MODULE 5-Unfolding Clinical Reasoning Case Study.

MODULE 5-Unfolding Clinical Reasoning Case Study. Pharmacology Reasoning Bradycardia Suggested Answer Guidelines Marilyn Fitch, 78 years old Medication Categories: Concepts/Content: Antidysrhythmics ACE Inhibitors Beta Blockers Statins Oral Anticoagulants Diuretics Electrolytes Assessment Drug-drug interactions Evaluation of desired outcomes Monitoring for adverse effects Emergency treatment of dysrhythmias Client education Psychosocial support NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment  Management of Care 17-23% X  Safety and Infection Control 9-15% X Health Promotion and Maintenance 6-12% X Psychosocial Integrity 6-12% X Physiological Integrity  Basic Care and Comfort 6-12%  Pharmacological and Parenteral Therapies 12-18% X  Reduction of Risk Potential 9-15% X  Physiological Adaptation 11-17% X © 2020 KeithRN LLC. All rights reserved. No part of this case study may be reproduced, stored in retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN I. Initial Presentation: Marilyn Fitch is a 78-year-old Caucasian woman with a history of hypercholesteremia, hypertension, and heart failure and has NKDA. She was brought in by her daughter after Marilyn complained of feeling dizzy several times this morning and then almost passed out at home. Marilyn has a six-month history of paroxysmal atrial fibrillation. Her heart rate has been regular and she has had no episodic dizziness since she had a synchronized cardioversion one week prior to this visit. Her initial VS in triage were: T: 98.9 F/37.2 C (oral) P: 52 R: 16 BP: 94/52 and O2 sat: 98% room air. Personal/Social History: Marilyn is a widow and lives alone in her own home. She denies smoking and admits to drinking one glass of wine with her dinner. 1. What data from the histories are RELEVANT and must be NOTICED as clinically significant by the nurse?(NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: Hx of hypercholesteremia, hypertension, and heart failure Felt dizzy several times this am 6 mo Hx of intermittent A-Fib. Had sync. Cardioversion 1 wk ago, heartbeat regular and no dizziness since until today. Pulse: 52 BP 94/52 Pt already has pre- existing conditions that can implicate heart complications. Would support showing an intermittent A-Fib. Pt is elderly and having dizziness, can be a fall risk and may need help with setting up home for safety measures if this is continuous. Will need to keep eye on this as it seems to be continuing even after treatment for this. Seemed to work short term, but a-fib seems to be appearing again so we may need a longer-term treatment/ and /or a better treatment plan for care. Pulse and BP are sig. low but pt is also on ace inhibitor and beta blocker. Need to keep watch on these values. RELEVANT Data from Social History: Clinical Significance: Lives alone as a widow Drinks wine with dinner. Safety concern with her continually getting dizzy spells and possible fall risks. Would want to evaluate home for safety precautions and adjustments for falls. May want to see if doctor asks to limit the alcohol as pt is already dizzy and a fall concern. Maybe only drink one glass when someone is over for dinner. Family or friends. In case she becomes dizzy afterwards. 2. 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) Medical History (PMH): Home Medications: As the nurse responsible for this patient, you promptly review the medical history and current home medications in the medical record: Hypercholesteremia Hypertension Heart failure Atrial fibrillation Apixaban 2.5 mg po bid Captopril 100 mg po BID daily Amiodarone 100 mg po bid Hydrochlorothiazide 50 mg po daily Atorvastatin 10 mg po daily Carvedilol 6.25 mg po bid Applying your knowledge of pharmacology, to provide safe patient care, answer the following essential information: 3. List each home medication from the scenario and answer the following: (NCLEX Pharmacologic and Parenteral Therapies) Home Medication: Pharm. Class: Indication(s): Mechanism of Action In OWN WORDS: Body System Impacted Common Side Effects: (1- 3) Nursing Assessments: Apixaban 2.5 mg po bid anticoagulants Thromboembolis m/ preventative for stroke Blocks an enzyme that clots blood so that it wont clot easily. Circulatory/ blood Bleeding Anemia nausea Will need to watch for excessive bruising, watch iron ferratin levels for anemia and also watch for pt feeling nauseous Captopril 150 mg po daily ACE Inhibitor HTN, Diabetic nephropathy, MI, heart failure Stops the ability of an enzyme to convert from angio l to angio ll Circulatory/ki dney as renin is the enzyme its stopping. Hypotension Dizziness pruritis Need to monitor BP closely for drops. Pt can become dizzy on this medicine. Should watch for falls. See if pt is showing signs of scratching or complaining of itching. Amiodarone 100 mg po bid Antiarrhythmics Vent. Arrhythmias (malignant), ACLS VF, pulseless VT, AFib, Wide Complex Tachycardia. Blocks the potassium during the action potential phase III which stops the repolarization of the heart. Circulatory/ cardiac/ muscle (with relation to the heart). General malaise, fatigue, hyperkinesia, nausea, Vomiting, Dizziness, Bradycardia. Will need to assess for the side effects, watch the heart rate continually, make sure pt isn’t having nausea, and what the lightheaded and dizziness as that is a fall risk. Hydrochloro thiazide 50 mg po daily Diuretic HTN, peripheral edema Inhibits reabsorption of salt and chloride in the DCT. Which allows for the release of more water from the body since the water follows salt and the salt is leaving the body. Renal, circulatory, cardiac (BP) Electrolyte imbalances, Ortho hypotension, Dizziness, Anorexia, headache Will need to watch BP and see if it drops esp. ortho readings, also pull labs for any imbalances in electrolytes- esp. K+. Carvedilol 6.25 mg po bid Beta Blockers HTN, Heart failure with reduced eject. Fraction, post-MI Blocks beta and alpha adrenergic receptors to allow the vasculature to relax and dilate for lower blood pressure. Circulatory, and cardiac. Dizziness, fatigue, weight gain, hypotension, dyspnea, bradycardia. Watch for signs of dizziness, and low blood pressure. Can be a fall risk. Potential for weight gain. Daily weights. Watch for struggling with catching breath .