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- 1. 83 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. 2 Scenario You are a public health nurse working at a county immunization and tuberculosis (TB) clinic. B.A. is a 61-year-old woman who wishes to obtain a food handler's license and is required to show proof of a neg- ative Mantoux (purified protein derivative [PPD]) test before being hired. She came to your clinic 2 days ago to obtain a PPD test for TB. She has returned to have you evaluate her reaction. 1. What is TB, and what microorganism causes it? • TB is the common term for tuberculosis. Years ago, it was known as consumption (some older adults still use that term). TB is a communicable disease; it is a requirement that cases be reported to the CDC. • Tubercle bacilli are called Mycobacterium tuberculosis, or M. tuberculosis for short. 2. What is the route of transmission for TB? TB is an airborne bacterium. 3. The Centers for Disease Control and Prevention (CDC) recommends screening people at high risk for TB. List five populations at high risk for developing active disease. • Medically underserved populations. • Recent immigrants from countries with high prevalence of TB. • Persons who have had domestic or occupational contact with infectious TB cases. • Alcoholics and IV drug abusers. • Residents and staff of acute and long-term care facilities, prisons, detention facilities, homeless shelters, and residential facilities for AIDS patients. Some employers may require proof that a person does not have TB before he or she is hired. • Individuals with chronic disease who are immunosuppressed or have multiple comorbidities. • Medical personnel who work in the microbacteriology lab. 4. Describe the two methods for TB screening. • The preferred method is a TB skin test (Mantoux Two-Step) performed by injecting 0.1mL of PPD (5 tuberculin units) intradermally in the midvolar region of the left arm using a 27-gauge needle on a tuberculin syringe. A discrete pale elevation of the skin (wheal) should be produced. The person then returns within 48-72 hours to be assessed for a reaction on the arm. This method is required for screening employees and volunteers who are working in or are applying for work at clinics, and for persons born in TB-endemic countries. Respiratory Disorders Case Study 18 Tuberculosis Difficulty: Beginning Setting: Public health clinic Index Words: tuberculosis (TB), Centers for Disease Control and Prevention (CDC) guidelines, diagnostic test, risk factors, public health, assessment 2Respiratory Winninghams Critical Thinking Cases in Nursing 5th Edition Harding Solutions Manual Full Download: http://alibabadownload.com/product/winninghams-critical-thinking-cases-in-nursing-5th-edition-harding-solutions-manual/ This sample only, Download all chapters at: alibabadownload.com
- 2. 84 PART 1 MEDICALSURGICAL CASES Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. • TB blood tests (also called interferon-gamma release assays or IGRAs) measure how the immune system reacts to the bacteria that cause TB. A TB blood test requires only one visit to draw blood for the test. The QuantiFERON-TB Gold test (QFT-G), QuantiFERON-TB Gold In-Tube test (GFT-GIT), and T-SPOT.TB test are three Food and Drug Administration–approved TB blood tests. Test results are generally available in 24 to 48 hours. 5. How do you determine whether a Mantoux test is positive or negative? • You measure the area of induration (not erythema), which is defined as a hardened area under the skin. The area is measured transverse to the long axis of the forearm. • The CDC has the following guidelines for positive Mantoux reaction: • A PPD induration greater than 5mm is considered positive for persons with, or at risk for, HIV infection; those who have had close, recent contact with someone who has infectious TB; or persons who have a CXR that shows old, healed TB, patients with organ transplants, and people who are immunosuppressed for other reasons. • A PPD induration greater than 10mm is considered positive for foreign-born persons from high-prevalence countries; IV drug users; medically underserved, low-income populations; residents of long-term care facilities; people with chronic illnesses; mycobacteriology lab personnel; and all children and adolescents. • A PPD induration greater than 15mm is considered positive for all other persons. CASE STUDY PROGRESS B.A. consumes 3 to 4 ounces of alcohol (ETOH) per day and has smoked 1.5 packs of cigarettes per day for 40 years. She is a natural-born American, has no risk factors according to the CDC guidelines, lives with her daughter, and becomes angry at the suggestion that she might have TB. She admits that her mother had TB when she was a child but says she herself has never tested positive. She says,“I feel just fine and I don't think all this is necessary.” 6. What additional information would you want to obtain from B.A. before interpreting her skin test result as positive or negative? • Obtain a social history: ETOH ingestion, prescription or illegal drug use, smoking history; note domestic and occupational conditions. • Take a medical history: Exposure to TB, S/S of active TB infection, medications, PMH. Find out whether she has had regular access to health care. • Ask about current symptoms. 7. Determine whether B.A.'s skin test is positive or negative. 10 mm 20 30 40 50 B.A.'s test is positive because the area of induration is greater than 15mm. 2Respiratory
- 3. 85 CHAPTER 2 RESPIRATORY DISORDERS CASE STUDY 18 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. 8. B.A. asks you what a positive PPD result means. How will you respond? B.A. has been exposed to infectious TB. Because previous testing has been negative and this test was positive, B.A. may have been exposed to active TB since her last negative Mantoux test. 9. What steps will need to be done to determine whether B.A. has an active TB infection? First, B.A. will need a CXR. For persons with reactions greater than or equal to 10mm and persons with symptoms suggestingTB (e.g., cough, anorexia, weight loss, fever)—regardless of the size of the skin-test reaction—this should be done within 72 hours. If the CXR is abnormal, and/or symptoms compatible withTB are present, the patient should also have sputum smear and culture examinations. At least three sputum specimens should be submitted. In the absence of spontaneous production of sputum, suction of laryngeal or pharyngeal mucus is satisfactory if sterile water is used in clearing the catheter. CASE STUDY PROGRESS The physician orders a chest x-ray (CXR) and informs B.A. that her CXR is clear (shows no signs of TB). He tells her that she has a latent TB infection and that he will report her condition to the local public health department. The health department will monitor her over time and initiate treatment if she gets TB. 10. What is a latent TB infection (LTBI)? Persons with LTBI are infected with M. tuberculosis but do not have active TB disease; they do not feel sick or have any symptoms. The only sign of a TB infection is a positive reaction to the tuberculin skin test or to the TB blood tests. Persons with LTBI are not infectious and cannot spread TB infection to others. Overall, about 5% to 10% of patients with latent disease will develop active TB disease at some time in their lives. About half of those people who develop active TB will do so within the first 2 years of infection. For persons whose immune systems are weak, especially those with HIV infection, the risk of developing active TB disease is considerably higher than for persons with normal immune systems. 11. What parameters are used to determine whether treatment should be initiated for LTBI? Persons in the following high-risk groups should be given treatment for LTBI if their reaction to the Mantoux tuberculin skin test is greater than or equal to 5mm: • HIV-infected persons • Recent contacts of a TB case • Persons with fibrotic changes on chest radiograph consistent with old TB • Patients with organ transplants • Persons who are immunosuppressed for other reasons (e.g., taking the equivalent of greater than 15mg/day of prednisone for 1 month or longer, taking TNF-a antagonists) In addition, persons in the following high-risk groups should be considered for treatment of LTBI if their reaction to the Mantoux tuberculin skin test is greater than or equal to10 mm: • Recent arrivals (less than 5 years) from high-prevalence countries • Injection drug users • Residents and employees of high-risk congregate settings (e.g., correctional facilities, nursing homes, homeless shelters, hospitals, and other health care facilities) • Mycobacteriology laboratory personnel • Persons with clinical conditions that make them high risk • Children under 4 years of age, or children and adolescents exposed to adults in high-risk categories Because B.A. does not fall in to any of these categories, she would not be a candidate for preventive therapy, at this time. 2Respiratory
- 4. 86 PART 1 MEDICALSURGICAL CASES Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. 12. According to the most current CDC guidelines, what constitutes usual preventive therapy for LTBI? The preferred treatment regimen is the use of isoniazid (INH) for 9 months. Treatment must be modified if the patient is a contact of an individual with INH, multidrug-resistant TB, or is HIV positive. If the person is adherent to the isoniazid (INH) preventive therapy, it is highly effective in preventing latent TB infection from progressing to clinically apparent disease. 13. Different medications are associated with different side effects. Identify the test used to monitor each possible side effect listed as follows: A. Peripheral neuropathy B. Clinical hepatitis C. Fever and bleeding problems D. Nephrotoxicity/renal failure E. Hyperuricemia F. Optic neuritis G. Hearing neuritis 1. Audiogram 2. CBC (WBC and platelets) 3. Cr/BUN, Cr Cl (creatinine clearance) 4. AST/ALT 5. Physical exam and monofilament testing 6. Red-green discrimination and visual acuity 7. Uric acid Answers: A. 5; B. 4; C. 2; D. 3; E. 7; F. 6; G. 1 Monofilament testing is used to test sensation in the lower extremities. Clinical hepatitis is associated with elevations in aspartate aminotransferase (AST) and alanine aminotransferase (ALT) with a positive hepatitis C virus (HCV). Upward deviations in the WBC may signal an inflammatory event that accompanies a fever, and alterations in the platelet count can identify patients at risk for altered coagulopathy. Elevations in creatinine and BUN with a decrease in creatinine clearance signify diminished renal function associated with nephrotoxicity and acute renal failure. Uric acid levels are monitored for elevations. Those with optic neuritis might have alterations in red-green discrimination and visual acuity. An audiogram is used as a diagnostic test for determining the degree and type of hearing loss and would be used to detect hearing neuritis. 14. Nonadherence to drug therapy is a major problem that leads to treatment failure, drug resistance, and continued spread of TB. The CDC recommends two methods to ensure compliance with medication for all patients who have drug-resistant TB and for those who take medication two or three times every week. Identify one of those methods. • Direct observation therapy: A health care worker actually observes each patient take his or her medications. • Hospitalization until the tubercle bacilli is no longer identified in the sputum. 15. What information should B.A. receive before leaving the clinic? • She should understand the S/S of active TB (in case her TB becomes active)—for example, fever, night sweats, fatigue, anorexia, and weight loss. • She should be told that she will always have a positive TB skin test because she has been exposed. The only way to determine whether she has active disease is by CXR. CASE STUDY OUTCOME B.A. is hired under the condition that she must immediately report any signs and symptoms of active disease to the county health department or her physician and have a yearly CXR. 2Respiratory
- 5. 87 CHAPTER 2 RESPIRATORY DISORDERS CASE STUDY 19 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. Scenario M.N., age 40, was admitted with acute cholecystitis. After undergoing an open cholecystectomy, she is being admitted to your surgical floor. She has a nasogastric tube to continuous low wall suction, one peripheral IV, and a large abdominal dressing. Her orders are as follows: 1. Are these orders appropriate for M.N.? State your rationale. • M.N. should not receive a diet order until she resumes bowel sounds and passes flatus. Then the nasogastric tube will be removed, and M.N. can start eating. • M.N. would be NPO. It usually takes 48 to 72 hours for the bowels to resume peristalsis after abdominal surgery. • Morphine sulfate should be given in small doses (1 to 2mg) by IV more frequently (q1h prn). IM injections are both painful and unnecessary. 2. What gastrointestinal complication might result from one of the medications listed in M.N.'s orders? Morphine sulfate can result in constipation because of decreased peristalsis. As the stool sits in the colon, water is reabsorbed, thereby resulting in dry, hard stool. Any narcotic should be accompanied by a bowel management plan. CASE STUDY PROGRESS Four hours after admission, the nursing assistive personnel (NAP) reports to you the following: ■ Chart View Physician's Orders Progress diet to low-fat diet as tolerated D5 ½ NS with 40mEq KCl at 125mL/hr Turn, cough, and deep breathe q2h Incentive spirometer q2h while awake Dangle in AM, ambulate in PM Morphine sulfate 10mg IM q4h prn for pain Ampicillin (Omnipen) 2g IVPB q6h Chest x-ray in AM Case Study 19 Atelectasis Difficulty: Beginning Setting: Hospital Index Words: atelectasis, acute cholecystitis, chest x-ray (CXR), incentive spirometer (IS), medications, laboratory values, diagnostic tests, patient education, assessment, symptom management 2Respiratory
