DECISION - MAKING CASE SUMMARIES CASE NAME OVERVIEW MAJOR CASE DECISIONS Jim Edgerly Mr. Jim Edgerly is a 28 - year - old man who presents to the ED front desk with complaints of heart palpitations and lightheadedness. Symptoms have been present for about one hour, and Mr. Edgerly drove himself to the ED. He has no significant medical or surgical history and currently takes only a daily multivitamin. Mr. Edgerly exercises regularly, does not use tobacco or recreational drugs, and consumes 2 - 3 alcoholic drinks per day. 1. Identifying and responding to dysrhythmias 2. Prioritizing medication administration 3. Monitoring for side effects of treatments 4. Identifying and responding to changes in patient condition 5. Assessing for stabilization of vital signs and hemodynamics 6. Recognizing a need for additional patient teaching Estimated Case Length: 1 hour Difficulty Level: High Learning Objectives:  Describe the characteristics of supraventricular tachycardia (SVT).  Prioritize the nursing interventions for stable SVT.  Prioritize the nursing interventions for unstable SVT.  Present pertinent patient education regarding the management of SVT.  Provide discharge teaching for a patient who has experienced SVT. Questions Correct Answers 1. After obtaining vital signs and placing the patient on a continuous cardiac monitor, what should your next actions be? Select all that apply. Obtain IV access Perform a 12 - lead EKG 2. A 12 - lead EKG is quickly performed. It reveals that the Sudden onset and termination CRITICAL CARE NURSING # 1 : SUPRAVENTRICULAR TACHYCARDIA patient is experiencing supraventricular tachycardia (SVT) with a heart rate of 170 beats per minute. SVT is characterized by which of the following? Select all that apply. Re - entry rhythm Possible palpitations and syncope 3. The ER physician confirms that Mr. Edgerly is experiencing SVT. Which of the following measures may the physician choose as an initial treatment option? Vasovagal maneuver 4. The initial intervention proves unsuccessful in terminating Mr. Edgerly’s SVT, so the ED physician decides to administer adenosine (Adenocard). Which of the following guidelines should you follow when administering this medication? Select all that apply. Monitor the patient’s cardiac rhythm during administration for run of asystole prior to conversion to sinus rhythm. Administer adenosine via rapid IV push, followed by 20 ml normal saline via rapid IV push. Inform the patient that he may become flushed, experience chest pain, and feel lightheaded following administration. 5. Mr. Edgerly continues in SVT at 180 beats per minute. He begins to lose consciousness. As the ED nurse, what is your next step? Prepare for synchronized electrocardioversion at 50 joules 6. As the team prepares for electrocardioversion, which of the following nursing actions are appropriate? Place one defibrillator pad on the patient’s right upper chest and the second either on the lower left chest or the back under the left shoulder blade. 7. Mr. Edgerly converts to sinus rhythm on the monitor after one shock. What should be your first action after this successful conversion? Palpate the carotid artery for a pulse 8. Mr. Edgerly’s vital signs stabilize, with BP 113/60, P Pharmacological rate control with either beta blockers or calcium channel blockers 80 sinus rhythm, RR 16, and O 2 sat 98% on room air. Mr. Edgerly is admitted for cardiology consult and observation. Later, when you have the opportunity to obtain a more thorough health history, Mr. Edgerly reveals that he has experienced similar palpitations and lightheadedness in the past, with approximately six episodes in the last three months. What potential future interventions should Mr. Edgerly anticipate for this dysrhythmia? Select all that apply. Ablation therapy Ongoing outpatient management with a cardiologist Pharmacological rate control with either beta blockers or calcium channel blockers 9. Mr. Edgerly is discharged the following day. His discharge medications include a multivitamin and metoprolol (Toprol XL) 25 mg daily. He has a scheduled appointment with a cardiologist. Which of the following options would be considered essential patient education for Mr. Edgerly? Select all that apply. Teaching Mr. Edgerly how to palpate and time his carotid or radial pulse Teaching Mr. Edgerly to hold metoprolol and notify his physician if his pulse is less than 60 bpm Teaching Mr. Edgerly about the potential triggers/etiologies of SVT Teaching Mr. Edgerly vasovagal maneuvers Teaching Mr. Edgerly to call 911 if he becomes lightheaded during an episode of SVT DECISION - MAKING CASE SUMMARIES CASE NAME OVERVIEW MAJOR CASE DECISIONS Duncan McLaughlin Mr. Duncan McLaughlin is a 64 - year - old man who presents to the ED front desk with diaphoresis, nausea, and chest discomfort extending down his left arm and into his jaw . Symptoms have been present for about one hour, and Mr. McLaughlin drove himself to the ED. He has a history of hypertension, hyperlipidemia, GERD, hypothyroidism, and Type II diabetes . Mr. McLaughlin is a 40 - pack year smoker and consumes 1 - 2 beers on weekdays and 6 - 8 beers on weekend days. 1. Identifying and responding to symptoms of MI 2. Monitoring for side effects of medication 3. Assessing for and responding to complications of a medical procedure 4. Responding to patient questions 5. Identifying and responding to changes in patient condition 6. Recognizing a need for additional patient teaching Estimated Case Length: 1 hour Difficulty Level: High Learning Objectives:  Prioritize nursing actions for the care of a patient with myocardial infarction.  Identify and describe diagnostic findings associated with an ST elevation myocardial infarction.  Discuss the nurse’s responsibilities when caring for a patient following cardiac catheterization.  Identify essential discharge teaching for a client who has undergone coronary intervention. Questions Correct Answers 1. As Mr. McLaughlin’s triage nurse, which of the following actions should be your priority? Select all that apply. Place Mr. McLaughlin on the continuous cardiac monitor Start oxygen via nasal cannula 2. Which of the following diagnostic tests will most accurately and quickly Troponin and CPK CRITICAL CARE NURSING # 2 : MYOCARDIAL INFARCTION determine whether acute coronary syndrome is the cause of Mr. McLaughlin’s symptoms? 3. The 12 - lead ECG reveals ST segment elevations in leads I, aVL, and V2 – V5. The ER physician writes the following order: “Nitroglycerin 0.4 mg SL for chest pain. May repeat q5 minutes x 3. Notify MD for ongoing chest discomfort.” What are the appropriate nur sing actions for this medication? Check the patient’s BP before and after medication administration 4. Which of the following statements is true regarding ST elevation myocardial infarction (STEMI)? STEMI is considered a transmural infarction. 5. Mr. McLaughlin’s BP drops to 85/49 after the first dose of SL nitroglycerin. Mr. McLaughlin also continues to have chest pain. Given these circumstances, what should be your next course of action? Notify the healthcare provider and prepare to administer IV fluids 6. Which of the following diagnostic tests would be essential to obtain before cardiac catheterization? PT/INR/PTT, CBC, and basic metabolic profile 7. During the initial post - catheterization exam, you note that the fingers on Mr. McLaughlin’s right hand are cool and capillary refill is > 3.0 seconds. Mr. McLaughlin’s compression band has been in place for 1 hour. What is the priority nursing action? Notify the healthcare provider 8. The day after his cardiac catheterization, Mr. McLaughlin’s urine output is 10 ml/h and his creatinine is 2.4 (baseline 1.3). When told about these results, Mr. McLaughlin says, “My kidneys have always been fine. What happened?” What is your best response? “The dye from a cardiac catheterization can sometimes affect the kidneys.” 9. Which type of rhythm is Mr. McLaughlin experiencing? Atrial fibrillation 10. What should be the healthcare team’s immediate action to treat this unstable rhythm? Synchronized electrocardioversion 11. What specific information regarding clopidogrel (Plavix) should be reinforced with this patient? Select all that apply. You should not take omeprazole with this medication. You should take this medication with a baby aspirin. 12. As part of discharge education, you note that Mr. McLaughlin had not been taking his preadmission prescribed medications. What is the best way for you to address this situation with Mr. McLaughlin? “Could you share with me why you were not taking the medications that were prescribed for you?” DECISION - MAKING CASE SUMMARIES CASE NAME OVERVIEW MAJOR CASE DECISIONS Robert Barnes Mr. Robert Barnes is a 70 - year - old male who was admitted to the ICU from the emergency department for community - acquired pneumonia. One week prior to admission he began complaining of feeling tired and a dull ache in his right chest when coughing. His wife brought him to the ED today because he did not seem to know where he was, had a fever, was coughing repeatedly and breathing rapidl y. 1. Administering medications 2. Selecting oxygen therapy 3. Implementing priority nursing actions 4. Interpreting and responding to laboratory results 5. Assisting with emergency intubation 6. Responding to questions from the patient’s family 7. Responding to ventilator alarms 8. Communicating with an intubated patient 9. Implementing nutrition strategies 10. Recognizing risk factors for extubation 11. Extubating the patient Estimated Case Length: 1 hour Difficulty Level: High Learning Objectives:  Identify the manifestations of acute respiratory failure.  