Submitted by:

Jimson R. de Jesus
2nd Semester AY 2011-2012

Submitted to:

Ida S. Tionko
Assoc. Professor

UNIVERSITY OF SANTO TOMAS USTGS MedSurg II Ida S. Tionko AY: 2nd Semester 2011-2012 Jimson R. de Jesus, RN

GRADUATE SCHOOL ADVANCED MS II 2012 CASE SCENARIO PREREQUISITE: Review the ff concepts: **For each of the concepts, take note of the ff: Assessment Anatomy & Physiology Pathophysiology Management: Medical, Nursing & Collaborative

1. Respiration a. COPD b. Pneumonia c. Respiratory Failure i. Mechanical Ventilation ii. Oxygen therapy 2. Cardiovascular Function a. CAD b. Angina c. ACS AMI - Complications d. Cardiac Surgery: CABG e. Cardiac Rehabilitation 3. Neurologic Function a. Increase ICP b. Stroke - Acute Brain Attack 4. Diabetes Mellitus 5. Musculo-skeletal function: a. Fracture- Fracture management b. RehabilitationComplications of Immobility c. Goals and interventions 6. End-of-life Care USTGS MedSurg II Ida S. Tionko AY: 2nd Semester 2011-2012 Jimson R. de Jesus, RN

PART 1 SCENARIO
J.T is a 62-year-old male from Mindanao admitted to your ward because of increasing weakness over the last couple of weeks and has been unable to go to work as a clerk in a government office. Apparently, he has been complaining of on and off chest heaviness over the last few days and swelling in her ankles and feet by late afternoon and has nocturnal diuresis x 4. Because he speaks very little Tagalog and English, his wife, who is a teacher, helps you obtain his health history: Type 2 DM, significant abdominal obesity, hypertension, CHF, chronic hypoxia, COPD, frequent pneumonia, hyperlipidemia, and polycythemia. He has been smoking a pack a day for the past 30 years inspite of his COPD. He weighs 200 lbs. Over the last week he has had intermittent chest pain with SOB on exertion. The SOB has increased during the last 12 hours. He has been hospitalized two years ago for chest pain diagnosed as Angina Pectoris. On admission today he has orthopnea, a severe productive cough, palpitations and SOB. His VS are 166/104, 94, 22, 36.7C. You hear muffled S1 and S2 heart sounds and a possible S3. He has moderate pretibial edema to his knees and a few bibasilar crackles. You place him on O 2 at 2L/min by nasal cannula and insert a Foley catheter as ordered by his MD. His blood glucose level is 347mg/dl and Hct is 50%. Cholesterol and triglyceride levels are 320mg/dl and 268mg/dl, respectively. Na 134 mmol/L, K 3.5mmol/L, Cl 103mmol/L.

1. List down the critical findings in the data presented. Why do you consider them critical data? Chest heaviness Swelling of ankles and feet Type 2 DM Abdominal obesity Hypertension CHF Chronic hypoxia COPD Frequent pneumonia Polycythemia Intermittent chest pain SOB Orthopnea Palpitations BP: 166/104, RR: 22 Muffled S1 and S2 heart sounds, possible S3

USTGS MedSurg II

Ida S. Tionko AY: 2nd Semester 2011-2012

Jimson R. de Jesus, RN

Pretibial edema of knees Few basilar crackles

These are critical data because most are manifestations of respiratory and cardiac compromise. These systems are necessary for delivery of oxygen to the body for its optimal functioning.

Smoking or use of tobacco, hypertension, hyperlipidemia and diabetes mellitus, obesity, elevated serum TG and cholesterol are factors that increases the probability of developing heart disease.

(CV) Chest pain, shortness of breath, palpitations, S3 heart sounds and elevated blood pressure because of sympathetic stimulation, (Resp) tachypnea , SOB are the climical manifestations of Myocardial Infarction

2. From these critical findings, group your data and identify the initial nursing problems that are evident. What further data do you need regarding each problem? What further tests do you expect to be done on J.T.?