- 6. 88 PART 1 MEDICALSURGICAL CASES Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. 3. Based on her vital signs, what do you think could be happening with M.N., and why? • Her blood pressure, pulse, and respirations are high, perhaps because of incisional pain, fever (inflammatory process), or hypoxemia. • Temperature is elevated; this might be because of inflammatory response from infection (cholecystitis on admission) or a normal postoperative reaction. • Her SaO2 is low: Incisional pain might cause splinting and shallow respirations, resulting in atelectasis and/or hypoxemia. She might also be developing pneumonia or an embolus. 4. You know M.N. is at risk for postoperative pneumonia and atelectasis. What is atelectasis, and why is M.N. at risk? Atelectasis is a collapsed or airless state of the lung, which might be acute or chronic and might involve all or part of the lung. Inadequate lung expansion is a primary cause of postoperative atelectasis.The effects of anesthesia, reluctance to cough and deep breathing resulting from inadequate pain control or location of the surgical incision, and immobility contribute to inadequate lung expansion. 5. Describe the assessment you would need to perform to differentiate what might be occurring with M.N. Common presenting symptoms of atelectasis are dyspnea and hypoxia, which might be accompa- nied by fever, crackles, or diminished or absent breath sounds. Postoperative pneumonia generally occurs after the third postoperative day. Although there are similar symptoms as atelectasis, in addition, those with pneumonia usually have a productive cough and pleuritic chest pain. Pulmonary embolism is another postoperative complication. Common signs and symptoms are tachypnea, anxiety, tachycardia, dyspnea, pleuritic chest pain, cyanosis, and hypoxia. Atelectasis after a pulmonary embolism typically does not occur until 24 hours later. A chest x-ray (CXR) is the best way to distinguish between atelectasis and pneumonia. CASE STUDY PROGRESS Knowing M.N.'s vital signs, you do an assessment and auscultate decreased breath sounds and crackles in the right base posteriorly. Her right middle and lower lobes percuss slightly dull. She splints her right side when attempting to take a deep breath. She does not have a productive cough, chest pain, or any anxiety. You suspect that she is developing atelectasis. 6. Describe four actions you would take next in the next few hours. • Administer pain medication, and tell her that you are going to let her rest for 20 minutes until the morphine has time to take effect; then you will be back to help her cough and deep breathe. • Demonstrate cough and deep-breathing techniques. Show her how to use a pillow to splint her incision, and coach her while she coughs, dangles at the side of the bed, and walks around the room. • Explain and demonstrate the correct use of the incentive spirometer (IS). Have her use the IS every hour while awake. Vital Signs Blood pressure 148/82mm Hg Heart rate 118 beats/min Respiratory rate 24 breaths/min Temperature 101° F (38.3°C) SaO2 88% ■ Chart View 2Respiratory
- 7. 89 CHAPTER 2 RESPIRATORY DISORDERS CASE STUDY 19 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. • Reassess her vital signs every 2 hours and monitor for signs of deterioration. • Be prepared to call a physician if her condition worsens. 7. Outline nursing interventions that are used to prevent pulmonary complications in patients undergoing abdominal surgery. • Administration of pain medications should be given as frequently as necessary during the immediate postoperative period. • Encouraging and assisting the patient to turn, cough, and deep breathe at least every 1 to 2 hours to minimize the risk for atelectasis and pneumonia. • Position changes and range-of-motion exercises are instituted immediately after surgery and carried out every 1 to 2 hours. • Ambulatory efforts generally are begun on the evening of surgery. • Fluids are administered as ordered to thin secretions. 8. To promote optimal oxygenation with M.N., which action(s) could you delegate to the NAP? (Select all that apply.) a. Reminding the patient to cough and deep breathe b. Instructing the patient on the use of IS c. Assisting the patient in getting up to the chair d. Taking the patient's temperature and reporting elevations e. Encouraging the patient to splint the incision f. Auscultating the patient's lung sounds Answers: A, C, D, E To prevent pulmonary complications, patients should be encouraged to cough and deep breathe, ambulate as soon as possible, and splint the incision to minimize discomfort during activity. For patient safety, the nurse should enlist the assistance of other staff members, including NAP, dur- ing these efforts, while encouraging the patient to help. The NAP cannot instruct the patient on the use of the IS; teaching is the responsibility of the RN; however, the NAP could reinforce teaching provided by the RN. The NAP can take the patient's vital signs as long as the RN has given the NAP parameters that the NAP would need to report to the RN. Auscultating lung sounds is not within the scope of practice for the NAP. 9. Identify three outcomes that you expect for M.N. as a result of your interventions. • Decreased resting respiratory rate • Increased breath sounds over the right lower lobe by auscultation • Crackles clearing or clear lung sounds • SaO2 greater than 90% • Afebrile status • Resonant percussion 10. M.N.'s sister questions you, saying, “I don't understand. She came in here with a bad gallbladder. What has happened to her lungs?” How would you respond? • The sister and perhaps M.N. are concerned that something might have gone wrong with M.N. during her hospitalization. They need to be reassured. • State everything in positive terms. • Inform them that M.N. was very sick when she was admitted and that her incision site is painful. Explain that you are giving M.N. pain medication so that she will be able to cough and breathe deeply, move around in bed, and walk so that she will not develop atelectasis or pneumonia. • Assure them that M.N. is recovering well from surgery. • Show M.N.'s sister how to help M.N. with ambulation and coughing. 2Respiratory
- 8. 90 PART 1 MEDICALSURGICAL CASES Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. 11. Despite your interventions, 4 hours later M.N. is not improved. Using SBAR, what would you report to the physician? You would first need to identify yourself and the patient. Then, the nurse would describe the situation, focusing on the SaO2 of 88% and describing the earlier assessment findings: 118, 24, 101° F, auscultated decreased breath sounds and crackles in the right base posteriorly, right middle and lower lobes percussed slightly dull, without productive cough, chest pain, or any anxiety. You state how many hours postoperative the patient is; review the interventions you performed, including pain medications given, ambulation efforts, and the use of IS and coughing and deep breathing; and review the current status of the patient. You would conclude your remarks with the belief that atelectasis is present and the recommendation that a CXR is needed. 12. The physician orders a CXR. Radiology calls with a report, confirming that M.N. has atelectasis. Will that change anything that you have already planned for M.N.? Explain what you would do differently if M.N. had pneumonia. • No. You should continue your plans and monitor effectiveness. • If M.N. had pneumonia, you would carry out the same plan and monitor the outcomes; the only thing that might change would be new antibiotics added to her treatment plan. 2Respiratory
- 9. 91 CHAPTER 2 RESPIRATORY DISORDERS CASE STUDY 20 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. Scenario S.R. is a 69-year-old man who presents to the clinic because his“wife complains that his snoring is difficult to live with.” 1. As the clinic nurse, what routine information would you want to obtain from S.R.? VS and O2 saturation Pertinent medical history: lung diseases such as asthma or emphysema, diabetes mellitus, hypothyroidism Environmental factors: wood-burning stove, animals in the home (especially birds and cats) Pertinent nasal problems: deviated septum, chronic sinusitis Allergies: particularly airborne particles such as animal dander, dust mites, cockroach droppings Medications he is currently taking: opioids, modafinil (Provigil), amphetamines (prescribed and illegal), OTC drugs, and herbals CASE STUDY PROGRESS After interviewing S.R., you note the following: S.R. is under considerable stress. He owns his own busi- ness. The stress of overseeing his employees, meeting deadlines, and carrying out negotiations has led to poor sleep habits. He sleeps 3 to 4 hours per night. He keeps himself going by drinking 2 quarts of coffee and smoking three to four packs of cigarettes per day. He has gained 50 pounds over the past year, lead- ing to a current weight of 280 pounds. He complains of difficulty staying awake, wakes up with headaches on most mornings, and has midmorning somnolence. He states that he is depressed and irritable most of the time and reports difficulty concentrating and learning new things. He has been involved in three auto accidents in the past year. S.R.'s vital signs are BP of 164/90, pulse of 92 beats/min, 18 breaths/min with SaO2 90% on room air. His examination is normal, except for multiple bruises over the right ribcage. You inquire about the bruises, and S.R. reports that his wife jabs him with her elbow several times every night. In her own defense, the wife states, “Well, he stops breathing and I get worried, so I jab him to make him start breathing again. If I don't jab him, I find myself listening for his next breath and I can't go to sleep.” You suspect sleep apnea. 2. Identify two of the main types of apnea, and explain the pathology of each. Central sleep apnea: This type of apnea is less common and occurs when the brain fails to send the appropriate signals to the inspiratory muscles to initiate respiration. There is no respiratory effort. Obstructive sleep apnea (OSA): This type of apnea is more common and is due to the obstruction and/or collapse of the tongue, uvula, and soft palate, forming a tight blockage that prevents air from entering the lungs. Respiratory effort continues despite lack of airflow—this is an apnea event. The actual cause of OSA is unknown, but sleep apnea is a potentially life-threatening condition. Early recognition and treatment are important because the long-term consequences of sleep apnea include MI, high BP (HTN), and arrhythmias. If it continues over a prolonged period, it can lead to pulmonary HTN and right-sided HF, polycythemia, and CVA. Although the mechanism is unknown, uncontrolled DM has been associated with apnea; conversely, controlling DM has been shown to control OSA. Difficulty: Beginning Setting: Clinic Index Words: sleep apnea, symptoms, polysomnogram, sleep hygiene, continuous positive airway pressure (CPAP), CPAP with mask over mouth and nose (BiPAP), durable medical equipment (DME) Case Study 20 Obstructive Sleep Apnea 2Respiratory
- 10. 92 PART 1 MEDICALSURGICAL CASES Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. 3. Identify at least five signs or symptoms of obstructive sleep apnea (OSA), and star those symptoms that S.R. is experiencing. • Cessation of respiration during sleep usually followed by gasping for breath* • Excessive daytime somnolence or fatigue* • Reports of“not feeling rested”in the morning* • Memory loss* • Poor judgment • Lethargy • High BP* • Confusion • Headache* • Weight gain* 4. What tests help the provider diagnose OSA? • Physical examination of the upper airway is performed. • Overnight screening oximetry test is done to determine whether the patient desaturates during sleep. • Polysomnogram is the gold standard for diagnosis, and it is often done if desaturation is detected during overnight screening oximetry. • Many insurance companies are authorizing limited channel monitoring to define and treat OSA. The polysomnogram is reserved for more complicated cases. • Portable sleep study in the home setting might also be used. 5. S.R. and his wife ask why it is so important to determine whether or not S.R. has OSA. You would tell them that properly diagnosing OSA is important because effective treatment is necessary to prevent which common complications of OSA? (Select all that apply.) a. Stroke b. Early onset of chronic obstructive pulmonary disease (COPD) c. Hypotension d. Right-sided heart failure e. Cardiac dysrhythmias Answers: A, D, E Complications that can result from untreated sleep apnea include cardiovascular changes, such as hypertension, right-sided heart failure from pulmonary hypertension caused by chronic nocturnal hypoxemia, cardiac dysrhythmias, as well as an increased risk of stroke and insulin resistance. Untreated OSA does not lead to hypotension or an early onset of COPD. CASE STUDY PROGRESS The primary care provider (PCP) examined S.R. and documented a long soft palate, recessed mandible, and medium-sized tonsils. S.R.'s overnight screening oximetry study showed 143 episodes of desatura- tion ranging from 68% to 76%; episodes of apnea were also documented. He was diagnosed with OSA with hypoxemia, and a full sleep study is ordered. 6. S.R. and his wife ask about a full sleep study. How would you explain a polysomnogram to them? A polysomnogram will determine the depth and type of sleep, as well as how well you are breathing during sleep. The test will take place in a sleep laboratory; a sleep technician will monitor you throughout the night. Your chest and abdominal movement, oral airflow, nasal airflow, SpO2 , ocular movement, and heart rate and rhythm will be monitored. All of this monitoring will require that several wires be taped to your head and face. Although the testing will not be painful, you might find it difficult to sleep with all of the equipment attached to you and in the unfamiliar environment of the laboratory. 2Respiratory
