Really good case study for the critical thinkers

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I come across some posts about case studies and critical thinking. I've seen a lot of people asking for some. I came across this one that was a challenge. So for all of you who like a challenge, I'll chip this one in. It really makes you think and I'm sure someone will come up with ideas I didn't even think of.

SCENARIO

J.F. is a 50-year-old married homemaker with a genetic autoimmune defi ciency; she has suffered from

recurrent bacterial endocarditis. The most recent episodes were a Staphylococcus aureus infection of

the mitral valve 16 months ago and a Streptococcus mutans infection of the aortic valve 1 month ago.

During this latter hospitalization, an ECG showed moderate aortic stenosis, moderate aortic insuffi -

ciency, chronic valvular vegetations, and moderate left atrial enlargement. Two years ago J.F. received

an 18-month course of parenteral nutrition (PN) for malnutrition caused by idiopathic, relentless nausea

and vomiting (N/V). She has also had coronary artery disease (CAD) for several years, and 2 years ago

suffered an acute anterior wall myocardial infarction (MI). In addition, she has a history of chronic joint

pain.

Now, after being home for only a week, J.F. has been readmitted to your fl oor with endocarditis,

N/V, and renal failure. Since yesterday she has been vomiting and retching constantly; she also has

had chills, fever, fatigue, joint pain, and headache. As you go through the admission process with her,

you note that she wears glasses and has a dental bridge. She is immediately started on PN at 85 ml/hr

and on penicillin 2 million units IV piggyback (IVPB) q4h, to be continued for 4 weeks. Other medications

are furosemide (Lasix) 80 mg/day PO, amlodipine 5 mg/day PO, potassium chloride (K-Dur)

40 mEq/day PO (dose adjusted according to lab results), metoprolol 25 mg PO bid, and prochlorperazine

(Compazine) 2.5 to 5 mg IV push (IVP) prn for N/V. On admission vital signs (VS) are 152/48

(supine) and 100/40 (sitting), 116, 22, 100.2° F. When you assess her, you fi nd a grade II/VI holosystolic

(throughout systole) murmur and a grade III/VI diastolic murmur; 2+ pitting tibial edema but no peripheral

cyanosis; clear lungs; orientation \3 but drowsy; soft abdomen with slight left upper quadrant

(LUQ) tenderness; hematuria; multiple petechiae on skin of arms, legs, and chest; and splinter hemorrhages

under the fi ngernails.

1. What is the significance of the orthostatic hypotension, the wide pulse pressure, and the

tachycardia?

2. What is the significance of the abdominal tenderness, hematuria, joint pain, and petechiae? Give the pathophysiological basis for each of the four symptoms.

3. As you monitor J.F. throughout the day, what other signs and symptoms (S/S) of embolization will you watch for? List the four systems of the body involved in this case study and give the signs and symptoms you’d watch for to detect embolization of each of the four systems.

4. Three important diagnostic criteria for infectious endocarditis are anemia, fever, and cardiac

murmurs. Explain the cause for each sign. Give the pathophysiological basis for each sign seen in this case study.

5. On the day after admission, you review J.F.’s laboratory test results: Na 138 mmol/L, K

3.9 mmol/L, Cl 103 mmol/L, BUN 85 mg/dl, creatinine 3.9 mg/dl, glucose 185 mg/dl,

WBCs 6.7 thou/cmm, Hct 27%, Hgb 9.0 g/dl. Identify the values that are not within

normal ranges, and explain the reason for each abnormality. State why each of the lab values is abnormal for this pt.

6. Which laboratory value(s) reflect(s) catabolism of muscle, and why does muscle catabolism

occur? Name the correct lab value and stating why muscle catabolism occurs in this case study.

7. If Parenteral Nutrition (PN) is scheduled on a 24-hour basis, when would blood glucose be drawn, and why? What is your facility's protocol for a pt getting PN; and give the rationale for the protocol.

8. Why would blood glucose monitoring be important?

9. What is the greatest risk for J.F. during the process of rehydration, and what would you

monitor to detect its development? State which complication would be the greatest risk; list at least four symptoms that you help determine if the pt. were developing that particular complication

CASE STUDY PROGRESS

As you admitted J.F., you were aware that as soon as she became stable, she would be going home

in a few days on PN and IV antibiotics. The home care agency that will be supervising her care is contacted

to coordinate discharge preparations and teaching ASAP.

10. List five important questions in assessing her home health care needs.

CASE STUDY PROGRESS

Fortunately, J.F. has a supportive husband and 2 daughters who live nearby who can function as caregivers

when J.F. is discharged. They, along with the patient, will need teaching about endocarditis.

Although J.F. has been ill for several years, you discover that she and her family have received little

education about the disease. You prepare a teaching plan for the family. The home care agency has

a parenteral-enteral nutrition (PEN) team to address her nutritional needs, which will also include vitamins,

minerals, and lipids. PN formulations require complex calculations. The PEN team takes care of

the formulation of the PN through the pharmacy or dietary staff (depending on local arrangements).

11. List two predisposing causes of bacteremia. Explain. Try to think of two distinctly separate casuses which have not been discussed in previous questions/answers.

12. List three other things you would teach. List four teaching needs this pt. needs to know for her safety after discharge.

CASE STUDY PROGRESS

Your hospital discharge planner facilitates J.F.’s transition to home care.

13. During the initial home visit, the home health nurse evaluates J.F.’s IV site for

implementation of the IV therapy program. The nurse interviews the family members to

determine their willingness to be caregivers and their level of understanding and enlists the

patient’s and family’s assistance to identify 10 teaching goals. What topics would be

included on this list? List ten teaching topics, all of which are directly related to the pt’s home IV therapy.

14. The home health nurse also writes short- and long-term goals for J.F. and her family.

Identify two short-term and three long-term goals. Give 5 goals, which are all related to pt. being safe at home and with this condition.

CASE STUDY PROGRESS

Mr. F. and his 2 daughters learned to administer J.F.’s PN during the 18-month treatment. Be aware

that IV cases are covered by most insurers on a case-by-case basis and with clear documentation.

15. What documentation would be required to obtain reimbursement? (You need to clearly

document everything that is done and why, in detail. List six interventions that require documentation for this pt’s home health needs, in order for the insurance payer to allow reimbursement.