Problem Based Learning 3

A 78 year old female was admitted in the acute care facility with complaints of shortness of breath, fatigue, and dizziness. She has a 6-year history of HPN and CAD, lives independently and reports that her diet consists primarily of canned soup and other packaged food. The clients admission assessment reveals the presence of dyspnea with bilateral rales in the lower lobes, irregular heart rate with a bounding pulse of 92bpm BP: 190/96 and 4+ pitting edema of both ankles. The client states that her vision is blurred and that she sometimes feel lightheaded.

1. What condition is the client probably suffering from?

-LEFT SIDED AND RIGHT SIDED CONGESTIVE HEART FAILURE 2. What data in the clients history support the diagnosis? According to the history the patient had history of HPN and CAD which are both risk factors for heart failure adding her diet which primarily consists of food which are high in trans-fat which could exacerbate her CAD and predispose to heart failure. LEFT SIDED HEART FAILURE According to the history the had shortness of breath, fatigue, dizziness and dyspnea with bilateral rales in the lower lobes. Basically these symptoms may relate to left sided heart failure since they are pulmonary in nature and left sided heart failure may directly affect the lungs. RIGHT SIDED HEART FAILURE Right sided heart failure which has systemic signs and symptoms are also manifested by the patient which irregular heart rate with a bounding pulse of 92bpm BP: 190/96 and 4+ pitting edema of both ankles. The client states that her vision is blurred and that she sometimes feel lightheaded.

3. How does the above condition occur?

Heart failure is a progressive disorder in which damage to the heart causes weakening of the cardiovascular system, two of the most common risk factors for heart failure is Coronary Artery Disease and Hypertension, with CAD the arteries that supply blood to heart muscle become hardened and narrowed. This is due to the buildup of cholesterol and other material, called plaque, on their inner walls. This buildup is called atherosclerosis. As it grows, less blood can flow through the arteries. As a result, the heart muscle can't get the blood or oxygen it needs. This can lead to chest pain or a heart attack. Most heart attacks happen when a blood clot suddenly cuts off the hearts' blood supply, causing permanent heart damage while in Hypertension, High blood pressure increases the pressure in blood vessels. As the heart pumps against this pressure, it must work harder. Over time, this causes the heart muscle to thicken. The heart must work harder to pump blood out to the body and thus cause permanent damage. 4. What are the possible explanations of the conditions signs and symptoms? LEFT SIDED HEART FAILURE When there is an inability or difficulty of the left side of the heart to pump blood to the system, pooling occurs in the left ventricular chamber, if too much blood pools in the left ventricular chamber some of the blood backflow to the lungs where it basically came from these then leads to the pulmonary symptoms of heart failure which includes shortness of breath, fatigue, dizziness and dyspnea with bilateral rales in the lower lobes RIGHT SIDED HEART FAILURE Right Sided heart failure is somewhat the same with left heart failure but the pooling of blood occurs in the right ventricular chamber which thus leads to systemic symptoms of heart failure which includes irregular heart rate with a bounding pulse of 92bpm BP: 190/96 and 4+ pitting edema of both ankles. 5. List 3 nursing diagnosis including related factors that are appropriate for the client based on the history of current data.

o o

Ineffective breathing pattern related to decreased ability of the lungs to Inflate due to increased fluid secondary to left sided congestive heart failure Impaired Gas Exchange related to increased presence of blood in the lungs secondary to left sided congestive heart failure Ineffective Peripheral Tissue Perfusion; Cardiopulmonary related to decreased ability of the heart to pump blood secondary to heart failure

6. Prioritize the nursing interventions with 1 as the most important interventions, Include rationale for prioritization. ___2__ ___5__ ___1__ ___4__ ___3__ Assess breath sounds and breathing pattern Report laboratory results Assess capillary refill Monitor urine output Place client in Semi-Fowlers position

