DR ERIC
PART ONE Medical-Surgical Cases
1
abirb.com/test
Cardiovascular Disorders abirb.com/test
Case Study 1 Heart Failure abirb.com/test
Difficulty: Beginning
Setting: Emergency department, hospital
Index Words: heart failure (HF), cardiomyopathy, volume overload, patient education abirb.com/test
Giddens Concepts: Fluid and Electrolyte Balance, Perfusion, Patient Education
HESI Concepts: Assessment, Fluid and Electrolyte, Perfusion, Patient Education
abirb.com/test
u Scenario
M.G., a “frequent flier,” is admitted to the emergency department (ED) with a diagnosis of heart failure
abirb.com/test
(HF). She was discharged from the hospital 10 days ago and comes in today stating, “I just had to come
to the hospital today because I can't catch my breath and my legs are as big as tree trunks.” After further
questioning, you learn that she is strictly following the fluid and salt restriction ordered during her last
hospital admission. She reports gaining 1 to 2 pounds every day since her discharge.
abirb.com/test
1. What error in teaching most likely occurred when M.G. was discharged 10 days ago?
A breakdown of successful communication occurred regarding when to call with early weight
abirb.com/test
gain. It is imperative that patients understand when to call their provider after being discharged
from the hospital for exacerbated HF. Comprehensive patient education starting at admission is
considered a standard of care and is mandated by The Joint Commission when care is provided to
hospitalized patients. The goal of the discharge treatment plan is to facilitate successful patient self-
abirb.com/test
management, minimize symptoms, and prevent readmission.
CASE STUDY PROGRESS
abirb.com/test
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 abirb.com/test
Enalapril (Vasotec) 5 mg PO bid
Pioglitazone (Actos) 45 mg PO every morning
Furosemide (Lasix) 40 mg/day PO abirb.com/test
Potassium chloride 20 mEq/day PO
2. Which of these medications may have contributed to M.G.'s HF? Explain.
abirb.com/test
Thiazolidinediones, such as pioglitazone, may increase the risk of HF and should not be used in
patients with symptoms of HF. They commonly cause peripheral edema and weight gain (which are
the result of both water retention and increased deposit of adipose tissue).
abirb.com/test
abirb.com/test
Copyright © 2016 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
DR ERIC
abirb.com/test
, DR ERIC
PART 1 MEDICAL-SURGICAL CASES
abirb.com/test
3. How do angiotensin-converting enzyme (ACE) inhibitors, such as enalapril (Vasotec), work
1 Cardiovascular Disorders
to reduce HF? Select all that apply. ACE inhibitors:
a. prevent the conversion of angiotensin I to angiotensin II.
b. cause systemic vasodilation. abirb.com/test
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. abirb.com/test
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 theabirb.com/test
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.
abirb.com/test
CASE STUDY PROGRESS
After reviewing M.G.'s medications, the physician writes the following medication orders.
Chart View abirb.com/test
Medication Orders
Enalapril (Vasotec) 5 mg PO bid
Carvedilol (Coreg) 3.125 mg PO twice daily
abirb.com/test
Glipizide (Glucotrol) 10 mg PO every morning
Furosemide (Lasix) 80 mg intravenous push (IVP) now, then 40 mg/day IVP
Potassium chloride (K-Dur) 20 mEq/day PO abirb.com/test
4. What is the rationale for changing the route of the furosemide (Lasix)?
M.G. is fluid overloaded and needs to decrease fluid volume in a short period. Intravenous
abirb.com/test
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.
abirb.com/test
5. You administer furosemide (Lasix) 80 mg IVP. Identify three parameters you would use to
monitor the effectiveness of this medication.
• Increased urine output abirb.com/test
• Daily weight, looking for weight loss
• Intake and output (I&O)
• Decreased dependent edema
abirb.com/test
• 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)
abirb.com/test
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 abirb.com/test
c. Complete blood count (CBC)
abirb.com/test
2 Copyright © 2016 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
DR ERIC
abirb.com/test
, DR ERIC
PART 1 MEDICAL-SURGICAL CASES CASE STUDY 1
abirb.com/test
d. Serum glucose level
e. Potassium level
f. Coagulation studies
Answers: a, b, d, e abirb.com/test
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
abirb.com/test
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.
7. What is the purpose of the beta blocker carvedilol? It is given to: abirb.com/test
a. increase the contractility of the heart.
b. cause peripheral vasodilation.
c. increase urine output.
d. reduce cardiac stimulation from catecholamines. abirb.com/test
Answer: d
Beta-blockers reduce or prevent stimulation of the heart from circulating catecholamines.
