Nursing # Case Study 1: ( 2 pages ), Chapter 46, Management of Patients With Oral and Esophageal Disorders
- George Smith, a 55-year-old patient is admitted to the intensive care unit after a thoracotomy approach was used for an esophagectomy to remove an early stage adenocarcinoma of the distal esophagus and gastroesophageal junction. The patient has a history of GERD and Barrett’s esophagus. The patient sought medical treatment for dysphagia with solid foods, feeling that there was a lump in his throat and substernal pain with swallowing and subsequent regurgitation of undigested food and the development of hiccups. The patient has no other medical problems. (Learning Objectives 6 and 7)
a.Describe the esophageal cancer that the patient has and how it relates to his history of GERD and Barrett’s esophagus.
b.Explain the rationale for the early symptoms and late symptoms of esophageal cancer.
c.What course of cancer treatment should the nurse anticipate that the patient in this case study would have?
d.What nursing care should be provided for the patient in the intensive care unit in the early postoperative period?
e.Explain the care the nurse should provide when the patient begins to eat.
- Mr. Owens is a 62-year-old man who underwent a neck dissection yesterday due to cancer of the mouth. You are the nurse assigned to care for Mr. Owens during his first postoperative day. Initial assessment finds Mr. Owens sitting up in bed; he is drowsy, but oriented ×3 when aroused. He has significant edema in his neck and mouth area, but does not appear to be in respiratory distress. His respiratory rate is 16 to 18, and his oxygen saturation is 96% on 40% oxygen via face tent. He has two peripheral IV lines both infusing Lactated Ringer’s solution at 75 mL/hr. Two Jackson Pratt drainage tubes are partially filled with serosanguinous drainage. (Learning Objective 5)
a.What is the rationale for the patient being placed in Fowler’s position after surgery?
b.The nurse notes that there has been 240 mL output in the drainage tubes during the first 24 hours after the surgical procedure. What should the nurse do?
c.Postoperatively, the nurse identifies that the patient is at risk for imbalanced nutrition, less than body requirements related to anorexia and dysphagia. The nurse instructs Mr. Owens to eat soft food and suggests that he tilt his head to the unaffected side to facilitate swallowing. What is the rationale for these instructions?
d.In reviewing Mr. Owens’ medical record, what findings in his health history are associated with development of oral cancer?
Case Study 2: (2 pages), Chapter 47, Management of Patients With Gastric and Duodenal Disorders
- Crystal Monte, 32 years of age, is a female patient who is admitted to the medical-surgical unit after a laparoscopic Roux-en-Y gastric bypass for weight loss. Prior to choosing the surgery, the patient tried numerous diets and exercise programs without success and developed metabolic syndrome that led to insulin resistance. The patient’s parents both had complications related to morbid obesity and diabetes, so the patient wanted to have successful long-term weight loss and to decrease the risk factors for developing diabetes. The patient met with the multidisciplinary team before surgery, which consisted of a social worker, nurse counselor, dietitian, psychologist, exercise therapist, and surgeon. The patient received intensive preoperative teaching and followed the diet she would follow after surgery for several weeks before the operation.
a.What nursing management should be provided for the patient postoperatively?
b.What discharge instructions should the nurse provide the patient?
- Ms. George is a 32-year-old computer programmer. Over the last several months, she has had increased episodes of a burning sensation in the mid epigastrium and back. The pain subsides after eating. Based on her history, the physician orders an endoscopy that reveals several peptic ulcers. Treatment of the ulcers includes antibiotics, proton pump inhibitors, and bismuth salts. (Learning Objectives 1 and 3)
a.Correlate Ms. George’s clinical presentation to the pathophysiology of peptic ulcers.
b.Ms. George asks why eating decreases her pain; how does the nurse respond?
c.Explain the rationale for the prescribed pharmacologic therapy.
Case Study 3: (2 pages) Chapter 48, Management of Patients With Intestinal and Rectal Disorders
- Paul Jones, a 35-year-old patient, presents at the clinic after a CT scan of the abdomen with contrast was positive for diverticulitis. The patient presents with nausea, vomiting, fever, and chills; left lower quadrant abdominal pain described as spasms; and a firm mass. Bowel sounds are present in all four quadrants. The patient reports bouts of constipation with a hard narrow stool that is difficult to pass and periods of diarrhea with abdominal cramping. The stool is negative for occult blood. The patient has no other medical conditions. The vital signs include: BP 110/70, P 100, R 22, and T 101°F. The white blood count and ESR are elevated. The physician orders a broad spectrum antibiotic, amoxicillin clavulanate for 10 days, and propantheline bromide (Pro-Banthine) before meals and at bedtime, psyllium (Metamucil), and docusate sodium (Colace). Diet is as follows: clear liquids until inflammation subsides for 24 to 48 hours, and then advance diet, as tolerated, increasing the intake of fresh fruits and vegetables at least five servings per day, and bran cereal every day. The patient is also instructed to eat whole grain bread. (Learning Objective 3)
a.What questions should the nurse ask the patient while taking a history?
b.What patient education should the nurse provide to the patient being treated for diverticulitis on an outpatient basis?
- Mr. Thompson sustained a gunshot wound to the abdomen and underwent an exploratory laparotomy and creation of an ileostomy due to damage to the small bowel. You are assigned to care for Mr. Thompson on the third postoperative day. He has a nasogastric tube to low intermittent suction, and he is emitting greenish aspirate. IV access is through a triple lumen right subclavian catheter, and he is receiving D5 0.9% NS with 20 mEq K (potassium)/liter. Mr. Thompson has a dressing to the left abdomen, and there is moderate amount of fluid draining out of his ileostomy.
a.What is the rationale for the nasogastric tube to low intermittent suction?
b.Mr. Thompson is at risk for which kinds of electrolyte imbalances?
c.Upon assessment of the stoma, what findings substantiate a healing stoma?
d.Mr. Thompson asks when his bowel output will become more solid and if he will be able to have a continent ostomy. How should the nurse respond?
e.What is the rationale for a low residue diet in the patient with an ileostomy?
Case Study 4: (2 pages), Chapter 45, Digestive and Gastrointestinal Treatment Modalities
- Molly Baker, a patient 35 years of age weighs 72 kg. She was admitted to the burn unit for full-thickness or third-degree burns over 36% of her body surface according to the use of the rule of nines. She has a paralytic ileus and has high residuals with enteral feeding using the nasojejunal tube. The physician ordered a lower rate for the enteral feeding and ordered total parenteral nutrition (TPN) via a subclavian triple lumen catheter to provide the patient’s nutritional needs. When a patient has burns over a large portion of the body, the patient is in a hypermetabolic state and usually requires 35 to 40 kcal/kg/day and needs 25% of the calories each day in high biologic value proteins.
a.What nursing measures should the nurse implement to prevent potential complications related to the patient’s enteral feeding?
b.What nursing measures should the nurse implement to prevent potential complications related to the administration of TPN?
- The nurse working in a rehabilitation facility receives a patient from the acute care hospital for management after a severe closed-head injury. The patient is in a semiconscious state, and has impaired swallowing. The admission orders call for insertion of a nasogastric (NG) tube for feedings and medication administration.
a.What is the correct method for measuring the length of an NG tube for correct placement in the stomach?
b.You note that the student caring for Mr. Fields is verifying tube placement by listening when a bolus of air is injected into the NG tube via a syringe. How should you intervene? What other methods can the student use to verify tube placement? What is the rationale?
c.What is the correct procedure for administering medications via an NG tube that has a continuous feeding infusing?
d.The patient develops diarrhea the second day at the rehabilitation facility. The nurse assesses for which electrolyte abnormalities? What actions can the nurse implement to decrease the diarrhea?
Case Study 5: (2 pages) –Chapter 24, Management of Patients With Chronic Pulmonary Disease
- Howard Long, 50 years of age, is a male patient diagnosed with bronchiectasis. He has smoked 1 pack per day of cigarettes for 35 years. He has a long history of recurrent bronchial infections. He has a chronic productive cough with copious amounts of purulent sputum. The patient complains that he is short of breath even at rest. He has clubbing of his fingers. The chest CT scan reveals bronchial dilation.
a.How should the nurse explain to the patient and family the pathophysiology of bronchiectasis as it is related to the symptoms the patient is experiencing?
b.How should the nurse explain to the patient and family the goals of medical management that may be used to treat the bronchiectasis?
c.What does the nursing management for bronchiectasis entail?
- Sallie Thorp, a 21-year-old patient, presents to the physician’s office with an asthma action plan form she acquired from a literature search on the World Wide Web at http://www.nhlbi.nih.gov/health/public/lung/asthma/asthma_actplan.pdf. She states that she would like to develop the plan with the help of the nurse and physician and review it at each appointment to keep it current. She has had moderate persistent asthma for 5 years, and she has visited the emergency department several times in the past year with severe asthma attacks. She stated that she forgets to take her medications, because the medications are at times that the hospital provided the inhalers (12 noon and midnight), and she gets confused on which inhalers are the long-acting ones and which inhaler is the short-acting rescue inhaler she is supposed to use when she has an exacerbation. She stated that if she could, she would like to take the inhalers at 8 am and again at 8 pm. The patient stated that she has a flow meter and that a respiratory therapist at the hospital taught her how to use it in the past, and he wrote down her personal best peak flow, which is 400 L/sec. The nurse reviews the patient’s medical chart and discovers that she has been prescribed the following from today’s visit:
Use albuterol (Proventil): 2 to 4 puffs every 20 minutes for up to 1 hour as rescue inhaler. If symptoms improve, then take the inhaler every 4 hours for 1 to 2 days. If no improvement after 2 days, call the physician.
Salmeterol (Serevent): 50 mcg every 12 hours
Fluticasone (Flovent): 88 mcg or 2 puffs every 12 hours
Cromolyn sodium (Nasalcrom): one spray to each nostril once daily and before being exposed to known asthma triggers. You may use the spray up to every 4 hours.
Measure peak flow meter every morning before using inhalers and record. Use peak flow meter, as needed, if you develop symptoms, such as cough, shortness of breath, wheezing, chest tightness; use of neck and chest muscles to breathe; problems talking or walking because of extreme shortness of breath.
Follow-up in 3 months.
Have the nurse provide education on asthma self-management and fill out the action plan that the patient brought with her today and have the physician review it and sign it.
The nurse also notes that the medications have not changed from the last visit.
a.Print out the form and complete the form using the information from the case study.
b.Explain the medications to the patient and practice filling in the asthma action plan.
c.Explain ways to evaluate the patient’s mastery of the content?
Case Study 6: (2 pages)– Chapter 12, Pain Management
- Mr. Will, a 67-year-old patient, is postoperative day 2 after a coronary artery bypass graft operation to revascularize his coronary arteries that were significantly blocked. He has a midline incision of his chest and a 7-inch incision on the inner aspect of his right thigh where a saphenous vein graft was harvested and used to vascularize the blocked coronary artery. The surgeon ordered Oxycodone 5 mg every 4 hours PRN for moderate pain and Oxycodone 10 mg every 4 hours PRN for severe pain. (Learning Objectives 7 and 8)
a.Considering the patient’s age, what medication administration considerations should the nurse incorporate into the pain management plan and why?
b.What measures should the nurse provide the patient to prevent adverse effects of analgesic agents from occurring?
c.What nonpharmacologic pain management methods should the nurse teach to Mr. Will to assist with pain management?