Cardiovascular: Chest heaviness, swelling of ankles and feet, abdominal obesity, hypertension, CHF, polycythemia, intermittent chest pain, palpitations, BP: 166/104, muffled S1 and S2 heart sounds, possible S3, pretibial edema of knees, DM Nursing Problems: Ineffective cardiopulmonary tissue perfusion related to reduced coronary blood flow, potential ineffective air exchange related to fluid overload, potential ineffective tissue perfusion related to decreased cardiac output Further Data: Further Tests: serum electrolyte levels, BUN level, serum glucose level, chest x-ray, ECG, CBC

Respiratory: Chronic hypoxia, COPD, frequent pneumonia, SOB, orthopnea, RR: 22, few basilar crackles Nursing Problems: Impaired gas exchange related to ventilation-perfusion inequality, ineffective breathing pattern related to shortness of breath, activity intolerance related to chronic hypoxia and ineffective breathing patterns Further Data: Further Tests: spirometry, arterial blood gas measurement, chest x-ray

USTGS MedSurg II

Ida S. Tionko AY: 2nd Semester 2011-2012

Jimson R. de Jesus, RN

3. In what order should the problems be addressed and why? What initial actions would you take for the first three priority problems? Ineffective breathing pattern related to shortness of breath Impaired gas exchange related to ventilation-perfusion inequality Ineffective cardiopulmonary tissue perfusion related to reduced coronary blood flow Activity intolerance related to chronic hypoxia and ineffective breathing patterns Potential ineffective air exchange related to fluid overload Potential ineffective tissue perfusion related to decreased cardiac output

Initial Actions: Ineffective breathing pattern related to shortness of breath Teach patient diaphragmatic and pursed-lip breathing. Encourage alternating activity with rest periods.

Impaired gas exchange related to ventilation-perfusion inequality Administer bronchodilators as prescribed. Instruct and encourage patient in diaphragmatic breathing. Administer oxygen by the method prescribed.

Ineffective cardiopulmonary tissue perfusion related to reduced coronary blood flow Administer medication therapy as prescribed. Ensure physical rest.

4. Judging from the admission information, what risk factors can be noted or those that might exist in J.T that predisposes him to his medical problems? Smoking contributes to the development of CAD i.i. the inhalation of smoke increases the blood carbon monoxide level, causing hemoglobin, the oxygencarrying component of blood, to combine more readily with carbon monoxide than with oxygen. A decreased amount of available oxygen may decrease the hearts ability to pump i.ii the nicotinic acid in tobacco triggers the release of catecholamines, which raise the heart rate and blood pressure. Nicotinic acid can also cause the coronary arteries to constrict i.iii causes a detrimental vascular response and increases platelet adhesion, leading to a higher probability of thrombus formation

i.

USTGS MedSurg II

Ida S. Tionko AY: 2nd Semester 2011-2012

Jimson R. de Jesus, RN

ii.

diabetes mellitus Hyperglycemia fosters dyslipidemia, increased platelet aggregation, and altered red blood cell function, which can lead to thrombus formation.

iii.

hypertension

1. Long-standing elevated bloodpressure increased stiffness of the vessel walls vessel injury inammatory response within the intima 2. Increase BP increase left ventricular workload (pump harder to eject blood into the arteries) hypertrophy (heart enlarge/thicken) cardiac failure .
iv. hyperlipidemia

5. J.T wants to smoke a cigarette. He has had none since admission and he is angry because the nurses would not let him smoke. He says I will die soon without my cigarette. What is your major concern about J.Ts smoking? How will you deal with this?

Answer: Smoking is the most important risk factor for COPD because it depresses the activity of scavenger cells and affects the respiratory tracts ciliary cleansing mechanism, which keeps breathing passages free of inhaled irritants, bacteria, and other foreign matter. Advise the patient to refrain from smoking because smoking cessation is the single most effective intervention to slow the progression of COPD. The nurse may ask how could the patient says that hell die without cigarette and inculcate that smoking is strictly prohibited in the hospital especially with oxygen

6. What kind of CHF does J.T. have? Cite your evidence. What could be the pathophysiologic basis of this medical problem?

Answer: The patient has Right-sided heart failure resulting from COPD and left-sided heart failure resulting from HPN, DM. Manifestations of both are present in J.Ts assessment. Dyspnea, cough, pulmonary crackles, extra heart sounds (S3), orthopnea or difficulty in breathing when lying at are the manifestations of left-sided heart failure which are present to JT. The cough associated with left ventricular failure is initially dry and nonproductive.