- 11. 93 CHAPTER 2 RESPIRATORY DISORDERS CASE STUDY 20 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. 7. The PCP asks you to counsel S.R. about lifestyle changes that he could make immediately to help with his situation. Name four topics you would address with S.R. • Begin efforts to lose weight. He could immediately begin a walking program and start an appropriate diet. • Abstain from alcohol. • Avoid back sleeping. He can sew a pouch in the back of a nightshirt and put tennis balls in it, so he is less likely to sleep on his back. • Avoid opioids, benzodiazepines, muscle relaxants. • Elevate the head of bed (HOB). • Initiate smoking cessation efforts. He can enroll in a smoking cessation program, use nicotine patches, gum, or a prescription for bupropion (Zyban) to help him stop smoking. • Decrease caffeine intake. He can start mixing his coffee with decaffeinated coffee to decrease the caffeine. CASE STUDY PROGRESS S.R. returns for a follow-up visit after being diagnosed with OSA. He reports that he has lost 10 pounds, but there has been little improvement in his symptoms. He states that he fell asleep while driving to work and wrecked his car. He wants to discuss further treatment options. 8. What are the treatment options for OSA? Describe each. Appliances: Mild OSA can be treated using dental appliances that move and hold the mandible in a forward position. Continuous positive airway pressure (CPAP): A machine generates a continuous flow of air to the upper airways throughout the respiratory cycle. The airflow is delivered with sufficient pressure to prevent the upper airway from collapsing during inspiration. This method can be used through a ventilator, endotracheal tube, nasal pillow, nasal mask, or full face mask. CPAP with O2 : This is the same as CPAP but with added O2 through the machine or by nasal cannula. This method can be used with a nasal pillow, nasal mask, or full face mask. BiPAP: The mask fits over both the mouth and nose. SURGICAL OPTIONS Tonsillectomy, with or without adenoidectomy, or a uvulopalatopharyngoplasty (UPPP) (the removal of the uvula, part of the soft palate, and mucosa of the pharynx) might be done to enlarge the throat. Reports of success vary widely, from 40% to 80%. Mandibular advancement surgery for the congenital small mandible can be performed. Tracheostomy: This surgical procedure creates an artificial opening into the trachea from the neck. The patient places a cap over the opening during the day, allowing the patient to breathe and speak normally. The patient connects himself or herself to humidified O2 at night, thereby bypassing any upper airway obstruction. This treatment option is reserved for life-threatening sleep apnea. Bariatric surgery might be considered in the efforts to facilitate weight loss, therefore improving symptoms of OSA. CASE STUDY PROGRESS S.R. and the PCP decide on the least invasive treatment—continuous positive airway pressure (CPAP). The provider writes a prescription for CPAP.The patient has a choice of which durable medical equipment company he wants to get his equipment from. You help him by giving him the names of three reputable companies and advise him to call his insurance company to find out how much they will pay and how much he will be responsible for. 2Respiratory
- 12. 94 PART 1 MEDICALSURGICAL CASES Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. 9. S.R. calls in 2 weeks with complaints of dry nasal membranes, nosebleeds, and sores behind his ears. What advice would you give S.R.? • Instruct him to ask the DME company to check the mask and tubing to make sure they are fitting properly. • Instruct him to ask the company to add humidification to his O2 . • Get saline nasal spray at any drugstore or make your own. Use two sprays in each nostril up to q2h prn. A recipe for ocean saline spray: Boil water 20 minutes and let cool. Then to 1 quart water, add 1 tsp salt, plus a pinch of baking soda. Store at room temperature in a covered container for up to 72 hours, then discard. • Teach S.R. how to pad and protect the skin behind his ears. • Have him gently cleanse the nares every 8 hours with a cotton-tipped applicator moistened with saline. 2Respiratory
- 13. 95 CHAPTER 2 RESPIRATORY DISORDERS CASE STUDY 21 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. Scenario B.T., a 22-year-old man who lives in a small mountain town in Colorado, is highly allergic to dust and pol- len. B.T.'s wife drove him to the clinic when his wheezing was unresponsive to fluticasone/salmeterol (Advair) and ipratropium bromide (Atrovent) inhalers, he was unable to lie down, and he began to use accessory muscles to breathe. B.T. is started on 4L oxygen by nasal cannula and an IV of D5W at 15mL/hr. He appears anxious and says that he is short of breath. 1. Are B.T.'s vital signs (VS) acceptable? State your rationale. No. His systolic blood pressure is too high (152mm Hg), he is tachycardic (124 beats/min) and tachypneic (42 breaths/min), and his temperature is elevated at 100.4° F. B.T. is anxious and experiencing shortness of breath. His respiratory muscles are working hard to breathe, thereby increasing his metabolic rate, temperature, and stress. 2. What is the pathophysiology of asthma? The primary pathophysiologic process in asthma is chronic inflammation, which leads to airway hyperresponsiveness or hyperreactivity and acute airflow limitation. Asthma begins with exposure to allergens or irritants that initiates the inflammatory cascade. As the inflammatory process begins, mast cells beneath the basement membrane of the bronchial wall degrade and release multiple inflammatory mediators. Some of these inflammatory mediators have effects on the blood vessels, causing vasodilation and increasing capillary permeability. The effects of others include vascular congestion; edema formation; production of thick, tenacious mucus that fills the airway and inhibits the movement of air; bronchial muscle spasm; and thickening of airway walls. The increased swelling of tissue makes it more difficult to expand lungs with inspiration and results in decreased lung compliance. Impaired mucociliary function occurs as the increased mucus production covers cilia and inhibits their sweeping motion. 3. How is asthma categorized? Describe the characteristics of each classification. Asthma can be classified according to the frequency and severity of symptoms, the pattern of airflow limitation, and the treatment steps necessary to decrease symptoms or prevent exacerbations. Mild Intermittent Symptoms occur twice weekly or less. ■ Chart View Vital Signs Blood pressure 152/84mm Hg Pulse rate 124 beats/min Respiratory rate 42 breaths/min Temperature 100.4° F (38.4° C) Difficulty: Beginning Setting: Outpatient clinic Index Words: asthma, allergies, respiratory distress, patient education, assessment, aerosol treatment, inhaler Case Study 21 Asthma 2Respiratory
- 14. 96 PART 1 MEDICALSURGICAL CASES Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. Patient is asymptomatic between exacerbations. Exacerbations are brief (hours to days). Intensity of exacerbations varies. Nocturnal symptoms occur twice a month or less. Mild Persistent Symptoms occur more frequently than twice weekly but less often than once daily. Exacerbations might affect activity. Nocturnal symptoms occur more frequently than twice a month. Moderate Persistent Daily symptoms occur. Daily use of inhaled short-acting beta agonist is needed. Exacerbations affect activity. Exacerbations occur at least twice weekly and might last for days. Nocturnal symptoms occur more frequently than once weekly. Severe Persistent Symptoms are continuous. Physical activity requires limitations. Frequent exacerbations occur. Nocturnal symptoms occur frequently. 4. Interpret B.T.'s arterial blood gas results. B.T.'s pH indicates that he is acidotic. His PaCO2 level is high which indicates that he is retaining carbon dioxide, consistent with poor respiratory function. This means B.T. has respiratory acidosis. His bicarbonate level is within normal limits. B.T. lives at high altitude. Although his PaO2 will be decreased at this altitude, his SaO2 should be above 90%; the 88% SaO2 and the PaO2 55 indicate hypoxemia related to the asthma attack is at a level that could indicate impending respiratory failure. 5. What is the rationale for immediately starting B.T. on O2 ? Bronchoconstriction has caused an increase in airway resistance and a decrease in tidal volume (VT ). The goal of therapy is to compensate by increasing the concentration of inspired O2 . 6. You will need to monitor B.T. closely for the next few hours. Identify four signs and symptoms of impending respiratory failure that you will be assessing for. • Breathlessness at rest • Muteness • Inability to recline • Respiratory rate greater than 30 breaths/min • Paradoxic thoracoabdominal movement • Few or absent breath sounds ■ Chart View Arterial Blood Gases pH 7.31 PaCO2 48mm Hg HCO3 26mmol/L PaO2 55mm Hg SaO2 88% 2Respiratory
- 15. 97 CHAPTER 2 RESPIRATORY DISORDERS CASE STUDY 21 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. • Relative bradycardia • Absent pulsus paradoxus • Peak expiratory flow (PEF) less than 50% predicted • PaCO2 greater than 42mm Hg 7. What is the rationale for the albuterol 2.5mg plus ipratropium 250mcg nebulizer treatment STAT (immediately)? Albuterol (e.g., Ventolin, Proventil) is a fast-acting, beta-2 agonist that acts to relax and open airways and increase ciliary movement to help clear secretions. It may cause shakiness, nervousness, tachycardia, and/or increased BP, so B.T. should be closely monitored. Ipratropium is an anticholinergic that causes bronchodilation and inhibits secretions without causing systemic anticholinergic effects. The combination is more effective than either drug alone. 8. Identify the drug classification and expected outcomes B.T. should experience through using metaproterenol sulfate (Alupent) and Fluticasone (Flovent). Metaproterenol sulfate is a short acting beta-2 receptor adrenergic bronchodilator. It is used to reverse airway constriction caused by acute and chronic bronchial asthma. It has a rapid onset (a few minutes) and is used to treat acute bronchospasm. During acute exacerbations, it can be used every 3 to 4 hours. Fluticasone (Flovent), an inhaled corticosteroid, is used to control the inflammatory response that is believed to be a cause of asthma. It is often used concurrently with bronchodilators, primarily beta-adrenergic agonists. Flovent is typically taken twice daily. The use of this combination should result in reducing swelling, mucus production, and spasm in/of the airways resulting in the easing of airway constriction. 9. B.T. stated he had taken his Advair that morning, then again when he started to feel short of breath. Is fluticasone/salmeterol (Advair) appropriate for use during an acute asthma attack? Explain. No, it is not a fast-acting medication and is not appropriate for the relief of acute shortness of breath. An Advair inhaler contains two medications: It is a combination of a low-dose inhaled steroid (fluti- casone) that decreases the inflammation of the airways and a long-acting beta agonist (salmeterol) that acts as a bronchodilator. This pairing is useful in reducing swelling, mucus production, and spasm in/of the airways. For Advair to be most effective, it needs to be used regularly. 10. What are your responsibilities while administering aerosol therapy? A major nursing responsibility during aerosol therapy is to assess the effectiveness of the treatment, the patient's tolerance of the procedure, and the patient's ability to perform the procedure and to use equipment correctly. Assess breath sounds, work of breathing, and pulse oximetry readings and heart rate before and after treatments. After breathing treatments, you need to assist the patient with performing oral hygiene. ■ Chart View Medication Orders Albuterol 2.5mg plus ipratropium 250 mcg nebulizer treatment STAT Albuterol (Ventolin) inhaler 2 puffs q4h Metaproterenol sulfate (Alupent) 0.4% nebulizer treatment q3h Fluticasone (Flovent) 250mcg by MDI twice daily 2Respiratory
