NextGen UNFOLDING Reasoning Atrial Fibrillation/Heart Failure (2/2) Suggested Answer Guidelines/Bill Hill, 71 years old

NextGen UNFOLDING Reasoning Atrial Fibrillation/Heart Failure (2/2) Suggested Answer Guidelines Bill Hill, 71 years old Primary Concept Perfusion Gas Exchange Interrelated Concepts (In order of emphasis) • Clinical judgment • Patient education • Communication • Collaboration 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 Present Problem: Part I: Initial Nursing Assessment Bill Hill is a 71-year old male with a past medical history of benign prostatic hyperplasia (BPH), peripheral vascular disease and myelodysplastic syndrome 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 am today feeling short of breath, harsh coughing 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 more pale, 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 us 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: Myelodysplastic syndrome diagnosed one month ago 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 am today feeling short of breath, harsh coughing 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 more pale and took his vital signs, which were BP: 96/62, HR: 140 irreg, RR: 24. This is a categorical diagnosis, and this patient needs another bone marrow biopsy to obtain a definitive diagnosis, per his oncologist, and treatment plan. Until this happens, the underlying disease is not treated and can contribute to this patient’s symptoms. This recent medical history is relevant to his current presentation. He may again be anemic and be in atrial fibrillation that may be contributing to his current cluster of complaints. Consider the causes: anemia, low BP, dehydraton. What started as a viral infection could progress to more severe lung pathology or secondary infection. When examining patient listen to the lungs for pneumonia, pleural effusion, allergy, infection? What physical findings align? Weakness can indicate an electrolyte imbalance, dehydration, sepsis, and anemia. This raises the concern of a primary infectious source of his current problem. Indicates a problem with the respiratory or cardiac system. will require a thorough assessment of the respiratory and cardiac systems and additional lab and diagnostic work. This degree of weakness is significant and a clinical RED FLAG that indicates the underlying severity of his current cluster of complaints. Being pale could be multifactorial and could include severe anemia and hypotension. His initial vital signs are concerning because his blood pressure is too low, his heart rate is too high and his respiratory rate is too high and causing shortness of breath. Knowing that he has a history of paroxysmal atrial fibrillation, knowing that his heart rate is Bill admits to losing 15 lb (6.8 kg) over the last 2-3 months. this rapid and irregular is a clinical red flag for atrial fibrillation been a contributor a cause to his current problem. Weight loss is more than expected and another clinical RED FLAG that requires further investigation by the nurse. RELEVANT Data from Social History: Clinical Significance: 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 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. New onset of disease and change in condition for patient and wife.These psychosocial considerations will need to be integrated into the plan of care once he is admitted to the hospital. Identify the psychosocial impact of this change in status upon his overall emotional and mental well-being. This defines the patient’s values and relates to the decisions made by this patient. Consider supporting the patient’s Christian perspective by offering pastoral care. What is the RELATIONSHIP of the past medical history and current medications? Why is your patient receiving these medications? (Which medication treats which condition? Draw lines to connect) Past Medical History: Home Medications: Benign prostatic hypertrophy (BPH) Peripheral vascular disease (PVD) Myelodysplastic syndrome (MDS) Paroxysmal atrial fibrillation (PAF) Clopidogrel 75 mg PO daily Tamsulosin 0.4 mg PO daily Atenolol 50 mg PO daily Benign prostatic hypertrophy (BPH)tamsulosin Peripheral vascular disease (PVD)clopidogrel Myelodysplastic syndrome (MDS) no medications Paroxysmal atrial fibrillation (PAF)atenolol Bill is transferred to a cart in the ED and quickly brought to a room. You introduce yourself, and collect the following clinical data: Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 99.6 F/37.6 C (oral) Provoking/Palliative: P: 148 (irreg) Quality: Denies R: 24 (reg) Region/Radiation: BP: 104/60 Severity: O2 sat: 88% room air Timing: What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: T: 99.6 F/37.6 C (oral) This is a slight temp elevation but could be an indicator of infection. Infection is a clinical RED FLAG with MDS patients since white cells may be altered P: 148 (irreg) Heart rate is increased and tachycardic. Most likely cause is an arrhythmia such as atrial fibrillation because his rate is rapid and irregular. R: 24 (reg) Respiratory rate is increased and indicates the patient is compensating or headed to further distress. Tachypnea is always a clinical RED FLAG that needs to be recognized by the nurse. No patient can sustain an elevated respiratory rate…respiratory failure WILL OCCUR if not corrected BP: 104/60 Hypotensive-could be secondary to early sepsis or more likely rapid HR. Discuss application of CO=SVxHR and impact of rapid HR to filling of ventricles that impacts stroke volume and overall cardiac perfusion. O2 sat: 88% room air Is clearly hypoxic and despite tachypnea is unable to maintain adequate oxygenation. This is a clinical RED FLAG that must be recognized by the nurse. 