NURS 307: Concepts of Adult Health Nursing

NURS 307: Concepts of Adult Health Nursing

Unfolding Case Study: Cardiovascular Complications

E. P. Wieber | NDSU | 9/24

Instructions:

Review the entire case study (parts 1-3), then complete a bowtie concept map for Mr. Thompson based on your assigned priority

problem and the case presented.

Part 1: Review Case 1. Review the entire case study.

2. Choose two priority concepts from the table below. a. Concepts can relate to any part of the case or primary medical diagnosis (PMD) – part 1, 2, or 3. Focus on one

part when completing the concept map.

Concept Options:

Options for Patient Problems (choose one for each bowtie)

Oxygenation

Perfusion

Skin Integrity

Fluid/Electrolyte balance

Infection

Nutrition

Teaching/Learning

Elimination (bowel or bladder)

Endocrine

Part 2: Complete Two (2) Bowtie Concept Maps 1. Patient Problem (Blue box):

a. Add priority problems chosen above to the blue box at the center of

each concept map

b. Add “related factors” (r/t) – Physiologic factors related to the patient problem

c. Add “secondary factors” (s/t) – Medical diagnosis (the PMD noted in ONE part

of the case study) i. Focus on one pathophysiologic process/PMD in each bowtie; don’t add in multiple secondary factors.

2. Cues (Yellow Boxes): a. Add 6 cues (3-4 signs/symptoms/lab findings and 2-3 risk factors) relevant to the “patient problem” and/or

related/secondary factors (blue box).

i. Cues should come directly from ONE PART of the case study, but may be presumed based on knowledge of

pathophysiology and nursing care related to PMD. ii. Risk factors (i.e. patient history) may be taken from any previous part of the case study.

3. Actions (Green boxes): a. Add 5 different nursing actions/interventions related to the “patient problem” (blue box).

i. Include rationale for each action/intervention.

ii. Actions/interventions should be presumed, based on knowledge of pathophysiology and nursing care related to

the PMD.

iii. Provider orders may be used to guide actions, but actions should be within nursing scope of practice.

4. Evaluate Outcomes (Red Box): a. Add relevant cues (signs/symptoms, lab findings, etc.) that would indicate to the nurse that the patient problem

(blue box) is resolving or improving: i. Signs/symptoms/lab values indicative of improved status.

ii. Signs/symptoms/lab values that indicate a complication of the PMD has not occurred.

Oxygenation

r/t bronchoconstriction and

increased mucous production

s/t COPD exacerbation

NURS 307: Concepts of Adult Health Nursing

Unfolding Case Study: Cardiovascular Complications

E. P. Wieber | NDSU | 9/24

Introduction: Each of the following case studies follow Phyllis Vance, a female with multiple endocrine disorders.

Patient Case 1: Type 1 Diabetes and Diabetic Ketoacidosis (DKA)

Admission Note

Chief Complaint: Nausea, vomiting, abdominal pain, and profound fatigue for 2 days.

History of Present Illness:

Phyllis Vance is a 48-year-old female with a history of Type 1 Diabetes diagnosed at age 26. She reports rationing insulin while recently ill with gastroenteritis, since she wasn’t eating and due to financial constraints. Symptoms began with nausea and fatigue, progressing to vomiting and abdominal pain. She notes increased urine output and thirst today.

Key Labs: Comprehensive Metabolic Panel (CMP):

• Blood glucose: 512 mg/dL

• Potassium: 5.5 mEq/L ABGs:

• pH: 7.15

• HCO3: 12 mmol/L

• Anion gap: 20 Urinalysis:

• Color: clear, cloudy

• Glucose: 4+

• Ketones: Large

Physical Exam:

Alert but fatigued. Kussmaul respirations noted. Dry mucous membranes. No focal abdominal tenderness. Complaints of nausea.

Vital Signs: Temperature: 99.8°F (oral) Heart Rate: 118 bpm Respiratory Rate: 28 breaths/min

Blood Pressure: 100/65 mmHg Oxygen Saturation: 98% on room air Weight: 68 kg (150 lbs)

Orders

1. Fluid Management: – Initiate 0.9% Normal Saline IV at 1 L/hr for the first 2 hours. – Transition to 0.45% saline at 250-500 mL/hr once MAP >70 mmHg

2. Insulin Therapy: – Begin IV insulin infusion at 0.1 units/kg/hr. Continue until blood glucose is < 250 mg/dL. – Once BG is below 250 mg/dL, switch to subcutaneous insulin (novolog) – sliding scale.