- 16. 98 PART 1 MEDICALSURGICAL CASES Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. 11. When combination inhalation aerosols are prescribed without specific instructions for the sequence of administration, you need to be aware of the proper recommendations for drug administration. What is the correct sequence for administering B.T.'s treatments? Whenever a beta-agonist (Alupent) is prescribed, the beta-agonist is always administered first, with a 5-minute wait before administration of the second drug. Therefore, the fluticasone (Flovent) should be given 5 minutes after the albuterol (Ventolin). Do not administer separate aerosols in rapid sequence because there is the possibility of inducing fluorocarbon toxicity, and there is a decreased effectiveness of both drugs. 12. List five independent nursing interventions that may help relieve B.T.'s symptoms. • Remove or loosen constrictive clothing. • Promote a quiet environment with minimal stimulation. • Elevate the head of the bed or have B.T. sit in a chair to promote maximum lung expansion. • Hydration will help thin pulmonary secretions and facilitate expectoration. This can be achieved by encouraging PO fluids. • Coach B.T. to cough effectively to facilitate airway clearance. • Coach B.T. in pursed-lip breathing to increase pressure throughout the airways and facilitate expiration. CASE STUDY PROGRESS After several hours of IV and PO rehydration and aerosol treatments, B.T.'s wheezing and chest tightness resolve, and he is able to expectorate his secretions. The physician discusses B.T.'s asthma management with him; B.T. says he has had several asthma attacks over the last few weeks. The physician discharges B.T. with a prescription for oral steroid “burst” (prednisone 40mg/day × 5 days), fluticasone/salmeterol (Advair) 100/50mcg two puffs twice daily, albuterol (Proventil) metered-dose inhaler (MDI) two puffs q6h as needed using a spacer, and montelukast (Singulair) 10mg daily each evening. He recommends that B.T. call the pulmonary clinic for follow-up with a pulmonary specialist. 13. What is the rationale for B.T. being on the oral steroid “burst”? Glucocorticoids reduce symptoms of asthma by suppressing inflammation. Specific anti-inflammatory effects include decreased edema of the airway mucosa; decreased synthesis and release of inflamma- tory mediators; and decreased infiltration and activity of inflammatory cells, including eosinophils and leukocytes. By suppressing inflammation, glucocorticoids reduce bronchial hyperreactivity. In addition to reducing inflammation, glucocorticoids decrease airway mucus production and increase the number of bronchial beta-2 receptors, as well as their responsiveness to beta-2 agonists. 14. What issues will you address in discharge teaching with B.T.? • Have his wife join him before giving B.T. any instructions. • Review and reinforce the information given by the physician for the benefit of B.T. and his wife.The physician told B.T. that his inhalers are OK for day-to-day control, but they act slowly and are not adequate to open his airways during an asthma attack.The physician gave B.T. a prescription for a fast-acting inhaler to help him open his airways and advised him to see a pulmonary specialist in the clinic. • Help B.T. and his wife make the pulmonary clinic appointment. • Educate the patient and wife on medications, dosage, and use, stressing which medications are used for acute attacks. • Demonstrate both MDI/spacer and peak flow techniques. • Have a written plan for exacerbations. • Have B.T. keep a journal to identify triggers (heat, humidity, cold, dry air, dust, animal dander, different pollens, perfumes, etc.). Once the patient is aware of the diagnosis, triggers become more evident. 2Respiratory
- 17. 99 CHAPTER 2 RESPIRATORY DISORDERS CASE STUDY 21 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. CASE STUDY PROGRESS You ask B.T. to demonstrate the use of his MDI. He vigorously shakes the canister, holds the aerosolizer at an angle (pointing toward his cheek) in front of his mouth, and squeezes the canister as he takes a quick, deep breath. 15. What common mistakes has B.T. made when using the inhaler? • Not using the spacer • Inhaling too fast (he should take a slow, deep breath) • Lack of coordination between activating the inhaler and initiating the deep breath • Angling the inhaler to spray the tongue or side of the mouth • Failing to hold his breath for 10 seconds after inhalation • Failing to clean the inhaler after each use, which results in crystallization of medication around orifice and failure to deliver entire dose • Failing to rinse mouth after using steroid inhalers, which can result in a Candida albicans infection in the oropharynx 16. What would you teach B.T. about the use of his MDI? • Instruct him in the use of the spacer (such as an Aerochamber). Research shows that spacers let patients get more medicine, and they don't have to worry about timing their breath with the discharge of the canister. If he is someplace and does not have a spacer, have him open his mouth wide, hold the MDI 1 inch from his lips, and spray during a deep inhalation (acts like a carburetor). • Remind him to hold his deep breath for 10 seconds before breathing out. • Instruct him to clean the MDI and spacer in warm water and place them on a paper towel to air dry. This should be done daily. • Instruct him to rinse his mouth with water after each use of inhaled corticosteroids 17. B.T.'s wife asks about the possibility of B.T. having another attack. How would you respond? • “Yes, it is very likely that B.T. will have another asthma attack in the future.” • “B.T. should become aware of triggers that seem to precipitate an exacerbation. He should keep an asthma diary and be prepared to avoid these triggers or appropriately treat the triggers. Management of asthma is the goal.” • “Pulmonary physicians specialize in pulmonary problems, such as asthma, and are knowledgeable about the latest treatments and drug therapy.” 18. B.T. states he would like to read more about asthma on the Internet. List three credible websites you could give him. Credible websites include those maintained by the National Institutes of Health (www.nhlbi.nih.gov); Asthma and Allergy Foundation of America (www.aafa.org); National Library of Medicine (www.nlm. nih.gov/medlineplus/asthma.html); and the Centers for Disease Control and Prevention (www.cdc. gov/asthma). 2Respiratory
- 18. 101 CHAPTER 2 RESPIRATORY DISORDERS CASE STUDY 22 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. Scenario L.B. is a 30-year-old secretary who is being seen in the clinic with 6 weeks of a dry, hacking cough after recovering from bronchitis this winter. The cough is worse at night and associated with shortness of breath. In the past, she has experienced coughing spells after running a 5K race. She has hay fever that seems to be year-round and has eczema in the winter. Both of her children and her maternal grand- mother have asthma. 1. As the intake nurse, what routine information do you want to obtain from L.B.? • VS, including oximetry • Personal and family history • Medications • Allergies, skin conditions • Description of her symptoms: location, quality, quantity, timing, setting, factors that aggravate or relieve, associated symptoms • Whether she has ever experienced these symptoms before 2. L.B.'s chief complaint is a cough. What are the main causes of chronic cough, and what questions should you ask to elicit information about each cause? Asthma • Do you have a history of asthma? • Do you ever experience musical breathing or wheezing? • Do you experience chest tightness or SOB? • Is your cough brought on by exercising, high pollen counts, cold air, laughing, or illness? Postnasal Drip • Do you have allergies or sinus problems? • Do you have chronic drainage down the back of your throat? • Do you have a tickle in your throat? • Do you clear your throat a lot? Gastroesophageal Reflux Disease • Do you experience acid reflux (does stomach acid come up into your throat)? • Is the heartburn worse after you eat certain foods or beverages, go to bed within 4 hours of eating a meal, exercise too soon after eating, or overeat? • How often do you take antacids or some type of stomach medication? • Do the antacids help your cough? Smoking • Have you ever smoked? • Do you currently smoke? • How many packs did you smoke, and how many years have you smoked? Difficulty: Intermediate Setting: Outpatient clinic Index Words: asthma, exercise-induced asthma assessment, peak flow meter (PFM), medications, patient education, symptom management Case Study 22 Asthma 2Respiratory
- 19. 102 PART 1 MEDICALSURGICAL CASES Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. Chronic Bronchitis • How long have you had this cough? • Do you cough up anything? • Have you had a productive cough at least 3 months of the year for 2 consecutive years? Medication Induced • What medications do you take? • Did your cough begin after starting any medication? Post-Respiratory Infection • Did your cough begin during a respiratory infection? CASE STUDY PROGRESS L.B. denies symptoms in answers to all of your questions except those given in the initial interview. She is not taking any medication other than a multiple vitamin. 3. What would you include in your physical examination, and why? VS: Carefully note respiratory effort, respiratory rate, and oximetry. ENT: There is a close correlation between asthma and allergic rhinitis; inadequately controlled allergic rhinitis correlates with uncontrolled asthma. Findings for allergic rhinitis are pale, boggy turbinates and serous otitis with or without mucous drainage in the posterior pharynx. Lung sounds: Often wheezing is heard, but breath sounds may be clear; if the patient's airways are very constricted, treatment with a beta agonist may relax the airways enough to hear wheezing. Patients with COPD often have distant breath sounds; patients with pneumonia may have crackles, wheezes, and egophony. Abdominal palpation: Look for gastric tenderness that often accompanies GERD. GERD is another trigger for asthma. L.B. reported increased cough at night. Skin: Eczema can be an atopic manifestation of asthma. CASE STUDY PROGRESS L.B. was not in acute distress.Vital signs were 110/60, 55, 18. She had no sinus tenderness, ears were nega- tive, nasal mucosa was pale and boggy, mouth was negative, there was no cervical adenopathy, and lungs were clear to auscultation. Forced expiration using the peak flow meter (PFM) generated a cough. Her peak flow was 350L/min with good effort. Expected peak flow for her height and age is 512L/min, giving a response of 68% of predicted. 4. The provider orders a predilator and postdilator pulmonary function test (PFT). What is the purpose of completing the PFTs predilator and postdilator? PFTs are performed initially, then 15 minutes after inhalation of a beta agonist. This is called a“pre- post dilator study”and is meant to determine whether a person has asthma. If L.B. has asthma, the postdilator maneuver will show more than 15% improvement in airflow. 5. The diagnosis of asthma is confirmed, and L.B. returns to the clinic for asthma education. What topics will you address? • Educate the patient that asthma is a controllable disease. • Explain what each medication is and why she is taking it. • Demonstrate PFM and MDI technique and ask for a return demonstration. • Encourage the patient to keep a journal to identify and treat triggers. The patient needs to track seasonal symptoms and symptoms related to temperature, humidity, dust, animal dander, pollen, perfume, etc. Once the patient is aware of the diagnosis, the triggers become more evident. • Makecertainshehasawrittenplantotreatexacerbationsandknowswhentoseekemergencyassistance. 2Respiratory
