Oral and Parenteral Medication Administration
Skills & Reasoning
Suggested Answer Guidelines
Jerry Williams, 62 years old
1RELEVANT Data:
Clinical
... [Show More] Significance:
History of diastolic heart failure and type II diabetes.
Last evening, he began having difficulty breathing with activity. He thought he might be getting a cold because he had a runny nose. He reports more swelling in his lower legs the past couple days.
He woke up this morning with increased difficulty breathing when he woke up and his wife called 911.
Paramedics report that his initial VS: HR:92 RR: 28 BP: 172/88 O2 sat: 80% on room air with scattered expiratory wheezing bilat.
He was placed on oxygen by facemask and an albuterol nebulizer given with some improvement in his breathing.
His RR is 24 upon arrival.
His initial labs included a creatinine of 2.5 (last adm. 1.8), K+ 3.5 (last adm. 3.7), BNP 944 (last adm. 322).
PMH is always relevant and needs to be noted by the nurse. Understanding the pathophysiology of heart failure will help the nurse recognize what clinical data is the most important/relevant in this scenario.
SOB with a history of heart failure is always a clinical RED FLAG and the most likely reason for this chief complaint. Difficulty breathing with activity is an EARLY RED FLAG of decompensating heart failure if that is the primary problem.
His difficulty breathing was significant enough to warrant a 911 call which is another clinical RED FLAG. Difficulty breathing at rest is a progression and worsening that is expected with exacerbation of heart failure.
His RR is too high and his O2 sat too low!
Has no known history of asthma or COPD. Why does he have wheezing? Discuss cardiac asthma and how acute exacerbation of heart failure can cause bronchoconstriction and wheezing with heart failure.
His blood pressure is also too high! Discuss the correlation of systolic blood pressure to afterload and how increased afterload increases the workload of the heart and can continue to exacerbate the underlying problem of heart failure.
If patient has “cardiac asthma” will albuterol help significantly? Not really. EMS decision making is driven by protocol and not always benefits the patient.
His RR has decreased but is still too high at rest. This is a clinical RED FLAG.
His creatinine is too high and trending upwards. This is a clinical RED FLAG that represents worsening renal function most likely as a result of heart failure exacerbation and impaired diffusion to the kidneys.
This potassium is within normal limits but is low normal. This is a clinical red flag that needs to be noted because of the loop diuretic that has already been given that will deplete this potassium even
History of Present Problem:
Jerry Williams is a 62-year old obese (BMI 35.2) Caucasian male with a history of diastolic heart failure and type II diabetes. Last evening, he began having difficulty breathing with activity. He thought he might be getting a cold because he had a runny nose. He reports more swelling in his lower legs the past couple days. He woke up this morning with increased difficulty breathing when he woke up and his wife called 911.
Paramedics report that his initial VS: HR:92 RR: 28 BP: 172/88 O2 sat: 80% on room air with scattered expiratory wheezing bilat. He was placed on oxygen by facemask and albuterol nebulizer administered with some improvement in his breathing. His RR is now 24 upon arrival to the emergency department ED). His initial labs have resulted; creatinine of 2.5 (last adm. 1.8), K+ 3.5 (last adm. 3.7) and BNP 944 (last adm. 322). Jerry is given furosemide 40 mg IV in the ED and had 800 mL urine output in the last hour. He is admitted to cardiac telemetry, and you are the nurse responsible for his care.
What data from the present problem do you NOTICE as RELEVANT and why is it clinically significant?
(Reduction of Risk Potential/Health Promotion and Maintenance)
2Past Medical History (PMH):
Home Medications:
Hyperlipidemia
Hypothyroidism
Type II diabetes
Diastolic heart failure Chronic kidney disease stage III
Furosemide 20 mg PO every morning Atorvastatin 40 mg PO at bedtime Metoprolol 50 mg PO BID Levothyroxine 112 mcg PO daily
Exenatide microspheres 2 mg subq. weekly
Current VS:
Most Recent in ED:
P-Q-R-S-T Pain Assessment:
T: 98.2 F/36.8 C (oral)
T: 98.8 F/37.1 C (oral)
Provoking/Palliative:
P: 88 (reg)
P: 92 (reg)
Quality:
Denies
R: 24 (reg)
R: 24 (reg)
Region/Radiation:
BP: 142/76
BP: 148/80
Severity:
O2 sat: 93% 4 liters n/c
O2 sat: 94% 4 liters n/c
Timing:
Jerry is given furosemide 40 mg IV in the ED and had 800 mL urine output in the last hour.
further and cause possible arrhythmias as a result.
