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LRCC Nursing II Clinical 2.9.
RAPID Reasoning Case Study-STUDENT
I. Data Collection
History of Present Problem:
Mike Kelly is a 51 year old Caucasian male. He is 6 feet tall and weighs 275 pounds (BMI 37.3) with an abnormal distribution of weight around his abdomen. He does not regularly exercise, does not like to cook, and eats fast food 3-5x during the week. He has smoked 1 pack per day since the age of 20 (31 pack years). He has no current diagnosed medical problems. He becomes concerned and came to the urgent care facility today because he is more easily fatigued and has a headache for the past 3 days that has not improved. He didn’t go to work today and that is not typical for Mike. Personal/Social History: Mike is self-employed and owns his own auto mechanic business. He currently has no health insurance. His father had hypertension and died of a myocardial infarction (MI) at the age of 50. Angelina, his wife, came with him to urgent care and shares that he is usually stoic with health problems so this must really bother him or he is afraid. He took Excedrin and Motrin for pain and it didn’t help that she gave him a dose of Castor oil since she is from Puerto Rico and that is the first thing they do for any illness in her country of origin. What data from the histories is important & RELEVANT; therefore it has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: -more easily fatigued -headache for past 3 days -BMI of 37. -fast food eaten 3-5x per week -smoker for the past 31 years -does not regularly exercise -self employed Etiology of essential hypertension (Ignatavicius 710) Includes: -smoking -excessive intake of sodium -obesity -physical inactivity -high stress RELEVANT Data from Social History: Clinical Significance: -father has medical history of hypertension and MI -took Excedrin, Motrin, and castor oil before coming in -family history puts him at a greater risk for a heart attack
- Excedrin is a combo of Tylenol, aspirin, and caffeine (Caffeine can create tachycardia) -Castor oil relieves pain and promotes healing used culturally, more useful for open wounds -Motrin is a NSAID as well that thins the blood (Prescription) II. Patient Care Begins: Current VS: WILDA Pain Scale (5th^ VS) T: 98.9 (oral) W ords: Ache
LRCC Nursing II Clinical 2.9. P: 88 (regular) I ntensity: 8/ R: 20 L ocation: Global head ache BP: 220/118 D uration: Continuous O2 sat: 95% RA A ggravate: A lleviate: Nothing Nothing What VS data is RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT VS Data: Clinical Significance:
-BP 220/
Pain: Ache, 8/ Headache Continuous -BP over 140/90 is suggestive of hypertension for ages under 60 (Swearingin 179) -the headache pain can be an indicator of a hypertensive urgency or crisis (Ignatavicius 718) Current Assessment: GENERAL APPEARANCE: Appears uncomfortable RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses bounding, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact What assessment data is RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Assessment Data: Clinical Significance:
-uncomfortable -bounding pulse -being uncomfortable isn’t normal and indicates a possible problem
- increase in blood pressure may create a bounding pulse suggesting inadequate perfusion (Ignatavicius) III. Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting with? Hypertension is the most likely problem that my patient is presenting with. 2. What is the underlying cause/pathophysiology of this problem?
LRCC Nursing II Clinical 2.9.
8. What will be the consequences of uncontrolled hypertension to the rest of Mike’s body if it remains out of control? List body systems and potential permanent injury.
Body System: Potential permanent injury:
Cardiac Neuro Urinary Endocrine (Ignatavicius 709) Heart disease, leading to coma or death Stroke leading to permanent disability or death Renal Failure Diabetes Medical Management: Rationale for Treatment & Expected Outcomes Care Provider Orders: Rationale: Expected Outcome: Basic metabolic panel (BMP) Complete cell count (CBC) BNP (B-natriuretic Peptide) Lipid profile Urine analysis (UA) 12 lead EKG Chest x-ray Labetalol (Trandate) 10- mg IV push every 15 “. Goal BP: 160/ To identify contributing factors To look for infection To look at how hard the heart has been working To see if they are elevated because it would signify plaque in the arteries To check for kidney abnormalities To check for signs of MI To actually look at the heart To lower blood pressure All within normal range No signs of infection It would be elevated due to such high blood pressure With a blood pressure, so high I would expect an elevated lipid panel Signs of kidney dysfunction Possible signs of MI, but hopefully normal sinus rhythm Signs that the heart has been working harder than normal Blood pressure would steadily decline with each push
12 Lead EKG :
LRCC Nursing II Clinical 2.9.
Nursing II: Reading an EKG strip is done by someone who has had advanced cardiac life
support (ACLS) training. For the purpose of the scenario the results have been provided for
you as being Normal Sinus Rhythm.
Interpretation: Normal Sinus Rhythm
Clinical Significance: He is not in early signs of MI, but he is at high risk
Medication Dosage Calculation: Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations : Labetolol (Trandate) 20 mg IV push 5mg/mL vial 4mL Normal Range: (high/low/avg?) **Produces decrease in BP without reflex tachycardia or significant reduction in heart rate. (Skidmore
Loading dose (672) IV Push: Volume every 15 seconds? IV 20mg/2minutes Q 10minutes would be safe Assess BP, and pulse (Skidmore 674) Assess for therapeutic response or a radical decrease in blood pressure Watch for orthostatic hypotension Radiology Reports:** What diagnostic results are RELEVANT that must be recognized as clinically significant to the nruse? RELEVANT Results: Clinical Significance:
Chest x-ray :
The cardiac size is enlarged. There are no
focal infiltrates or consolidations or pleural
Cardiomegaly is a sign of heart disease.