USTGS MedSurg II

Ida S. Tionko AY: 2nd Semester 2011-2012

Jimson R. de Jesus, RN

Most often, patients complain of a dry hacking cough that may be mislabeled as asthma or chronic obstructive pulmonary disease (COPD). The cough may become moist. Large quantities of frothy sputum, which is sometimes pink (blood tinged), may be produced, usually indicating severe pulmonary congestion (pulmonary edema)

Adventitious breath sounds may be heard in various lobes of the lungs. Usually, bi-basilar crackles that do not clear with coughing are detected in the early phase of left ventricular failure. As the failure worsens and pulmonary congestion increases, crackles may be auscultated throughout all lung elds. At this point, a decrease in oxygen saturation may occur.

The patient also has NOCTURNAL diuresis. Blood flow to the kidneys decreases resulting to decrease perfusion and oliguria. This, in turns, results in the release of renin from the iney leading to the secretion of aldosterone, hence fluid and sodium retention occur which further increases intravascular volume. However, when the patient is sleeping, cardiac workload decreases, improving renal perfusion.

PALPITATIONS. The decrease in the ejected ventricular volume causes the sympathetic nervous system to increase the heart rate (tachycardia), often causing the patient to complain of palpitations. The pulses become weak and thready. Without adequate CO, the body cannot respond to increased energy demands, and the patient is easily fatigued and has decreased activity tolerance. Fatigue also results from the increased energy expended in breathing and the insomnia that results from respiratory distress, coughing, and nocturia.

The patient also has Right-sided heart failure as manifested by swelling of ankles and feet and pretibial edema of knees due to congestion of peripheral tissues .

Pathophysiology: The right side of the heart cannot eject blood and cannot accommodate all the blood that normally returns to it from the venous circulation which, in turns, increases capillary pressure forcing excess fluid from the capillaries into the interstitial space. This causes tissue edema, typically in the lower extremities

USTGS MedSurg II

Ida S. Tionko AY: 2nd Semester 2011-2012

Jimson R. de Jesus, RN

(L) increase workload and end-diastolic volume enlarge left ventricle diminished left ventricular function pooling of blood in the ventricle and atrium blood eventually back up into the pulmonary veins and capillaries engorged pulmonary circulation increase capillary pressure Na & H2O come out into the interstitial space pulmonary edema > pulmonary vascular resistance & left ventricular pressure (R) stressed right ventricle formation of stretched tissue pooling of blood in the right side of the heart pressure and congestion in the venacava and systemic circulation

7. What is a possible explanation of his chronic hypoxia? What further tests do you need to check on this problem? What considerations would you take regarding oxygen administration on J.T? Explain the hypoxic drive in COPD.

Answer; The chronic hypoxia is probably related to COPD. The confirming diagnostic measures are: i. Physical examination reveals hyperresonance on percussion, decreased breath sounds, expiratory prolongation ii. Chest X-ray in advanced disease the diaphragm is flattened, reduced vascular markings at lung periphery, hyperinflation of the lungs, enlarged antero-posterior chest diameter iii. iv. Pulmonary function test increased residual volume, total lung capacity, and compliance; ABG analysis to obtain baseline oxygenation and gas exchange; reduced partial pressure of arterial oxygen (PaO2), with normal partial pressure of arterial CO2 (PaCO2)

8. Do you see the pathophysiologic relationship among the chronic disease conditions of J.T? Illustrate your answer and discussion with a diagram or flowchart.

Answer: Refer to diagram

9. Given the admission information, which of the ff orders can you anticipate as appropriate for J.T? Carefully review the order to determine whether it is appropriate or not as written.