His BNP is too high and trending upwards. This is a clinical RED FLAG that represents heart failure exacerbation with increased workload of the heart.
Furosemide is a potent loop diuretic. This is a safe dose. 800 mL urine output is adequate and expected response with furosemide. What electrolytes are depleted with diueresis? Primarily K+ and Mg+. Be sure to note these levels in the chart.
Current Assessment:
GENERAL SURVEY:
Pleasant, in no acute distress, calm, body relaxed, no grimacing, appears to be resting comfortably.
NEUROLOGICAL:
Alert & oriented to person, place, time, and situation (x4); muscle strength 5/5 in both upper and lower extremities bilaterally.
HEENT:
Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist.
RESPIRATORY:
Breath sounds coarse crackles in bases bilat.with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort.
CARDIAC:
Pale/pink, warm & dry, 2+ pitting edema in feet and ankles, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. Unable to assess JVD due to obesity/thick neck
ABDOMEN:
Abdomen round, soft, and nontender. BS + in all four quadrants
GU:
Voiding without difficulty, urine clear/yellow
INTEGUMENTARY:
Skin warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill <3
What is the RELATIONSHIP of his past medical history and current medications? Why is your patient receiving these medications? (Which medication treats which condition? Draw lines to connect)
Hyperlipidemia>>> Atorvastatin 40 mg PO at bedtime
Hypothyroidism>>> Levothyroxine 112 mcg PO daily
Type II diabetes>>> Exenatide microspheres 2 mg subq. weekly
Diastolic heart failure>>>Furosemide 20 mg PO every morning/Metoprolol 50 mg PO BID Chronic kidney disease stage III>>>none specifically to address and treat
Nursing Assessment Begins:
3seconds, Hair soft-distribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present.
Problem:
Pathophysiology of Problem in OWN Words:
Primary Concept(s):
Biventricular Heart failure
Heart failure (HF) occurs when the heart is unable to pump sufficient blood to meet the metabolic needs of the body. It is the most common cardiovascular disorder. Heart failure results in the inadequate cardiac output (CO) with poor organ perfusion and vascular congestion in the pulmonary or systemic circulation. Heart failure may result from some causes that affect preload (venous return), afterload (resistance the heart has to overcome to eject contents), or contractility (Sommers & Fannin, 2015).
Based on physical assessment findings, this patient is in both left- and right-sided heart failure. Left-sided failure begins when the left ventricle is unable to keep up and left ventricle end diastolic pressures to increase in both the left ventricle/atrium. This causes increased pulmonary venous volume and pressure in the pulmonary veins and pulmonary circulation that pushes fluid into the alveoli, causing the coarse crackles, which then causes tachypnea and respiratory distress. The alveoli are compromised in
Perfusion
RELEVANT VS Data:
Clinical Significance:
TREND:
T: 98.2 F/36.8 C (oral) P: 88 (reg)
R: 24 (reg) BP: 142/76
O2 sat: 93% 4 liters n/c
All VS are vital and need to be noted by the nurse even if they are normal!
Afebrile. No infection likely present influencing SOB Not excessive-high normal. Continue to assess Too high! Clinical RED FLAG! Continue to assess
closely and TREND direction.
Slightly elevated but not critical at this time. Is trending DOWNWARDS
Low normal, but no critical concern
Use the initial set of vital signs that the paramedics collected to compare the trend. Stable
Stable
Improving but assess closely
Improving Improving
RELEVANT Assessment Data:
Clinical Significance:
TREND:
RESPIRATORY: Breath sounds coarse crackles in bases bilat. with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort.
CARDIAC: Pale/pink, warm & dry, 2+ pitting edema in feet and ankles, Unable to assess JVD due to obesity/thick neck
Coarse crackles are a clinical RED FLAG and represent fluid in the alveoli due to exacerbation and presence of left-sided heart failure. Wheezing that was present earlier is no longer present. Despite fluid and tachypnea, respirations are nonlabored. This can change so continue to assess closely.
2+ pitting edema consistent with right-sided heart failure
A slight change with coarse crackles now present. Assess closely especially with diuresis with furosemide
No change-stable
What clinical data do you NOTICE that is RELEVANT and why is it clinically significant?
(Reduction of Risk Potential/Health Promotion and Maintenance)
1. INTERPRETING relevant clinical data, what is the primary problem? What primary health-related concept(s) does this problem represent? (Management of Care/Physiologic Adaptation)
4their ability to exchange O2 and CO2. The heart rate increases. Pale, cool skin is [Show Less]