You are just getting caught up with your work when you receive the following phone call: “Hi, this is Deb in the emergency department (ED). We’re sending you M.M., a 63-year-old Hispanic woman with a past medical history of coronary artery disease (CAD). Her daughter reports that her mom has become increasingly weak over the past couple of weeks and has been unable to do her housework. Apparently, she has had swelling in her ankles and feet by late afternoon so much that she could not wear her shoes and has nocturnal diuresis × 4. Her daughter brought her in because she has had heaviness in her chest off and on over the past few days but denies any discomfort at this time. She says that the chest heaviness is not related to activity and has become increasingly more frequent over the past few days, sometimes lasting up to 10 minutes at a time. The daughter took her to see her family physician, who immediately sent her here.
Vital signs are 146/92, 96, 24, 99 ° F (37.2 ° C). She has an IV of D5W at 50 mL/hr in her right forearm. Her lab results are as follows: Na 134 mEq/L (134 mmol/L), K 3.5 mEq/L (3.5 mmol/L), Cl 103 mEq/L (103 mmol/L), HCO3 23 mEq/L (23 mmol/L), BUN 13 mg/dL (4.6 mmol/L), creatinine 1.3 mg/dL (115 mcmol/L), glucose 153 mg/dL (8.5 mmol/L), WBC 8300/mm3 (8.3 x 109/L), Hct 33.9%, Hgb 11.7 g/dL (117 g/L), platelets 162,000/mm3 (162 x 109/L), PT/INR/PTT, and urinalysis are pending. She has had her chest x-ray and ECG, and her orders have been written.”
1. What additional information do you need from the emergency department nurse?
2. How are you going to prepare for this patient?
3. M.M. arrives by wheelchair. As she transfers to the bed, what observations will you make? Why?
4. With the interpreter phone, M.M. tells you that she feels very tired. Is this symptom significant? Explain your answer.
5. Based on M.M.’s history, you suspect that she is experiencing angina. Which type of angina do you think she has? Explain your answer.
6. Given the previous information, you expect orders for M.M. Carefully review each to determine whether it is appropriate or inappropriate as written. If the order is appropriate, mark it as A; if the order is inappropriate, mark it as I and change the order to make it appropriate. Provide any other orders that might be appropriate for M.M.
_____1. VS once per shift
_____2. Serum magnesium (Mg) STAT
_____3. Up ad lib
_____4. 10 g sodium (Na), low-fat diet
_____5. Change IV to a saline lock
_____6. Cardiac enzymes on admission and q8h × 24 hr, then daily every morning
_____7. CBC, BMP, and fasting lipid profile in morning
_____8. Schedule for abdominal CT scan for morning
_____9. Heparin 10,000 units subQ q8hr
_____10. Docusate sodium (Colace) 100 mg PO daily
_____11. Ampicillin 250 mg IV piggyback q6hr
_____12. Furosemide (Lasix) 200 mg IV push STAT
_____13. Nitroglycerin (NTG) 0.4 mg 1 SL q4hr prn for chest pain
_____14. Schedule echocardiogram
7. Which interventions are appropriate for administering subcutaneous heparin? Select all that apply.
- Massage the area after the injection.
- Rotate injection sites with each dose.
- Do not aspirate the syringe before injecting the heparin.
- Give the injection at least 2 inches (5 cm) away from the umbilicus.
- Monitor activated partial thromboplastin time (aPTT) levels daily.
CASE STUDY PROGRESS
Shortly after admission, M.M.’s call light comes on. When you respond to M.M.’s call light, you observe she is talking rapidly in Spanish and pointing to the bathroom. Her speech pattern indicates she is short of breath; she is having trouble completing a sentence without taking a labored breath. You help her use a bedpan and note that her skin feels clammy. While sitting on the bedpan, she vomits.
8. On a scale of 0 to 10 (0 being no problem, 10 being a code-level emergency), how would you rate this situation, and why?
9. Identify at least 4 actions you should take next and state your rationale.
10. M.M.’s physician calls your unit to find out what is happening. Using SBAR, what information would you need to convey at this time?
11. The hospital’s staff physician is coming to the floor immediately to evaluate the patient. In the meantime, she orders furosemide (Lasix) 40 mg IV push STAT. You have only 20 mg in stock. Should you give the 20 mg now, and then give the additional 20 mg when it comes up from the pharmacy? Explain your answer.
12. M.M. continues to experience vomiting and diaphoresis that are unrelieved by medication and comfort measures. A STAT 12-lead ECG reveals ischemic changes, and she is transferred to the coronary care unit. As you give the report to the receiving registered nurse, what lab value is the most important to report, and why?
13. You are observing while a new nurse prepares to administer IV potassium to M.M. Which technique is correct? Explain why the other answers are incorrect.
- Give the IV potassium by slow IV push.
- Administer the IV potassium by gravity drip.
- Add potassium to a hanging IV bag as needed.
- The rate of IV administration should not exceed 10 mEq/hr (10 mmol/L).
CASE STUDY PROGRESS
A case manager has been asked to evaluate M.M.’s home to see whether she can be discharged to her own home or will need to stay in a long-term care facility.
14. Identify at least 8 things that the case manager would assess.
15. M.M.’s nutritional intake over the past few weeks has been poor. What are some of the nutritional needs that should be met? What would you recommend to help her with this?
CASE STUDY PROGRESS
Because the case manager determined that M.M. lived in an apartment with poor access, M.M. elects to stay with her daughter and 5 grandchildren in their small home. A home care nurse comes 3 times a week to check on her. M.M. is easily fatigued, and the children are quite lively. School is out for the summer.
16. Suggest some ways for M.M.’s daughter to ensure that her mother is not overwhelmed and does not become exhausted in this situation.
CASE STUDY OUTCOME
M.M. stays with her daughter for 2 weeks, but the active children are too much for her and she moves back to her apartment. Her daughter checks on her there daily and brings her meals.