- 20. 103 CHAPTER 2 RESPIRATORY DISORDERS CASE STUDY 22 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. 6. What is a PFM? Give L.B. precise instructions to perform the PFM maneuver. PFM is a hand-held device that measures the maximum flow rate that can be generated when an individual takes a maximum inspiration then expels the volume with a maximum expiratory effort through the PFM device. Breathe in as deeply as you can, place the PFM in your mouth, and blow as hard and fast as you can, then record the reading. Repeat two times for a total of three measurements. Remembering that the PFM reading is effort dependent, it is important for the readings to be within 5% of each other. If one reading is much smaller than the other two, it should be discarded and another reading taken. A decreased PEFR indicates airway obstruction. The maneuver requires a consistent maximal effort on the part of the individual being tested. 7. L.B. asks why she has to use the PFM. Explain the purpose of the peak expiratory flow rate (PEFR) measurement and what role it plays in L.B.'s self-management of her asthma. The PEFR, measured in liters per minute, indicates the presence or absence of airflow obstruction. Normal PEFRs are based on height, age, and gender. PEFRs are used to monitor the effect of medication and can detect a worsening condition before symptoms are apparent to the individual. PEFR should be completed bid before and after inhaled medications for 2 weeks to develop a personal best or goal.The provider then calculates 80% and 50% of the patient's personal best and marks the meter with a green zone (which equals 80% to 100% of the personal best), yellow zone (50% to 79%), and red zone (below 50%). Readings in the green zone indicate that the patient is OK and may continue with daily activities. Readings in the yellow zone indicate that the patient is having a moderate asthma attack and should follow the plan for increasing the flow rate to the green zone. Readings in the red zone indicate the patient is having a severe asthma attack and should seek immediate medical assistance. It is important that each patient has a care plan to address what to do if the readings fall in the yellow or red zones. 8. The provider ordered triamcinolone (Azmacort) two puffs bid and albuterol (Ventolin) two puffs q6h prn. What points will you include when teaching L.B. about her medications? Asthma is an inflammatory disease, and triamcinolone is an anti-inflammatory drug. The goal of treatment for mild asthma is to identify triggers, control inflammation with an anti-inflammatory, and control secondary wheezing with a beta-2 agonist (albuterol). Albuterol is a bronchodilator that relaxes smooth muscles around the large airways. The albuterol MDI has fewer side effects than oral medication, but she might experience some anxiety, heart palpitations, or slight tremors. These symptoms can be worse if the MDI is not used correctly. 9. L.B. asks, “Why do I have to use this inhaler? Can't I just take some different pills?” Your response to L.B. is based on the knowledge that the inhalation route is: a. Safer and more effective than pills b. Less expensive than combination therapy c. Easier to master than oral therapy d. More likely to assist in curing her asthma Answer: A Because using the inhaled route delivers the drug directly to the lungs, lower drug doses are possible, and there are fewer systemic side effects. Unfortunately, there is considerable expense involved with some inhalers, and more manual dexterity is required to master an inhaler or other devices. Any medica- tion currently prescribed for asthma is used to control symptoms; they are not curative. 10. You instruct L.B. in the proper use of the metered-dose inhaler (MDI) using a spacer. How would you explain proper MDI use? • Remove the protective cap from the inhaler, shake well, and insert the inhaler into the back of the spacer. • Breathe out normally, put the opening of the spacer in your mouth, and close your lips around it. 2Respiratory
- 21. 104 PART 1 MEDICALSURGICAL CASES Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. • Spray one puff into the spacer, then slowly breathe in as deeply as you can over a period of 3 or 4 seconds (the spacer will whistle or make a musical sound if you breathe in too quickly). • Remove the spacer from your mouth, and hold your breath for 10 seconds, then exhale. • Wait 1 minute between puffs. 11. Because L.B. is taking two puffs twice daily of triamcinolone (Azmacort), how long should the inhaler last? The canister label states that it contains 200 inhalations. Answer: 50 days An inhaler typically has 200 inhalations: At 200/4 (2 × 2) = 50 days. The ordered dose is two puffs two times a day. The canister has a total of 200 puffs. You complete the following calculations to determine how long the MDI will last: 2puffs × 2timesaday = 4puffsper day 200puffs ÷ 4puffsper day = 50days 12. What will you teach L.B. to do if her PEFR value falls? If the PEFR is within the yellow zone, it indicates caution. Something is triggering the patient's asthma, such as a cold or infection. A temporary increase in medications, such as using a beta-2- adrenergic agonist inhaler more frequently, might be needed. If the PEFR is in the red zone, it indicates a serious problem and action must be taken. A typi- cal rescue plan consists of two to four puffs of a short-acting inhaled beta-2-adrenergic agonist for up to three treatments at 20-minute intervals or a single nebulizer treatment. The patient needs to contact or be seen by the health care provider. Depending on symptoms, oral corticosteroids may be indicated. 13. You would recognize the need for additional teaching if L.B. says: (Select all that apply.) a. “I will use the albuterol inhaler thirty minutes before exercising.” b. “My husband needs to know what to do in case I have an attack.” c. “I will keep a diary of all of my PEFR measures.” d. “I will place a plastic cover on our mattress and my pillows.” e. “The bed linens need to be washed in cold water to reduce dust mites.” Answer: A, E The treatment of asthma is aimed at avoiding known allergens and respiratory irritants and controlling symptoms and airway inflammation. Beta-2-adrenergic agonists are most successful at maintaining bronchodilation during exercise when they are inhaled 10 to 20 minutes before exer- cise. Bedding should be washed in hot water to reduce or destroy dust mites. A family member or significant other should be taught what can be done to help the patient during an asthmatic attack. This person should know where the patient's inhalers, oral medications, and emergency phone numbers are located. The significant other can also be instructed on how to decrease the patient's anxiety if an asthma attack occurs. All PEFRs should be written down in a journal that should be brought to each visit with the health care provider. CASE STUDY OUTCOME During a follow-up visit, L.B.'s asthma is listed as mild persistent asthma. Her peak flow on the albuterol (Ventolin) and triamcinolone (Azmacort) has increased to 450L/min, which is 88% of the predicted; her cough has subsided, and she can again participate in sports without problems. There is no nighttime awakening, no loss of work, and no emergency department visits. She can demonstrate appropriate inhaler technique and has her completed peak flow diary with her. 2Respiratory
- 22. 105 CHAPTER 2 RESPIRATORY DISORDERS CASE STUDY 23 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. Scenario The sister of C.K. brought her 71-year-old brother to the primary care clinic after he came down with a fever 2 days ago. She said he has shaking chills, a productive cough, and he can't lie down to sleep because“he can't stop coughing.”After C.K. is examined, he is diagnosed with community-acquired pneu- monia (CAP) and admitted to your floor. The intern is busy and asks you to complete your routine admis- sion assessment and call her with your findings. 1. Identify the four most important things to include in your assessment. • Obtain complete VS with SaO2 on room air. • Perform a full physical assessment, especially a cardiovascular and pulmonary assessment. • Ask about medication and drug allergies. • Question the patient about presence of pain or discomfort. • Determine nutritional status and fluid intake. • Determine a previous history (Hx) of pneumonia, pneumococcal polyvalent vaccine (Pneumovax), yearly flu vaccine. CASE STUDY PROGRESS Your assessment findings are as follows: C.K.'s vital signs are 154/82, 105, 32, 103° F (39.4° C), SaO2 84% on room air. You auscultate decreased breath sounds in the left lower lobe anteriorly and posteriorly and hear coarse crackles in the left upper lobe. His nail beds are dusky on fingers and toes. He has cough pro- ductive of rust-colored sputum and complains of pain in the left side of his chest when he coughs. C.K. seems to be well nourished and adequately hydrated. He is a lifetime nonsmoker. Past medical history includes coronary artery disease and myocardial infarction (MI) with a stent; he is currently on metopro- lol (Lopressor), amlodipine (Norvasc), lisinopril (Zestril), and furosemide (Lasix); for his type 2 diabetes mellitus, he is also taking metformin (Glucophage) and rosiglitazone (Avandia). He has never gotten the Pneumovax or flu shot. He does report getting“hives”when he took“an antibiotic pill”a few years ago but doesn't remember the name of the antibiotic. 2. Which of these assessment findings concern you? State your rationale. • C.K.'s pulse, respirations, and temperature are elevated; SaO2 indicates hypoxemia if Hgb and Hct are normal. • Decreased breath sounds in the LLL and crackles in the LUL may indicate fluid accumulation or atelectasis. • Dusky nail beds indicate lack of O2 uptake by the tissues. • Rust-colored sputum indicates blood and probable infection. • Pain with coughing is consistent with inflammation and/or infection. • Allergy to antibiotics: Try to find out whether he knows which one because, with his pulmonary infection, he will be started on an antibiotic. • The presence of comorbidities (CAD, MI, and DM) increases his mortality risk. Difficulty: Intermediate Setting: Hospital Index Words: pneumonia, assessment, laboratory values, medications, diagnostic tests Case Study 23 Community-Acquired Pneumonia 2Respiratory
- 23. 106 PART 1 MEDICALSURGICAL CASES Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. 3. Review the orders and outline a plan of what you need to do in the next 2 to 3 hours. The patient has a fever of 103° F (39.4° C). Start O2 , administer the Alupent treatment, order STAT CXR and blood cultures, and try to get the first sputum specimen and UA before beginning the antibiotic. Obtain admission blood work; start the IV fluids, and then repeat vital signs. 4. Is the IV fluid of D5 ½NS appropriate for C.K.? State your rationale. D5 ½ NS is considered a“hydrating fluid.”Solutions consisting of dextrose with hypotonic saline provide more water than is required for excretion of salt. C.K. has an infection and will need hydra- tion to help the body dispose of the infectious toxins and wastes. The rate of 125mL/hr is considered adequate for maintenance of normal fluid balance. However, because the solution contains dextrose and C.K. is a type II diabetic, he will require frequent monitoring of his blood glucose levels because the use of this solution might raise blood glucose levels. 5. What is the rationale for ordering O2 to maintain Sao2 over 90%? The order means that you are to titrate the O2 flow rate to maintain the saturation reading on C.K.'s oximeter (SaO2 ) above 90%. According to the oxyhemoglobin dissociation curve, a Hgb saturation of 90% (SaO2 of 90%) means that the partial pressure of O2 in the arterial blood (PaO2 ) is approximately 60mm Hg (remember that normal PaO2 at sea level is 80 to 100mm Hg). Below this point on the curve, the slope becomes very steep, which means that small decreases in Hgb saturation reflect larger decreases in PaO2 (e.g., SaO2 of 85% reflects a PaO2 of 50mm Hg; SaO2 of 80% means the PaO2 is 44mm Hg). 6. What is a C&S test, and why is it important? The term C&S means“culture and sensitivity.”A culture is a growth of an organism on a nutrient media to specifically identify the microbe. After the microbe is isolated, its susceptibility to specific antibiotics, or its sensitivity of the microbe to drugs, is determined. If required, broad-spectrum antibiotic therapy is prescribed until the C&S results are available and a more suitable antibiotic can be identified and prescribed. 7. Why were blood cultures ordered to be drawn? According to one theory, bacteria are being shed into the bloodstream when the patient spikes a tem- perature. Blood cultures should be drawn STAT and before any antipyretic agent or antibiotic is given to try to identify the infecting organism. Blood cultures are positive for a pathogen 7% to 16% of the time. ■ Chart View Physician's Orders 2100-Calorie ADA diet VS with temperature q2h IV of D5½NS at 125mL/hr Ceftriaxone (Rocephin) 1g IV bid Metaproterenol sulfate (Alupent) 0.4% nebulizer treatment q3h Titrate O2 to maintain SaO2 over 90% Obtain sputum for C&S Blood cultures for temperature over 102° F (38.9° C) CBC with differential and basic metabolic panel Urinalysis (UA) with C&S Chest x-ray (CXR) now and in the morning 2Respiratory
- 24. 107 CHAPTER 2 RESPIRATORY DISORDERS CASE STUDY 23 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. 8. Why are blood cultures drawn from two different sites? Blood is drawn from two different sites to increase the likelihood of culturing the offending organism. If the patient has an arterial or central venous catheter, one set of cultures might be withdrawn from the catheter after a 10-mL discard sample is withdrawn. Invasive catheters should always be suspected as a source of infection. 9. What would you expect the CXR results to reveal? • In a patient with pneumonia, you would expect the CXR to reveal patchy areas of consolidation in the area that is affected. • Other findings from the CXR would include size and fluid accumulation (in lungs, pleural space, or around heart), congestion in large blood vessels of the chest, and the placement of tubes and catheters. 10. The pharmacy sends the ceftriaxone (Rocephin) IV 1g in 100mL 0.9% NaCl with instructions to infuse over 40 minutes. At how many milliliters per hour will you regulate the IV infusion pump? Answer: 150mL/hr 11. Which of the following assessment findings would best indicate that C.K. is responding to therapy? a. Complaints of dyspnea; respiratory rate of 26 on 2L oxygen; clear lung sounds b. Cough productive of white sputum; temperature of 100.0° F (37.8° C); Sao2 98% on 2L NC c. Coarse crackles in posterior lower lobes; respiratory rate 22; no complaints of chills d. Cough productive of yellow sputum; lung sounds clear; Sao2 96% on room air Answer: D If C.K. is responding to therapy, it would be expected that an improvement in symptoms would be seen. Therefore, you would not expect continued complaints of dyspnea, coarse crackles in the posterior lower lobes, or a continued fever. A SaO2 96% on room air is satisfactory.While clearing of sputum is preferable, a cough productive of yellow sputum could be expected for several weeks following an episode of CAP. CASE STUDY PROGRESS C.K. recovers from his pneumonia and is preparing for discharge.You know that C.K. is at increased risk for contracting CAP infections. 12. Discuss four strategies for prevention. • Teach the importance of immunization with pneumococcal vaccine with a booster in 6 years for patients older than 60 years of age. • Teach the importance of yearly influenza vaccine. Each year, the CDC predicts which three strains of influenza virus will infect the United States. The vaccine is an inactivated antigen for all three strains. • Teach the importance of avoiding exposure to people with colds or flu. • Teach good handwashing technique. • Teach C.K. how to handle and properly dispose of secretions. • Teach the importance of PO fluids to thin pulmonary secretions and facilitate expectoration. 13. C.K. confides in you, “You know, my wife died a year ago, and I live alone now. I've been thinking ... this pneumonia stuff has been a little scary.” How will you respond? • Tell him you appreciate his sharing this with you. • Explore whether he wants to talk more about it. 100mL/40minutes : x/60minutes x = 150mL 2Respiratory
