Case Study Help

[scrubsandpearls]

I am working on a case study for class and I am just wanting to make sure I am thinking along the right lines before I start going into major detail on everything. This is what I have so far. If you could provide any input that would be great. The thing I am struggling the most with is relating the lung cancer.

You are caring for a 56 year-old-client who has been hospitalized with chest pain. The client's history includes diabetes, chronic renal failure (on peritoneal dialysis), history of Cancer of the lung, and alcoholism. He presents with jaundice of the sclera and skin. Striae are noted on the abdomen.

The client's lab values are as follows:

NA 120

K⁺ 6.0

Cl 99

CO2 24

BUN 23

Creat 3.0

Glu 420

Troponin (on admission) 1.5, ECG shows ST elevation in anterior leads

Medications include:

Metformin,

Glyburide

Lisinopril

Deltiazem

Diazepam

1. Create a CONCEPT MAP with the above information only. Include all areas on the map (all areas include- medical, pharmacology, risk factors, lab results, nursing problems and goals only). (20%)

2. What diagnostic tests do you anticipate and why? What will the nursing care be, including care pre/post testing and teaching?

a. 12 lead ECG

b. CKMB

c. cardiac catheterization

d. GFR

e. urinalysis

f. CBC

g. c-reactive

h. echocardiogram

i. Patient weight and BMI: determine if obesity is a potential risk factor

j. Cholesterol and Triglycerides: if elevated, would be a risk factor

k. liver Function tests

3. Is this client a candidate for tPA - why or why not?

The client is not a candidate for tPA because it has not been confirmed that a clot is the cause of his MI. Also, tPA is contraindicated in clients with CKD and elevated glucose levels greater than 400.

Ten (10) hours after admission, the client begins to hallucinate, and is screaming with pain in the abdomen. You suspect acute alcohol withdrawal. The MD is notified and the client is placed on Librium. You take over the peritoneal dialysis since the client is not able to himself. The current peritoneal return is slightly cloudy. Lab work at this time is as follows:

Amylase 650

Lipase 1200

Ammonia 575

What disease process do you think this client may have? Defend your answer in detail.

Pancreatitis (elevated amylase, lipase and ammonia) ?

4. What medical treatment will this client require?

NPO, TPN IV, fluids IV, supplemental O2, Demerol for pain, histamine H2 receptor blocker (proton pump inhibitor), antacids, anticholinergics, antiemetic, parenteral antibiotics, NG tube, pancreatic enzymes (pancreatin)

5. Nursing care?

Turn q2h, encourage incentive spiromenter, daily weights, provide oral hygiene, monitor bowel sounds, vital signs q2h (BP, respirations, HR and O2), I&Os q8h, assess pain, HOB 30 degrees or greater, monitor H&H, WBC, Ca+, glucose, BUN, creatinine and K+ and monitor LOC and mentation. Teach client to avoid alcohol, caffeine, tea and nicotine and worsening S&Sx of pancreatitis: abdominal pain, clay colored stools and dark urine.

The client is treated for the above disease process and improves.

Four days after admission, the nursing assistant reports to you that the client is short of breath, HR 158 and B/P of 100/62. Assessment of the client reveals an irregular heart rate and O2 saturation of 89%.

6. What do you think is going on with the client at present? If there is more than 1 problem, only follow one of the problems that you have identified.

Heart Failure and atrial fib.

7. What treatment/diagnostic tests do you anticipate the MD ordering?

BNP

Chest xray

Digoxin: used in CHF clients when a. fib. Coexists

Coreg

Anticoagulations

Hydralizine

Amiodarone: to correct atrial fib. ?

morphine

8. In detail, what will the nursing care consist of for this client?

High fowler's

Give O2

Admin diuretics

I&Os

Daily weights

Monitor for edema

Monitor lung sounds and for JVD

Vital signs q15min

Assess for decreased tissue perfusion: capillary refill, peripheral pusles, color, temperature

Monitor LOC and mentation

Decrease workload on the heart: minimize activities and provide ample amount of rest between activities

Monitor digoxin levels

[Esme12, ASN, BSN, RN]

I will be back to help, but I want you to think about the pancreatitis. What other disease process would an alcoholic have due to the lack of drinking and what liver disease would cause jaundice? What do you need to do to control the diabetes

What about the glucose? How often would you need to check the capillary glucose? How is the patient oxygenating? With the elevated glucose, renal failure, dialysis, liver failure and cancer what other labs would you need to see the patients acid base balance as well as the oxygenation? What causes cloudy peritoneal return? What is a complication of peritoneal dialysis? What other meds are given for elevated ammonia level? Is this patient septic as well.

Look up each disease process for labs and treatment. check out this thread....https://allnurses.com/nursing-student-assistance/cad-chf-train-755639.html

[VickyRN, MSN, DNP, RN]

I would also look into which of the medications are contraindicated in renal insufficiency and/or liver failure. What PRN medications should this client not receive with liver failure? (hint anything containing acetaminophen; anything else?)

Also, what medications are commonly given for hepatic failure? (especially for high ammonia levels)

[nurseprnRN, BSN, RN]

also, please look beyond the usual same-old, same-old nursing diagnoses commonly attached to medical diagnoses as if everyone has them. sure, he has those, fine. but i don't see a lot else about him in those, and i do see indications for several other nursing dx.

what's with the hyponatremia/hyperkalemia?

what else could cause dropping oxygens, bp, and irregular heart rate? who says he has atrial fib? are there other causes? how was atrial fibrillation diagnosed...and if it wasn't, does that suggest another common diagnostic test?

cloudy peritoneal dialysate returns are a very bad thing, and i don't see you addressing it. why is it bad? what might the next day or so look like? what might happen to him?

[NCRNMDM, ASN, RN]

Since this is peritoneal dialysis we are talking about, and the return is cloudy, I'm going to say that the cause could be possible peritonitis. Also, with the ammonia level as high as it is, is it possible that some of the confusion and hallucinations are related to this? As for the dropping sat, the first thing I think of in an immobilized and otherwise unhealthy patient is PE. This doesn't do much to explain the irregular heart beat, though. I think a D-Dimer may be in order for this patient, to rule out or confirm some type of embolism.

That's just my two cents, feel free to correct me if I'm wrong. I'm here to learn just like everyone else.

[Esme12, ASN, BSN, RN]

OP? Is this what you needed?