Medical Surgical Cases. {GRADED A)

Part One: Medical Surgical Case (Cardiovascular Disorders) Student Name Institutional Affiliation Course Date Part One: Medical Surgical Case (Cardiovascular Disorders) Case Study 1: 1. The pat ient most likely failed to adequately apply the fluid and sodium restriction diet properly. Upon discharge teaching, she probably did not have an appropriate understanding of how much sodium to restrict in her diet, as well as what foods may be high in sodium. She also may not have an adequate understanding of what a "fluid" restriction diet entails. 2. The contributing medication to M.G.’s high blood pressure was Pioglitazone (Actos) 45 mg PO every morning; because the side effects are severe weight gain and fluid retention (edema) and both are known to contribute to HF. 3. How do angiotensin-converting enzyme (ACE) inhibitors, such as enalapril (Vasotec), work to reduce HF? Select all that apply. ACE inhibitors: a. Prevent the conversion of angiotensin I to angiotensin II. b. Cause systemic vasodilation. c. Promote the excretion of sodium and water in the renal tubules. d. Reduce preload and afterload. e. Increase cardiac contractility. f. Block sympathetic nervous system stimulation to the heart (Does not block but it reduces) 4. The rational is: The patient has fluid overload (hypervolemia), and fluid volume overload is needed to be decreased in a short time. IV is administer straight into the vascular system and begins to work immediately. 5. The following are required parameters. I & O Decreased SOB, decreased crackles in the bases of lungs Decreased dependent edema Daily weight Decrease O2 demands Decreased JVD 6. What laboratory tests should be ordered for M.G. related to the order for furosemide (Lasix)? (Select all that apply.) a. Magnesium level b. Sodium level c. Complete blood count (CBC) d. Serum glucose levels e. Potassium level f. Coagulation studies N/B: The electrolytes are crucial in maintaining a steady rhythm of the heart. 7. What is the purpose of the beta-blocker carvedilol? It is given to: a. Increase the contractility of the heart b. Cause peripheral vasodilation c. Increase urine output d. Reduce cardiac stimulation by catecholamine’s 8. You assess M.G. for conditions that may be a contraindication to carvedilol. Which condition, if present, may cause serious problems if the patient takes this medication? a. Angina b. Asthma c. Glaucoma d. Hypertension * (Explanation): Beta Blockers may cause bronchoconstriction and/or increased airway resistance. 9. What is the action of the digoxin? Digoxin: a. Causes systemic vasodilation. b. Promotes the excretion of sodium and water in the renal tubules. c. Increases cardiac contractility and cardiac output. d. Blocks sympathetic nervous system stimulation to the heart. 10. Which findings from M.G.'s assessment would indicate an increased possibility of digoxin toxicity? Explain your answer. a. Serum potassium level of 2.2 mEq/L b. Serum sodium level of 139 mEq/L c. Apical heart rate of 64 beats/minute d. Digoxin level 1.6 ng/mL (Explanation) Low potassium levels can increase potential digoxin toxicity. The patient is also, taking a loop diuretic that excretes potassium as well as sodium and water. 11. When you go to give the digoxin, you notice that it is available in milligrams (mg) not micro Grams (mcg). Convert 125 mcg to mg. 0.125 mg 12. The primary care provider will need to assess whether the change from IV to oral can maintain a stable weight, one of the fluid management goals for patients with HF is to maintaining a target weight. This can be accomplished by monitoring daily weight, keeping accurate 1&O and recording subjective symptoms. 13. The most important factor should be education, and teaching the patient without overloading them with facts are realistic key points. The 5 most important for a patient with HF are MAWDS instructions. Medication: Take as directed by physician, not skipping doses or run out of medications. Activity: Stay active, but remain conscious of triggers of over execration. Weight: Weight yourself every morning, call your doctor if you gain or lose 2 pounds or more overnight or gain. Diet: Follow a low salt diet and limit fluids to less than 2 quarts a day. Symptoms: Know your normal status, report the unusual weight gains, fatigue, heavy breathing upon walking early to health care provider to prevent readmission to hospital. 14. After the teaching session, which statement by M.G. indicates a need for further education? a. “I will weigh myself daily and tell the doctor at my next visit if I am gaining weight” b. “I will not add salt when I am cooking.” c. “I will try to take a short walk around the block with my husband three times a week.” d. “I will use a pill calendar box to remind me to take my medicine.” Case Study #2 Cardiovascular Disorders: Hypertension 1 According to the most recent Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (2014), M.P's blood pressure falls under Stage 1 Hypertension, Systolic Blood Pressure (SBP) of 140-150 and Diastolic Blood Pressure (DBP) of 90-99. 2 M.P. was given instruction to take the thiazide every morning but she may be taking it at night which might be the cause of her nocturia making her having to get up at night to urinate. Thiazide is a diuretic and it is best to take it in the morning. 