Case Study: Cardiovascular Alterations

Book Use: Introduction to Critical Care Nursing Sixth edition by Sole/Klein/Moseley
Case Study
Cardiovascular Alterations
Chapter 12
Mrs. D presents to the ER complaining of progressive dyspnea on exertion and lower leg edema over the past 3 days. She states that she cannot climb the stairs to her second-floor bedroom without gasping for air, which she had no problem doing last wk. The ER nurse attaches Mrs. D to the cardiac monitor and obtains a set of vital signs. Mrs. D is in the
following rhythm (see attached document). Her BP is 170/94 mm Hg and her RR is 28 breaths/min and labored. Her O2 sat is 96%. She is placed on 2 liters oxygen by nasal cannula. The nurse inserts an intravenous catheter (saline lock) and obtains a brief history from the patient.
The interview indicates that Mrs. D. is a 68 yr old female with a history of hypertension, diabetes, and coronary artery disease. She had an MI 3 years ago. She has never smoked, uses alcohol only socially, and has no allergies. Her height is 65 inches and she weights 150 lbs. Meds include carvedilol 25 mg BID, lisinopril 40 mg QD, simvastatin 20 mg QD at bedtime, and aspirin 81 mg daily. She states that she has been compliant with taking her medications. Her diabetes is well controlled with diet.
Lab tests and 12 lead EKG ordered. Results below.
Physical exam
Crackles ½ up bilaterally on posterior examination
S1 and S2 and S3
1 plus pitting edema bilaterally up to her mid calves
BUN 20 mg/dL
R 1.0 mg/dL
Na 144 mEq/L
K 4.0 mEq/L
Chloride 109 mEq/L
Carbon dioxide 33 mEq/L
Glucose 123 mg/dL
Magnesium 1.5 mEq/L
BNP 656 ng/L
Cardiac Enzymes negative
CBC Normal
1) What is the rate and rhythm Mrs. D presents with? If you can't name it, how would you describe it to the MD?
2) What is Mrs. D primary nursing diagnosis? What data helped you come to this decision?
3) What would you expect as the treatment for this diagnosis?
4) Where will that drug work with respect to preload, afterload, and contractility?
5) What labs would you expect to monitor based on Mrs. D's drug treatment you described in answer 4?
6) What test would you expect to be ordered next to evaluate the patient's heart function? (EF)
7) What is a normal EF?
8) Prior to discharge, list two important teaching points to teach Mrs. D. How will you be sure she understands what you taught her? (Think back to wk 1 lecture on effective communication strategies)
9) Look at the12 lead EKG attached- where do you think Mrs. D's old MI was located? What coronary vessel do you think has an occlusion?
10) Evidenced based practice tells us what 2-3 drugs are the standard therapy for essentially all patients with this diagnosis. (HINT- patients often only need two drugs initially, then a third drug is added as the disease progresses).