Atrial Fibrillation/Heart Failure (2/2)

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 weak, barely able to stand. Appetite has decreased recently HEENT: conjunctiva pale bilaterally. Lips, tongue, and oral mucosa pale and dry. RESPIRATORY: Breath sounds clear but very diminished bilaterally with fine crackles in the bases. could be related to MDS, fluid and electrolyte abnormalities, or sepsis. More clinical data is needed Anemia secondary to MDS. Will need to assess current Hgb. Why would breath sounds be difficult to auscultate with a patient who has no history of COPD or lung disease and is SOB/hypoxic? This cluster of data is consistent with pleural effusions which are also common with any oncological process. Cluster this data with other clinical data. Slightly labored respiratory effort on room air. Persistent cough of clear sputum. CARDIAC: Pale warm & dry, 1+ edema, heart sounds irregular and tachycardic, pulses faint, equal with palpation GU: Voiding frequently with hesitancy, urine clear/dark amber INTEGUMENTARY: Pale nail beds, skin turgor with mild tenting present. What could be causing his crackles in the basis of his lungs? Depending on how long he has been atrial fibrillation with a rapid ventricular response, over time this can cause acute heart failure even though he does not have a history of this primary problem. Patient admits to URI symptoms over last two weeks. Assess for pneumonia or other lung pathology. Infectious process will typically have colored sputum (yellow to green) due to dead neutrophils in sputum that have responded to infection. Pale color consistent with anemia or impaired cardiac perfusion. Depending on how long he has been atrial fibrillation with a rapid ventricular response, over time this can cause acute heart failure even though he does not have a history of this primary problem. This can cause the pitting edema that is present. Irregular rapid rhythm consistent with atrial fibrillation. Pulses that are faint is consistent with tachycardia that is this rapid. Hesitancy is consistent with past history of prostatic hypertrophy. Dark amber urine consistent with dehydration or liver pathology causing with increased bilirubin that can darken urine. Pale nail beds expected with anemia, but important to cluster with other related clinical data Indicates dehydration or can occur in elderly due to loss of turgor with aging process. Cardiac Telemetry Strip: Regular/Irregular: irregular P wave present? none QT : PR: n/e QRS: 0.06 Interpretation: atrial fibrillation-rate 168/with rapid ventricular response (rate >100) Clinical Significance: Has prior history of paroxysmal atrial fibrillation. Has now returned and the rapid rate is a clinical RED FLAG. At risk for dropping BP and becoming symptomatic due to rapid rate and loss of atrial kick which results in loss of 20-30% cardiac output. 1. Interpreting relevant clinical data, identify potential problems. What additional data is needed to identify the priority problem and nursing priorities? (NCSBN: Step 2 Analyze cues/NCLEX Management of Care/Physiologic Adaptation) Likely Problems: Additional Clinical Data Needed: Infection/pneumonia/sepsis Complete blood count (CBC) Chest x-ray Lactate Sputum, Blood, urine specimens Atrial fibrillation w/rapid 12 lead EKG ventricular response (RVR) Caring and the “Art” of Nursing 2. What is the patient likely experiencing/feeling right now in this situation? What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person? (Psychosocial Integrity) What Patient is Experiencing: How to Engage: The nurse needs to put her/himself in the place of the patient to identify what the patient is experiencing in this situation. The patient is likely aware of the seriousness of the current change in status and may be fearful and anxious. Support the patient and family by intentionally giving them as much information about his/her current status and explain the plan of care from both a nursing and medical perspective. KNOWLEDGE is POWER from a patient’s perspective, and when the nurse provides this information, it will DECREASE anxiety and fear and make a real difference in the patient’s well-being. Even in the context of a patient who is critically ill, when you simply and matter-of-factly share what you are doing and why, it demonstrates the caring and support that is needed. Regardless of the clinical setting, remember the importance of touch and your presence as you