3 M.P. blood pressure (BP) of 162/102 and her lack of physical activity are risk factors that can increase her risk for cardiovascular disease. 4 According to the JNC 8 national guidelines (2014), since M.P. is an African American over 60, she can take the Thiazide (HCTZ) and a Calcium channel blocker (CCB). 5 M.P. wants to know if she should lose weight but at 5feet 4inches and 110 pounds, according to the National Institute of Health (2016) she is a normal weight with a body mass index (BMI) of 18.9. 6 M.P. can use non-pharmacologic lifestyle alteration measures such as weight reduction, using the DASH eating plan, dietary restriction of sodium, restricted alcohol intake, avoidance of tobacco products, and participating in physical activity (Lewis, Dirksen, Heitkemper, Bucher, and Camera, 2011). 7 The internist decreased M.P. dose of HCTZ because of the addition of benazepril mg. The combination of HCTZ and Benazepil is used to treat high blood pressure. 8 Education was provided to M.P. about the side effects of benazepril such as headache, cough, constipation and dizziness (Lehne, 2010). 9 Because it is sometimes difficult to remember to take your medication, some techniques that might help M.P. remember to take her medication are for her to get daily dosing container which she can get at her local pharmacy. She can keep her medications where you’ll notice them for instance if she takes her medication in the morning, put those medications in the bathroom next to her toothbrush (FDA.gov, 2015). 10 After her teaching session, M.P. stated that "It's okay to skip a few doses if I am feeling bad as long as it's just for a few days." This statement indicates that she needs for further instructions. According to the FDA, poor adherence can interfere with the ability to treat many diseases, leading to greater complications from the illness and a lower quality of life for patients. 11 Since M.P. is taking HCTZ and benazepril, the following laboratory test, potassium, sodium, chloride, CO2, Blood urea nitrogen (BUN), and Creatinine results should be monitored. 12 M.P.’s laboratory test results from fasting are back and the glucose is of slight concern to me because at 112 mEq is considered pre-diabetic. 13 On M.P.’s 1 month visit her BP was 134/82, she asks whether these readings were okay. She would be told that BP has gotten better since her last visit but she is still in the pre- hypertensive stage. This is according to the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (2014). She still need to monitor her diet and participate in activity 3-4 days a week. 14 Three important ways that can be used to help M.P. to maintain her success are for her to maintain a healthy weight by eating well; she can continue with her daily physical activity and for her to take her medications as prescribed (American Heart Association, 2016). 15 M.P. stated that she was recently at a luncheon with her garden club and that her friends take different BP pills that are of different shapes and colors. It should be explained to her that yes, it is confusing, and unfortunately, it's fairly common. The same generic drug, made by a different manufacturer, can indeed look different. Due to certain patent laws that govern brand-name medications, generic drug manufacturers are not allowed to copy how a brand- name pill looks in terms of its shape, its color and its size (C, 2012) 16 M.P. stated that she has not have an eye exam in about 2 years and wanted to know what an eye has to do with her BP. It should be explained to her that high blood pressure can damage blood vessels in the retina. The higher the blood pressure and the longer it has been high, the more severe the damage is likely to be. Most people with hypertensive retinopathy do not have symptoms until late in the disease. They may have symptoms such as double vision, dim vision, or vision loss as well as headaches. Case Study 3: Case study 3: Q1. 1.5 packs x 365 days/year = 547.5 x 20 = 10,950 packs and 219, 000 cigarettes smoked for a period of 20 years. Q2. There are several risk factors for coronary artery disease (CAD). For each risk factor listed, mark whether it is nonmodifiable or modifiable. a. Age - nonmodifiable b. Smoking - modifiable c. Family history of CAD - nonmodifiable d. Obesity - modifiable e. Physical inactivity - modifiable f. Gender - nonmodifiable g. Hypertension - modifiable h. Diabetes mellitus - modifiable i. Hyperlipidemia - modifiable j. Ethnic background - nonmodifiable k. Stress - modifiable l. Excessive alcohol use – modifiable Q3. All risk factors listed in question 2 applies to B.T. Case Study Progress: Chart View: Laboratory Testing (Fasting) Total cholesterol - 240 mg/dL – He is at high risk. Normal is 200 and below HDL - 35 mg/dL – He is at major risk. Normal is 40 and above LDL - 112 mg/dL – He is at a desirable level. Normal is 115 and below Triglycerides - 178 mg/dl - He is borderline high because should be 150 Q4. Q5. LDL is the bad cholesterol that triggers unhealthy build up in the arterial blood vessels when very high. HDL is the good cholesterol assists in maintaining arterial blood vessels clear. Triglyceride is a type of fat that originates from the type of foods you eat, every eaten calorie that is not required by the body transform to a triglyceride. Total cholesterol = LDL + HDL + (0.2 * triglycerides) Depending on the score determines the danger for cardiovascular disease. HDL is the good cholesterol assists in maintaining arterial blood vessels clear. His HDL 35 mg/dl He is at major risk. Normal is 40 and above. It helps blood to circulate with no restraints. LDL is the bad cholesterol that triggers unhealthy build up in the arterial blood vessels when very high. His LDL is 112 mg/dl He is at a desirable level. Normal is 115 and below, but if it continues to rise he will increase his chances of cardiovascular disease. Q6. 