7. What advise should you give to the client regarding her diet? Patient needs to decrease her intake of processed food like canned soup and other packaged food because they are high in trans fat which are likely the cause of coronary artery diseases and they also exacerbate hypertension and could pose a great risk for the development of hypertensive complications instead the patient is recommended to: Eat less fat Some fats are more likely to cause heart disease. These fats are usually found in foods from animals, such as meat, milk, cheese, and butter. They also are found in foods with palm and coconut oils. Eat less of these foods. Eat less sodium Eating less sodium can help lower some people's blood pressure. This can help reduce the risk of heart disease. Sodium is something we need in our diets, but most of us eat too much of it. Much of the sodium we eat comes from salt we add to our food at the table or that food companies add to their foods. So, avoid adding salt to foods at the table. Eat fewer calories When we eat more calories than we need, we gain weight. Being overweight can cause heart disease. When we eat fewer calories than we need, we lose weight. Eat more fiber Eating fiber from fruits, vegetables and grains may help lower chances of getting heart disease

8. What pharmacologic interventions would you expect for this client and what would be the implications for the clients health? Medications would include: Diuretic decreases fluid in the body and is used for high blood pressure. It is given to the patient to decrease fluid volume since the patient has right sided heart failure causing systemic symptoms including edema and hypertension. ACE (angiotensin converting enzyme) inhibitor stops the production of a chemical that makes blood vessels narrow and is used to help control high blood pressure and for damaged heart muscle. It may be prescribed after a heart attack to help the heart pump blood better. It is also used for persons with heart failure, a condition in which the heart is unable to pump enough blood to supply the body's needs.

Beta blocker slows the heart and makes it beat with less contracting force, so blood pressure drops and the heart works less hard. It is used for high blood pressure, chest pain, and to prevent a repeat heart attack . Thrombolytic agentsalso called "clot busting drugs," they are given during a heart attack to break up a blood clot in a coronary artery in order to restore blood flow. Blood cholesterol-lowering agents decrease LDL cholesterol levels in the blood.

9. What are the age-related considerations and complications would you teach this client as a part of the patients education? 1. Provide an explanation of congestive heart failure. Give a definition of the disease, and tell patient that congestive heart failure refers to the inability of the heart muscles to function properly in transporting blood to organs and tissues of the body. Explain that the "congestive" component of congestive heart failure refers to the way in which blood becomes trapped in the lungs, rather than being transported to other areas of the body. 2. List the symptoms of congestive heart failure. For patients to understand more about the disease than just its definition, they should know its symptoms. The symptoms are shortness of breath, swelling of the abdomen and ankles, increased urination, nausea and stomach pain. 3. Explain the causes of congestive heart failure. It is caused by high blood pressure, alcohol abuse, heart attack, coronary artery disease and thyroid disorders. 4. Explain how congestive heart failure can be prevented. Living a healthy lifestyle involves eating food that is low in sodium, exercising regularly and not consuming alcohol. These factors also prevent congestive heart failure. Explain how eating an excessive amount of sodium is not healthy and can lead to high blood pressure, which can then lead to congestive heart failure. Not exercising leads to clogged arteries, which can result in a heart attack. Heart attacks put people at risk for congestive heart failure. Make these connections while teaching. Alcohol abuse is also not healthy and contributes to congestive heart failure.

Problem Based Learning 4

A 50 year old woman was admitted to the intensive care unit after her family finds her unconscious this morning. Her husband and three teenaged daughters accompany her. The admission assessment reveals no history of hypertension or other health problems, client complains of headache a day prior to admission. Vital signs: BP 150/100, RR-16cpm, PR-56bpm, T-38.3C and GCS 5. Her admitting medical diagnosis is CVA,bleed. 1. Prioritize the following nursing intervention with 1 being most important. Give rationale for each priority _2_ monitor temperature _4_assess neurological status _1_ assess respiratory status _3_elevate the clients head to a 45 degree position 2.The client begins to seize as her condition worsens. Cite three nursing interventions that are essential at this time.

o Ensure that the environment is safe, i.e., cot sides are in place, that the patient
is not banging limbs or head on objects. Positioning a blanket or soft object or padding may help prevent injury occurring- To prevent the patient from causing injury to him/herself. Call for assistance but aim to never leave any child having a seizure - Due to the patient potentially losing the airway, or vomiting, or becoming cyanosed.

o Monitor and support patients vital functions -If necessary nurse the patient using a
saturation monitor to monitor oxygen saturations, heart rate and respiration rate, Monitor consciousness level using Glasgow coma scale if deemed necessary.

