Female AGE 71 SETTING ■ Hospital ETHNICITY ■ Russian CULTURAL CONSIDERATIONS PREEXISTING CONDITIONS ■ Heart failure (HF, CHF); pneumonia; chronic obstructive pulmonary disease (COPD); gastroesophageal reflux disease (GERD) COEXISTING CONDITION COMMUNICATION ■ Russian speaking only; daughter speaks English
■ Lives with daughter’s family SPIRITUAL/RELIGIOUS PHARMACOLOGIC
■ Digoxin (Lanoxin); potassium chloride (KCl); atropine sulfate (Atropine); digoxin immune fab (Digibind) LEGAL ETHICAL ALTERNATIVE THERAPY
■ Licorice (glycyrrhiza, licorice root)
Mrs. Kidway is a 71-year-old woman who lives at home with her daughter’s family. Her daily medications prior to admission include digoxin 0.125 mg once a day. Case Study Mrs. Kidway arrives in the emergency room with her daughter who explains, “She was fine this morning but then this afternoon she developed terrible abdominal pain and got short of breath.” Mrs. Kidway is lethargic. Her physical examination is unremarkable except for facial grimacing when palpating her abdomen. She is afebrile with a blood pressure of 105/50, pulse 60, and respiratory rate 18. Blood work on admission reveals a digoxin level of 3.8 ng/mL.
1. How does digoxin work in the body?
2. Why is Mrs. Kidway taking digoxin?
3. Given Mrs. Kidway’s digoxin level, briefly explain what electrolyte imbalance is of concern. 4. During a nursing assessment of Mrs. Kidway’s current medications, the nurse asks if Mrs. Kidway takes any over-the-counter medications or herbal remedies. Mrs. Kidway’s daughter says, “Is licorice considered an herbal remedy? My mother started taking licorice capsules about a month ago because we heard that licorice helps decrease heartburn.” Does licorice interact with digoxin? If so, explain.
5. Discuss what the terms loading dose and steady state indicate.
6. What are the onset, peak, and duration times of digoxin when it is taken orally?
7. If Mrs. Kidway was having difficulty swallowing her digoxin capsule and her health care provider changed her prescription to the elixir form of digoxin, theoretically would she still receive 0.125 mg?
8. What is a medication’s “half-life”? What is the half-life of digoxin? Theoretically, if Mrs. Kidway took her digoxin at 8:00 a.m. on a Monday, when will 75% of the digoxin be cleared from her body according to the half-life? Since the half-life of digoxin is prolonged in the elderly, use the high end of the range of digoxin’s half-life.
9. What is the normal therapeutic range of serum digoxin for a client taking this medication?
10. What symptoms may be noted when digoxin levels are at toxic levels?
11. At what serum digoxin range do cardiac dysrhythmias appear and what is the critical value for adults?
12. Mrs. Kidway’s heart rate drops to 50 beats per minute. Her potassium is 2.1 mEq/L. She is given four vials of intravenous digoxin immune fab (reconstituted with sterile water) and admitted to the intensive care unit for monitoring. Discuss how her digoxin toxicity will be treated.
13. What are the two highest priority nursing diagnoses appropriate for Mrs. Kidway’s plan of care?
GENDER Female AGE 92
SETTING ■ Hospital
ETHNICITY ■ White American
CULTURAL CONSIDERATIONS PREEXISTING CONDITION COEXISTING CONDITION ■ Urinary tract infection (UTI) COMMUNICATION ■ Impaired communication secondary to altered mental status
Mrs. Greene is a 92-year-old woman who presents to the emergency room with an acute change in mental status and generalized weakness. Her past medical history is unremarkable. She has not had episodes of confusion in the past. Case Study It is determined that Mrs. Greene has a urinary tract infection (UTI) for which she is started on intravenous (IV) levofloxacin (Levaquin). Mrs. Greene’s confusion escalates to visual hallucinations, the pulling out of two IV sites, and restless nights of little sleep. Bilateral soft wrist restraints are prescribed to maintain her safety, the integrity of the IV site, and the Foley catheter. While the nurse is providing care for Mrs. Greene, Mrs. Greene’s son visits. He is very distraught over Mrs. Greene’s state of confusion and her inability to recognize him. Mrs. Greene is unable to answer her son’s questions appropriately and frequently states, “I told you I do not want to cook today.” Visibly upset and tearful, Mr. Greene states, “I don’t understand. She was perfectly normal three days ago. I stopped by to visit and she was outside working in her garden and her conversation with me made perfect sense.”
1. What do you suspect is the reason for Mrs. Greene’s confusion?
2. Would you describe Mrs. Greene’s confusion as delirium or dementia? Provide a rationale for your decision and explain the difference between delirium and dementia.
3. What are three appropriate nursing diagnoses that address Mrs. Greene’s change in mental status?
4. State at least three outcome goals that should be included in the plan of care for Mrs. Greene’s diagnosis of acute confusion.