6. Identify health-related problems in this case description; the problem that is potentially life- threatening should be listed first. a. Heart attack b. Hypertension c. Stroke d. Diabetes And many other as with these four diseases, he will not want nothing else Q7. That’s like saying which one came first the chicken or the egg, but he could have smoked more or ate more if he exercised. The most significant is smoking for sure. Q8. What interventions would you recommend to assist B.T. in addressing this behavior? a. Smoking cessation b. An exercise plan geared towards him c. Visiting a dietician would benefit d. Alcohol treatment e. Medication adherence f. Education about lifestyle changes!!!! Q9. I would sit down and access B.T. for his readiness to learn, and what his goals are for his future health. I would educate him about the damage smoking causes to his arteries. Along with assessing for bad habits, I could evaluate for potential changes he could make in his eating habits. If B.T. is resistant to change all the education in the world won’t help. Q10. The second thing I would address with B.T. would be the diabetes. At this point, there is nothing mentioning he has diabetes, but at the rate of his lifestyle choices he is on the diabetes train headed closer to death or stroke. I would educate him about the need to change his sedentary lifestyle. Q11. I would ask her to tell me more about her fears. I would encourage her to have that long overdue conversation with her husband about lifestyle changes. She could introduce them to different types of food that are healthier for the entire family. She could also plan family activities could involve more walking, dancing or anything other than sitting around. Q12. Have B.T. stop any activity and sit or lie down because you want to decrease the workload on his heart and decrease his body's need for oxygen. You will also check his vital signs and ask whether he has any SL NTG tablets with him. 13. B.T. is still uncomfortable, and he has an unopened bottle of sublingual nitroglycerin (SL NTG) tablets. His blood pressure is 158/98, and his pulse is 122. You decide to give him one tablet. After 5 minutes, which is the appropriate action to take? a. If the chest discomfort is relieved, call 911. b. If the chest discomfort is not relieved, give another SL NTG tablet, and wait 5 minutes more. c. If the chest discomfort is not relieved, have someone else call 911 while you give B.T. another SL NTG tablet. d. If the chest discomfort is not relieved, obtain a 12-lead electrocardiogram (ECG) to look for ischemic changes, and call 911. Q14. Continue to monitor his vital signs, and consider checking a 12-lead ECG (if available) to look for ischemic changes. Keep him quiet, and reassure him that you will stay with him. Q15. Have one nurse call 911 and request emergency transport to the nearest emergency department (ED) while you stay with B.T. Have B.T. chew two low-dose (81 mg, or “baby”) aspirin tablets, if available. Following the department protocols, while you are waiting for the medics, start 2 to 4 L of O2/NC and establish intravenous (IV) access, in case IV medications have to be administered. Run a 12-lead ECG or rhythm strip to look for dysrhythmias and ischemic changes. Run a long rhythm strip. If B.T. needs to be transported by the paramedics to the ED, it may be valuable to the medical personnel at the hospital. Continue to observe B.T. carefully and monitor his vital signs, reassure him, and make him as comfortable as possible. Notify B.T.'s attending physician and his wife. Q16. Headache is a common side effect of NG therapy because of vasodilation. You need to reassure him that this is a side effect of the NTG and that he is not getting worse. Encourage him to rest quietly as the NTG may also cause a drop-in blood pressure (orthostatic changes) if he tries to get up. Case Study 4: Q1. Increased heart rate at 105 beats/ min is concerning (increased preload, afterload/ contractility) Q2. Chest pain? Shortness of breath? Family history? Diet? Smoking? Q3. Atherosclerosis: plaque buildup in arteries which leads to Myocardial Ischemia: inadequate oxygen supply to meet metabolic demands, caused by occluded vessels, platelet aggregation forming a thrombus, vessel spasms. Q4. You are now ready to do you physical assessment. For each potential assessment finding for HF, indicate whether the finding indicates left-sided HF or right sided HF Fatigue, weakness, especially with activity _Right_ Jugular (neck vein distention _Right_ Dependent edema (legs and sacrum) _Right_ Hacking cough, worse at night _Left_ Enlarged liver and spleen _Right_ Exertional dyspnea Left Distended abdomen _Right_ Weight gain _Left_ S3/S4 gallop _Left_ Crackles and wheezes in lungs _Right_ Show Less