8. You assess M.G. for conditions that may be a contraindication to carvedilol. Which
abirb.com/test
condition, if present, may cause serious problems if the patient takes this medication?
a. Angina
b. Asthma abirb.com/test
c. Glaucoma
d. Hypertension
Answer: b
Blocking of beta2 receptors leads to a decrease in bronchial smooth muscle relaxation,
abirb.com/test
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.
abirb.com/test
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. abirb.com/test
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. abirb.com/test
c. increases cardiac contractility and cardiac output.
d. blocks sympathetic nervous system stimulation to the heart.
Answer: c
abirb.com/test
Digoxin works by increasing cardiac contractility and thus increasing cardiac output.
10. Which findings from M.G.'s assessment would indicate an increased possibility of digoxin
toxicity? Explain your answer. abirb.com/test
a. Serum potassium level of 2.2 mEq/L
b. Serum sodium level of 139 mEq/L
abirb.com/test
abirb.com/test
Copyright © 2016 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
DR ERIC
abirb.com/test
, DR ERIC
PART 1 MEDICAL-SURGICAL CASES
abirb.com/test
c. Apical heart rate of 64 beats/minute
1 Cardiovascular Disorders
d. Digoxin level 1.6 ng/mL
Answer: a
Low potassium levels can increase the potential for digoxin toxicity. M.G.abirb.com/test
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.
11. When preparing to give the digoxin, you notice that it is available in milligrams (mg) not
abirb.com/test
micrograms (mcg). Convert 125 mcg to mg.
125 mcg = 0.125 mg
If the student answers “.125 mg” the answer should be incorrect, because, per the Joint Commission
abirb.com/test
“Do Not Use” list, the leading zero should not be omitted.
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
abirb.com/test
euvolemic state. What will determine whether the oral dose will be adequate for discharge to
be considered?
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 abirb.com/test
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.
abirb.com/test
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?
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
abirb.com/test
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. abirb.com/test
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.
abirb.com/test
Symptoms: Know what symptoms to report to your provider; report early to prevent readmission.
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 amabirb.com/test
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.”
Answer: a abirb.com/test
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!
abirb.com/test
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.
abirb.com/test
abirb.com/test
4 Copyright © 2016 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
DR ERIC
abirb.com/test
PART ONE Medical-Surgical Cases
1
abirb.com/test
Cardiovascular Disorders abirb.com/test
Case Study 1 Heart Failure abirb.com/test
Difficulty: Beginning
Setting: Emergency department, hospital
Index Words: heart failure (HF), cardiomyopathy, volume overload, patient education abirb.com/test
Giddens Concepts: Fluid and Electrolyte Balance, Perfusion, Patient Education
HESI Concepts: Assessment, Fluid and Electrolyte, Perfusion, Patient Education
abirb.com/test
u Scenario
M.G., a “frequent flier,” is admitted to the emergency department (ED) with a diagnosis of heart failure
abirb.com/test
(HF). She was discharged from the hospital 10 days ago and comes in today stating, “I just had to come
to the hospital today because I can't catch my breath and my legs are as big as tree trunks.” After further
questioning, you learn that she is strictly following the fluid and salt restriction ordered during her last
hospital admission. She reports gaining 1 to 2 pounds every day since her discharge.
abirb.com/test
1. What error in teaching most likely occurred when M.G. was discharged 10 days ago?
A breakdown of successful communication occurred regarding when to call with early weight
abirb.com/test
gain. It is imperative that patients understand when to call their provider after being discharged
from the hospital for exacerbated HF. Comprehensive patient education starting at admission is
considered a standard of care and is mandated by The Joint Commission when care is provided to
hospitalized patients. The goal of the discharge treatment plan is to facilitate successful patient self-
abirb.com/test
management, minimize symptoms, and prevent readmission.
CASE STUDY PROGRESS
abirb.com/test
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 abirb.com/test
Enalapril (Vasotec) 5 mg PO bid
Pioglitazone (Actos) 45 mg PO every morning
Furosemide (Lasix) 40 mg/day PO abirb.com/test
Potassium chloride 20 mEq/day PO
2. Which of these medications may have contributed to M.G.'s HF? Explain.
abirb.com/test
Thiazolidinediones, such as pioglitazone, may increase the risk of HF and should not be used in
patients with symptoms of HF. They commonly cause peripheral edema and weight gain (which are
the result of both water retention and increased deposit of adipose tissue).
abirb.com/test
abirb.com/test
Copyright © 2016 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
DR ERIC
abirb.com/test
, DR ERIC
PART 1 MEDICAL-SURGICAL CASES
abirb.com/test
3. How do angiotensin-converting enzyme (ACE) inhibitors, such as enalapril (Vasotec), work
1 Cardiovascular Disorders
to reduce HF? Select all that apply. ACE inhibitors:
a. prevent the conversion of angiotensin I to angiotensin II.
b. cause systemic vasodilation. abirb.com/test
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. abirb.com/test
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 theabirb.com/test
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.
abirb.com/test
CASE STUDY PROGRESS
After reviewing M.G.'s medications, the physician writes the following medication orders.
Chart View abirb.com/test
Medication Orders
Enalapril (Vasotec) 5 mg PO bid
Carvedilol (Coreg) 3.125 mg PO twice daily
abirb.com/test
Glipizide (Glucotrol) 10 mg PO every morning
Furosemide (Lasix) 80 mg intravenous push (IVP) now, then 40 mg/day IVP
Potassium chloride (K-Dur) 20 mEq/day PO abirb.com/test
4. What is the rationale for changing the route of the furosemide (Lasix)?
M.G. is fluid overloaded and needs to decrease fluid volume in a short period. Intravenous
abirb.com/test
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.
abirb.com/test
5. You administer furosemide (Lasix) 80 mg IVP. Identify three parameters you would use to
monitor the effectiveness of this medication.
• Increased urine output abirb.com/test
• Daily weight, looking for weight loss
• Intake and output (I&O)
• Decreased dependent edema
abirb.com/test
• 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)
abirb.com/test
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 abirb.com/test
c. Complete blood count (CBC)
abirb.com/test
2 Copyright © 2016 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
DR ERIC
abirb.com/test
, DR ERIC
PART 1 MEDICAL-SURGICAL CASES CASE STUDY 1
abirb.com/test
d. Serum glucose level
e. Potassium level
f. Coagulation studies
Answers: a, b, d, e abirb.com/test
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
abirb.com/test
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.
7. What is the purpose of the beta blocker carvedilol? It is given to: abirb.com/test
a. increase the contractility of the heart.
b. cause peripheral vasodilation.
c. increase urine output.
d. reduce cardiac stimulation from catecholamines. abirb.com/test
Answer: d
Beta-blockers reduce or prevent stimulation of the heart from circulating catecholamines.
8. You assess M.G. for conditions that may be a contraindication to carvedilol. Which
abirb.com/test
condition, if present, may cause serious problems if the patient takes this medication?
a. Angina
b. Asthma abirb.com/test
c. Glaucoma
d. Hypertension
Answer: b
Blocking of beta2 receptors leads to a decrease in bronchial smooth muscle relaxation,
abirb.com/test
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.
abirb.com/test
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. abirb.com/test
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. abirb.com/test
c. increases cardiac contractility and cardiac output.
d. blocks sympathetic nervous system stimulation to the heart.
Answer: c
abirb.com/test
Digoxin works by increasing cardiac contractility and thus increasing cardiac output.
10. Which findings from M.G.'s assessment would indicate an increased possibility of digoxin
toxicity? Explain your answer. abirb.com/test
a. Serum potassium level of 2.2 mEq/L
b. Serum sodium level of 139 mEq/L
abirb.com/test
abirb.com/test
Copyright © 2016 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
DR ERIC
abirb.com/test
, DR ERIC
PART 1 MEDICAL-SURGICAL CASES
abirb.com/test
c. Apical heart rate of 64 beats/minute
1 Cardiovascular Disorders
d. Digoxin level 1.6 ng/mL
Answer: a
Low potassium levels can increase the potential for digoxin toxicity. M.G.abirb.com/test
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.
11. When preparing to give the digoxin, you notice that it is available in milligrams (mg) not
abirb.com/test
micrograms (mcg). Convert 125 mcg to mg.
125 mcg = 0.125 mg
If the student answers “.125 mg” the answer should be incorrect, because, per the Joint Commission
abirb.com/test
“Do Not Use” list, the leading zero should not be omitted.
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
abirb.com/test
euvolemic state. What will determine whether the oral dose will be adequate for discharge to
be considered?
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 abirb.com/test
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.
abirb.com/test
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?
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
abirb.com/test
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. abirb.com/test
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.
abirb.com/test
Symptoms: Know what symptoms to report to your provider; report early to prevent readmission.
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 amabirb.com/test
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.”
Answer: a abirb.com/test
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!
abirb.com/test
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.
abirb.com/test
abirb.com/test
4 Copyright © 2016 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
DR ERIC
abirb.com/test