USTGS MedSurg II

Ida S. Tionko AY: 2nd Semester 2011-2012

Jimson R. de Jesus, RN

____ Routine VS ____ Serum magnesium stat ____ Up ad lib ____ Start IV of NS at 100ml/h ____ Cardiac enzymes on admission and q 8h x 24h then every AM. ____ Schedule for abdominal CT scan in AM ____ Heparin 10,000U SQ q8h (Use of heparin in treating patients with unstable angina reduces the occurrence of MI) ____ Docussate sodium 100mg PO daily ____ Furosemide 200mg IVP stat ____ Nitroglycerine 0.4mg. 1 SL q 4h PRN for chest pain (is administered to reduce myocardial oxygen consumption, which decreases ischemia and relieves pain. It ncreases coronary blood ow by preventing vasospasm and increasing perfusion through the collateral vessels. 10. Angina is not always experienced as pain (as many people understand pain). How would you describe symptoms he wants you to warn you about? Why is this important? Angina is a substernal or retrosternal pain spreading across the chest which may radiate to inside of arm, neck or jaw. It is usually related to exertion, emotion, eating or cold. The patient often feels tightness or a heavy, choking, or strangling sensation that has a viselike, insistent quality. It is important to identify and report angina because this can be a manifestation of myocardial infarction.

11. What assessment parameters would you use to differentiate Angina from Acute Coronary Syndrome (ACS)? ACS is the term used for unstable angina and acute MI. This is different from stable angina because symptoms occur more frequently and lasts longer.

12. Although he has been taking SL NTG for a long time, you want to be sure he is using it correctly. What information would you make sure he understands about the side effects, use and storage of SL NTG? Make sure the mouth is moist, the tongue is still, and saliva is not swallowed until the nitroglycerin tablet dissolves. Because nitroglycerin is very unstable, it should be secured in its original container (capped dark glass bottle). Possible side effects of NTG are flushing, throbbing headache, hypotension, and tachycardia.

USTGS MedSurg II

Ida S. Tionko AY: 2nd Semester 2011-2012

Jimson R. de Jesus, RN

13. When you come into J.Ts room at 10:00PM to answer his call light, you see he is holding his left arm and complaining of aching in his left shoulder and arm. What information are you going to gather? This is a possible manifestation of myocardial infarction. Assess the onset and duration of the pain and if it continues despite rest and medication. Assess for other manifestations of MI including ECG result.

14. Differentiate between pain of cardiac origin and that of non-cardiac origin? And also the clinical symptoms experienced by women versus those experienced by men.

Answer: Pain of non-cardiac origin is atypical that radiates to both arms rather than just the left arm Women with coronary artery disease commonly experience atypical chest pain, vague chest pain, or lack of chest pain. However, they may also experience classic chest pain which may occur without any relationship to activity or stress. Although men tend to complain of crushing pain in the center of the chest, women are more likely to experience arm or shoulder pain; jaw, neck, or throat pain; toothache; backpain; or pain under the breastbone or in the stomach. Other signs and symptoms women may experience include nausea or dizziness; SOB; unexplained anxiety, weakness, or fatigue; and palpitations, cold sweat, or paleness

15. Based on your assessment findings, you decide to call the attending physician. What information are you going to report to him and why? The onset, duration, and characteristics of pain shall be reported to the physician.

16. The resident on duty arrives and evaluates the patient immediately. He orders Furosemide 40mg IVP stat. You only have 20mg in stock in the ward. Should you give the 20 mg. Now, then give the additional 20 mg. when it comes up from the pharmacy? Explain your answer. 20 mg of furosemide would be enough to meet its diuretic effect however dosage of administration is depending upon on doctors order. We have to follow what is being ordered. Observed the ten rights of medication administration

17. A stat 12-lead EKG reveals ACS NSTEMI. The MD orders that J.T be transferred to the ICU. STEMI (ST Elevation MI) is when there is a transmural infarction of the myocardium which means that the entire thickness of the myocardium has undergone necrosis, resulting in ST elevation usually due to a complete block of a coronary artery (occlusive thrombus).

USTGS MedSurg II

Ida S. Tionko AY: 2nd Semester 2011-2012

Jimson R. de Jesus, RN

This requires the use of thrombolytics like Streptokinase to lyse the thrombus. NSTEMI (Non-ST Elevation MI) is when there is partial dynamic block to coronary arteries (nonocclusive thrombus). There will be no ST elevation or Q waves on ECG, as transmural infarction is not seen.

