Case study help for school

[LPN2RN2009]

I was wondering if someone can help me? We have been given this case study and there are some questions that I need help with. Here is the case study:

A 64-year-old male patient is a direct admission to the nursing unit with the complaint of abdominal pain, nausea, an extreme weakness. The patient has a history of diabetes, chronic renal failure, and sleep apnea. Admission nursing assessment findings include temperature of 99.3 F, BP 174/110 mm Hg, pulse of 96 and irregular, PMI shifted to the left, JVD 4.5 cm above the angle of Louis, 3+ pitting edema in the lower extremities, and tenderness in the Right Upper Quadrant with abdominal palpation.

The question is this: The nurse obtains lab results from tests drawn on admission including BNP 1275 pg/mL; K+ 5.4 mEq/L, creatinine 2.7 mg/dL, BUN 42 mg/dL. The nurse contacts the physician who orders a stat electrocardiogram which shows S-T changes. What action should the nurse take at this point?

Any help would be GREATLY appreciated!!!!

[Little Panda RN, ASN, RN]

I am a student myself so I am just going to give this my best shot. According to all the data it sounds like this patient is in heart failure. This could be due to fluid overload due to his chronic renal failure.

I would first start O2. I would place the patient in a semi fowlers position for easier breathing and to decrease venous return to the heart. With the fluid overload the patients heart is working harder than ever. I would then asses the patient and contact the physician for further orders. I wouldnt be surprised if the physician orders lasix.

Always remember your ABC's, Airway, Breathing, Circulation.

Like I said I am a student also, so I am sure I did not hit on everything that needs to be done.

[HonestRN]

I would place patient in bed with HOB elevated or sitting with legs dangling, which ever is more comfortable for the patient, apply O2 with nonrebreather face mask, assess lung sounds then call MD with lab & EKG results and assessment data. I would expect orders for sublingual nitrostat, lasix, enapril, fluid restrictions, low Na+ diet, daily weights, tele, and continuous pulse oximetry.

[vashtee, RN]

I would place patient in bed with HOB elevated or sitting with legs dangling, which ever is more comfortable for the patient, apply O2 with nonrebreather face mask, assess lung sounds then call MD with lab & EKG results and assessment data. I would expect orders for sublingual nitrostat, lasix, enapril, fluid restrictions, low Na+ diet, daily weights, tele, and continuous pulse oximetry.

:yeahthat:

[Little Panda RN, ASN, RN]

I would place patient in bed with HOB elevated or sitting with legs dangling, which ever is more comfortable for the patient, apply O2 with nonrebreather face mask, assess lung sounds then call MD with lab & EKG results and assessment data. I would expect orders for sublingual nitrostat, lasix, enapril, fluid restrictions, low Na+ diet, daily weights, tele, and continuous pulse oximetry.

Excellent Job!!!! You Rock!

[LPN2RN2009]

Thank you for your input. As a nursing student I always question myself!!!! Your information was VERY helpful. Good luck with school!!