5. Provide five nursing interventions to include in the plan of care for Mrs. Greene’s diagnosis of acute confusion.
6. Briefly discuss strategies that help prevent the need for restraints. List five nursing interventions to include in Mrs. Greene’s plan of care now that she needs bilateral soft wrist restraints for her safety
GENDER Female AGE 67
SETTING ■ Hospital ETHNICITY ■ Black American
CULTURAL CONSIDERATIONS ■ Risk of hypertension and heart disease PREEXISTING CONDITION ■ Hypertension (HTN)
Client Profile
Mrs. Darsana was sitting at a family cookout at approximately 2:00 p.m. when she experienced what she later describes to the nurse as “nausea with some heartburn.” Assuming the discomfort was because of something she ate, she dismissed the discomfort and took Tums. After about two hours, she explains, “My heartburn was not much better and it was now more of a dull pain that seemed to spread to my shoulders. I also noticed that I was a little short of breath.” Mrs. Darsana told her son what she was feeling. Concerned, her son called emergency medical services.
En route to the hospital, emergency medical personnel established an intravenous access. Mrs. Darsana was given four children’s chewable aspirins and three sublingual nitroglycerin tablets without relief of her chest pain. She was placed on oxygen 2 liters via nasal cannula. Upon arrival in the emergency department, Mrs. Darsana is very restless. She states, “It feels like an elephant is sitting on my chest.”
Her vital signs are blood pressure 160/84, pulse 118, respiratory rate 28, and temperature 99.38F (37.48C). Her oxygen saturation is 98% on 2 liters of oxygen. A 12-lead electrocardiogram (ECG, EKG) shows sinus tachycardia with a heart rate of 120 beats per minute. An occasional premature ventricular contraction (PVC), T wave inversion, and ST segment elevation are noted. A chest X-ray is within normal limits with no signs of pulmonary edema. Mrs. Darsana’s laboratory results include potassium (K1) 4.0 mEq/L, magnesium (Mg) 1.9 mg/dL, total creatine kinase (CK) 157 μ/L, CK-MB 7.6 ng/mL, relative index 4.8%, and troponin I 2.8 ng/mL. Her stool tests negative for occult blood.
1. What are the components of the initial nursing assessment of Mrs. Darsana when she arrives in the emergency department?
2. Mrs. Darsana has a history of unstable angina. Explain what this is.
3. Briefly discuss what causes an MI. Include in the discussion the other terms used for this diagnosis.
4. The nurse listens to Mrs. Darsana’s heart sounds to see if S3, S4, or a murmur can be heard. What would the nurse suspect if these heart sounds were heard?
5. What factors are considered when diagnosing an acute myocardial infarction (AMI)?
6. Besides her unstable angina, what factors increased Mrs. Darsana’s risk for an MI?
7. Identify which of Mrs. Darsana’s presenting symptoms are consistent with the profile of a client who is having an MI.
8. The nurse overhears Mrs. Darsana’s son asking his mother sternly, “Mom. Why didn’t you tell me that you were having chest pain sooner? You should have never ignored this. You could have died right there at my house.” How might the nurse explain Mrs. Darsana’s actions to the son?
9. Provide a rationale for why Mrs. Darsana was given sublingual nitroglycerin and aspirin en route to the hospital.
10. Briefly discuss the laboratory tests that are significant in the determination of an acute myocardial infarction (AMI).
11. Laboratory results follow: April 1 at 1645: Total CK 5 216 units/L CK-MB 5 5.6 ng/mL relative index 5 2.2% Troponin I 5 2.8 ng/mL April 2 at 0045: Total CK 5 242 units/L CK-MB 5 8.1 ng/mL relative index 5 3.3% Troponin I 5 5.2 ng/mL CASE STUDY 6 ■ MRS. DARSANA 15 April 2 at 0615: Total CK 5 298 units/L CK-MB 5 9.2 ng/mL relative index 5 3.0% Troponin I 5 4.1 ng/mL April 3 at 0615: Total CK 5 203 units/L CK-MB 5 6.1 ng/mL relative index 5 3.0% Troponin I 5 1.7 ng/mL Are Mrs. Darsana’s laboratory results consistent with those expected for a client having an acute myocardial infarction?
12. Describe four pharmacologic interventions you anticipate will be initiated/considered during an acute MI.
13. Identify five criteria that could exclude an individual as a candidate for thrombolytic therapy with a tissue plasminogen activator (tPA).
14. An echocardiogram reveals that Mrs. Darsana has an ejection fraction of 50%. How could the nurse explain the meaning of this result to Mrs. Darsana?
15. Identify three appropriate nursing diagnoses for the client experiencing an AMI.
16. Rank the following five nursing diagnoses for Mrs. Darsana in priority order.
• Decreased Cardiac Output related to (r/t) ineffective cardiac tissue perfusion secondary to ventricular damage, ischemia, dysrhythmia.
• Deficient Knowledge (condition, treatment, prognosis) r/t lack of exposure, unfamiliarity with information resources.
• Risk for Injury r/t adverse effect of pharmacologic therapy.
• Acute Pain r/t myocardial tissue damage from inadequate blood supply.
• Fear r/t threat to well-being.

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