provide care. If you are using Swanson’s Caring framework (which I encourage you to do–see my “Teaching Caring” tab on KeithRN.com), the following practical caring interventions can be “tools” in your caring toolbox to use depending on the circumstance and the patient needs (Swanson, 1991). Comforting • Little things to comfort–whatever it may be–are needed and appreciated! i.e., hand or foot massage for pain control Anticipating their needs • Staying one step ahead and not behind, especially in a crisis, is essential! Is everything where the patient can reach it before you leave the room? Performing competently/skillfully • Remember that when a nurse or student nurse does their job well and competently, this demonstrates caring to the patient! Preserving dignity • Maintaining privacy at all times is essential and is all too easily forgotten because of the pressing physical needs that may be present. Pulling the curtain as well as covering exposed genitalia is all that is needed. They are little things, but so important to preserve human dignity. Accomplishing bodily functions which are disrupted with someone else present is significant. Be respectful of privacy issues. Informing/explaining–patient education • Even in a crisis, simply explain all that you are doing. If your patient is not able to respond but family are present, explain to them all that you are doing and why. This is truly the “art” of nursing and makes such a difference when done in practice! Part II: Interpreting Diagnostic Data The primary care provider orders the following diagnostic tests and the results just posted in the electronic health record: Radiology Reports: What diagnostic results are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential/Reduction of Risk Potential/Physiologic Adaptation) Radiology: Chest X-ray Results: Clinical Significance: Bilateral diffuse pulmonary infiltrates consistent with pulmonary edema This suggests that heart failure is present with resultant pulmonary edema that is contributing to resp. distress. What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential/Physiologic Adaptation) Radiology: CT Chest Results: Clinical Significance: Bilateral moderate pleural effusions with mild to moderate pericardial effusion Pericardial and pleural effusions are most likely related to MDS disease process. MDS can effect multisystem changes in the body. This patient has no other reason to have pericardial effusion since he was a healthy male until this time. Pericardial effusion may be precipitating the atrial fibrillation which is a new onset for this patient. Lab Results: Complete Blood Count (CBC) WBC HGB PLTs % Neuts Bands Current: 6.7 6.2 91 52 0 6 weeks ago: 12.5 8.5 98 65 0 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stabl e: These labs are ALWAYS RELEVANT, therefore they must be intentionally noted by the nurse! WBC: 6.7 ● MDS can lower either one or all three blood components in stem cells in bone marrow (RBC, WBC, platelets). WBC is lower but not critical. Continue to assess closely in future visits. ● ALWAYS RELEVANT based on its correlation to the presence of inflammation or infection ● Usually increased if infection present. Worsening Hgb: 6.2 Platelets: 91 Neutrophil 52%: ● Considering the patient has leukemia it could indicate the beginning of the leukemic process with elevation in number of WBC’s. ● Too low! This is a contributing problem to weakness and pale color. ● ALWAYS RELEVANT to determine the cause of anemia. In leukemia, bone marrow failure results in anemia. ● Too low. Most likely as a result of MDS and impact on stem cells in bone marrow. Risk for bleeding ● FIRST RESPONDER to any bacterial infection within several hours or when the inflammatory response is activated ● Infection can increase Neutrophils. ● Lower than normal finding may be the result of MDS though not critically low at this time. Worsening Worsening Worsening Basic Metabolic Panel (BMP) Na K Gluc. Creat. Current: 135 4.0 141 0.96 6 weeks ago: 139 3.7 122 1.01 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: These labs are ALWAYS RELEVANT, therefore they must be intentionally noted by the nurse! Sodium: 135 ● I consider Na+ the “Crystal-Light” electrolyte. Though this is simplistic, it does help to understand in principle how basic Na+ is to fluid balance Stable ● When you add one small packet of Crystal Light to your 16-ounce bottle of water, the concentration is just right. This