3.What signs, other the seizure, should the nurse that the client is developing increased intracranial pressure? In general, symptoms and signs that suggest a rise in ICP including headache, vomiting without nausea, ocular palsies, altered level of consciousness, back pain and papilledema. If papilledema is protracted, it may lead to visual disturbances, optic atrophy, and eventually blindness. In addition to the above, if mass effect is present with resulting displacement of brain tissue, additional signs may include pupillary dilatation, abducens (CrN VI) palsies, and the Cushing's triad. Cushing's triad involves an increased systolic blood pressure, a widened pulse pressure,bradycardia, and an abnormal respiratory pattern. In children, a slow heart rate is especially suggestive of high ICP. Irregular respirations occur when injury to parts of the brain interfere with the respiratory drive. Cheyne-Stokes respiration, in which breathing is rapid for a period and then absent for a period, occurs because of injury to the cerebral hemispheres or diencephalon. Hyperventilationcan occur when the brain stem or tegmentum is damaged. As a rule, patients with normal blood pressure retain normal alertness with ICP of 2540 mmHg (unless tissue shifts at the same time). Only when ICP exceeds 4050 mmHg do CPP and cerebral perfusion decrease to a level that results in loss of consciousness. Any further elevations will lead to brain infarction and brain death. In infants and small children, the effects of ICP differ because their cranial sutures have not closed. In infants, the fontanels, or soft spots on the head where the skull bones have not yet fused, bulge when ICP gets too high. A swollen optic nerve is a reliable sign that ICP is elevated. 4.After determining the client had suffered extensive cerebral damage, the doctor wrote a DNR order per familys request. List three nursing diagnosis that are appropriate at this time.

o Anticipatory Grieving related to perceived impending death o Ineffective breathing related to the dying process o Risk for spiritual distress related to challenged beliefs and value systems

Problem Based Learning 5

A 60 year old male is admitted into the emergency room with complaints of shortness of breath, wheezing and fatigue, exacerbated by activity. Assessment revealed a thin, frail man with barrel chest who leans forward to breathe. Breath sounds are decreased bilaterally and the client is tachypneic with respiratory rate of 36cpm. His past medical history indicates a 40 year history of smoking one and a half pack of cigarettes per day. The client is admitted to the ICU with a medical diagnosis of chronic obstructive pulmonary disease. His physician placed the client on bed rest with bathroom privileges and orders a chest x-ray and STAT ABG. The clients admission blood gas analysis reveals: pH 7.25; PaO2: 52mmHg; HCO3 20mEq/L and O2 saturation 84%. 1. What do the ABG findings suggest and why are these findings indicative of COPD? The pH of 7.25 suggest that the patient is acidic, PaO2 of 52 mmHg indicates that the patient is not oxygenated properly, and is hypoxemic, HCO3 of 20 mEq/L indicates metabolic acidosis and O2 saturation of 84 % indicates that not enough oxygen is dissolved in plasma and chemically bound to hemoglobin. The findings are indicatve of COPD for COPD is characterized by hypoxemia