18. What other significant diagnostic studies do you expect to be ordered to J.T? What findings will support the diagnosis of AMI? ECG T-wave inversion, ST-segment elevation, and development of abnormal Q wave. Echocardiogram hypokinetic and akinetic wall motion Laboratory tests rise in CK-MB, myoglobin, and troponin

19. The MD prescribes10mg Morphine sulphate IV push stat. Explain two reasons for this order. Morphine reduces pain and anxiety. It reduces preload, which decreases the workload of the heart. Morphine also relaxes bronchioles to enhance oxygenation. However, patient must be monitored for cardiovascular response such as lowered BP and depressed respiratory rate

20. Would you expect tPA to be given at this time? Why? What assessments are required before this drug can be given? Why? Tissue plasminogen activator (tPA) is expected to be given at this time because it is a thrombolytic that can dissolve and lyse the thrombus in coronary artery, allowing blood to flow through the coronary artery. It activates plasminogen on the clot more than the circulating plasminogen. Allergy to alteplase must be assessed because it is a naturally occurring enzyme.

21. J.T continues to feel symptomatic. What symptoms do you need to watch out for? What possible complications may develop as a result of the cardiac problem and why? What could be the most dreaded? The nurse monitors the patient closely for changes in cardiac rate and rhythm, heart sounds, blood pressure, chest pain, respiratory status, urinary output, skin color and temperature, sensorium, ECG changes, and laboratory values. Any changes in the patients condition are reported promptly to the physician, and emergency measures are instituted when necessary. Some complications are arrhythmia and cardiac tamponade. Among the complications, arrhythmia is considered as the most dreaded. The nurse should be alert on ECG changes (PVC to Vtach to Vfib to Vasystole) 22. What further physicians orders (tests, drugs or procedures) should you anticipate? Give the rationale for such orders.

USTGS MedSurg II

Ida S. Tionko AY: 2nd Semester 2011-2012

Jimson R. de Jesus, RN

Electrocardiogram provides information that assists in diagnosing acute MI. Echocardiogram used to evaluate ventricular function Laboratory tests i. creatine kinase - CK-MB is found mainly in cardiac cells and therefore rises only when there has been damage to these cells. ii. Myoglobin - Myoglobin is a heme protein that helps to transport oxygen. Like CK-MB enzyme, myoglobin is found in cardiac and skeletal muscle iii. Troponin- a protein found in the myocardium, regulates the myocardial contractile process. Thrombolytics to dissolve and lyse the thrombus in a coronary artery, allowing blood to flow through the coronary artery again, minimizing the size of the infarction, and preserving ventricular function. To be effective, thrombolytics must be administered as early as possible after the onset of symptoms that indicate an acute MI Administer these medications within 30 minutes from the time the patient arrives in the emergency department. This is called door-to-needle time (Ryan et al., 1999) Analgesics morphine reduces pain and anxiety ACE Inhibitors in the absence of angiotensin II, the blood pressure decreases and the kidneys excrete sodium and fluid, decreasing the oxygen supply of the heart. Emergent percutaneous coronary intervention (PCI) may be used to open the occluded coronary artery in an acute MI and promote reperfusion to the area that has been deprived of oxygen.

23. Cardiac catheterization reveals 80% blockage of the LAD artery. The MD orders CABG in the morning. Outline your pre-op and post-op care of J.T. including the goals of care.

Pre-op Nursing responsibilities before cardiac catheterization include the following: Instruct the patient to fast, usually for 8 to 12 hours, before the procedure. If catheterization is to be performed as an outpatient procedure, explain that a friend, family member, or other responsible person must transport the patient home. Prepare the patient for the expected duration of the procedure; indicate that it will involve lying on a hard table for less than 2 hours. Reassure the patient that mild sedatives or moderate sedation will be given intravenously.

USTGS MedSurg II

Ida S. Tionko AY: 2nd Semester 2011-2012

Jimson R. de Jesus, RN

Prepare the patient to experience certain sensations during the catheterization. Knowing what to expect can help the patient cope with the experience. Explain that an occasional pounding sensation (palpitation) may be felt in the chest because of extrasystoles that almost always occur, particularly when the catheter tip touches the myocardium. The patient may be asked to cough and to breathe deeply, especially after the injection of contrast agent. Coughing may help to disrupt a dysrhythmia and to clear the contrast agent from the arteries. Breathing deeply and holding the breath helps to lower the diaphragm for better visualization of heart structures. The injection of a contrast agent into either side of the heart may produce a ushed feeling throughout the body and a sensation similar to the need to void, which subsides in 1 minute or less.

