Download NextGen UNFOLDING Reasoning Atrial Fibrillation/Heart Failure 4) (2 and more Exams Health sciences in PDF only on Docsity!
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 ✓
NextGen UNFOLDING Reasoning
Atrial Fibrillation/Heart Failure
(2/ 4) - Latest 2022 - 2025
Bill Hill, 71 years old
- Pharmacological and Parenteral Therapies
- Reduction of Risk Potential ✓
- Physiological Adaptation ✓ Part I: Initial Nursing Assessment Present
Problem:
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:
- BPH, PVD, MDS, and Afib
- Acute Anemia
- Hemoglobin
- Weakness, syncope, fatigue, SOB, fever/chills, congestion
- Productive cough with clear sputum
- Weight loss
- BP 96/62 – HR 140 irregular – RR 24
- Obstructions/decrease in urination, possible retention from BPH that could lead to FVD, which could then lead to BP issues, which could then lead to electrolyte imbalances.
- Risk of inadequate perfusion from AFib
- Anemia could be the cause of weakness/fatigue, syncope, or weight loss
- Infection caused from urinary retention or obstruction from BPH
- Hypotensive, tachycardic, and tachypnea could be heart related (AFib/anemia)
RELEVANT Data from Social History: Clinical Significance:
- Retired
- Christian faith
- Enjoys outdoor activities
- Emotional distress from not being able to participate in activities that he enjoys, like being outdoors
- Could effect decisions or already declining health like poor nutrition due to being depressed
HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white
bilaterally, conjunctiva pale bilaterally. Lips, tongue, and oral mucosa pale and dry.
RESPIRATORY: Breath sounds clear but very diminished bilaterally with fine crackles in both bases.
Slightly labored respiratory effort on room air. Persistent cough of clear sputum.
CARDIAC: Pale warm & dry, 1+ edema, heart sounds irregular and tachycardic, pulses faint,
equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. No JVD
noted at 30-45 degrees.
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:
- General: patient is ill, weak, unable to stand, appetitie has recently decreased
- HEENT: lips, tongue, and mucosa are pale and dry
- Respiratory: breath sounds are clear, but observed crackles bilaterally in both lower lobes, labored respirations on room air, and persistent cough that is productive with clear sputum.
- Cardiac: pale and dry but warm, 1+ pitting edema, irregular heart sounds, heart rate is elevated (tachy), faint but equal pulses at radial/tibial (post)/pedal landmarks, and no JVD is noted
- GU: frequent voiding, dark in color, and hesitancy is noted when trying to urinate.
- Integumentary: mild tenting is present when assessing skin turgor. - Possible fluid and electrolyte imbalances or shock - Indication of fluid volume deficit caused by either renal function issues, hemoglobin lab being low at 6.9 which is related to anemia - No history of any respiratory diseases such as emphysema or COPD, could be an indicator of progressing HF would need to order a lab to check BNP for verification, or edema caused by excess fluid on the lungs because the patient is unable to secrete these with cough - Decreased perfusion, excess fluid on the lungs which could cause the increase in heart rate and the decrease in blood pressure. - Could be the cause of fluid volume deficit, an infection (UTI), or home nutrition – a decrease in adequate fluid or food. - Typically a sign of dehydration which is a result of fluid volume deficit, or a sign of altered or decrease in cardiac output.
Cardiac Telemetry Strip:
Regular/Irregular: IRREGULAR P wave present? Present PR: Irregular – 4mm distance
QRS: Irregular – 2mm distance QT : Irregular – 3mm distance
Interpretation: Patient is experience AFib with RVR
Clinical Significance:
This shows a reduction of cardiac output, a possible electrolyte imbalance. The need to convert back to AFib
or possible sinus is needed, either chemically or by electric needs. All of this causes a decrease in perfusion
to tissues and organs of the rest of the body.
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:
- Fluid and electrolyte imbalances
- Decrease in perfusion
- Shock
- Effusion
- Worsening AFib or a possible clot/MI - Current and up to date labs and vitals - ABGs to determine if the patient is in metabolic/respiratory acidosis/alkalosis - Current temperature and labs to determine if fever is developing or if WBC counts are elevated. Would also need to check vitals to determine heart rate, blood pressure and respiration rate. - CT, Xray, MRI or any other visual diagnostic test needed to check for fluid located on the lungs. - Would need to know troponin level to determine if patient is having an MI, an EKG would be needed to visualize rate and rhythm of heart, and a heart catherization would be used to determine if there is a clot present or an issue within the left ventricular valve, as well as determine if ejection fraction has worsened.