3. Electrolyte Monitoring and Replacement: – Monitor potassium every 2-4 hours. Add potassium chloride (20-40 mEq) to IV fluids if serum K+ < 5.5 mEq/L. – Monitor bicarbonate; administer only if pH < 7.0.

4. Infection Workup: – Obtain blood and urine cultures. – Administer empiric antibiotics (e.g., ceftriaxone) if infection suspected.

5. Monitor Labs: – Check blood glucose hourly – ABG every 2-4 hours – comprehensive metabolic panel every 4-6 hours.

NURS 307: Concepts of Adult Health Nursing

Unfolding Case Study: Cardiovascular Complications

E. P. Wieber | NDSU | 9/24

Patient Case 2: Hashimoto’s Thyroiditis and Hypoparathyroidism s/p Thyroidectomy

Admission Note

Chief Complaint: Fatigue, weight gain, cold sensitivity, neck swelling, and muscle cramps.

History of Present Illness:

Phyllis Vance, a 58-year-old female, presents with worsening fatigue, cold intolerance, and weight gain over the past 6 months. Six weeks ago, she underwent a total thyroidectomy for a multinodular goiter compressing the trachea. Since the surgery, she has experienced recurrent muscle cramps, paresthesias, and fatigue. She reports no improvement despite thyroid hormone replacement.

Key Labs: Pre-Surgery Labs: – TSH 10.8 μIU/mL (elevated) – Free T4 0.5 ng/dL (low) – TPO Antibodies positive. Post-Surgery Labs: – Serum calcium 7.0 mg/dL (low) – Ionized calcium 0.78 mmol/L (low) – Parathyroid hormone (PTH) 5 pg/mL (low) – Vitamin D 25(OH) 22 ng/mL (low-normal).

Physical Exam:

Puffy face, dry skin, and mild periorbital edema. Surgical scar noted in the anterior neck, well-healed. Positive Chvostek’s and Trousseau’s signs, indicating hypocalcemia.

Vital Signs: Temperature: 97.4°F (oral) Heart Rate: 62 bpm (bradycardic) Respiratory Rate: 16 breaths/min

Blood Pressure: 132/84 mmHg Oxygen Saturation: 98% on room air Weight: 78 kg (172 lbs)

Orders

1. Thyroid Hormone Replacement: – Continue levothyroxine 75 mcg PO daily. Recheck TSH and free T4 in 4-6 weeks

2. Calcium and Vitamin D Supplementation: – Calcium carbonate 1,000 mg PO three times daily with meals. – Calcitriol (active Vitamin D) 0.5 mcg PO twice daily.

3. Hypocalcemia Monitoring: – Check serum calcium, ionized calcium, phosphorus, and PTH daily until stable.

4. Emergency Calcium: – If ionized calcium less than 0.8 mg/dL (or if symptoms develop), administer calcium gluconate 1-2 g IV over 10 minutes. – Transition to oral calcium once calcium is greater than 1.1 mmol/L

5. Imaging and Follow-Up: – Neck ultrasound to assess for residual thyroid or parathyroid tissue if hypoparathyroidism persists.

NURS 307: Concepts of Adult Health Nursing

Unfolding Case Study: Cardiovascular Complications

E. P. Wieber | NDSU | 9/24

Patient Case 3: Primary Adrenal Insufficiency, Pituitary Adenoma, and Central Diabetes Insipidus (DI)

Admission Note

Chief Complaint: Fatigue, muscle weakness, weight loss, dizziness, excessive thirst, and frequent urination.

History of Present Illness:

Phyllis Vance, a 68-year-old female, presents with progressive fatigue, generalized muscle weakness, and significant unintentional weight loss over the past year. She also describes extreme thirst and polyuria over the last 3 months, requiring her to drink up to 6 liters of water daily. She reports dizziness upon standing and darkening of her palms and mucous membranes. Diagnostic Tests:

• inadequate cortisol response to ACTH stimulation test.

• A water deprivation test confirms central DI.

Key Labs: Serum Labs:

• Morning cortisol 2.5 μg/dL (low)

• ACTH 102 pg/mL (elevated)

• Sodium 149 mEq/L (elevated)

• serum osmolality 310 mOsm/kg (elevated) Urinalysis:

• urine osmolality 100 mOsm/kg (low)

• Spec. Grav: 1.003 (low)

• Glucose, proteins, ketones: negative Imaging: MRI brain reveals 6-mm pituitary microadenoma with mild stalk thickening.

Physical Exam:

Hyperpigmentation of palms, elbows, and oral mucosa. Orthostatic hypotension (BP drop from 110/70 mmHg supine to 82/60 mmHg standing). Signs of dehydration, including dry mucous membranes.

