Instant download Case Solutions for Winninghams Critical Thinking Cases in Nursing 6th Edition by Harding pdf docx epub after payment.
1. What error in teaching most likely occurred when M.G. was discharged 10 days ago?
CASE STUDY PROGRESS
During the admission interview, the nurse makes a list of the medications M.G. took at home.
Chart View
Nursing Assessment: Medications Taken at Home
| Enalapril (Vasotec) Pioglitazone (Actos) Furosemide (Lasix) Potassium chloride |
5 mg PO bid 45 mg PO every morning 40 mg/day PO 20 mEq/day PO |
2. Which of these medications may have contributed to M.G.’s HF? Explain.
Cardiovascular Disorders 1
PART ONE Medical-Surgical Cases
Answers: a, b, d
ACE inhibitors prevent the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor.
This results in systemic vasodilation, thereby reducing preload (reducing the volume of blood
entering the left ventricle) and afterload (reducing the resistance to the left ventricular contraction)
in patients with HF. ACE inhibitors do not promote the excretion of sodium and water, and they do
not cause increased cardiac contractility or block the sympathetic nervous system to the heart.
M.G. is fluid overloaded and needs to decrease fluid volume in a short period. Intravenous
administration is delivered directly into the vascular system, where it can start to work immediately.
In HF, blood flow to the entire gastrointestinal (GI) system is compromised; therefore the absorption
of orally ingested medications may be variable and take longer to work.
• Increased urine output
• Daily weight, looking for weight loss
• Intake and output (I&O)
• Decreased dependent edema
• Decreased shortness of breath, diminished crackles in the bases of the lungs, decreased work of
breathing, and decreased O2 demands
• Decreased jugular venous distention (JVD)
PART 1 MEDICAL-SURGICAL CASES
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1 Cardiovascular Disorders
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.
CASE STUDY PROGRESS
After reviewing M.G.’s medications, the physician writes the following medication orders.
Chart View
Medication Orders
| Enalapril (Vasotec) Carvedilol (Coreg) Glipizide (Glucotrol) Furosemide (Lasix) Potassium chloride (K-Dur) |
5 mg PO bid 3.125 mg PO twice daily 10 mg PO every morning 80 mg intravenous push (IVP) now, then 40 mg/day IVP 20 mEq/day PO |
4. What is the rationale for changing the route of the furosemide (Lasix)?
5. You administer furosemide (Lasix) 80 mg IVP. Identify three parameters you would use to
monitor the effectiveness of this medication.
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)
Answers: a, b, d, e
Furosemide is a potent diuretic, especially when given via IVP, and may cause the loss of
electrolytes such as magnesium, sodium, and potassium. These electrolytes will need to be
supplemented if the levels are low. In addition, furosemide may increase serum glucose levels, which
is an issue, considering that M.G. has diabetes. It is not necessary to monitor CBC or coagulation
studies while the patient is on furosemide.
Answer: d
Beta-blockers reduce or prevent stimulation of the heart from circulating catecholamines.
Answer: b
Blocking of beta2 receptors leads to a decrease in bronchial smooth muscle relaxation,
or bronchoconstriction. Nonspecific (nonselective) beta-blocking drugs may precipitate
bronchoconstriction and/or increased airway resistance. Therefore any preexisting respiratory
condition such as asthma might be worsened by the concurrent use of any of these medications.
Answer: c
Digoxin works by increasing cardiac contractility and thus increasing cardiac output.
PART 1 MEDICAL-SURGICAL CASES CASE STUDY 1
Copyright © 2016 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 3
1 Cardiovascular Disorders
d. Serum glucose level
e. Potassium level
f. Coagulation studies
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 from catecholamines.
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
CASE STUDY PROGRESS
One day later, M.G. has shown only slight improvement, and digoxin (Lanoxin) 125 mcg PO daily is added
to her orders.
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
It is critical to provide the primary care provider with accurate, timely assessment data after the
change from intravenous to oral diuretic therapy. One of the fluid management goals for patients
with HF is to maintain a target weight. This is done by monitoring daily morning weight, keeping an
accurate I&O, and recording subjective symptoms.
Answer: a
Low potassium levels can increase the potential for digoxin toxicity. M.G. is taking furosemide,
a loop diuretic that excretes potassium as well as sodium and water. Potassium levels should be
monitored carefully during digoxin therapy. The other findings are within normal limits.
125mcg = 0.125mg
If the student answers “.125 mg” the answer should be incorrect, because, per the Joint Commission
“Do Not Use” list, the leading zero should not be omitted.
The most essential aspect of teaching hospitalized patients is to focus on realistic key points.
Teaching should be aimed at successful communication of data to improve symptoms and prevent
readmission, without overwhelming the learner. The five most essential concepts for patients with
HF are included in MAWDS instructions.
Medications: Take as directed, do not skip a dose, and do not run out of medications.
Activity: Stay as active as you can while limiting your symptoms.
Weight: Weigh every morning. Call if you gain or lose 2 pounds overnight or are 5 pounds from your
target weight.
Diet: Follow a low-salt diet, and limit fluids to less than 2 quarts or liters per day.
Symptoms: Know what symptoms to report to your provider; report early to prevent readmission.
Answer: a
If she notices a weight gain, she needs to notify her physician right away, not at the next office
visit. This is what brought her back to the hospital in the first place!
PART 1 MEDICAL-SURGICAL CASES
4 Copyright © 2016 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
1 Cardiovascular Disorders
c. Apical heart rate of 64 beats/minute
d. Digoxin level 1.6 ng/mL
11. When preparing to give the digoxin, you notice that it is available in milligrams (mg) not
micrograms (mcg). Convert 125 mcg to mg.
12. M.G.’s symptoms improve with intravenous diuretics and the digoxin. She is placed back
on oral furosemide (Lasix) once her weight loss is deemed adequate for achievement of a
euvolemic state. What will determine whether the oral dose will be adequate for discharge to
be considered?
13. M.G. is ready for discharge. According to the mnemonic MAWDS, what key management
concepts should be taught to prevent relapse and another admission?
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 OUTCOME
After 3 days, the STOP Heart Failure Nurse calls M.G. to ask about her progress. M.G. reports that her
weight has not changed since she has been home.