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 SURVEY: Appears ill and is This is a change in condition for this patient and a clinical RED FLAG. It weak, barely able to stand. Appetite has decreased recently HEENT: conjunctiva pale bilaterally. Lips, tongue, and oral mucosa pale and dry. RESPIRATORY: Breath sounds clear but very diminished bilaterally with fine crackles in the bases. could be related to MDS, fluid and electrolyte abnormalities, or sepsis. More clinical data is needed Anemia secondary to MDS. Will need to assess current Hgb. Why would breath sounds be difficult to auscultate with a patient who has no history of COPD or lung disease and is SOB/hypoxic? This cluster of data is consistent with pleural effusions which are also common with any oncological process. Cluster this data with other clinical data. 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 GU: Voiding frequently with hesitancy, urine clear/dark amber INTEGUMENTARY: Pale nail beds, skin turgor with mild tenting present. What could be causing his crackles in the basis of his lungs? Depending on how long he has been atrial fibrillation with a rapid ventricular response, over time this can cause acute heart failure even though he does not have a history of this primary problem. Patient admits to URI symptoms over last two weeks. Assess for pneumonia or other lung pathology. Infectious process will typically have colored sputum (yellow to green) due to dead neutrophils in sputum that have responded to infection. Pale color consistent with anemia or impaired cardiac perfusion. Depending on how long he has been atrial fibrillation with a rapid ventricular response, over time this can cause acute heart failure even though he does not have a history of this primary problem. This can cause the pitting edema that is present. Irregular rapid rhythm consistent with atrial fibrillation. Pulses that are faint is consistent with tachycardia that is this rapid. Hesitancy is consistent with past history of prostatic hypertrophy. Dark amber urine consistent with dehydration or liver pathology causing with increased bilirubin that can darken urine. Pale nail beds expected with anemia, but important to cluster with other related clinical data Indicates dehydration or can occur in elderly due to loss of turgor with aging process. Cardiac Telemetry Strip: Regular/Irregular: irregular P wave present? none QT : PR: n/e QRS: 0.06 Interpretation: atrial fibrillation-rate 168/with rapid ventricular response (rate 100) Clinical Significance: Has prior history of paroxysmal atrial fibrillation. Has now returned and the rapid rate is a clinical RED FLAG. At risk for dropping BP and becoming symptomatic due to rapid rate and loss of atrial kick which results in loss of 20-30% 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: Infection/pneumonia/sepsis Complete blood count (CBC) Chest x-ray Lactate Sputum, Blood, urine specimens Atrial fibrillation w/rapid 12 lead EKG ventricular response (RVR) 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 nurse needs to put her/himself in the place of the patient to identify what the patient is experiencing in this situation. The patient is likely aware of the seriousness of the current change in status and may be fearful and anxious. Support the patient and family by intentionally giving them as much information about his/her current status and explain the plan of care from both a nursing and medical perspective. KNOWLEDGE is POWER from a patient’s perspective, and when the nurse provides this information, it will DECREASE anxiety and fear and make a real difference in the patient’s well-being. Even in the context of a patient who is critically ill, when you simply and matter-of-factly share what you are doing and why, it demonstrates the caring and support that is needed. Regardless of the clinical setting, remember the importance of touch and your presence as you provide care. If you are using Swanson’s Caring framework (which I encourage you to do–see my “Teaching Caring” tab on KeithRN.com), the following practical caring interventions can be “tools” in your caring toolbox to use depending on the circumstance and the patient needs (Swanson, 1991). Comforting • Little things to comfort–whatever it may be–are needed and appreciated! i.e., hand or foot massage for pain control Anticipating their needs • Staying one step ahead and not behind, especially in a crisis, is essential! Is everything where the patient can reach it before you leave the room? Performing competently/skillfully • Remember that when a nurse or student nurse does their job well and competently, this demonstrates caring to the patient! Preserving dignity • Maintaining privacy at all times is essential and is all too easily forgotten because of the pressing physical needs that may be present. Pulling the curtain as well as covering exposed genitalia is all that is needed. They are little things, but so important to preserve human dignity. Accomplishing bodily functions which are disrupted with someone else present is significant. Be respectful of privacy issues. Informing/explaining–patient education • Even in a crisis, simply explain all that you are doing. If your patient is not able to respond but family are present, explain to them all that you are doing and why. This is truly the “art” of nursing and makes such a difference when done in practice! Part II: Interpreting Diagnostic Data The primary care provider orders the following diagnostic tests and the results just posted in the electronic health record: