help with case study

Editorial Team / Admin · Apr 28, 2012

Hello and welcome to allnurses.com

We don't mind assisting you with homework, but first, you must show your own work. Members will then come along and assist you with input, but we wil not do your homework for you.

There are many talented members here who will be happy to assist you.

So, show your work and let's go from there. :)

Esme12, ASN, BSN, RN · Apr 28, 2012

I'm new to this sites. please can someone help me with the following case study questions. I will rely much appreciate it. Thanks!

Like sirI said we will help you discover the answer yourself. Learning the "critical thinking" skills are necessary to becomming a good murse. You are the dective and it is your job to figure out how to best care foir this patient. You are the Head Chef that needs to know what is needed to perfect the recipe......the plan of care for the patient.

Ok here we go.....

A 75 year old female is admitted with complications of shortness of breath, increasing with exertion and at night, feeling fatigue, and difficulty sleeping. Upon your assessment you note she has 2+ pitting edema and brownish discoloration of lower extremities, crackles and wheezing in lungs and is in a tripod position to breathe with a dry hacking cough and overweight. Vital signs are blood pressure of 168/102, temperature is 101.4, pulse 102, respirations 20 and labored, pulse oximeter reads oxygen saturation is 88%. She is cyanotic and cool to touch. She reports a 20 year history of Type 2 diabetes, smokes approximately 3 packs a week for 50 years. A chest ex-ray reports left lower lobe pneumonia and enlarged heart. IV antibiotics are initiated, an echocardiogram is ordered and she is put on oxygen 2 liters.

1.) Based on the information you obtained and your assessment what do you suspect is the underlying medical diagnosis?

What are you studying right now? If someone is short of breath what system in involved? If the SOB is more at night and causes trouble sleeping does that mean the can't breath lying down? What disease process causes that? The CXR shows PNA and an "enlarged heart" What disease causes an enlarged heart? They smoke...what disease is caused by smoking? They have diabetes...what is diabetes. Think about the patient "Assessment" picture them in front of you. Know the pathophysiology of all the disease processes so you can determine what meds to look for or what meds they may need.

They can't breathe. They are sitting on the edge of the bed with their hands branched to help them sit in a certain position. They are exhausted and complain they "tire" easily. Their lungs sound "full" with wheezing their legs are swollen and discolored (does this represent a long term issuer?). They have a fever and bad congested cough, they can't catch their breath.

All of this will become an automatic process the longer you are a nurse. This is getting you to thinking what to do for a patient when they are admitted to you. What orders you need from the MD...what might the patient need so you don't have to bother the MD 15 times for simple things. What meds would be common for the disease process and ask the patient if missing.....patients will many time say. "Oh yeah...I forgot about that one, Thank You for reminding me....tee hee hee!" NOT funny. But it happens.

2.)What information given led you to the diagnosis?

Look at the symptoms, the assessment....the answers are right there.

The rest of these will be answered when you get you medical diagnosis for the disease processes.....What disease processes do you think the patient has.......Let us know and we will go to the next step.

MattNurse, MSN, RN · Apr 29, 2012

Based on the information you obtained and your assessment what do you suspect is the underlying medical diagnosis?
What information given led you to the diagnosis?
What class of medications do you expect the patient to be taking for this underlying medical diagnosis you identified?

Are you in medical school or nursing school? (rhetorical)

Why are your teachers asking you to make medical diagnoses? I thought the trend in nursing school was to have you make NURSING diagnoses. (not your fault)

Oh well, seems ridiculous to me.

I also agree w/ above posters on doing your own homework then asking for help in right direction.

Esme12, ASN, BSN, RN · Apr 29, 2012

MAtt there is value in the nurse recognizing symptoms and associating them with a disease process to better know how to care for a patient, develop her nursing diagnosis and care for the patient while the physician sleep snug in his bed.

Knowing symptoms and the disease process is not a process specific to the physician domain. The ideology went out with mercury thermometers and reusable red rubber NGT's. The last time I Was asked by a physician as to where I got my medical degree I told him "Harvard.....but I decided to further advance my medical career and went on to become a nurse."

