
Case study NextGen UNFOLDING Reasoning Atrial
Fibrillation/Heart Failure (2/4)
BP 108/54 x O2 sat: 94% 2 liters n/c x Able to walk to bed from transfer cart x Breath sounds diminished bilat. w/fine crackles in bases x Complains of pain that just started where his IV is infusing. The site looks puffy and is cool to the touch. x
2. Has the overall status of the patient improved, declined, or remain unchanged? If the patient has not
improved, what other interventions need to be considered by the nurse?
(NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care)
Overall Status: Additional Interventions to Implement: Expected Outcome:
- Some improvements - Continually monitor respiratory status and auscultate lung sounds - Continually monitor cardiac status, HR, rhythm and EKG - New IV inserted due to infiltration - Detect any changes in status early and continue IV medications as ordered.
Bill has converted to sinus rhythm, Hgb is 8.9 and he will be discharged to
home tomorrow on enoxaparin subcut. What are the educational priorities for this
patient/family to successfully manage the current problem and maintain optimal state
of health?
3. What educational/discharge priorities are needed to develop a teaching plan for this patient and/or family? (Health Promotion and Maintenance)
PRIORITY Topics to Teach: Rationale:
- S/S to look out for
- Follow medication regimen
- S/S such as shortness of breath, and palpitations can be red flags for worsening conditions
- Following a strict medication regimen is the best way for the medication to be at maximum effectiveness.
Reflect on Your Thinking to Develop Clinical Judgment
To develop clinical judgment, reflect on your thinking that was used to complete this case study by answering
the following questions:
What did you do well in this case study? What knowledge gaps did you identify?
Case study NextGen UNFOLDING Reasoning Atrial
