Case Study 11
The time is 1900 hours. You are working in a small, rural hospital. It has been snowing heavily all day, and the medical helicopters at the large regional medical center, 4 hours away by car (in good weather), have been grounded by the weather until morning. The roads are barely passable. WR., a 48 year old construction worker with a 36 pack year smoking history, is admitted to your floor with a diagnosis of rule out myocardial infarction (R/O MI). He has significant male pattern obesity (beer belly, large waist circumference) and a barrel chest, and he reports a dietary history of high fat food. His wife brought him to the ED after he complained of unrelieved indigestion. His admission VS were 202/124, 96, 18, and 98.2°F. WR. Was put on O2 by nasal cannula titrated to maintain SaO2 over 90%, and an IV of nitroglycerin was started in the ED. He was also given aspirin 325 mg and was admitted to Dr. A’s service. There are plans to transfer him by helicopter to the regional medical center for a cardiac catheterization in the morning when the weather clears. Meanwhile you have to deal with limited laboratory and pharmacy resources. The minute WR. Comes through the door of your unit, he announces he’s just fine in a loud and angry voice and demands a cigarette. 1. From the perspective of basic human needs, what is the first priority in his care? Breathing – oxygen applied to maintain SaO2 over 90%
2. Are these VS reasonable for a man his age? If not, which one(s) concern(s) you? Explain why or why not? The BP obtained is not reasonable for a man his age. This reading denotes Stage 2 Hypertension – SBP ≥160, DBP ≥ 100. Hypertensive urgency (no evidence of target organ damage) (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 741) 3. Identify five priority problems associated with the care of a patient like W.R.
Monitor for s/s of impending MI
It would also be important to discuss modifiable risk factors: i. Stress
a. Client is a construction worker (currently snowing outside, so I would gather this is probably a very stressful season for him trying to make ends meet when the weather is bad). ii. Diet
a. Excess dietary sodium
b. High Fat Diet - ↑ serum lipids
iii. Smoking History
a. 36 pack history
v. Sedentary Lifestyle
4. Which of the following laboratory tests might be ordered to investigate WR’s condition? If the order is appropriate, place an A in the space provided. If inappropriate, mark with an I, and provide rationales for your decisions. __A__ CBC
__I__ EEG in the morning
__A__ Chem 7 (electrolytes) –K+ levels to detect hyperaldosteronism (cause of secondary htn) __I___ PT/PTT
__I___ Bilirubin every morning
__ A__ Urinalysis
__ A__ Stat 12 lead ECG
___I__ Type and crossmatch for 4 units of packed RBCs
EEG – no evidence of stroke to warrant EEG, cerebral edema, intracranial pressure, etc. PT/PTT, Bilirubin, Type and crossmatch of packed RBC’s would be related to anemias, not warranted for HTN. (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 744) 5. What significant lab tests are missing from the previous list? BMP to include BUN, serum creatinine levels, and glucose. Serum lipid profile and Serum uric acid. Troponin, CRP (C-reactive protein) Optional: 24 hr urinary creatinine clearance, echocardiography, liver function studies, and serum thyroid stimulating hormone (TSH). (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011, p. 744)
6. How are you going to respond to WR’s angry demands for a cigarette? He also demands something for his heartburn. How will you respond? The hospital is a non-smoking facility. Also tobacco use causes vasoconstriction and increases your blood pressure. It is a risk factor for heart disease, stroke, myocardial infarction. When you are ready we should discuss smoking...
References: Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. M. (2011). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (Eighth Edition). St. Louis, MO: Elsevier Mosby.
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