1. George Brown, 72 years of age, is a male patient who is admitted with the diagnosis of acute pulmonary edema secondary to acute left ventricular heart failure. The patient has a history of coronary artery disease that has been treated medically. The patient is anxious, pale, cold, clammy, and dyspneic. The vital signs are: blood pressure 88/50 mm Hg, heart rate 110 bpm, respiratory rate 32 breaths/min, and temperature 97°F. There are bubbling crackles and wheezing throughout the lung fields and the patient is raising frothy blood-tinged clear sputum. The patient’s admission weight is 100 kg.
a. What first actions should the nurse take and what are the rationales for these actions?

The physician ordered furosemide (Lasix) 40 mg IVP STAT.

b. What are the actions of furosemide that will help the patient?

c. What nursing actions should be implemented when administering a diuretic?
2. Carl Edwards is a 75-year-old man with congestive heart failure. Having sustained three myocardial infarctions in the last 10 years, he has decreased left ventricular function. Mr. Edwards takes Digoxin, Capoten, Coreg, and Lasix for management of this disease. Today he presents to the emergency department with fatigue, generalized weakness, and feelings of “skipping” heartbeats. Upon arrival, he is placed on the cardiac monitor, his vital signs are assessed, and an IV is inserted. He currently denies chest pain, but is experiencing some shortness of breath, and is placed on 2 L of oxygen via nasal cannula.
a. Which of his medications might be contributing to his symptoms of generalized weakness and heart irregularities?

b. For what clinical manifestations should you assess to correlate to his left-sided heart failure?

c. How do his medications treat his congestive heart failure?

d. How does the hypokalemia affect the effects of Digitalis?

Case Study, Chapter 31, Assessment and Management of Patients With Hypertension

1. The community health nurse is preparing a program about hypertension for a local community center. The focus of the program is on the reduction of risk factors and compliance for those who have been diagnosed with high blood pressure. The target population includes older adults.
a. The nurse focuses on primary hypertension because it accounts for 90% to 95% of hypertension in the United States. What risk factors does the nurse include for this population?

b. The nurse prepares to discuss the changes in how the JNC 7 defines hypertension. What ranges and descriptions should the nurse include?

c. Because this is a gerontologic audience, the nurse needs to review why blood pressure increases with age. Explain how the structural and functional changes of aging contribute to higher blood pressure in the older adult.

d. What information does the nurse include about lifestyle modifications that may decrease risk of hypertension (or complications associated with diagnosed hypertension)?

Case Study, Chapter 51, Assessment and Management of Patients With Diabetes
1. Sallie Smith, 42 years of age, is newly diagnosed with type 2 diabetes. During the patient education, the patient asks the nurse, “What should I do if I am sick and can’t eat; should I still take my medicine for the diabetes?”
a. What management strategies should the nurse provide the patient to deal with “sick days”?
2. Jerry Thomas is a 26-year-old type 1 diabetic. He was originally diagnosed at the age of 14, and currently manages his disease with an intensive regimen of insulin injections. Jerry is employed as a schoolteacher and soccer coach. He presents today with a 2-day history of vomiting and diarrhea. He has been closely monitoring his blood glucoses, and is using regular insulin for high blood glucose levels. He has only been able to tolerate liquids such as Gatorade, but today he is unable to even tolerate that, and comes to the clinic for evaluation of possible diabetic ketoacidosis (DKA).
a. Describe the pathophysiology of DKA and why it occurs in patients with type 1 diabetes.

b. Based on the diagnosis of DKA, what assessment findings does the nurse correlate to this disorder?

c. The physician orders a complete metabolic panel, and Jerry’s blood glucose is 425. Other lab values include a serum sodium of 152, serum potassium of 3.0, and BUN of 64. What is your assessment of these results?

d. Explain why it is important for Jerry to continue to take his insulin even though his oral intake is decreased.
Case Study, Chapter 20, Assessment of Respiratory Function
1. John April, 24 years of age, is a male patient who was admitted to the surgical unit after a successful repair of an inguinal hernia. He is 5 feet 10 inches tall and weighs 120 kg. He has a neck circumference of 21 inches. The patient has a morphine PCA. He has no known drug allergies. His vital signs are as follows: blood pressure 122/70 mm Hg, respiratory rate 26 breaths/min, heart rate 88 bpm, and temperature 98.6°F. The patient complains of incision pain and rates it on the pain scale as 7 of 10. His family is visiting at the bedside. The nurse administers a bolus dose of morphine. Fifteen minutes after administering the pain medication, a family member enters the hallway and yells, “We need help in here! John is not breathing.” The nurse finds John having periods of apnea lasting a few seconds followed by a short snorting gasp and then he begins breathing at a rate of 12 breaths per minute. His lips are bluish in coloration and so are his nail beds. The patient is lying supine in the bed. He awakens as the nurse enters, but is very lethargic and somnolent.