- Mr. Rogers is 2 days postoperative of a thoracotomy for removal of a malignant mass in his left chest. His pain is being managed via an epidural catheter with morphine (an opioid analgesic). As the nurse assumes care of Mr. Rogers, he is alert and fully oriented, and states that his current pain is 2 on a 1-to-10 scale. His vital signs are 37.8 – 92 – 12, 138/82.
a.What are benefits of epidural versus systemic administration of opioids?
b.The nurse monitors Mr. Rogers’ respiratory status and vital signs every 2 hours. What is the rationale for these frequent assessments?
c.The nurse monitors Mr. Rogers for what other complications of epidural analgesia?
d.Mr. Rogers complains of a severe headache. What should the nurse do?
e.Mr. Rogers’ epidural morphine and decreased mobility increase his chances of constipation. What interventions should be included in his plan of care to minimize constipation?
Case Study 7: ( 2 pages) Chapter 14, Shock and Multiple Organ Dysfunction Syndrome
- Adam Smith, 77 years of age, is a male patient who was admitted from a nursing home to the intensive care unit with septic shock secondary to urosepsis. The patient has a Foley catheter in place from the nursing home with cloudy greenish, yellow-colored urine with sediments. The nurse removes the catheter after obtaining a urine culture and replaces it with a condom catheter attached to a drainage bag since the patient has a history of urinary and bowel incontinence. The patient is confused, afebrile, and hypotensive with a blood pressure of 82/44 mm Hg. His respiratory rate is 28 breaths/min and the pulse oximeter reading is at 88% room air, so the physician ordered 2 to 4 L of oxygen per nasal cannula titrated to keep SaO2 greater than 90%. The patient responded to 2 L of oxygen per nasal cannula with a SaO2 of 92%. The patient has diarrhea. His blood glucose level is elevated at 160 mg/dL. The white blood count is 15,000 and the C-reactive protein, a marker for inflammation, is elevated. The patient is being treated with broad-spectrum antibiotics and norepinephrine (Levophed) beginning at 2 mcg/min and titrated to keep systolic blood pressure greater than 100 mm Hg. A subclavian triple lumen catheter was inserted and verified by chest x-ray for correct placement. An arterial line was placed in the right radial artery to closely monitor the patient’s blood pressure during the usage of the vasopressor therapy. (Learning Objectives 6 and 7)
a.What predisposed the patient to develop septic shock?
b.What potential findings would suggest that the patient’s septic shock is worsening from the point of admission?
c.The norepinephrine concentration is 16 mg in 250 mL of normal saline (NS). Explain how the nurse should administer the medication. What nursing implications are related to the usage of a vasoactive medication?
d.Explain why the effectiveness of a vasoactive medication decreases as the septic shock worsens. What treatment should the nurse anticipate to be obtained to help the patient?
e.Explain the importance for nutritional support for this patient and which type of nutritional support should be provided?
- Carlos Adams was involved in a motor vehicle accident and suffered blunt trauma to his abdomen. Upon presentation to the emergency department, his vital signs are as follows: temperature, 100.9°F; heart rate, 120 bpm; respiratory rate, 20 breaths/min; and blood pressure, 90/54 mm Hg. His abdomen is firm, with bruising around the umbilicus. He is alert and oriented, but complains of dizziness when changing positions. The patient is admitted for management of suspected hypovolemic shock.
The following orders are written for the patient:
Place two large-bore IVs and infuse 0.9% NS at 125 mL/hr/line
Obtain complete blood count, serum electrolytes
Oxygen at 2 L/min via nasal cannula
Type and cross for 4 units of blood
Flat plate of the abdomen STAT
(Learning Objectives 1, 4, and5)
a.Describe the pathophysiologic sequence of events seen with hypovolemic shock.
b.What are the major goals of medical management in this patient?
c.What is the rationale for placing two large-bore IVs?
d.What are advantages of using 0.9% NS in this patient?
e.What is the rationale for placing the patient in a modified Trendelenburg position?