Encourage the patient to express fears and anxieties. Provide teaching and reassurance to reduce apprehension.

Post-op

Observe the catheter access site for bleeding or hematoma formation, and assess the peripheral pulses in the affected extremity (dorsalis pedis and posterior tibial pulses in the lower extremity, radial pulse in the upper extremity) every 15 minutes for 1 hour, and then every 1 to 2 hours until the pulses are stable.

Evaluate temperature and color of the affected extremity and any patient complaints of pain, numbness, or tingling sensations to determine signs of arterial insufciency. Report changes promptly.

Monitor for dysrhythmias by observing the cardiac monitor or by assessing the apical and peripheral pulses for changes in rate and rhythm. A vasovagal reaction, consisting of bradycardia, hypotension, and nausea, can be precipitated by a distended bladder or by discomfort during removal of the arterial catheter, especially if a femoral site has been used. Prompt intervention is critical; this includes raising the feet and legs above the head, administering intravenous fluids, and administering intravenous atropine.

Instruct the patient to report chest pain and bleeding or sudden discomfort from the catheter insertion sites immediately.
Encourage uids to increase urinary output and ush out the dye.

USTGS MedSurg II

Ida S. Tionko AY: 2nd Semester 2011-2012

Jimson R. de Jesus, RN

Ensure safety by instructing the patient to ask for help when getting out of bed the rst time after the procedure, because orthostatic hypotension may occur and the patient may feel dizzy and lightheaded.

Focus on achieving or maintaining hemodynamic stability and recovery from general anesthesia. Provide wound care, progressive activity, and nutrition. . Major Goals of Care Restoring cardiac output Promote adequate gas exchange Maintain fluid and electrolyte balance Minimize sensory-perception imbalance Relieve pain Maintain adequate tissue perfusion Maintain normal body temperature

Assess for complications:

USTGS MedSurg II

Ida S. Tionko AY: 2nd Semester 2011-2012

Jimson R. de Jesus, RN

24. Would you expect Insulin to be given to the J.T. prior to surgery? Yes. Because he has a high sugar level.

25. The wife of J.T. approaches you and says, I am so afraid to lose him. I dont think I can manage without him in my life. How will you address his wifes concern? Therapeutic techniques of communication shall be used to address the wifes concern. Restatement or paraphrasing will help the client express her feelings or concerns in more depth.

PART 2 (FEB 21) J.Ts recovery from the heart surgery seem uneventful. On the seventh day after admission, J.T. developed chills and fever with a temperature of 38.5C and an SaO 2 of 88% on 3L O2/nc. The physician says he is developing an infection. 26. What are the two most likely sources of infection that might be responsible for J.Ts fever? Why? Depressed immune system due to stress of surgery and nosocomial infection are the two most likelt sources of infection.

The MD starts J.T. on azithromycin and cefuroxime for bacterial pneumonia. 27. Is the pneumonia CAP or HAP? Whats your basis? The patients pneumonia is HAP or hospital-acquired because it was not present or incubating at the time of hospital admission. HAP or nosocomial pneumonia is defined as the onset of pneumonia symptoms more than 48n hours after admission to the hospital.

28. When and how should his antibiotics be administered? What lab exams do you need to monitor for complications? As soon as the appropriate antibiotic is determined by the results of the Gram stain, treatment must be initiated. Complete course of the antibiotic must be completed. Gram stain to determine appropriate antibiotic prevents complication of superinfecttion. 29. What is the pathophysiologic relationship of J.Ts COPD and pneumonia? What factors appear to contribute to your patients pneumonia? What measures can you do to prevent the frequent occurrence of pneumonia in the patient?