Peace:paw:

MattNurse, MSN, RN · Apr 29, 2012

MAtt there is value in the nurse recognizing symptoms and associating them with a disease process to better know how to care for a patient, develop her nursing diagnosis and care for the patient while the physician sleep snug in his bed.
Knowing symptoms and the disease process is not a process specific to the physician domain. The ideology went out with mercury thermometers and reusable red rubber NGT's. The last time I Was asked by a physician as to where I got my medical degree I told him "Harvard.....but I decided to further advance my medical career and went on to become a nurse."
Peace:paw:

I agree there is value in the recognizing a disease process, but to me a nurse shouldn't be diagnosing patient's with medical diagnoses. If you are working on the floor of a newly admitted patient with these s/s you would think that they have been diagnosed, considering they have orders entered.

When I was teaching clinicals a few years back I would ask questions similar of my students in case studies but instead of asking for a medical diagnosis I would ask for nursing diagnosis. I would ask for independent, collaborative interventions. I look at that list of signs and symptoms presented and could easily come up with 10 differential medical diagnoses. I also think these questions are unfair to a student because to me it looks like multiple co-morbidities in the case study and the OP may be unclear as to what goes with what.

minemine · Apr 29, 2012

thank you siri for the info. thanks esmel2 for making me think as a nurse. thanks mattnurse for seeing where the mistake come from, i just started my nursing program this year, so i was taught that as a nurse you can't do medical diagnose, you can only do nursing diagnose. i'm not really sure if this medical diagnose kind of make it a little bit hard to just go straight to the point without thinking otherwise, because the sign and symptoms are also related to other diagnose. like you guys said i need to give my own opinion about the case study before you can correct me if am on the right track. i try my best, please kindly correct me if am wrong. the following are the answers to the case study:

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answers below are subject for review/correction...comments and corrections are welcome... thanks!

1. asessment: chronic kidney disease secondary to dm nephropathy, hypertensive cardiovascular disease, coronary artery disease, in congestive heart failure iiic, pneumonia(cap).

2. smoker, diabetic x 20 years, hypertensive, with signs of heart failure/renal failure. signs of infection.

3. sepsis, respiratory failure.

4. effects of smoking to cardio(so many to identify).

5. aside from echo (12-l-ecg, abg, electrolytes, dont forget bun/crea, kub ultrasound to confirm if the cause of renal failure is really secondary to dm(usually normal in size, if hypertensive-small size).

6. restrict diet that will futher damage the kidney & cardio...

7. diuretics, statins, insulin, antihypertensive probably central sympatholytics.

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MattNurse, MSN, RN · Apr 29, 2012

thank you siri for the info. thanks esmel2 for making me think as a nurse. thanks mattnurse for seeing where the mistake come from, i just started my nursing program this year, so i was taught that as a nurse you can't do medical diagnose, you can only do nursing diagnose. i'm not really sure if this medical diagnose kind of make it a little bit hard to just go straight to the point without thinking otherwise, because the sign and symptoms are also related to other diagnose. like you guys said i need to give my own opinion about the case study before you can correct me if am on the right track. i try my best, please kindly correct me if am wrong. the following are the answers to the case study:
[table=class: table2, width: 100%, align: center]
[tr]
[td=class: formtext2, width: 95%, colspan: 2]answers below are subject for review/correction...comments and corrections are welcome... thanks!
1. asessment: chronic kidney disease secondary to dm nephropathy, hypertensive cardiovascular disease, coronary artery disease, in congestive heart failure iiic, pneumonia(cap).
2. smoker, diabetic x 20 years, hypertensive, with signs of heart failure/renal failure. signs of infection.
3. sepsis, respiratory failure.
4. effects of smoking to cardio(so many to identify).
5. aside from echo (12-l-ecg, abg, electrolytes, dont forget bun/crea, kub ultrasound to confirm if the cause of renal failure is really secondary to dm(usually normal in size, if hypertensive-small size).
6. restrict diet that will futher damage the kidney & cardio...
7. diuretics, statins, insulin, antihypertensive probably central sympatholytics.

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great job!

a 75 year old female is admitted with complications of shortness of breath, increasing with exertion and at night, feeling fatigue, and difficulty sleeping.