(Ignatavicius 707)
LRCC Nursing II Clinical 2.9. Lab: Normal Value: <100 Why Relevant? Nursing Assessment/Interventions Required: BNP (B-natriuretic Peptide) **Value: 758 Critical Value:
If your BNP is high your heart has to work harder over a longer period of time Assess pulse and BP Decrease your BP to take workload off of heart (Ignatavicius) IV. Evaluation:** Evaluate the response of your patient to the nursing medical interventions during your shift. All physician orders have been implemented that are listed under medical management. Two hours later: Jim has received a third dose of Labetalol 20 mg IV push and you obtain the following clinical data when he is reassessed: Current Assessment: GENERAL APPEARANCE: Resting comfortably, appears in no acute distress RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses bounding, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact
1. What clinical data is RELEVANT that must be recognized as clinically significant?
RELEVANT VS Data: Clinical Significance:
BP 176/104 BP is getting closer to goal BP but not quite there yet, may need another labetalol push IV Current VS: Most Recent: WILDA Pain Scale (5th^ VS) Most Recent: T: 98.6 (oral) T: 98.9 (oral) W ords: Ache Ache P: 82 (regular) P: 88 (regular) I ntensity: 3/10 8/ R: 16 R: 20 L ocation: Global head ache Global head ache BP: 176/104 BP: 220/118 D uration: Continuous Continuous O2 sat: 96% RA O2 sat: 95% RA A ggravate: A lleviate: Nothing Nothing Nothing Nothing
LRCC Nursing II Clinical 2.9.
RELEVANT Assessment Data: Clinical Significance:
Bounding pulse Indication of vasodilation and high workload for the heart. (Ignatavicius 710)
2. Has the status improved or not as expected to this point? It has improved, but has not met the goal yet. 3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? No, we still need to focus on getting the BP down to take strain off of the heart. 4. Based on your current evaluation, what are your nursing priorities and plan of care? Labetalol IV until goal BP met and monitor BP and pulse until goal BP met. You communicate the following SBAR verbally to the ED primary care provider based on your evaluation:
S ituation:
51 year old Caucasian male with high blood pressure
B ackground:
Came in with complaints of being more easily fatigued and has had a headache for the last 3
days.
Father has a history of hypertension and MI
A ssessment:
Most recent vital signs: T: 98.6 P: 82 R:16 BP:176/104 O2 sat: 96% RA
LRCC Nursing II Clinical 2.9.
A ssessment:
Most recent vital signs: T: 98.6 P: 82 R:16 BP:176/104 O2 sat: 96% RA
Pulse is still bounding but pain is down to a 3/10 from an 8/
Blood pressure is at a steady decline with IV labetalol
R ecommendation:
Reassess pulse and BP on a regular basis.
Push IV labetalol Q15 minutes until BP is <160/
Watch for complications such as chest pain
Perform a repeat ECG
Assess for signs of hypotension
V. Education Priorities/Discharge Planning:
1. What will be the most important discharge/education priorities you will reinforce with their medical condition to prevent future readmission with the same problem? Lifestyle changes are the most important in maintaining hypertension 2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient? They verbalize a plan for lifestyle changes. Such as -exercise three times per week -low sodium diet -take antihypertensive medications -lower stress -monitor BP regularly -watch for cardiac complications such as pain in your chest -keep up with regular doctors’ appointments -quit smoking
VI. Caring and the “Art” of Nursing:
1. What is the patient likely experiencing/feeling right now in this situation? He is most likely feeling overwhelmed and anxious, this is a big wake up call for him if he doesn’t want to have a heart attack he needs to change his lifestyle. It is hard to change your lifestyle if you have formed habits. With support, he may be successful. 2. What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person?
LRCC Nursing II Clinical 2.9. You can show empathy for them and put yourself in their shoes. Validation is huge as it can show the patient that they really matter to you and that you are doing everything you can to ensure their comfort and wellbeing. References Ignatavicius, D. D., & Workman, M. L. (2013). Medical-surgical nursing: Patient-centered collaborative care. St. Louis: Elsevier Saunders. Lab Values: Cheat sheet. (n.d.). Allen's College. Retrieved February 9, 2017, from https://www.allencollege.edu/filesimages/Current%20Students/Academic%20Resources/lab%20values %20cheat%20sheet.pdf Prescription Drug Information, Interactions & Side Effects. (n.d.). Retrieved from https://www.drugs.com/ Skidmore-Roth, L. (2017). Mosby's 2017 nursing drug reference. St. Louis, MO: Elsevier. Swearingen, P. L. (2016). All-in-one nursing care planning resource: Medical-surgical, pediatric, maternity, and psychiatric-mental health. St. Louis, MO: Elsevier.