is where a normal Na+ will be (135-145) ● Where free water goes, sodium will follow to a degree. Therefore if there is a fluid volume deficit due to dehydration, Na+ will typically be elevated because it’s concentrated (less water) ● If there is fluid volume excess, Na+ will be diluted and will likely be low. It is the “foundational” fluid balance electrolyte! Potassium: 4.0 ● Essential to normal cardiac electrical conduction, as is Mg+ and Stable Glucose: 141 Creatinine: 0.96 ● If too high or low can predispose to rhythm changes including atrial fibrillation ● K+ tends to deplete more quickly with loop diuretic usage than Mg+ ● If potassium is low, also check the mag level Required fuel for metabolism for every cell in the human body, especially the brain ● Relevant with history of diabetes or stress hyperglycemia due to illness ● Elevated levels post-op can increase risk of infection/sepsis. ● GOLD STANDARD for kidney function and adequacy of renal perfusion Stable Stable Liver Panel Albumin Total Bili Alk. Phos. ALT AST Current: 3.1 0.8 272 171 144 6 weeks ago: 3.5 0.7 45 22 28 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: What is the most likely reason that all of the values on Trop. BNP Mg Current: Less than 0.04 475 2.2 6 weeks ago: n/a n/a 1.8 What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential/Physiologic Adaptation) RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Troponin: Less than 0.04 BNP: 475 Magnesium: 2.2 ● No evidence of myocardial infarction. ● When ordered to rule out myocardial infarction, it is ALWAYS RELEVANT ● Most sensitive cardiac marker and will be elevated if there is cardiac muscle damage ● Can take up to six hours after chest pain to elevate, so labs are always ordered every 6–8 hours x 3 and each is carefully trended to the prior to see if trend is increasing and positive ● This elevated finding confirms that there is some degree of heart failure contributing to his presentation of shortness of breath. ● What troponins are to MI, BNP is to heart failure ● Neurohormone secreted by myocytes in the ventricles ● When ventricles are stressed and overloaded, BNP is a compensatory hormone that is a vasodilator and also diuretic to help the body naturally decrease the workload of the heart ● Slight elevation is indicator of CHF. ● Essential to normal cardiac electrical conduction, as is K+ ● If too high or low, can predispose to rhythm changes that can be lifethreatening or atrial fibrillation. Must always be noted by the nurse when there is a rhythm change to rule out a low magnesium as a contributing problem Stable Worsening Stable Part III: Put it All Together to Think Like a Nurse 1. Interpreting all clinical data collected, what are the most likely problems? Rank by priority. Which problem is most serious? Why? (NCSBN: Step 3 Prioritize hypotheses/NCLEX Management of Care ) Likely Problems: Rank by Priority: Rationale: 2. What is the pathophysiology of the priority problem? (NCLEX Management of Care/Physiologic Adaptation) Priority Problem: Pathophysiology of Problem in OWN Words: Atrial fibrillation w/RVR [rapid ventricular rate] “Unlike other cells, cardiac cells are capable of self-stimulation. Although this ability is protective if the heart's conduction system fails, it can also cause ectopic activity in the cardiac cells and result in atrial (or, worse, ventricular) fibrillation. In atrial fibrillation, multiple atrial cells self-stimulate, behaving as individual pacemakers and competing with the sinoatrial node for control of cardiac activity. Normal atrial contractions are replaced by rapid quivering movements, and the atria stop contracting effectively.” This is why there are no identifiable P waves on a telemetry strip. “This lack of coordinated atrial contractions can result in two of the most common complications of atrial fibrillation-thrombi formation and heart failure. The formation of thrombi on the atrial walls and within the left atrial appendage (LAA) occurs when ineffective emptying allows blood to pool in these chambers. Commonly referred to as mural thrombi, these clots can dislodge and cause strokes and other systemic thromboemboli. The lack of coordinated atrial contractions can also result in less blood entering and leaving the left ventricle. The loss of what is often called "atrial kick" can decrease cardiac output by as much as 30%. If normal cardiac output cannot be maintained, heart failure and pulmonary congestion will result” (Cutugno, 2015). 