--sounds like she could benefit from a sleep study for possible sleep apnea.

upon your assessment you note she has 2+ pitting edema and brownish discoloration of lower extremities,

--sounds like she could have some peripheral vascular issues too, i would assess her pulses, hair patterns. also cor-pulmonale.

crackles and wheezing in lungs and is in a tripod position to breathe with a dry hacking cough and overweight (also sleep apnea-- weight).

vital signs are blood pressure of 168/102, temperature is 101.4, pulse 102, respirations 20 and labored, pulse oximeter reads oxygen saturation is 88%. she is cyanotic and cool to touch. she reports a 20 year history of type 2 diabetes, smokes approximately 3 packs a week for 50 years. a chest ex-ray reports left lower lobe pneumonia and enlarged heart. iv antibiotics are initiated, an echocardiogram is ordered and she is put on oxygen 2 liters.

for interventions in addition to your interventions:

smoking cessation, including a nicotine patch or gum

i would anticipate an a1c lab

would probably benefit from some albuterol/atrovent nebs prn

tylenol for fever

blood cultures before initiating antibiotics.

corticosteroids - which will increase her sugars in addition to diabetes.

spiriva is usually added for copd.

advair or symbicort would probably be started.

watch for diarrhea on a broad spectrum antibiotic for possible cdiff.

iv fluids (would want to watch closely w/ edema, daily weights)

turn/cough/deep breath

incentive spirometry

ambulate in hallway if tolerated.

purse-lip breathing

pneumovax is not previously vaccinated

flu vaccine if in season

low salt diabetic diet w/ calorie restriction

multivitamins, overweight people tend to be malnourished.

dvt prophylaxis

wound checks daily

minemine · Apr 29, 2012

thanks mattnurse for taking your time to elaborate the case study. i was thinking if the case study is asking for only one medical diagnose. i was thinking of copd seen they are the main reason why patient are tripod.

tripod breathing: patients with advanced lung disease (in this case copd) will often assume a tripod position (leaning forward, hands on knees) when breathing difficulties occur. this provides a position that optimizes respiratory mechanics.

4. how do smoking and diabetes contribute to the patient’s underlying medical diagnosis you identified?

smoking is the number cause of copd, it damage the lung. patient with copd, have an increase risk of developing diabetes, the risk appear to exist regardless of severity of copd. elevate level of blood glucose are associate with abnormal lung function.

minemine · Apr 29, 2012

Thanks Esme12, i was thinking that the patient has COPD or what do you think?

Esme12, ASN, BSN, RN · Apr 29, 2012

I agree there is value in the recognizing a disease process, but to me a nurse shouldn't be diagnosing patient's with medical diagnoses. If you are working on the floor of a newly admitted patient with these s/s you would think that they have been diagnosed, considering they have orders entered.
When I was teaching clinicals a few years back I would ask questions similar of my students in case studies but instead of asking for a medical diagnosis I would ask for nursing diagnosis. I would ask for independent, collaborative interventions. I look at that list of signs and symptoms presented and could easily come up with 10 differential medical diagnoses. I also think these questions are unfair to a student because to me it looks like multiple co-morbidities in the case study and the OP may be unclear as to what goes with what.

I agree badly presented but need to be answeres jus tthe same.

Esme12, ASN, BSN, RN · Apr 29, 2012

Good job! Ok here we go.....

A 75 year old female is admitted with complications of shortness of breath, increasing with exertion and at night, feeling fatigue, and difficulty sleeping. Upon your assessment you note she has 2+ pitting edema and brownish discoloration of lower extremities, crackles and wheezing in lungs and is in a tripod position to breathe with a dry hacking cough and overweight. Vital signs are blood pressure of 168/102, temperature is 101.4, pulse 102, respirations 20 and labored, pulse oximeter reads oxygen saturation is 88%. She is cyanotic and cool to touch. She reports a 20 year history of Type 2 diabetes, smokes approximately 3 packs a week for 50 years. A chest ex-ray reports left lower lobe pneumonia and enlarged heart. IV antibiotics are initiated, an echocardiogram is ordered and she is put on oxygen 2 liters.

1.) Based on the information you obtained and your assessment what do you suspect is the underlying medical diagnosis?

First why do you thing renal failure with the information given. Do you have an absence of urine output or labs to indicate renal failure? where is your evidence?