Vital Signs: Temperature: 97.8°F (oral) Heart Rate: 98 bpm Respiratory Rate: 18 breaths/min

Blood Pressure: 98/62 mmHg Oxygen Saturation: 98% on room air Weight: 65 kg (143 lbs)

Orders

1. Hormone Replacement: – Hydrocortisone 20 mg PO in the morning and 10 mg in the afternoon. – Fludrocortisone 0.1 mg PO daily.

2. DI Management:

– Desmopressin (DDAVP) 0.1 mg PO at bedtime; titrate based on urine output and serum sodium.

3. Monitor Labs:

– Serum cortisol, ACTH levels every 3-6 months.

– Serum electrolytes (Na+, K+, osmolality) every 1-2 days initially, then monthly during dose adjustments.

– Monitor urine osmolality and volume daily initially, then periodically.

4. Emergency Sodium Correction: – Administer hypertonic saline (3%) for severe hypernatremia (>155 mEq/L) or neurological symptoms.

5. Imaging and Follow-Up: – Repeat MRI brain in 6 months to evaluate pituitary adenoma progression and stalk changes.

NURS 307: Concepts of Adult Health Nursing

Unfolding Case Study: Cardiovascular Complications

E. P. Wieber | NDSU | 9/24

Instructions:

Review the entire case study (parts 1-3), then complete a bowtie concept map for Mr. Thompson based on your assigned priority

problem and the case presented.

Part 1: Review Case 1. Review the entire case study.

2. Choose two priority concepts from the table below (one concept from each group). a. Concepts can relate to any part of the case or primary medical diagnosis (PMD) – part 1, 2, or 3.

i. There is no ‘correct’ concept; all listed concepts are relevant to the patient case.

Concept Options:

Options for Patient Problem #1 (choose one)

Options for Patient Problem #2 (choose one)

Oxygenation

Perfusion

Fluid/Electrolyte balance

Infection

Pain

Teaching/Learning

Part 2: Complete Two (2) Bowtie Concept Maps 1. Patient Problem (Blue box):

a. Add priority problems chosen above to the blue box at the center of

each concept map

b. Add “related factors” (r/t) – Physiologic factors related to the patient problem

c. Add “secondary factors” (s/t) – Medical diagnosis (the PMD noted in ONE part

of the case study) i. Focus on one pathophysiologic process/PMD in each bowtie; don’t add in multiple secondary factors.

2. Cues (Yellow Boxes): a. Add 6 cues (3-4 signs/symptoms/lab findings and 2-3 risk factors) relevant to the “patient problem” and/or

related/secondary factors (blue box).

i. Cues should come directly from ONE PART of the case study, but may be presumed based on knowledge of

pathophysiology and nursing care related to PMD. ii. Risk factors (i.e. patient history) may be taken from any previous part of the case study.

3. Actions (Green boxes):

a. Add 5 different nursing actions/interventions related to the “patient problem” (blue box). i. Include rationale for each action/intervention.

ii. Actions/interventions should be presumed, based on knowledge of pathophysiology and nursing care related to

the PMD.

iii. Provider orders may be used to guide actions, but actions should be within nursing scope of practice.

4. Evaluate Outcomes (Red Box): a. Add relevant cues (signs/symptoms, lab findings, etc.) that would indicate to the nurse that the patient problem

(blue box) is resolving/has resolved: i. Signs/symptoms/lab values indicative of improved status.

ii. Signs/symptoms/lab values that indicate a complication of the PMD has not occurred.

Oxygenation

r/t bronchoconstriction and

increased mucous production

s/t COPD exacerbation

NURS 307: Concepts of Adult Health Nursing

Unfolding Case Study: Cardiovascular Complications

E. P. Wieber | NDSU | 9/24

Case Study Part 1: Initial Presentation & Diagnosis

Patient Name: Mr. James Thompson Age: 68 years old Gender: Male Chief Complaint: Chest pain, fatigue, and shortness of breath

Background: Mr. Thompson is a 68-year-old male who presents to the ER with complaints of substernal chest pain radiating to his left arm, fatigue, and shortness of breath. The pain began two days ago, worsens when lying flat, and is relieved when sitting up and leaning forward. He reports feeling increasingly weak over the past week and has been experiencing swelling in his ankles.

Medical/Surgical History: He has a history of hypertension, hyperlipidemia, and coronary artery disease (CAD). He underwent percutaneous coronary intervention (PCI) with stent placement two years ago. Home medications include aspirin, lisinopril, metoprolol, and atorvastatin.