Lab Results:
Complete Blood Count (CBC)
WBC HGB PLTs % Neuts Bands
Current: 6.7 6.2 91 52 0
6 weeks ago: 12.5 8.5 98 65 0
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:
• WBC – 6.
• HGB – 6.
- WBC count has decreased from 6 weeks ago, indicative of possible previous infection that is no longer present. MDS can also lower WBC counts.
- Significant decrease in hemoglobin over the last 6 weeks. Patient received a blood transfusion which would show an increase. MDS also reduces the number of RBCs, as well as anemia. - Improved - Worsening
Platelets – 91 Neutrophils - 52
Result is on the higher end of low, but still considered stable. Decrease in neutrophils is indicative of no infection being present. The value 6 weeks ago would indicate an infection was present at that time.
Worsening Improved
Basic Metabolic Panel (BMP)
Na K Gluc. Creat.
Current: 135 4.0 141 0.
6 weeks ago: 139 3.7 122 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:
- Na – 135
- K – 4.
- Glucose – 141
- Creatinine – 0.
- Sodium level is within normal range, this is always something we need to look at in regards to fluid volume, electrolyte imbalance, and heart failure.
- Potassium level is within normal range, this is always something we need to look at in regards to fluid volume, electrolyte imbalance, and heart failure. Potassium plays a large role within the cardiac muscle.
- An alteration within the blood glucose can cause major fluctuations within the body systems. The value now is much higher than it was previously (6 weeks ago). This could be indicative of poor renal function and could cause dysrhythmias within the heart.
- Creatinine level is within normal range. A rise in this could cause issues with fluid volume, electrolyte imbalance, and cardiac function. This could be indicative of renal failure or worsening heart failure if levels were elevated. - Stable - Stable - Worsening - Stable
Liver Panel
Albumin Total Bili Alk. Phos. ALT AST
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:
- Alkaline Phosphate – 272
- ALT – 171
- AST – 144
- Albumin – 3.
- Primary sign of liver disease or biliary obstruction, viral hepatitis, or alcoholic liver disease. Could also be elevated due to heart failure.
- Specific liver enzyme value, but since there is no history of substance or alcohol abuse, this could be caused by worsening MDS.
- Specific liver enzyme value, but since there is no history of substance or alcohol abuse, this could be caused by worsening MDS.
- Slightly low, could be caused by malnutrition.
- Worsening
- Worsening
- Worsening
- Worsening
2. What is the pathophysiology of the priority problem? (NCLEX Management of Care/Physiologic Adaptation)
Priority Problem: Pathophysiology of Problem in OWN Words:
- Atrial Fibrillation - Caused by abnormal electrical impulses within the atria of the heart and only some of these impulses will reach the AV node. This results in a rapid and irregular heart rhythm and causes blood to pool within the left atria. 3. What body system(s) will you assess most thoroughly based on the primary/priority problem? Identify correlating specific nursing assessments. (NCLEX Reduction of Risk Potential/Physiologic Adaptation)
PRIORITY Body System: PRIORITY Nursing Assessments:
- Cardiovascular • Assess heart sounds, including rate and rhythm
- Check blood pressure
- Assess pedal, radial, brachial, femoral, popliteal pulses, as well as carotid
- Assess capillary refill bilaterally in hands and feet
- Assess for edema
- Assess skin temperature in lower extremities 4. What nursing priority(ies) and goal will guide how the nurse RESPONDS to formulate a plan of care? (NCSBN: Step 4 Generate solutions/Step 5: Take action/NCLEX Management of Care)
Nursing PRIORITY: • Decreased^ Cardiac Output
GOAL of Care: • Patient will demonstrated adequate cardiac
output by improvement of vital signs, decrease in heart failure symptoms, and control of dysrhythmias
Nursing Interventions: Rationale: Expected Outcome:
- Auscultate heart sounds, rate, and rhythm
- Monitor BP
- Assess peripheral pulses
- Heart sounds may be weak or diminished due to hearts lack of ability to pump adequately.