This patient has SOB greater at night, increased fatigue and difficulty sleeping due to SOB and fatigue. Orthopnea.....cannot sleep lying down.

What causes this typical presentation? Congested Heart failure.

She has 2+ pitting edema. What type of heart failure typically has lower extremity edema? Right or Left? Usually Right. When the right side of the heart (right ventricle) starts to fail, fluid begins to collect in the feet and lower legs. Puffy leg swelling (edema) is a sign of right heart failure, especially if the edema is pitting edema. With pitting edema, a finger pressed on the swollen leg leaves an imprint. Non-pitting edema is not caused by heart failure. As the right heart failure worsens, the upper legs swell and eventually the abdomen collects fluid (ascites). Weight gain accompanies the fluid retention and is a reliable measure of how much fluid is being retained.The brownish discoloration indicates this is a chronic long withstanding problem.

She possibly has respiratory failure aw well as evidenced by the severity of her symptoms, her enlarged heart and the chronic appearance of her legs. Is her "obesity" really ascites?

The patient smokes. what common ailment is diagnoses in smokers? COPD. There are 2 types of COPD right? SOme sources call it "Pink Puffers" (CO2 retainer) and "Blue Blowers" or Cor Pulmonary/right heart failure.

Your patient has a CXR that shows an enlarged heart. What diagnosis would accompany an enlarged heart? Cardiomyopathy. What is cardiomyopathy and how is it treated?

Cardiomyopathy, or heart muscle disease, is a type of progressive heart disease in which the heart is abnormally enlarged, thickened, and/or rigid. As a result, the heart muscle's ability to pump blood is weakened, often causing heart failure and the backup of blood into the lungs or rest of the body. The disease can also cause abnormal heart rhythms.Usually, cardiomyopathy begins in the heart's lower chambers (the ventricles), but in severe cases can affect the upper chambers, or atria. There are 4 main types of cardiomyopathy. Dilated, Hypertrophic, Restrictive, and Arrhythmogenic.

Cardiomyopathy - MayoClinic.com

Enlarged Heart (Cardiomyopathy) Symptoms, Causes, Treatments

The cardiomyopathy/enlarged heart is probably due to the HTN and obesity. Giving her the diagnosis of Hypertensive heart disease.

This patient is febrile indicating that she as an active infection probably pneumonia as evidenced by the CXR showing CAP.

She is cool pale and diaphoretic which means she in an acute distress. Some other things to look for would be JVD.....jugular neck vein distention.

2.) What information given led you to the diagnosis?

The patients presentation and symptoms as above.

3.) What are two complications the patient could be at risk for secondary to her pneumonia? you sepsis and respiratory failure.

4.) How do smoking and diabetes contribute to the patient’s underlying medical diagnosis you identified?

Look up HTN and smoking and get the pathophysiology about smoking and increasing the B/P and decreasing the elasticity of the artery walls as well as the smoking's contribution to her COPD. Right?

5.) What laboratory tests would suspect be ordered and why?

Well.....you are on the right track. Use the links I gave you to see the treatment aspects of these diseases and they give explanations.

CBC: Blood count, infection,

full Chemistry profile: Electrolytes,includes BUN/Creat, glucose renal function/hydration, liver function from right heart failure...Right?

A1C

ABGs: oxygenation, acid base balance.

12-lead EKG: looking for myocardial involvement/arrhythmia/strain

Cardiac enzymes/troponin: heart involvement/MI

BNP:B-type Natriuretic Peptide as specific substance secreted from the ventricles or lower chambers of the heart in response to changes in pressure that occur when heart failure develops and worsens.

B-type Natriuretic Peptide (BNP) blood test

Abd KUB: to check for.....ascites from right heart failure?

Echocardiogram: self explanatory but to see if condition has worsened.

6.) What diet does a DIABETIC NEED? What diet does a Cardiac patient need? What does a fluid overloaded patient need?

How about a 1500 ADA cardiac diet with fluid restriction?

7.) What class of medications do you expect the patient to be taking for this underlying medical diagnosis you identified?

You are on the right track think if the heart needs help think work load reductors like beta blockers/ace inhibitors, diuretics, think about the diabeties and oral hypoglycemics and what about the pneumonia? Look at the links provided and they go into treatment.