a. Which assessment parameters are appropriate to determine the characteristics and severity of the symptoms that the patient is exhibiting?

b. Which nursing interventions should the nurse institute? Which intervention must be provided immediately?

c. Explain the possible reasons for the patient’s sudden decline in the respiratory status.

Chapter 23 Case study

1. Harry Smith, 70 years of age, is a male patient who is admitted to the medical-surgical unit with acute community-acquired pneumonia. He was diagnosed with paraseptal emphysema 3 years ago. The patient smoked cigarettes one pack per day for 55 years and quit 3 years ago. The patient has a history of hypertension, and diabetes controlled with oral diabetic agents. The patient presents with confusion as to time and place. The family stated that this is a new change for the patient. The admission vital signs are as follows: blood pressure 90/50 mm Hg, heart rate 101 bpm, respiratory rate 28 breaths/min, and temperature 101.5°F. The pulse oximeter on room air is 85%. The CBC is as follows: WBC 12,500, platelets 350,000, HCT 30%, and Hgb 10 g/dL. ABGs on room air are pH 7.30, PaO2 55, PaCO2 50, HCO3 25. Chest x-ray results reveal right lower lobe consolidation, presence of apical bullae, flattened diaphragm, and a small pleural effusion in the right lower lobe. Lung auscultation reveals severely diminished breath sounds in the right lower lobe and absence of breath sounds at the base. The breath sounds in the rest of the lungs are slightly decreased. The patient complains of fatigue and shortness of breath and cannot finish a short sentence before the respiratory rate increases above the baseline and his nail beds and lips turn a bluish tinge and the pulse oximetry decreases to 82%. The patient is diaphoretic and is using accessory muscles. The patient coughs weakly, but he does not raise any sputum.
a. What nursing assessment findings support the diagnosis of pneumonia?

b. What diagnostic findings support the diagnosis of pneumonia?

c. What nursing diagnoses should the nurse formulate for the patient?

d. What goals should the nurse develop for the patient?

e. What overall interventions should the nurse provide?
Chapter 24 Case Study

2. Sallie Thorp, a 21-year-old patient, presents to the physician’s office with an asthma action plan form she acquired from a literature search on the World Wide Web at http://www.nhlbi.nih.gov/health/public/lung/asthma/asthma_actplan.pdf. She states that she would like to develop the plan with the help of the nurse and physician and review it at each appointment to keep it current. She has had moderate persistent asthma for 5 years, and she has visited the emergency department several times in the past year with severe asthma attacks. She stated that she forgets to take her medications, because the medications are at times that the hospital provided the inhalers (12 noon and midnight), and she gets confused on which inhalers are the long-acting ones and which inhaler is the short-acting rescue inhaler she is supposed to use when she has an exacerbation. She stated that if she could, she would like to take the inhalers at 8 AM and again at 8 PM. The patient stated that she has a flow meter and that a respiratory therapist at the hospital taught her how to use it in the past, and he wrote down her personal best peak flow, which is 400 L/sec. The nurse reviews the patient’s medical chart and discovers that she has been prescribed the following from today’s visit:
• Use albuterol (Proventil): 2 to 4 puffs every 20 minutes for up to 1 hour as rescue inhaler. If symptoms improve, then take the inhaler every 4 hours for 1 to 2 days. If no improvement after 2 days, call the physician.
• Salmeterol (Serevent): 50 mcg every 12 hours
• Fluticasone (Flovent): 88 mcg or 2 puffs every 12 hours
• Cromolyn sodium (Nasalcrom): one spray to each nostril once daily and before being exposed to known asthma triggers. You may use the spray up to every 4 hours.
• Measure peak flow meter every morning before using inhalers and record. Use peak flow meter, as needed, if you develop symptoms, such as cough, shortness of breath, wheezing, chest tightness; use of neck and chest muscles to breathe; problems talking or walking because of extreme shortness of breath.
• Follow-up in 3 months.
• Have the nurse provide education on asthma self-management and fill out the action plan that the patient brought with her today and have the physician review it and sign it.