USTGS MedSurg II

Ida S. Tionko AY: 2nd Semester 2011-2012

Jimson R. de Jesus, RN

COPD is a risk factor for the development of pneumonia. It is a condition that produces mucus or bronchial obstruction and interferes with normal lung drainage. Management of COPD which includes smoking cessation can prevent the occurrence of pneumonia in the patient.

30. Can a respiratory failure develop in J.T? How? What would be the assessment findings that indicate its onset? How can you prevent its occurrence? Respiratory failure may develop because it is a complication of pneumonia. Signs of deteriorating patient status such as decreased vital signs and pulse oximetry values indicate onset of respiratory failure. Proper and timely initiation and compliance to antibiotic regimen can prevent its occurrence.

31. What role can mechanical ventilation play in a patient with respiratory failure? Is there a difference in its use immediately after J.T had CABG? Intubation and mechanical ventilation may be required if respiratory failures occur. It maintains adequate ventilation and oxygenation while the underlying cause is corrected. Mechanical ventilation after immediately after CABG may elevate central venous pressure (CVP). 32. What factors prevailing can contribute to J.Ts decreased mobility? Are there other complications you need to watch out for as a result of decreased mobility of J.T.? What is the most dreaded among these complications? What actions will you take to prevent them? Surgery such as CABG can contribute to the patients decreased mobility. Hypercalcemia, thromboembolism, decreased skin integrity, and pneumonia are complications of decreased mobility. Thromboembolism is the most dreaded among these complications. Actions to prevent them are assisting patient with normal range of motion and encouraging progressive activities according to the level of fatigue.

33. Being a patient with Type 2 DM, what would be your nursing concerns as to the impact of this disease in the over-all medical condition of the J.T.? DM has substantial relationship with heart disease. Hyperglycemia fosters dyslipidemia, increased platelet aggregation, and altered red blood cell function which can lead to thrombus formation. Concerns should focus on prevention of thromboembolism because it can be a cause of myocardial infarction.

USTGS MedSurg II

Ida S. Tionko AY: 2nd Semester 2011-2012

Jimson R. de Jesus, RN

After 12 days of hospitalization, J.T states he is feeling a lot better. He is transferred to a private room in the ward. The therapist starts him on cardiac rehabilitation program. 34. Why is this program ordered by the physician after CABG? Cardiac rehabilitation program is ordered by physician after CABG because learning and lifestyle changes continue after discharge from the hospital. Emphasis is placed on monitored, progressive exercise, nutritional counselling, and stress management. At this time J.Ts family has been bringing him food and drinks from home despite explanations by the nurses that he is on 2000-calorie, low-salt, diabetic diet and on fluid restriction. 35. What action will you further take as the nurse of J.T? Inform the patients family of the nutrition plan that the patient has. The patient should follow the prescribed diet.

J.T. continues to improve and is now being prepared for discharge. You talk to him about health promotion and lifestyle change issues that are pertinent to his health problems.

36. Identify at least five health-related issues you might appropriately address with him and what you would teach in each area. Physical rest: use of bedside commode with assistance, backrest to promote comfort, arms supported during extremity activity, provision of restful environment Medication regimen: religiously follow the doctors prescription Nutrition: follow specific diet plan. Eat foods low in saturated fats and high in fibers. Lifestyle modification: stop smoking and avoid second hand-smoke Program of activities: progressive exercise, alternate activity with periods of rest

37. What medications do you expect him to continue at home? What pertinent instructions do you need to give him about them? Pain medications, antihypertensives. Instruct client to take medications as prescribed.

38. How do you plan to provide continuity of care to J.T after his discharge from the hospital? Arrangement for follow-up check-up must be done. The education plan must also be continued. The patient must be encouraged to maintain telephone contact with the surgeon, cardiologist, and nurses. Refer patients to supportive and rehabilitation programs.

USTGS MedSurg II

Ida S. Tionko AY: 2nd Semester 2011-2012

Jimson R. de Jesus, RN

J.T is discharged home and leaves the hospital in a fairly improved and stable condition.

Five months later, J.T. gets admitted into the hospital three hours after he slipped in the bathroom, hit his head on the floor and fractured his right hip. According to his wife, he has been complaining of body weakness, headache and dizziness during the past five days. His VS show BP 204/110, PR 78, RR 22. He has a GCS of 12 and drowsy, with aphasia. 39. T.J. is diagnosed with Acute brain attack (new name of CVA) that led to his fall. What are the types of stroke and differentiate them? What do you suspect does the patient have and why?