Describe indications for the use of noninvasive ventilation.  Explain the indications for and complications associated with mechanical ventilation.  Discuss nursing responsibilities when caring for a patient receiving mechanical ventilation.  Identify readiness to wean in the ventilated patient. Questions Correct Answers 1. The antibiotics for Mr. Barnes arrive from the pharmacy. You see that he has been prescribed both ceftriaxone and azithromycin. What is your best course of action? Plan to administer the ceftriaxone over 30 minutes, immediately followed by the azithromycin CRITICAL CARE NURSING # 3 : RESPIRATORY FAILURE 2. Mr. Barnes is receiving high - flow oxygen therapy with an FiO 2 of 80% at 60 L/min. Which of the following are reasons why high - flow therapy would be more appropriate for Mr. Barnes than lower flow rate therapy by mask? Select all that apply. High - flow therapy may also provide some positive end - expiratory pressure (PEEP). High - flow oxygen can be delivered by nasal cannula and may be more comfortable. Oxygen delivery is more variable with low - flow therapy because room air is mixed with the inspired gas. Patients receiving high - flow oxygen can often cough and speak more easily than patients receiving low - flow mask therapy. 3. When you assess Mr. Barnes 15 minutes after the high - flow oxygen has been instituted, he has a respiratory rate of 36 and an oxygen saturation of 88%. He is restless and complaining that someone is hammering on his roof. Which of the following is the appro priate course of action? Notify the physician of these findings 4. The physician is notified of Mr. Barnes’s status and requests that ABGs be drawn. When the ABG results arrive, they are as follows: pH 7.28, PCO 2 50, PO 2 60, and HCO 3 25. How should you respond? Inform the physician and team of the ABG results and anticipate possible intubation 5. The physician decides that Mr. Barnes requires immediate intubation and mechanical ventilation. Which of the following is a nursing responsibility prior to and during emergent intubation of Mr. Barnes? Verify that a CO 2 detector is used to determine placement of the endotracheal tube 6. Following intubation, Mr. Barnes is placed on a ventilator. When his wife “The ventilator will help your husband breathe until the antibiotics begin to work.” arrives at his bedside and sees the ventilator, she asks, “How is that machine going to make my husband better?” What is your best response? 7. The low pressure/low minute volume alarm on the mechanical ventilator begins to sound. What should be your first response to the alarm? Check the ventilator tubing for disconnection 8. After Mr. Barnes begins to awaken from the intubation, he looks at you and is trying to say something while pointing at his mouth and pumping his fist. What should you do? Select all that apply. Explain to Mr. Barnes that there is a tube in his throat that is helping him breathe Tell Mr. Barnes to blink once for yes and twice for no, then ask him yes - or - no questions 9. Mr. Barnes remains awake, anxious, and trying to speak while reaching for the endotracheal tube in his mouth. The goal for Mr. Barnes following intubation is light sedation. Currently, he is receiving IV propofol at 20 mcg/kg/min. What should you do next? Increase the rate of the propofol to 30 mcg/kg/min 10. The morning following Mr. Barnes’s admission, the multidisciplinary team is reviewing his care to decide whether he should begin enteral feeding. Since admission, Mr. Barnes’s orogastric tube has been attached to low continuous suction. Which of the follow ing findings related to the orogastric tube should you mention to the team because it will likely Placement of the orogastric tube has not been verified by x - ray. influence the decision of when to begin feedings? 11. Three days later, Mr. Barnes is showing clinical response to his antibiotics and the team is considering weaning then extubating him. Which of the following would indicate that Mr. Barnes is at high risk for failure to successfully wean from ventilation at this time? He is 70 years old and has a maximum inspiratory pressure of – 25 cm H 2 O. 12. The healthcare team determines that Mr. Barnes is ready to be extubated. Which of the following actions should you take prior to and following his extubation? Select all that apply. Turn off the orogastric tube feeding prior to extubation Notify the physician and respiratory therapist immediately if Mr. Barnes develops stridor