CV Disorder Critical Thinking Case Study

xtxrn, ASN, RN · Oct 8, 2011

Questions for "Deb" :

Why is she on straight D5W? :eek:

What did the EKG show?

CXR results?

O2 sats? Considering H & H, is O2 sat an issue?

Electrolytes? BUN?

Had the patient been sitting in a dependent position for long before coming in?

Is the edema better since being on a gurney?

How long has the nocturia been going on?

Any complaints about voiding a lot- of just often?

Current meds?

Pedal pulses strong?

Degree of edema?

Distal skin warm, dry?? Color normal?

Questions for you:

Why do you think she is diabetic?

What levels require a transfusion ( H & H)?

Has pt been compliant with treatment of CAD (from PCP)?

Good luck :)

Cupcake89121 · Oct 8, 2011

Thank you for your reply, all excellent suggestions of course! I will definitely be using some of those. I do already have some of the information you mentioned, I just didn't know if it was in "good form" to post all of the case study info. I thought only the abnormal stuff was relevant but maybe not:

Pt's daughter reports that she's become increasingly weak over the past couple of weeks and has been unable to do her housework...C/O swelling in ankles and feet by late afternoon ('she can't wear her shoes') and has nocturnal diuresis x4. Her daughter brought her in b/c she has had C/O heaviness in her chest off and on over the past few days but denies any discomfort at this time. The daughter took her to see family Dr. who immediately sent her to the hospital.

All of the labs the case study actually gives me values for are:

Na 134, K 3.5, Cl 103, HCO 23, BUN 13, creat 1.3, glucose 153, WBC 8.3, Hct 33.9%, Hgb 11.7 g/dl, platelets 162.

Here are the answers to your question for me! :nurse:

1. I assumed she was diabetic b/c her glucose is high and also b/c diabetes is a risk factor for CAD, but I researched it more in my textbooks and read: acute cardiac episode can elevate blood glucose levels.

#7 in the case study adds that I respond to the patient's call light and she is talking rapidly in Spanish and pointing to the bathroom. Speech pattern indicates she is SOB (having trouble completing a sentence w/o taking a labored breath). I assist her to the bathroom and note her skin feels clammy and while sitting on the toilet she vomits. -- So now I'm thinking that she's either having an MI "now" or she had an MI before she came in and it is now progressing to Left-sided HF -- ECG reveals ischemic changes -- some of the assessment findings for MI and HF are the same so I'm not sure what the exact progression of the disease process is.

2. In an older adult who already has cardiac issues my lab tests manual says transfusion may be rec'd when Hgb is below 10 and Hct is below 30%. This patient's values are definitely above those.

3. Unfortunately the case study does not mention if she has been compliant.

Thank you again for your response. It was extremely helpful and more than I could have asked for.

xtxrn, ASN, RN · Oct 8, 2011

\
Here are the answers to your question for me!
1. I assumed she was diabetic b/c her glucose is high and also b/c diabetes is a risk factor for CAD, but I researched it more in my textbooks and read: acute cardiac episode can elevate blood glucose levels.
So can D5W :) (and it can also cause cerebral edema- and not the usual KVO fluids)
#7 in the case study adds that I respond to the patient's call light and she is talking rapidly in Spanish and pointing to the bathroom. Speech pattern indicates she is SOB (having trouble completing a sentence w/o taking a labored breath). I assist her to the bathroom and note her skin feels clammy and while sitting on the toilet she vomits. -- So now I'm thinking that she's either having an MI "now" or she had an MI before she came in and it is now progressing to Left-sided HF -- ECG reveals ischemic changes -- some of the assessment findings for MI and HF are the same so I'm not sure what the exact progression of the disease process is.
OK...have serial cardiac enzymes been ordered? (or no info on that?) Could also be anxiety r/t SOB....but good to get labs. :)
2. In an older adult who already has cardiac issues my lab tests manual says transfusion may be rec'd when Hgb is below 10 and Hct is below 30%. This patient's values are definitely above those.
Yeah- some docs even wait until a hgb. of 8....but with SOB, may do a transfusion at a higher hgb.
3. Unfortunately the case study does not mention if she has been compliant.
Thank you again for your response. It was extremely helpful and more than I could have asked for.

No problem :)

I like students, no matter what the rumors are

I don't check here a lot- but maybe will now.... PM anytime :nurse:

nurseprnRN, BSN, RN · Oct 9, 2011

anybody give this nice lady some diuretics yet? does her daughter have any idea about weight gain? she retains fluid all day down in her dependent extremities d/t her chf, and then when she goes to bed her kidneys see more of it and make her pee all night.

jvd flat/45 degrees/upright? liver fullness/jvd c compression? can she lie down flat? how many pillows does she sleep with at home, or does she sleep in the recliner because she can't be flat?

any other signs of diabetes, like peripheral neuropathy, lousy peripheral circulation, vision? ua is pending but did anybody do a dipstick?

other meds that make for fluid retention? steroids, otcs, herbals?

she's already in chf: chest "heaviness" and escalating doe are classic sign of cardiac ischemia; the bad arteries come first, then the ischemia, then the bad contractility (then the "congestive" part of chf), then the infarct which makes things worse. if she's cold and clammy and vomiting, she's got a good chance of being in the middle of infarcting now; on the toilet, she could be doing a valsalva which will drop her heart rate and make her clammy, too, not a good thing-- check. back to beddy-bye, put her on tele if she isn't already, have the cart handy, and be sure the rapid-response team is on the way. later you can crank at the er for sending her to the floor and not the ccu or stepdown unit.

a d5w kvo isn't enough to make her hyperglycemic or give her cerebral edema, especially since her serum na+ is only a teeny bit low. she'd probably be better of c a heplock anyway, though if she's now clammy and vomiting she could probably use a second iv access before she shuts down entirely :lol2: .

that's just of the toppa my head. ymmv.

xtxrn, ASN, RN · Oct 9, 2011

anybody give this nice lady some diuretics yet? does her daughter have any idea about weight gain? she retains fluid all day down in her dependent extremities d/t her chf, and then when she goes to bed her kidneys see more of it and make her pee all night.

jvd flat/45 degrees/upright? liver fullness/jvd c compression? can she lie down flat? how many pillows does she sleep with at home, or does she sleep in the recliner because she can't be flat?

any other signs of diabetes, like peripheral neuropathy, lousy peripheral circulation, vision? ua is pending but did anybody do a dipstick?

other meds that make for fluid retention? steroids, otcs, herbals?

she's already in chf: chest "heaviness" and escalating doe are classic sign of cardiac ischemia; the bad arteries come first, then the ischemia, then the bad contractility (then the "congestive" part of chf), then the infarct which makes things worse. if she's cold and clammy and vomiting, she's got a good chance of being in the middle of infarcting now; on the toilet, she could be doing a valsalva which will drop her heart rate and make her clammy, too, not a good thing-- check. back to beddy-bye, put her on tele if she isn't already, have the cart handy, and be sure the rapid-response team is on the way. later you can crank at the er for sending her to the floor and not the ccu or stepdown unit.

a d5w kvo isn't enough to make her hyperglycemic or give her cerebral edema, especially since her serum na+ is only a teeny bit low. she'd probably be better of c a heplock anyway, though if she's now clammy and vomiting she could probably use a second iv access before she shuts down entirely .

that's just of the toppa my head. ymmv.

true- but still should be questioned imo :)