- 25. 108 PART 1 MEDICALSURGICAL CASES Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. • Inquire about his social support system. Does he have family or friends who can look in on him? • Recognize that he might be experiencing such psychosocial responses as grief, fear of death, and loneliness. Ask about a psychiatric nurse specialist or social services consultation if you consider it necessary. • How does he get his meals? How does he do his shopping and his laundry? Does he need a social services or a medical nutritional therapy consult? How about a referral to Meals-on-Wheels? • Make certain his concern is addressed in at least one concrete arrangement before he leaves the hospital. 2Respiratory
- 26. 109 CHAPTER 2 RESPIRATORY DISORDERS CASE STUDY 24 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. Scenario A.B., a 40-year-old man, is admitted to your medical floor with a diagnosis of pleural effusion. He com- plains of shortness of breath; pain in his chest; weakness; and a dry, irritating cough. His vital signs (VS) are 142/82, 118, respirations are 38 and labored and shallow, 102.1° F (38.9° C). His chest x-ray shows a large pleural effusion and pulmonary infiltrates in the right lower lobe consistent with pneumonitis. 1. Given his diagnosis, are A.B.'s admission VS expected? Explain. Yes. Because of pain, infection, possible anxiety, and other factors, A.B. has an increased metabolic rate; his body has to work harder to deliver O2 and nutrients to the cells. Because of this, A.B.'s SBP is slightly elevated, and he is tachycardic and tachypneic with shallow, labored breathing. His temperature is elevated because of an inflammatory response (pulmonary infection) and increased work of breathing. Hypoxemia will cause anxiety, increased heart rate, and SOB. 2. What is pleural effusion? Pleural effusion is an accumulation of either transudative (serous) or exudative (purulent material) fluid within the pleural space (between visceral and parietal pleura). 3. What is the difference between transudate and exudate? • Transudate is a watery fluid that diffuses out of the capillaries as a result of disorders that increase BP or decrease capillary oncotic pressure. • Exudate is a fluid with a high content of protein and cellular debris (pus) that has escaped from blood vessels and/or lymphatic vessels and has been deposited in tissues or on tissue surfaces, usually as a result of inflammation. 4. List three common causes of pleural effusion. Transudative • HF • Pulmonary edema or inflammation • Hypoproteinemia • Hemothorax—trauma, surgery, or malignancy Exudative • Pulmonary infections—pneumonia • Cancer—tumors 5. Review the pathophysiology and consequences of pleural effusion and pulmonary infiltrates. • The inflammation of the pleura alters capillary membrane permeability and impairs lymphatic drainage, resulting in excess pleural fluid. As the amount of exudate increases, it compresses lung tissue and reduces lung volumes. Ventilation to the affected area is decreased, but perfusion usually remains unchanged, resulting in a V . /Q . mismatch and hypoxemia. A.B.'s effusion freely moves to dependent areas of the lung; the fluid moves to the lower lobes when he is in the upright position and to the posterior lung fields when he is supine. Difficulty: Intermediate Setting: Hospital Index Words: pleural effusion, restrictive lung disease, pneumonitis, chest tube drainage systems, thoracentesis Case Study 24 Pleural Effusion and Restrictive Lung Disease 2Respiratory
- 27. 110 PART 1 MEDICALSURGICAL CASES Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. • Pulmonary infiltrate is the accumulation of fluid in the pulmonary tissues (parenchyma). The tissues become heavy and less elastic, thereby making it more difficult to move air in and out of the lungs and slowing diffusion of gases across the alveolar-capillary membrane. Also, accumulation of fluid in the pleural space reduces tidal volume, and hypoxemia continues. 6. How does the underlying pathophysiology give rise to A.B.'s presenting signs and symptoms? • Shallow, labored breathing is due to pulmonary infiltrates and fluid accumulation in the pleural space. • Weakness is due to hypoxemia related to fluid accumulation in the parenchyma (pulmonary infiltrates). • Pain in his chest is due to pleural irritation (pleuritic pain); the pleura are full of pain sensors. • A dry, irritating cough is most likely a result of pleural inflammation. 7. How do you differentiate between cardiac and pleural pain? A detailed description of chest pain helps distinguish whether pain is pleural or cardiac in origin. Ask the patient whether the pain is continuous or made worse by coughing, deep breathing, or swallowing. Cardiac pain is usually intense and“crushing.”It may also radiate to the arm, shoul- der, or neck. Cardiac pain may worsen with exercise. Pulmonary pain varies depending on the cause. Pain that feels like something or“rubbing”inside is more common with pulmonary pain. It commonly occurs on only one side of the chest, usually in the lower lateral portions of the chest wall. The pain might appear only on deep inhalation or be present at the end of inhalation and at the end of exhalation. Pleural pain might be aggravated by position changes or deep breathing. Referred shoulder pain might be either a cardiac or pleural condition. 8. How does A.B.'s increased metabolic rate affect his nutritional needs? He will need increased caloric intake to cover the additional work required by his body to deliver O2 and nutrients to the cells. CASE STUDY PROGRESS The physician performs a thoracentesis and drains 1500mL of fluid. A specimen for culture and sensitivity (C&S) is sent to the laboratory, and A.B. is started on cefuroxime (Ceftin) 1g IV piggyback q8h. 9. What is a thoracentesis? It is the removal of fluid from the pleural space using a needle or thin catheter. The fluid is sent for pathologic examination: C&S, cell count, glucose, and total protein. The thoracentesis can be repeated several times if fluid continues to accumulate in the pleural space. 10. The order for the cefuroxime (Ceftin) reads to infuse 1g in 100mL 0.9% NaCl over 30 minutes. You have IV tubing that supplies 20gtt/mL. At how many gtt per minute will you regulate the infusion? 50gtt/min (20gtt × 100mL/30min) 11. What maneuvers would promote the clearance of pulmonary secretions? • Coughing and deep breathing facilitate expectoration of secretions, promote lung expansion, and prevent atelectasis. • Use of an incentive spirometry promotes lung expansion and provides a visual feedback for A.B. For example, is he taking in enough air to expand his lungs? Incentive spirometry also provides an objective indicator to determine whether and when expected outcomes are achieved (appropriate volume for A.B.). • Nasal, oral, and pulmonary suctioning removes secretions. 2Respiratory
- 28. 111 CHAPTER 2 RESPIRATORY DISORDERS CASE STUDY 24 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. 12. The pleural C&S results indicate a large amount of Klebsiella organism growth that is not sensitive to cefuroxime (Ceftin). What action will you take next? Because the organism is not sensitive to the antibiotic, you would place the antibiotic on hold and notify A.B.'s physician of the C&S results. 13. Because fluid continues to collect in the pleural space, the physician decides to insert a pleural chest tube under nonemergent conditions. What is your responsibility as A.B.'s nurse? • Provide adequate analgesia. • Obtain a thoracotomy tray, various sizes of chest tubes (28 F and 32 F), sterile gowns, and extra packages of sterile gloves and towels. • Set up the chest drainage system, and adjust the suction pressure. • Ensure that sterile technique is maintained throughout the procedure. • Make certain the tubing connections are airtight and secured with adhesive tape or bands. • Make certain petroleum gauze is placed around the chest tube insertion site to create a complete seal. • Position the drainage system below the patient's chest. • Change A.B.'s position frequently. 14. Evaluate each of the following statements about chest tube drainage systems. Enter “T” for true or “F” for false. Discuss why the false statements are incorrect. ____ 1. It is the height of the column of water in the suction control mechanism, not the setting of the suction source, that actually limits the amount of suction transmitted to the pleural cavity. ____ 2. A suction pressure of +20cm H2 O is commonly recommended for adults. ____ 3. Bubbling in the water-seal chamber usually means that air is leaking from the lungs, the tubing, or the insertion site. ____ 4. The rise and fall of the water level with the patient's respirations reflect normal pressure changes in the pleural cavity with respirations. ____ 5. The chamber is a closed system; therefore, water cannot evaporate. ____ 6. To declot the drainage tubing, put lotion on your hands, compress the tubing, and vigorously strip long segments of the tubing before releasing. ____ 7. You lower the bed on top of the drainage system and break it. You immediately clamp the chest tube, leaving it clamped until you can reestablish the drainage system. ____ 8. The chest tube becomes disconnected from the drainage system. Because you noted an air leak from the lung during your initial assessment, you can submerge the chest tube 1 to 2 inches below the surface of a 250 mL bottle of sterile saline or water. ____ 9. The collection chamber is full, so you need to connect a new drainage system to the chest tube. It is appropriate to momentarily clamp the chest tube while you disconnect the old system and reconnect the new. ____10. The drainage system falls over, spilling the chest drainage into the other drainage columns. The total amount of drainage can be obtained by adding the amount of drainage in each of the columns. Answers: 1.T; 2. F; 3. T; 4. T; 5. F; 6. F; 7. F; 8. T; 9. T; 10. T Corrections to false statements: 2. Suction pressure is negative; −20cm H2 O is common. 5. The chest drainage system is not a closed system, and H2 O evaporates over time. Observe the H2 O level and add sterile H2 O or NaCl using a sterile catheter tip syringe as needed. 2Respiratory
- 29. 112 PART 1 MEDICALSURGICAL CASES Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. 6. This procedure, called chest tube stripping, is dangerous and should be avoided. Chest tube stripping can cause tissue biopsy (pieces of tissue are sucked through the holes of the chest tube); this procedure can generate up to 400cm H2 O pressure! 7. Clamping the chest tube in the presence of an air leak can result in a tension pneumothorax. If you disconnect the tubing without clamping the tubing, the lungs can pull air into the chest cavity; therefore, you need to clamp briefly to exchange the broken chamber for a new one. 15. How will you appropriately maintain A.B.'s chest tube system? • Frequently auscultate A.B.'s lungs. • Assess placement and site of chest tube frequently. • Observe and record amount, rate, and type of drainage. • Observe water seal fluid level. • Observe water seal fluctuations. • Evaluate any air leaks in system (bubbles in water seal). • Observe for fluid level and bubbling in suction control chamber. CASE STUDY PROGRESS After 7 days of aggressive antibiotic and pulmonary therapy, the chest tube is discontinued and A.B. is ready to be discharged. 16. What type of discharge instructions do you need to give to A.B.? • Because A.B. had a chest tube, he will need to keep a dressing over the site until instructed by the physician that the site is healed to prevent a pneumothorax. He will also need to notify the physician of signs of infection at the site, including fever or increasing redness, swelling, or drainage from the insertion site. • He will need to know the dates of his follow-up home care and clinic visit appointments. • Stress the importance of taking any medications that he will be taking at home as prescribed. • Instruct A.B. to maintain an adequate fluid intake and continue performing coughing and deep breathing efforts and using an incentive spirometer. He will need to get adequate rest until the cough, shortness of breath, and chest pain go away. He may use warm compresses or a moist heating pad to relieve any chest discomfort associated with coughing. • Instruct him to call the physician if he has a recurrence of symptoms, particularly fever and chills, increased shortness of breath, onset of nausea and vomiting, and a worsening of chest pain or cough. • Because coughing helps clear the airways of mucus and relieves the chest, instruct A.B. not to use cough medicine unless the physician has prescribed it. 2Respiratory