The nurse also notes that the medications have not changed from the last visit.
(Learning Objectives 8 and 9)
a. Print out the form and complete the form using the information from the case study.
Please use the form to help you answer the question below.

b. Define the green, yellow and red zone for this patient.

c. List the medications below :

Medication Dosage Classification Action Teaching points

d. Explain ways to evaluate the patient’s mastery of the content?

Case Study, Chapter 52, Assessment and Management of Patients With Endocrine Disorders
1. Don Smart, 55 years of age presents to the family physician to follow up on some symptoms he recently developed. The patient states that he is extremely tired and is having trouble concentrating. He states that his skin is dry and flaky. His nails are brittle and his hair is dry, dull, and falls out as he showers. He is 8 weeks postop after a modified radical neck procedure for laryngeal cancer and has completed the external radiation therapy. He is using a Blom-Singer prosthesis for speech. He states that his appetite is poor, yet he is gaining weight. The patient’s current medications include metformin (Glucophage) for a history of type 2 diabetes, digoxin 0.25 mg every day for a history of atrial fibrillation, and warfarin therapy being managed by the family physician for thromboembolism prophylaxis related to atrial fibrillation. The physician orders the following lab work: CBC with differential, serum albumin, TSH, FT4, PT, and INR.

a. What is the rationale for the labs ordered, based on the symptoms that the patient is exhibiting?

b. The physician follows up with the patient with the diagnosis of hypothyroidism. What are reasons why the patient developed hypothyroidism?

c. Based on the results of the TSH and FT4, the physician starts the patient on levothyroxine (Synthroid) 0.025 mg/day and to have follow-up TSH and FT4 labs and visit to the oncologist in 4 weeks. The physician informs the patient that he will continue to have lab tests and monthly follow-up until the TSH and FT4 are stable. What is the rationale for this treatment plan?

d. What nursing interventions should the nurse provide the patient?
2. Mrs. Ramirez was admitted to the hospital for wrist surgery secondary to rheumatoid arthritis. Postoperatively, she is stabilized and transferred to the general surgery unit. Mrs. Ramirez’s medications include digoxin, Lasix, captopril, Synthyroid, aspirin, Protonix, and prednisone. When administering morning medications, Mrs. Ramirez refuses her aspirin and prednisone, and the nurse holds the medications. Over the next 3 days, Mrs. Ramirez continues to refuse the prednisone, and the medication is not administered. On the third postoperative day, Mrs. Ramirez becomes hypotensive, tachycardic, and has a decrease in level of consciousness. STAT labs are sent for a complete blood cell count and chemistry panel, and the physician is notified of the change in patient status. On review of the patient’s record, the physician notes that Mrs. Ramirez has not received her prednisone for 4 days. Mrs. Ramirez has been on Prednisone for the past 5 years for her rheumatoid arthritis, and the physician begins to treat the patient for acute adrenal insufficiency.

a. What other clinical manifestations should the nurse monitor for with suspected adrenal insufficiency?

b. The physician orders a STAT dose of IV hydrocortisone. What is the rationale for this medication in this situation?

Case Study, Chapter 55, Management of Patients with Urinary Disorders
1. Sue Meade, 22 years of age, presents to the clinic with complaints of burning, pain, and urgency when urinating. The patient has a fever of 100°F. The urine is strong in odor and cloudy with sediments.

a. What questions should the nurse ask during the assessment to gain more information about the possible causes of the urinary tract infection?

b. What patient education should be provided?
2. John Lyons has undergone treatment for renal stones three times in the last year. Today he calls this primary health care provider with complaints of acute, excruciating, colicky, pain that radiates down the thigh toward the genitalia. The pain started last night, and has become progressively more severe. He also complains of the urge to void but has little urine output, and it is blood tinged. Due to the pain, he has not taken any fluids or food in 24 hours. Mr. Lyons undergoes lithotripsy, and analysis of stone fragments to reveal calcium stones.
a. Mr. Lyons’ symptoms are most indicative of stones in what area of the renal system?
Mr. Lyons has the following orders:

• Morphine sulfate 2 mg IVP every 2 hours as needed for severe pain
• Ibuprofen 600 mg every 6 hours
• Normal saline at 200 mL/hr
b. What are the rationales for the above orders?

c. Based on the calcium composition of the stone, what dietary teaching should the nurse include in Mr. Lyons’ plan of care?