The patient had ischemic stroke. Manifestations include aphasia, weakness, difficulty walking, dizziness, and loss of balance or coordination. 40. What is the FAST-G immediate assessment for a stroke? What constitutes your neuro check monitoring for the continuing assessment of J.T.? Assess and monitor the patients level of consciousness, intracranial pressure, Glasgow coma scale (GCS), neurologic deficits, and motor, sensory, and cranial nerve functions. F facial ( drooling, asymmetry) A arm drift S speech ( aphasia, proper use of words expressive/receptive) T time G glucose

41. J.T. is diabetic and hypoglycemia can mimic the signs of a stroke which is very important to check out during the early stage of a stroke. How will you go about differentiating these two problems? Hypoglycemia can cause focal neurological signs and can mimic stroke. A finger stick can be done to rapidly measure glucose level.

USTGS MedSurg II

Ida S. Tionko AY: 2nd Semester 2011-2012

Jimson R. de Jesus, RN

42. Would you expect the patient to have increase ICP? Why? What assessment findings will indicate an increase ICP? What measures will you take to help maintain a normal ICP in J.T.? Increased ICP can develop following stroke because of disturbed circulation of CSF. The earliest sign of increasing ICP is a change in level of consciousness. Slowing of speech and delay response to verbal suggestions are other early indicators. Other manifestations are restlessness, confusion, or increasing drowsiness. Interventions to maintain normal ICP include administering osmotic diuretic, elevation of the head to promote venous return, and continuous hemodynamic monitoring.

43. What goals of care and their interventions (both nursing and collaborative) do you expect to be implemented for J.Ts care during the acute stage? In the acute phase of the ischemic stroke, monitoring of all body systems is essential. Important measures of patients clinical status include change in LOC, presence or absence of voluntary or involuntary movements, stiffness or flaccidity of the neck, eye opening, color of the skin, quality of respirations and pulse, and ability to speak. Interventions include thrombolytic therapy, reduction of increased ICP, and management of potential complications.

44. Why is IV glucose infusion avoided in patients with a stroke? Hyperglycemia is a consequence of severe stroke and elevated blood sugar can be a marker of a serious vascular accident. Hyperglycemia can increase tissue necrosis secondary to anaerobic tissue acidosis and increased blood-brain barrier permeability. 45. J.Ts right leg is placed on Bucks extension traction. What is the purpose of this? What pertinent nursing care will you implement related to this. Bucks extension traction is skin traction to the lower leg. The pull is exerted in one plane when temporary immobilization is desired. It is used to provide immobility after fracture of the proximal femur before surgical fixation. Nursing care includes ensuring effective traction, skin care to prevent skin breakdown, and prevention of circulatory impairment.

46. With his condition and his leg immobilized, what vascular complication can possibly develop in J.Ts leg? How can you best prevent this from occurring? Circulatory impairment which can lead to thromboembolism is a potential vascular complication. This can be prevented by assessing circulation of the foot every 1 to 2 hours and encouraging patient to perform active foot exercises every hour.

USTGS MedSurg II

Ida S. Tionko AY: 2nd Semester 2011-2012

Jimson R. de Jesus, RN

47. J.Ts condition becomes unstable with unstable VS and neurologic condition. His children approach you crying and asks Will our father survive all these? An angry son states, The doctors dont seem to be doing their best to treat him. We dont want him to die. He has been a good father to us. If he should leave us, we are ready. What are the children manifesting? What stage is this in Kubler Ross theory? What is your response? The children are on the anger stage of Kubler Ross theory of grieving. It is expressed towards the health care providers. Emotional and psychological support is pertinent in this stage.

The MD orders a referral for rehabilitation for J.T. His recovery is uneventful with the good care given by the health care team. J.T. is discharged after 45 days in the hospital. CONGRATULATIONS TO THE HEALTH CARE TEAM!

USTGS MedSurg II

Ida S. Tionko AY: 2nd Semester 2011-2012

Jimson R. de Jesus, RN