3. What body system(s) will you assess most thoroughly based on the primary/priority problem? Identify correlating specific nursing assessments. (NCLEX Reduction of Risk Potential/Physiologic Adaptation) PRIORITY Body System: PRIORITY Nursing Assessments: Cardiovascular • Heart tones • Rate and rhythm • Blood pressure • Assessment of peripheral pulses for strength and equality • Assessment of capillary refill Respiratory Anticipating worst possible complication of a clot that dislodges from the atria and travels to the lungs causing a pulmonary embolus. Clinical changes from a pulmonary embolus can be subtle to dramatic. Subtle changes include slight increase in respiratory rate and decrease in oxygenation. Pleuritic chest pain can also be present. If the embolus is large you will see a more dramatic effect on breathing and shortness of breath with increasing oxygen needs and increased respiratory rate Neurologic Anticipating worst possible complication of a clot that dislodges from the atria and travels to the brain. Assess closely for any focal neurological deficits such as facial droop, slurred speech, weakness, numbness, tingling on one side of body 4. What nursing priority(ies) and goal will guide how the nurse RESPONDS to formulate a plan of care? (NCSBN: Step 4 Generate solutions/Step 5: Take action/NCLEX Management of Care) Nursing PRIORITY: Impaired gas exchange (heart failure/bilat pleural effusions) Ineffective tissue perfusion (aFib RVR/anemia) GOAL of Care: Improve oxygenation/lower HR to improve perfusion Nursing Interventions: Rationale: Expected Outcome: Impaired Gas Exchange Elevate head of bed Place on continuous pulse oximeter Place on oxygen per nasal cannula/titrate to keep O2 sat >92% Closely monitor/trend RR and O2 sat and breath sounds Administer PRBC as ordered (will indirectly improve oxygenation) To decrease work of breathing Continually assess O2 sat and identify hypoxia if it presents Need to improve oxygenation to keep >92% Need to cluster all relevant clinical data that relates to oxygenation. Hgb carries oxygen. When Hgb is low, there are fewer RBCs to carry O2. Breathing improved Early changes in oxygenation detected O2 >92% Evaluate oxygenation status and identify any changes early O2 needs decrease as Hgb increases Ineffective tissue perfusion Place on cardiac monitor Monitor HR and BP closely (every 15- 30”) Detect cardiac rate/rhythm changes Identify current TREND and recognize change in status early Rhythm remains stable HR and BP monitored Establish peripheral IV Anticipate need for blood products and IV medications to manage primary problems IV successfully established 5. What is the worst possible/most likely complication(s) to anticipate based on the primary problem? (NCLEX: Reduction of Risk Potential/Physiologic Adaptation) Worst Possible/Most Likely Complication to Anticipate: Symptomatic and hypotensive due to AF w/rapid ventricular response (RVR) CVA- embolic event from AF depending on how long has been in this rhythm Nursing Interventions to PREVENT this Complication: Assessments to Identify Problem EARLY: Nursing Interventions to Rescue: Assess cardiac rhythm continually to identify change in HR (AF-RVR) AF-RVR: BP/HR/color/presence of diaphoresis CVA: assess neuro status closely monitoring for focal neuro deficits, facial droop, or change in level of consciousness Chemical cardioversion (diltiazem or amiodarone) Electrical synchronized cardioversion. Head CT stat with any neuro changes. Expedite transfer to a hospital with interventional radiology if an embolic CVA is suspected 6. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity/Basic Care and Comfort) Psychosocial PRIORITIES: Use your lens of practice as an educator to determine how you would establish a plan of care for each of the psychosocial priorities identified above. I have some general recommendations below that can be used to initiate dialogue and discussion. PRIORITY Nursing Interventions: Rationale: Expected Outcome: CARE/COMFORT: Caring/compassion as a nurse Discuss the following principles to effectively engage and communicate caring by showing that the patient matters to the nurse: Emotional support Will feel valued and comforted BE PRESENT and AVAILABLE to your patient. When this is made intentional to your patient, it communicates caring (Swanson, 1991). Providing/offering hope Hope is related to meaning and purpose in