Initial Assessment: • Vital Signs:

o BP: 140/88 mmHg o HR: 95 bpm, regular o RR: 20 breaths/min o Temp: 37.1°C (98.8°F) o O2 Sat: 94% on room air

• Cardiovascular: Distant heart sounds, pericardial friction rub on auscultation, S3 heart sound, 2+ pitting edema in both ankles.

• Respiratory: Crackles heard bilaterally at lung bases. • ECG: ST elevation in the inferior leads and diffuse PR depression. • Lab Results:

o Elevated troponin: 0.3 ng/mL (mildly elevated) o BNP: 580 pg/mL o WBC count: 11,000/mm³

The cardiologist suspects Mr. Thompson is experiencing pericarditis with possible progression of heart failure due to his history of

CAD and current symptoms. An echocardiogram reveals mild pericardial effusion, reduced ejection fraction of 35% (indicative of

systolic heart failure), and moderate mitral valve regurgitation.

Updated Diagnoses: 1. Coronary Artery Disease (CAD) 2. Acute Pericarditis 3. Systolic Heart Failure (HFrEF) 4. Mitral Valve Regurgitation

NURS 307: Concepts of Adult Health Nursing

Unfolding Case Study: Cardiovascular Complications

E. P. Wieber | NDSU | 9/24

Case Study Part 1: Initial Presentation & Diagnosis (cont’d)

Provider Orders:

• Continuous telemetry

• Titrate oxygen to keep SpO2 greater than 94%

• Strict I/Os

• Consults: o Cardiology o Cardiohoracic surgery

• Activity: o Bedrest o Bathroom privileges

• Diet: o 2 g sodium diet o 2000 mL fluid restriction

• Diagnostics: o Echocardiogram STAT o Daily chest x-ray o BMP q 24 hrs o BNP q 48 hrs

• Medications: o Ibuprofen 600 mg three times daily o Furosemide 40 mg IV twice daily o Spironolactone 25 mg PO daily o Metoprolol succinate 50 mg PO daily o Aspirin 81 mg PO daily o Lisinopril 10 mg PO daily o Potassium chloride 20 mEq PO once daily

NURS 307: Concepts of Adult Health Nursing

Unfolding Case Study: Cardiovascular Complications

E. P. Wieber | NDSU | 9/24

Part 2: Progression of Disease

Despite medical management, Mr. Thompson's condition worsens over the next 48 hours. He becomes progressively short of breath, especially at night, and develops orthopnea and paroxysmal nocturnal dyspnea. His weight has increased by 4 lbs since admission. The echocardiogram shows worsening mitral valve regurgitation and an increased pericardial effusion, though still mild.

New Findings: • Vital Signs:

o BP: 130/80 mmHg o HR: 105 bpm, irregular o RR: 24 breaths/min o O2 Sat: 90% on 2L NC

• Physical Exam: JVD, bilateral crackles up to mid-lung fields, worsening pitting edema. • Echocardiogram Findings:

o Left Ventricular Ejection Fraction (LVEF): 35% (reduced, consistent with systolic heart failure). o Left Ventricular Size: Mildly dilated, with global hypokinesis (weakened and reduced contraction throughout the

heart). o Valve Function:

▪ Mitral Valve: Moderate to severe mitral regurgitation. Regurgitant jet observed during systole, leading to increased left atrial volume. Thickened and prolapsed posterior leaflet, contributing to regurgitation.

▪ Aortic Valve: Mild aortic valve calcification, no significant stenosis. ▪ Tricuspid Valve: No regurgitation.

o Right Ventricular Function: Normal size and function. o Pericardial Effusion: Small to moderate pericardial effusion present, no signs of tamponade. The effusion appears

non-compressive but could worsen if fluid accumulates. o Pulmonary Artery Pressure: Elevated pulmonary artery systolic pressure (45 mmHg), consistent with pulmonary

hypertension. o Left Atrium: Enlarged due to volume overload from mitral regurgitation.

The cardiologist decides that Mr. Thompson may need valve surgery to address the worsening mitral regurgitation and prevent further heart failure progression. Cardiothoracic surgery was consulted and scheduled surgery for the following day.

Part 3: Post-Surgical Recovery

Mr. Thompson undergoes successful mitral valve repair. Postoperatively, he is transferred to the cardiac ICU for monitoring. He remains intubated for 12 hours but is weaned off the ventilator and extubated successfully.

Postoperative Day 1 Findings: • Vital Signs:

o BP: 125/78 mmHg o HR: 88 bpm, regular o RR: 18 breaths/min o O2 Sat: 96% on 2L NC

• Cardiovascular: S1 and S2 audible without rubs or murmurs, no friction rub. • Lungs: Clear to auscultation bilaterally.