and hypercapnea, with elevated bicarbonate indicative of chronic metabolic correction of respiratory acidosis. 2. After evaluating the ABG results, the attending physician ordered O2 @ 2L/min per nasal cannula. What is the rationale for limiting the amount of oxygen administered to the client? Normally your body uses the concentration of CO2 in the blood to determine breathing rate. Some patients suffering from COPD (Congestive Obstructive Pulmonary Disorder) are unable to properly remove CO2, and so the body becomes used to perpetually high levels of CO2 and relatively low levels of O2. In these cases, breathing is triggered primarily by low O2 as opposed high CO2 (= hypoxic drive, or 'driven by low oxygen'). When such a patient is put on high flow oxygen (in a hospital or by a paramedic generally), the body suddenly experiences a much higher level of O2 then it's used to. Because the O2 levels stay so high much higher than normal, the body doesn't feel the need to breathe and may enter respiratory depression . 3. As the nurse caring for the client, what criteria will you use to evaluate the effectiveness of the clients oxygen therapy? As a nurse, the most effective way to evaluate effectiveness of client therapy is through pulse oximetry, Pulse oximetry is a simple, relatively cheap and non-invasive technique to monitor oxygenation. It monitors the percentage of haemoglobin that is oxygen-saturated. Oxygen saturation should always be above 95%, although in those with long standing respiratory disease like Chronic obstructive pulmonary disease or cyanotic congenital heart disease, it may be lower, corresponding to disease severity. The oxyhaemoglobin dissociation curve becomes sharply steep below about 90%,1 reflecting the more rapid desaturation that occurs with diminishing oxygen partial pressure (PaO2). On most machines the default low oxygen saturation alarm setting is 90%. 4. The next morning, the clients vital signs are: T=38.6C apical rate of 96bpm; respirations 30cpm; BP=150/90. The client has persistent, productive cough that is mucopurulent and copius. What is the clients priority diagnosis at this time? Ineffective airway clearance due increased mucopurulent cough production and tachypnea. The fever might be resolved when there is lesser mucus. Airway is prioritized because compromised airway and not enough oxygen may put the brain and body into a coma and even death. 5. In relation to the priority nursing problem in number four, prioritize the following nursing interventions with 1 as the most important intervention and give your rationale. _5_ initiate infusion of intravenous antibiotics as prescribed _2_check o2 saturation _1_ Auscultate breath sounds _3_ Administer Paracetamol for fever as prescribed _4_ Collect and send sputum specimen to laboratory for culture

Problem Based Learning 6 A 37 year old female is scheduled to undergo breast

biopsy for a lump she discovered in her left breast four days ago. Her history includes cigarette smoking for 17 years, use of oral contraceptives, one child who is 4 years old and family history of coronary artery disease. She denies breast trauma, alcohol use or exposure to radiation. She is 20 pounds overweight for her height. 1. What risk factors, if any, does the woman have for breast cancer?

o SEX- female has a higher risk of developing breast cancer because they have hormones
estrogen and progesterone which constantly stimulates growth with breast tissue.

o INCREASING AGE- About 1 out of 8 invasive breast cancers are found in women younger o o o o
than 45, while about 2 out of 3 invasive breast cancers are found in women age 55 or older PARITY- Women who have had no children or who had their first child after age 30 have a slightly higher breast cancer risk. CONTRACEPTION- use of contraceptive pills alter release of hormones OBESITY- Being overweight or obese has been found to increase breast cancer risk, especially for women after menopause. EXPOSURE TO RADIATION- most common risk factor for developing cancer of all types.

4. What is the most significant screening that can be conducted for breast cancer?
Why? MAMMOGRAPHY- Mammography is a specific type of imaging that uses a low-dose xray system to examine breasts. A mammography exam, called a mammogram, is used to aid in the early detection and diagnosis of breast diseases in women Current evidence supporting mammograms is even stronger than in the past. In particular, recent evidence has confirmed that mammograms offer substantial benefit for women in their 40s. Women can feel confident about the benefits associated with regular mammograms for finding cancer early. However, mammograms also have limitations. A mammogram will miss some cancers, and it sometimes leads to follow up of findings that are not cancer, including biopsies. 3. What are the implications of early pregnancy on the development of breast cancer? Early pregnancy decrease the risk for developing breast cancer because they decrease total menstrual cycles and thus decrease stress to ovary and also the stimulation of breast tissue.