life, but its emphasis is on having a future hope or expectation. This is closely related to spiritual care (Swanson, 1991). Nurse Engagement The nurse must remain clinically curious and responsive to the patient’s story and situation. When Will feel valued and comforted distracted and not engaged, the nurse will be unable to invest the energy needed to recognize relevant Physical comfort measures and urgent clinical signs that may require intervention. When nurses are not engaged with the patient and their clinical problem, patient outcomes will suffer. Nurse Presence To be present means that the nurse is AVAILABLE and ACCESSIBLE and this is communicated to the patient. Presence can also be defined as “being with” and “being there” to meet their needs in a time of need. Other ways to define or explain presence include caring, nurturance, empathy, physical closeness, and physical touch. (Rex–Smith, 2007). Use of touch Touch is a fundamental human need and an appropriate intervention that nurses should integrate into their practice. Touch is a positive way to influence the patient’s physical environment. It uses nature to influence the patient’s well-being (Bush, 2001). Never underestimate the power of the “little things’ that are done for your patients. I have observed that basic hygiene, a shave, back rub, or obtaining the patient’s story, are the BIG things that communicate caring and also make them feel so much better! Collaborative Care: Medical Management 7. State the rationale and expected outcomes for the medical plan of care. (NCLEX Pharm. and Parenteral Therapies) Care Provider Orders: Rationale: Expected Outcome: Establish peripheral IV Patient is anemic, and in atrial fibrillation. Will require IV meds and blood products Done prior to antibiotic therapy to detect systemic infection. Urgent to obtain cultures to detect infection Necessary to prepare for administration of PRBCs due to low Hgb Patient is anemic due to MDS and needs correction to improve oxygenation and perfusion.. Binds to bacterial cell wall membrane causing cell death which has a bacterialcidal action against susceptible bacteria. IV access established Blood cultures x2 sites Infection detected if present UA/UC Infection detected if present Type and crossmatch T&C identified PRBC 1 unit IV Hgb will increase after administration Cefepime IV 1 g every 12 hrs. over 30 minutes Infection treated if present Vancomycin IV 1 g. every 12 hrs. over 60 minutes Binds to bacterial cell walls resulting in cell death. Useful against numerous susceptible organisms when used with potentially life- Infection treated if present Diltiazem 10 mg IV x1 Diltiazem 5-15 mg IV gtt to keep HR <100 threatening infections or when less toxic anti-infectives are contraindicated. Inhibits transport of calcium into cardiac vascular smooth muscle cells which decreases contractility and also slows AV node conduction. Inhibits transport of calcium into cardiac vascular smooth muscle cells which decreases contractility and also slows AV node conduction. Heart rate lowered Heart rate lowered 8. Which orders do you implement first? Why? (NCLEX Management of Care) Care Provider Orders: Order of Priority: Rationale: • Establish peripheral IV 1. Establish peripheral IV Need to establish IV access as a primary priority in order to administer any of the IV medications or blood products. Because he may have an infectious illness, to prevent further progression and sepsis once blood cultures have been drawn antibiotics need to be given promptly. Need to control heart rate by giving diltiazem. This will also improve perfusion once the heart rate is slowed sufficiently. Though anemia and a low hemoglobin is a priority, because this is a chronic problem it can wait. A practical filter of nurse prioritization is to determine if a problem is acute or chronic. Since the infection and the atrial fibrillation are acute problems they become a higher priority in the chronic problem of anemia can wait until everything else has been completed related to the acute problem and its management. • PRBC 1 unit IV • Cefepime IV 1 g every 12 hrs. over 30 minutes 2. Cefepime IV 1 g every 12 hrs. over 30 minutes • Vancomycin IV 1 g. every 12 hrs. over 60 minutes • Diltiazem 10 mg IV x1 Diltiazem 5-15 mg IV gtt to keep HR <100 3. Vancomycin IV 1 g. every 12 hrs. over 60 minutes 4. Diltiazem 10 mg IV x1 Diltiazem 5-15 mg IV gtt to keep HR <100 5. PRBC 1 unit IV Part IV: Two Hours