- BP may be elevated because of heart rate or may be decreased due to the hearts inability to compensate.
- Decreased cardiac output may be apparent if peripheral pulses are irregular or weak. - When auscultating, heart sounds will appear normal with rate and rhythm. - BP will be within normal and acceptable limits - Peripheral pulses will fall within normal range, 2+.
- Assess mental status
- Inspect skin for color and temperature - Impaired oxygentation to tissues and organs can be evident by confusion or an alteration in consciousness. - Pallor can be indicative of decreased perfusion and cardiac output (vasoconstriction). Peripheral temperature will decrease with a decrease in cardiac output and perfusion. - LOC will be A & O x 4 - Skin color and temperature will be normal for ethnicity and warm upon assessment. 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:
- Thrombus formation due to hypotension r/t AFib. Nursing Interventions to PREVENT this Complication: Assessments to Identify Problem EARLY: Nursing Interventions to Rescue:
- Assess cardiac rate and rhythm to identify an abrupt change in heart rate. - Assess vital signs – BP, HR, skin color and temperature, LOC, muscle weakness. - Heart palpitations or sudden change in heart rate, sudden drop in blood pressure, abrupt change in LOC, pallor/cyanotic skin color or temperature.
- (^) Diltiazem 5-15 mg IV gtt to keep HR < - Helps to lower heart rate by relaxing blood vessels^ • Heart rate is within normal limits 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 hrs. over 30 minutes
- Vancomycin IV 1 g. every 12 hrs. over 60 minutes
- Diltiazem 10 mg IV x Diltiazem 5-15 mg IV gtt to keep HR <
- Establish peripheral IV
- PRBC 1 unit IV
- Diltiazem IV
- Vancomycin
- Cefepime
- Provide access to administer blood products, fluids, or IV medications.
- Control fluid volume and increase RBCs
- Control heart rate in hopes of converting to normal sinus rhythm
- Prophylactic antibiotic to treat any infection until blood cultures return positive or negative
- If positive for infection, provide to treat UTI or any other infection present.
8. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial
Integrity/Basic Care and Comfort)
Psychosocial PRIORITIES: Decrease anxiety and fears
PRIORITY Nursing Interventions: Rationale:^ Expected Outcome:
- Encourage patient to voice feelings of fear and anxiety - Provide therapeutic communication strategies that include listening, reiterating, and providing honest, truthful responses. This could also include silence and providing comfort by being present. - Builds a trusting relationship between the nurse and the patient.
Part IV-Evaluation: Two Hours Later…
All orders have been implemented. Bill has been admitted and just transferred to the
cardiac telemetry unit one hour ago. Bill was able to walk from stretcher to the bed and
was steady on his feet.
His primary nurse collects the following clinical data:
- T: 98.6 F/37.6 C (oral)
- P: 108 (irreg)
- R: 20 (reg)
- BP: 108/
- O2 sat: 94% 2 liters n/c
Breath sounds are diminished bilat. w/fine crackles in bases, does not feel as SOB and is
breathing comfortably. Telemetry rhythm is atrial fibrillation. Blood is infusing at 150
mL/hour and the diltiazem IV gtt is infusing at 5 mg/hour in a separate IV. Bill complains
of pain that just started where his IV is infusing. The site looks puffy and is cool to the
touch.
1. The nurse assesses the patient after implementing the plan of care. Interpret the clinical cues to determine
if the patient status is improving, declining, or reflects no change. (NCSBN: Step 6 Evaluate outcomes/NCLEX:
Management of Care)
Assessment Data: Improving: Declining: No
Change:
Rhythm: Atrial fibrillation X Heart rate 108/minute X Resp. rate: 20/minute X 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:
- I feel Like I did well in making sure the patient was comfortable and recognizing signs and symptoms of Afib - I had to look up some of the medications that the patient had to take to recognize them and what they were used for. What did you learn? How will you apply learning caring for future patients?
- I learned more about the mediations and lab values.
- I will be able to better look for the signs and symptoms of AFib to ensure that I can give appropriate care to my future patients.