- 30. 113 CHAPTER 2 RESPIRATORY DISORDERS CASE STUDY 25 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. Scenario A.W., a 52-year-old woman disabled from severe emphysema, was walking at a mall when she suddenly grabbed her right side and gasped, “Oh, something just popped.” A.W. whispered to her walking com- panion,“I can't get any air.”Her companion yelled for someone to call 911 and helped her to the nearest bench. By the time the rescue unit arrived, A.W. was stuporous and in severe respiratory distress. She was intubated, an IV of lactated Ringer's (LR) to KVO (keep vein open) was started, and she was transported to the nearest emergency department (ED). On arrival at the ED, the physician auscultates muffled heart tones, no breath sounds on the right, and faint sounds on the left. A.W. is stuporous, tachycardic, and cyanotic. The paramedics inform the physician that it was difficult to ventilate A.W. A portable chest x-ray (CXR) shows an 80% pneumothorax on the right. 1. Given the diagnosis of pneumothorax, explain why the paramedics had difficulty ventilating A.W. Air escaped from the right lung into the pleural space. Eventually, enough air collected in the pleural space to cause the mediastinum to shift toward the left. The collapsed right lung increased intrapleural pressure, and the leftward shift placed pressure on the left lung, making it difficult to ventilate A.W. 2. Interpret A.W.'s arterial blood gases (ABGs). Significant respiratory acidosis with profound hypoxemia. Without immediate resuscitation, A.W. is near death. 3. What is the reason for A.W.'s ABG results? Eighty percent of her right lung is collapsed and is not taking part in gas exchange. Her left lung, great vessels, and heart are compressed also. 4. The physician needs to insert a chest tube. What are your responsibilities as A.W.'s nurse? • Prepare for immediate needle aspiration (the physician will use a 14- or 16-gauge spinal or cardiac needle). • Set up a chest tube drainage system, obtain size 28F and 32F chest tubes, and prepare a thoracotomy tray for a thoracostomy (chest tube insertion). ■ Chart View Arterial Blood Gases (100% O2 ) pH 7.25 PaCO2 92mm Hg PaO2 32mm Hg HCO3 27mmol/L SaO2 53% Difficulty: Intermediate Setting: Hospital emergency department, hospital Index Words: pneumothorax, arterial blood gases (ABGs), emphysema, assessment, respiratory distress, patient education, pleurodesis, chest drainage system Case Study 25 Spontaneous Pneumothorax 2Respiratory
- 31. 114 PART 1 MEDICALSURGICAL CASES Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. • Monitor chest drainage. • Frequently assess for breath sounds. • Although A.W. is stuporous, you do not know what she can hear or process. Briefly tell her that her lung collapsed and that the physician is going to put a tube in her chest to get rid of the air and help her breathe. Be constantly aware of patient emotional support needs throughout the procedure. 5. As the nurse, it is your responsibility to ensure pain control. In A.W.'s case, would you administer pain medication before the chest tube insertion? • No. This is an emergency; you cannot take the time to obtain and administer pain medication. The physician will inject lidocaine at the insertion site. • In addition, pain medication might interfere with a neurologic examination and suppress BP and respiratory effort. 6. The ED physician inserts a size 32F chest tube in the sixth intercostal space, midaxillary line. Would you expect to observe an air leak when A.W.'s chest drainage system is in place and functioning? Yes. If A.W. ruptured a bleb into her pleural space, inspired air would continue to escape into the pleural space and into the chest tube drainage system until the hole healed. 7. Would you expect A.W.'s lung to reexpand immediately after the chest tube insertion and initiation of underwater suction? Explain. Not necessarily. It can take hours to days for the lungs to completely inflate. 8. Part of your responsibilities after the chest tube is inserted is to assess for fluctuation in the water-seal chamber and bubbling in the suction-control chamber. Label the areas on the chest drainage system that you would be monitoring. Suction control Water seal Drainage collection Air vent To suction From client 2Respiratory
- 32. 115 CHAPTER 2 RESPIRATORY DISORDERS CASE STUDY 25 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. 9. What do you need to document regarding A.W.'s chest drainage system? Most institutions have the nurse document the character, color, and amount of pleural drainage every 8 hours and as needed. The nurse also needs to note the presence/absence of an air leak every 8 hours; as well as the amount of suction being delivered. You will mark the level of drainage on chest drainage system columns a minimum of every 8 hours and record amount of output. Related assessment findings that need to be documented include A.W.'s lung sounds, respiratory pattern, pulse oximetry, vital signs, and pain level. 10. What instructions do you need to give to the nursing assistive personnel (NAP) who is working with A.W.? The NAP must keep the drainage system below A.W.'s chest at all times. The patient may ambulate with the chest tube; the drainage system should be kept on the side of insertion. The chest tube tubing should be kept as straight as possible, avoiding kinks and dependent loops. If already taught, the NAP can encourage A.W. to cough, deep-breathe, and use the incentive spirometer. 11. The clerk tells you A.W.'s husband has just arrived; A.W. will be admitted to the hospital. How would you address this issue with her husband? • Look for him in the ED waiting area, and tell him that A.W. is responding well to treatment. Inform him that one of her lungs collapsed, so the physician put a tube in her chest to let the air out and allow the lung to expand again.Tell him that the tube will stay in her chest until the lung stays inflated on its own. That means she will have to be admitted to the hospital so that her condition can be monitored. • Accompany him into A.W.'s room, and remain alert to help him into a chair or onto the floor if he experiences vertigo or a syncopal episode. • Explain the tubes and monitoring equipment in very simple terms—for example,“This machine allows us to watch her heart. This one measures her blood pressure. This is the tube that lets the air out of her chest so that she can breathe better.” • Provide tissues, and tell him where the restrooms are located. • Ask him whether he needs to use the telephone (someone might need to bring clothing, provide transportation, or stay with him to offer support). • Ask him whether he needs anything (juice, water) to make him more comfortable. 12. You approach A.W.'s bedside and ask about what looks like two healed chest tube sites on her right chest. A.W.'s husband informs you that this is the third time she has had a collapsed lung. He asks whether this trend will continue. How will you respond? If A.W. continues to experience spontaneous pneumothoraces in the same area of the lung, the physician might elect to“scar”the surface of the lung in that particular area. The medication is irritating, and scar tissue forms on the outside of the lung. It is more difficult for the thick scar tissue to rupture than the thinner lung tissue. The treatment is effective, but it is also painful for the patient. CASE STUDY PROGRESS Because A.W. has a history of spontaneous pneumothoraces on the right side, the physician elects to per- form chemical pleurodesis. 13. A.W. asks what a pleurodesis is. How would you describe this procedure and what will happen? Pleurodesis is the instillation of a liquid sclerosing substance, such as doxycycline, talc, or bleomycin, into the pleural space via a chest tube to create an inflammatory response that causes the pleura to adhere and sclerose to each other. Because the spreading of the medication can be associated with a sig- nificant amount of burning, the patient should receive adequate intravenous pain medication and seda- tion before and during the procedure. During the instillation, the patient is rolled side to side to spread the substance throughout the pleural space. Afterward, A.W. will be placed on a rotation schedule to assist with the distribution of the medication.Vital signs will be monitored every 4 hours for 24 hours. 2Respiratory
- 33. 116 PART 1 MEDICALSURGICAL CASES Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. CASE STUDY PROGRESS A.W. recovers and is discharged to her home 4 days later with a chest tube and Heimlich valve. The physi- cian connects the one-way (Heimlich) valve between the distal end of the chest tube and a drainage pouch. 14. Discuss the purpose of this device. During inspiration, negative intrapleural pressure closes the valve and prevents air from entering the pleural space. During expiration, positive pressure opens the valve and allows air and/or fluid to drain into a plastic pouch. This valve makes it possible to discharge patients who have a residual air leak. The chest tube is removed after the air leak heals. 15. You teach A.W. and her husband about the care of the chest tube and Heimlich valve. Which of these statements would indicate that further teaching is necessary? (Select all that apply.) a. “I will maintain an occlusive dressing around the chest tube site.” b. “I can shower if the device is completely covered in plastic.” c. “When moving around, the collection system must be kept below the insertion site.” d. “I will notify the physician if there is a change in the color or amount of drainage.” e. “The arrow on the flutter valve should always point toward me.” f. “I will check the insertion site twice daily for swelling, redness, and drainage.” Answers: B, E When a patient is discharged with a flutter valve and chest tube, the patient must be taught how to maintain patency of the system. The insertion site must be kept dry and clean. An occlusive dressing must be kept around the site. He or she needs to avoid swimming and bathing because the valve must not be submerged in water. To safely ambulate with a mobile chest tube drainage system, the collection system must be kept below the level of the insertion site and all connection must be secure. The patient and caregiver need to know when to contact the health care provider. Reasons for notifying the health care provider include changes in the drainage system, such as a change in color or amount of drainage and leakage on the dressing around the chest tube, as well as symptoms of fever, chest pain, and dyspnea. The insertion site should be checked twice daily for signs of infection: fever or increasing redness, swelling, or drainage from the insertion site; the physician should be notified if any of these are present. Because there is a mechanical one-way valve instead of a water-seal chamber, the arrow indicator on the one-way flutter valve housing must always point away from the patient. Otherwise, there is a risk for air trapping and a recurrent pneumothorax. 2Respiratory
- 34. 117 CHAPTER 2 RESPIRATORY DISORDERS CASE STUDY 26 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. Scenario P.R., a 61-year-old woman who has no history of respiratory disease, is being admitted to your unit with a diagnosis of pneumonia and acute respiratory failure. She was endotracheally intubated orally in the emer- gency room and placed on mechanical ventilation. Her vital signs are 112/68, 134, 101° F (38.3° C) with an SaO2 of 53%. Her ventilator settings are synchronized intermittent mandatory ventilation of 12 breaths/min (BPM), tidal volume (VT ) 700mL, FiO2 0.50, positive end-expiratory pressure (PEEP) 5cm H2 O. 1. Describe the pathophysiology of acute respiratory failure (ARF). ARF is the inability of the body to sustain respiratory drive resulting in a decreased capacity to exchange oxygen and CO2 . Acute respiratory failure can be a result of either the failure to oxygenate, the failure to ventilate, or a combination of both. Type I, or hypoxemic ARF, is defined as the inabil- ity to maintain a PaO2 greater than 60mm Hg with the client at rest and breathing room air. This type of ARF is associated with pulmonary edema, pulmonary emboli, atelectasis, pneumonia, emphy- sema, acute respiratory distress syndrome, and loss of functional lung tissue, such as following vari- ous lung removal surgeries. Type II ARF, or the failure to ventilate, results from disease processes that interfere with a client's ability to effectively remove CO2 . Type II ARF is characterized by a PaCO2 greater than 60mm Hg or a pH less than 7.35. It is associated with COPD, restrictive pulmonary dis- eases (obesity, pneumothorax, and diaphragmatic paralysis), neuromuscular defects (Guillain-Barré syndrome, myasthenia gravis, multiple sclerosis, intentional overdose, and spinal cord injury), cen- tral nervous system dysfunction (stroke, meningitis, and ICP), and chest trauma. 2. What assessment findings would you expect P.R. to exhibit? • Altered level of consciousness, with P.R. being confused and difficult to arouse • Electrolyte abnormalities, caused by a falling pH level, might cause cardiac dysrhythmias • Headache related to hypercapnia • Pulsus paradoxus or a drop in systolic blood pressure more than 10mm Hg during inspiration • Diaphoresis and fever related to infection • Tachycardia and hypotension related to vasodilation and hypoxia ■ Chart View Difficulty: Intermediate Setting: Intensive care unit Index Words: mechanical ventilation, endotracheal tube (ETT), assessment, acute respiratory failure (ARF), arterial blood gas (ABG) Case Study 26 MechanicallyVentilated Patient 2Respiratory