Later…(Evaluation/reflect-in-action) 1. The nurse assesses the patient after implementing the plan of care. Interpret the clinical cues to determine if the patient status is improving, declining, or reflects no change. (NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care) Assessment Data: Improving: Declining: No Change: Rhythm: Atrial fibrillation x Heart rate 108/minute x Resp. rate: 20/minute x BP 108/54 x O2 sat: 94% 2 liters n/c x Able to walk to bed from transfer cart x Breath sounds diminished bilat. w/fine crackles in bases x Complains of pain that just started where his IV is infusing. The site looks puffy and is cool to the touch. x 2. Has the overall status of the patient improved, declined, or remain unchanged? If the patient has not improved, what other interventions need to be considered by the nurse? (NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care) Overall Status: Additional Interventions to Implement: Expected Outcome: Though his overall status is improving with four assessment items that are getting better, three assessment items for unchanged and one is declining. Bill is not out of the woods yet and requires close and frequent assessment and monitoring by the nurse. • Further assessment of his peripheral IV is needed. Based on the clinical data that is provided this second IV is likely infiltrated and will require a prompt restart so that he continues to receive diltiazem that is having a positive benefit on his heart rate. • Continue to closely monitor his rhythm since he remains in atrial fibrillation but can spontaneously convert with the assistance of chemical cardioversion when receiving diltiazem Peripheral IV is successfully restarted Heart rate and rhythm continue to be closely assessed and any change i the tune s quickly identified Bill has converted to sinus rhythm, Hgb is 8.9 and he will be discharged to home tomorrow on enoxaparin subcut. What are the educational priorities for this patient/family to successfully manage the current problem and maintain optimal state of health? 3. What educational/discharge priorities are needed to develop a teaching plan for this patient and/or family? (Health Promotion and Maintenance) PRIORITY Topics to Teach: Rationale: How to administer enoxaparin subcut-assess and observe technique. Avoid infection Symptoms of recurrent atrial fibrillation Because he is in paroxysmal atrial fibrillation he is at risk for embolic complications such as a stroke or pulmonary embolus. Low molecular heparin will help prevent clot formation but needs to be administered correctly and ensure that patient understands clearly the rationale for taking. Because of his blood disease he is at risk for infection that can progress quickly to sepsis. Prevention of any infectious illness is always a priority Because he can go back into atrial fibrillation ensure that he and his family understands the classic signs and symptoms of palpitations and a rapid irregular heart rate or sudden onset of weakness or shortness of breath and even chest pain. Reflect on Your Thinking to Develop Clinical Judgment To develop clinical judgment, reflect on your thinking that was used to complete this case study by answering the following questions: What did you do well in this case study? What knowledge gaps did you identify? What did you learn? How will you apply learning caring for future patients? Author Barbara Hill, RN, MSN, CNE, CMSRN Keith Rischer, RN, MA, CEN, CCRN Reviewers Keith Rischer, RN, MA, CEN, CCRN Sarah R. Pierce, DNP, MSN, AGACNP-BC, PLNC, Assistant Professor, Department of Nursing, FreedHardeman University, Henderson, Tennessee References Cutugno, C. (2015). Atrial fibrillation: Updated management guideline and nursing implications. American Journal of Nursing, 115(5), 26-38. Hinkle and Cheever. ((2018). Brunner and Suddarth’s Textbook of Medical-Surgical Nursing. (14th ed.). Wolters Kluwer. Karch, Amy. (2016). Lippincott’s Nursing Drug Guide. Wolters Kluwer/Lippincott Williams and Wilkins. Rex-Smith, A. (2007). Something more than presence. Journal of Christian Nursing, 24(2), 82–87. Swanson, K.M. (1991). Empirical development of a middle range theory of caring. Nursing Research, 40(3), 161–166. Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204–211. Van Leeuwen, A. & Bladh, M.L. (2015). Davis’s comprehensive handbook of laboratory and diagnostic tests with nursing implications. (6th ed.). Philadelphia, PA: F.A. Davis Company.