5. How are the concerns of client with breast cancer similar to those of the person
with cervical or uterine cancer? The concerns in these three cancers (breast, uterine and cervical) include: Causes: 1. Continued production of estrogen 2. Obesity 3. Menstruation earlier than age 12 4. Nulliparity or less number of children 5. Use of oral contraceptives Effects of the therapy: (chemotherapy& radiation therapy) 1. Fatigue and Loss of Stamina: These symptoms are common lasting for months and years afterward in some patients. 2. Nervous System Problems: Nervous System abnormalities including stiff neck; headaches; vision problems; increased sensitivity to smells; ringing in your ears; decreased sensation and numbness in the extremities; and tingling; and pain. 3. Thyroid Problems: Radiotherapy to the neck area can cause damage to the thyroid gland. You many experience fatigue and weakness for years to come. 4. Decreased Immune Function: Many people report that they get sick easier and recover less quickly than they did before chemotherapy and radiation treatments 5. Bone Pain, Joint Pain, Bone Fractures, Osteoporosis: Chemotherapy agents like Femera for breast cancer cause severe to debilitating bone and joint pain throughout the whole body. 6. Infertility: Both radiotherapy and chemotherapy affect fertility in both men and women. Couples bank their sperm or eggs to be used later after they decide whether or not to have children. 7. Hormonal Disturbances: menstrual abnormalities; early menopause

Problem Based Learning 7 B.C is an elderly male diagnosed with dementia

five years ago. He lives with his wife, who is also an elderly person. His wife is concerned with his behaviour and deteriorating mental status, and is finding it increasingly difficult to care for him at home. He wanders out of the house, is oriented to time and place and is unable to dress and groom himself. Their attending physician encourages placement in a nursing home, but his wife resists. The physician instead arranges for a home health nurse to visit B.C and his wife at home. 1. Identify the pertinent client and caregiver information requiring nursing intervention. Pertinent client caregiver information that requires nursing interventions would include the o Safety of the patient o Behavior changes either abrupt or gradual o deteriorating mental status o orientation to time and place o hygiene care activities. o Change in lifestyle and medication administration. 2. What instructions regarding B.Cs safety should be given to his wife The best living environment for a person with dementia is one that assists them to be as happy and independent as possible. Familiarity is important for a person with dementia. The home environment should help them know where they are and find where they want to go. Changes in the environment may add to confusion and disorientation. Some tips for making the home a safe environment for the person with dementia include: Arrange furniture simply and consistently, and keep the environment uncluttered. Remove loose rugs and seal up carpet edges that may be safety hazards. Night-lights in the hallways and in the toilet may be useful to assist a person to find their way to the bathroom at night. Dispose of, or safely store, all old medications and hazardous materials such as kerosene. Electric blankets and hot water bottles can be a safety hazard for a person with dementia and are better removed. Automatic cut-off mechanisms for hot water jugs and other appliances are recommended. Replace more dangerous forms of heating, such as bar radiators, with safer heating options such as column heaters. Check appliances, such as heaters and toasters, to make sure they do not present any safety hazards. Replace long electrical cords on appliances with coiled or retractable cords. Thermostats are available to control the level of heat that comes out of the hot water taps. Smoke detectors are important for everyone. A person with dementia may need someone else to check the battery and make sure the alarm is loud enough. Safety outside the home Some people with dementia may become disoriented and get lost in unfamiliar, or even previously familiar, surroundings. It is important that they carry appropriate identification at all times, including their name and address and an emergency contact number. An identity bracelet is ideal. Some tips for making the area outside the home safe for the person with dementia include: Keep paths well swept and clear of overhanging branches. Check catches on gates. Remove poisonous plants and dispose of hazardous substances from sheds and garages. Wandering As well as making the home safer, it is important to ensure the person with dementia is as safe as possible if they go outside the home. Some things to check include: Identification bracelet Identification and emergency contact number in wallet Bell on door, window and gate. Some aids may help Aids to independence and safety includes:

 Hand-held shower hoses allow a person to direct the flow of water as desired. A shower chair or bath seat allows a person to be seated while bathing and eliminates the need to lower oneself into the bath. Rails at bath, shower and toilet provide support and balance. Easy-to-read clocks and large calendars will help to orient to date and time. Reminder timers can also be helpful. Heat sensors or alarms may help in case of emergency. A list of contact names and numbers in large print placed by the telephone allows the person to more easily stay connected. Sources:

http://www.nlm.nih.gov/medlineplus/heartfailure.html http://www.nlm.nih.gov/medlineplus/coronaryarterydisease.html http://www.gosh.nhs.uk/clinical_information/clinical_guidelines/cpg_guideline_000 36 http://wps.prenhall.com/chet_perrin_criticalcare_1/98/25168/6443041.cw/content/ index.html