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Cardiovascular Disorders 1 1 Cardiovascular PART ONE Medical-Surgical Cases Case Study 1 Heart Failure Difficulty: Beginning Setting: Emergency department, hospital Index Words: heart failure (HF), cardiomyopathy, volume overload, quality of life X Scenario M.G., a “frequent flier,” is admitted to the emergency department (ED) with a diagnosis of heart failure (HF). She was discharged from the hospital 10 days ago and comes in today stating, “I just had to come to the hospital today because I can't catch my breath and my legs are as big as tree trunks.” After further questioning, you learn she is strictly following the fluid and salt restriction ordered during her last hospital admission. She reports gaining 1 to 2 pounds every day since her discharge. 1. What error in teaching most likely occurred when M.G. was discharged 10 days ago? A breakdown of successful communication occurred regarding when to call with early weight gain. It is imperative that patients understand when to call their provider after being discharged from the hospital for exacerbated HF. Comprehensive patient education starting at admission is considered a standard of care and is mandated by The Joint Commission when providing care to hospitalized patients. The goal of the discharge treatment plan is to facilitate successful patient selfmanagement, minimize symptoms, and prevent readmission. CASE STUDY PROGRESS During the admission interview, the nurse makes a list of the medications M.G. took at home. ■ Chart View Nursing Assessment: Medications Taken at Home Enalapril (Vasotec) 5 mg PO bid Pioglitazone (Actos) 45 mg PO every morning Furosemide (Lasix) 40 mg/day PO Potassium chloride 20 mEq/day PO 2. Which of these medications may have contributed to M.G.'s heart failure? Explain. Thiazolidinediones, such as pioglitazone, may increase the risk of heart failure and should not be used in patients with symptoms of heart failure. They commonly cause peripheral edema and weight gain (which are the result of both water retention and increased deposit of adipose tissue). Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. 1 PART 1 MEDICALSURGICAL CASES 1 Cardiovascular 3. How do angiotensin-converting enzyme (ACE) inhibitors, such as enalapril (Vasotec), work to reduce heart failure? (Select all that apply.) ACE inhibitors: a. prevent the conversion of angiotensin I to angiotensin II. b. cause systemic vasodilation. c. promote the excretion of sodium and water in the renal tubules. d. reduce preload and afterload. e. increase cardiac contractility. f. block sympathetic nervous system stimulation to the heart. Answers: A, B, D ACE inhibitors prevent the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. This results in systemic vasodilation, thereby reducing preload (reducing the volume of blood entering the left ventricle) and afterload (reducing the resistance to the left ventricular contraction) in patients with HF. ACE inhibitors do not promote the excretion of sodium and water, and they do not cause increased cardiac contractility or block the sympathetic nervous system to the heart. CASE STUDY PROGRESS After reviewing M.G.'s medications, the physician writes these medication orders: ■ Chart View Medication Orders Enalapril (Vasotec) 5 mg PO bid Carvedilol (Coreg) 100 mg PO every morning Glipizide (Glucotrol) 10 mg PO every morning Furosemide (Lasix) 80 mg IV push (IVP) now, then 40 mg/day IVP Potassium chloride (K-Dur) 20 mEq/day PO 4. What is the rationale for changing the route of the furosemide (Lasix)? M.G. is fluid overloaded and needs to decrease fluid volume in a short period. IV administration is delivered directly into the vascular system, where it can start to work immediately. In HF, blood flow to the entire gastrointestinal (GI) system is compromised; therefore, the absorption of orally ingested medications may be variable and take longer to work. 5. You administer furosemide (Lasix) 80 mg IVP. Identify three parameters you would use to monitor the effectiveness of this medication. • • • • • Increased urine output Daily weight, looking for weight loss Intake and output (I&O) Decreased dependent edema Decreased shortness of breath, diminished crackles in the bases of the lungs, decreased work of breathing, and decreased O2 demands • Decreased jugular venous distention (JVD) 6. What laboratory tests should be ordered for M.G. related to the order for furosemide (Lasix)? (Select all that apply.) a. Magnesium level b. Sodium level 2 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. CHAPTER 1 c. d. e. f. CARDIOVASCULAR DISORDERS CASE STUDY 1 Complete blood count (CBC) Serum glucose levels Potassium level Coagulation studies 1 Cardiovascular Answers: A, B, D, E Furosemide is a potent diuretic, especially when given IVP, and may cause the loss of electrolytes such as magnesium, sodium, and potassium. These electrolytes will need to be supplemented if the levels are low. In addition, furosemide may increase serum glucose levels, which is an issue, considering that M.G. has diabetes. It is not necessary to monitor CBC or coagulation studies while on furosemide. 7. What is the purpose of the beta blocker carvedilol? It is given to: a. increase the contractility of the heart b. cause peripheral vasodilation c. increase urine output d. reduce cardiac stimulation by catecholamines Answer: D Beta blockers reduce or prevent stimulation of the heart by circulating catecholamines. CASE STUDY PROGRESS The next day, M.G. has shown only slight improvement, and digoxin (Lanoxin) 125 mcg PO daily is added to her orders. 8. What is the action of the digoxin? Digoxin: a. causes systemic vasodilation. b. promotes the excretion of sodium and water in the renal tubules. c. increases cardiac contractility and cardiac output. d. blocks sympathetic nervous system stimulation to the heart. Answer: C Digoxin works by increasing cardiac contractility, and thus increasing cardiac output. 9. Which findings from M.G.'s assessment would indicate an increased possibility of digoxin toxicity? Explain your answer. a. Serum potassium level of 2.2 mEq/L b. Serum sodium level of 139 mEq/L c. Apical heart rate of 64 beats/minute d. Digoxin level 1.6 ng/mL Answer: A Low potassium levels can increase the potential for digoxin toxicity. M.G. is taking furosemide, a loop diuretic that excretes potassium as well as sodium and water. Potassium levels should be monitored carefully during digoxin therapy. The other findings are within normal limits. 10. When you go to give the digoxin, you notice that it is available in milligrams (mg) not micrograms (mcg). Convert 125 mcg to mg. 125mcg = 0.125 mg If the student answers “.125 mg” the answer should be incorrect because, per The Joint Commission “Do Not Use” list, the leading zero should not be omitted. Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved. 3 PART 1 MEDICALSURGICAL CASES 11. M.G.'s symptoms improve with IV diuretics and the digoxin. She is placed back on oral furosemide (Lasix) once her weight loss is deemed adequate to achieve a euvolemic state. What will determine whether the oral dose will be adequate to consider her for discharge? 1 Cardiovascular It is critical to provide the primary care provider with accurate, timely assessment data after the change from IV to oral diuretic therapy. One of the fluid management goals for patients with HF is to maintain a target weight. This is done by monitoring daily morning weight, keeping an accurate I&O, and recording subjective symptoms. 12. M.G. is ready for discharge. Using the mnemonic MAWDS, what key management concepts should be taught to prevent relapse and another admission? The most essential aspect of teaching hospitalized patients is to focus on realistic key points. Teaching should be aimed at successful communication of data to improve symptoms and prevent readmission, without overwhelming the learner. The five most essential concepts for patients with HF are included in MAWDS instructions. Medications: Take as directed, do not skip a dose, and do not run out of medications. Activity: Stay as active as you can while limiting your symptoms. Weight: Weigh every morning. Call if you gain or lose 2 pounds overnight or 5 pounds from your target weight. Diet: Follow a low-salt diet, and limit fluids to less than 2 quarts or liters per day. Symptoms: Know what symptoms to report to your provider; report early to prevent readmission. 4 Copyright © 2013 by Mosby, an affiliate of Elsevier Inc. Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.
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Table of Contents
Here’s the complete overview of Winningham’s Critical Thinking Cases in Nursing 5th Edition PDF:
Develop your critical thinking and clinical reasoning skills with 150 realistic case studies from the four major clinical practice areas: medical-surgical, pediatric, maternity, and psychiatric/mental health nursing. Each case covers a common problem, drawn from actual clinical experiences and written by nurses who are clinical experts. All cases have been thoroughly updated and revised to reflect current clinical practices, with integrated content on pharmacology, nutrition, and diagnostic/laboratory tests to encourage you to think critically about all aspects of care. This fifth edition also features an increased emphasis on patient management, and new documentation and communication exercises. Plus new NCLEX ® Examination format-questions help you prepare for success on the NCLEX® Examination and provide safe, quality patient care.
Features of Winningham’s Critical Thinking Cases in Nursing 5th Edition PDF
Here’s a quick overview of the important features of this book:
- Three-part organization presents cases in three parts: 1) Medical-Surgical Cases; 2) Pediatric, Maternity, and Psychiatric Cases; and 3) Other/Advanced Cases, the latter covering key topics such as multi-system disorders and emergency situations.
- Realistic case study approach incorporates cases drawn from actual clinical experiences to help you identify changes, anticipate possible complications, and initiate therapeutic interventions.
- Increasing case complexity provides you with a foundation on which to build as you advance to more difficult cases.
- Two new pediatric case studies strengthen your ability to recognize and effectively manage common disorders presenting in pediatric patients.
- New NCLEX Examination-format questions have been added throughout, including multiple choice, prioritization/ordering, chart/exhibit, and dosage calculation questions.
- Increased number of higher-level questions requires clinical reasoning rather than simply memorizing and recalling information.
- An emphasis on patient management reinforces the type of clinical decision-making needed in the clinical setting as well as reflecting the type of questions on the latest NCLEX Examination.
- Over 25 new illustrations and graphics such as ECG strips, lab/diagnostic test reports, anatomical diagrams, and medication labels are now interwoven throughout the book.
- New documentation and communication exercises ask you to document relevant patient information or to use the “SBAR” communication technique to communicate patient findings to the physician.
Mariann M. Harding (Author)
Mariann M. Harding of Kent State University, OH KSU with expertise in Nursing Science.
Below is the complete table of contents offered inside Winningham’s Critical Thinking Cases in Nursing 5th Edition PDF:
PART ONE – MEDICAL-SURGICAL CASES
Chapter 1: Cardiovascular Disorders
Chapter 2: Respiratory Disorders
Chapter 3: Musculoskeletal Disorders
Chapter 4: Gastrointestinal Disorders
Chapter 5: Genitourinary Disorders
Chapter 6: Neurologic Disorders
Chapter 7: Endocrine Disorders
Chapter 8: Immunologic Disorders
Chapter 9: Oncologic and Hematologic Disorders
PART TWO – PEDIATRIC, MATERNITY, AND PSYCHIATRIC CASES
Chapter 10: Pediatric Disorders
Chapter 11: Maternal and Obstetric Disorders
Chapter 12: Women’s Health Disorders
Chapter 13: Psychiatric Disorders
PART THREE – OTHER/ADVANCED CASES
Chapter 14: Alternative Therapies
Chapter 15: Patients with Multiple Disorders
Chapter 16: Emergency Situations
Appendix: Abbreviations and Acronyms
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- Series: Winningham’s Critical Thinking Cases in Nursing
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- Publisher: Mosby; 5 edition (June 14, 2012)
- Language: English
- ISBN-10: 0323083250
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Book details · ISBN-10. 0323083250 · ISBN-13. 978-0323083256 · Edition. 5th · Publisher. Mosby · Publication date. June 14, 2012 · Language. English · Dimensions. 8.25
Product Description · Comprehensive case study approach uses cases drawn from actual clinical experiences to help you identify changes, anticipate possible
Develop your critical thinking and clinical reasoning skills with 150 realistic case studies from the four major clinical practice areas: