NextGen UNFOLDING Reasoning Atrial Fibrillation/Heart Failure (2/2) Suggested Answer Guidelines

NextGen UNFOLDING Reasoning Atrial Fibrillation/Heart Failure (2/2) Suggested Answer Guidelines Bill Hill, 71 years old Primary Concept Perfusion Gas Exchange Interrelated Concepts (In order of emphasis) • Clinical judgment • Patient education • Communication • Collaboration NCLEX Client Need Categories Covered in Case Study NCSBN Clinical Judgment Model Covered in Case Study Safe and Effective Care Environment Step 1: Recognize Cues • Management of Care Step 2: Analyze Cues • Safety and Infection Control Step 3: Prioritize Hypotheses Health Promotion and Maintenance Step 4: Generate Solutions Psychosocial Integrity Step 5: Take Action Physiological Integrity Step 6: Evaluate Outcomes • Basic Care and Comfort • Pharmacological and Parenteral Therapies • Reduction of Risk Potential • Physiological Adaptation Present Problem: Part I: Initial Nursing Assessment Bill Hill is a 71-year old male with a past medical history of benign prostatic hyperplasia (BPH), peripheral vascular disease and myelodysplastic syndrome two months ago after a bone marrow biopsy. Six weeks ago Bill was admitted because he had a syncopal episode. He was diagnosed with paroxysmal atrial fibrillation and acute anemia with a Hgb of 6.9 and received a transfusion of one unit of PRBCs. Bill presents to the emergency department today with increasing weakness, fatigue, sinus congestion, fever, and chills the past week. He was around grandchildren with colds two weeks ago. Bill woke up at 6 am today feeling short of breath, harsh coughing with clear sputum. He had difficulty walking back to bed after getting up to the bathroom. His wife who is a retired nurse noted that he was much more pale, took his vital signs, which were BP: 96/62, HR: 140 irreg, RR: 24. Bill admits to losing 15 lb (6.8 kg) over the last 2-3 months. Personal/Social History: Mr. Hill is retired and lives at home with his wife in a rural area. His two adult children live out of state. He has been an active, healthy male who enjoys gardening, hunting, and splits wood to heat his home in the winter. Since he has been dealing with changes in his health he has not been able to participate in these activities as much. In the past, he has been employed as a minister who has a strong Christian faith. He denies smoking, alcohol use, and illicit drug us What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: Myelodysplastic syndrome diagnosed one month ago Diagnosed with paroxysmal atrial fibrillation and acute anemia with a Hgb of 6.9 and received a transfusion of one unit of PRBCs. Bill presents to the emergency department today with increasing weakness, fatigue, sinus congestion, fever, and chills the past week. He was around grandchildren with colds two weeks ago. Bill woke up at 6 am today feeling short of breath, harsh coughing with clear sputum. He had difficulty walking back to bed after getting up to the bathroom. His wife who is a retired nurse noted that he was much more pale and took his vital signs, which were BP: 96/62, HR: 140 irreg, RR: 24. This is a categorical diagnosis, and this patient needs another bone marrow biopsy to obtain a definitive diagnosis, per his oncologist, and treatment plan. Until this happens, the underlying disease is not treated and can contribute to this patient’s symptoms. This recent medical history is relevant to his current presentation. He may again be anemic and be in atrial fibrillation that may be contributing to his current cluster of complaints. Consider the causes: anemia, low BP, dehydraton. What started as a viral infection could progress to more severe lung pathology or secondary infection. When examining patient listen to the lungs for pneumonia, pleural effusion, allergy, infection? What physical findings align? Weakness can indicate an electrolyte imbalance, dehydration, sepsis, and anemia. This raises the concern of a primary infectious source of his current problem. Indicates a problem with the respiratory or cardiac system. will require a thorough assessment of the respiratory and cardiac systems and additional lab and diagnostic work. This degree of weakness is significant and a clinical RED FLAG that indicates the underlying severity of his current cluster of complaints. Being pale could be multifactorial and could include severe anemia and hypotension. His initial vital signs are concerning because his blood pressure is too low, his heart rate is too high and his respiratory rate is too high and causing shortness of breath. Knowing that he has a history of paroxysmal atrial fibrillation, knowing that his heart rate is Bill admits to losing 15 lb (6.8 kg) over the last 2-3 months. this rapid and irregular is a clinical red flag for atrial fibrillation been a contributor a cause to his current problem. Weight loss is more than expected and another clinical RED FLAG that requires further investigation by the nurse. RELEVANT Data from Social History: Clinical Significance: He has been an active, healthy male who enjoys gardening, hunting, and splits wood to heat his home in the winter. Since he has been dealing changes in his health he has not been able to participate in these activities as much. In the past, he has been employed as a minister who has a strong Christian faith. New onset of disease and change in condition for patient and wife.These psychosocial considerations will need to be integrated into the plan of care once he is admitted to the hospital. Identify the psychosocial impact of this change in status upon his overall emotional and mental well-being. This defines the patient’s values and relates to the decisions made by this patient. Consider supporting the patient’s Christian perspective by offering pastoral care. 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) Past Medical History: Home Medications: Benign prostatic hypertrophy (BPH) Peripheral vascular disease (PVD) Myelodysplastic syndrome (MDS) Paroxysmal atrial fibrillation (PAF) Clopidogrel 75 mg PO daily Tamsulosin 0.4 mg PO daily Atenolol 50 mg PO daily Benign prostatic hypertrophy (BPH)>>>tamsulosin Peripheral vascular disease (PVD)>>>clopidogrel Myelodysplastic syndrome (MDS) no medications Paroxysmal atrial fibrillation (PAF)>>>atenolol Bill is transferred to a cart in the ED and quickly brought to a room. You introduce yourself, and collect the following clinical data: Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 99.6 F/37.6 C (oral) Provoking/Palliative: P: 148 (irreg) Quality: Denies R: 24 (reg) Region/Radiation: BP: 104/60 Severity: O2 sat: 88% room air Timing: What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: T: 99.6 F/37.6 C (oral) This is a slight temp elevation but could be an indicator of infection. Infection is a clinical RED FLAG with MDS patients since white cells may be altered P: 148 (irreg) Heart rate is increased and tachycardic. Most likely cause is an arrhythmia such as atrial fibrillation because his rate is rapid and irregular. R: 24 (reg) Respiratory rate is increased and indicates the patient is compensating or headed to further distress. Tachypnea is always a clinical RED FLAG that needs to be recognized by the nurse. No patient can sustain an elevated respiratory rate…respiratory failure WILL OCCUR if not corrected BP: 104/60 Hypotensive-could be secondary to early sepsis or more likely rapid HR. Discuss application of CO=SVxHR and impact of rapid HR to filling of ventricles that impacts stroke volume and overall cardiac perfusion. O2 sat: 88% room air Is clearly hypoxic and despite tachypnea is unable to maintain adequate oxygenation. This is a clinical RED FLAG that must be recognized by the nurse. What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential/Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: GENERAL SURVEY: Appears ill and is This is a change in condition for this patient and a clinical RED FLAG. It