4BS FY15 Case Study

1.

57 year old patient with GI Bleed/alcohol intoxication; Dr. ShakeThe patient calls you in to tell you that someone is watching him through the 2-way mirror and begins screaming. At the same time, the bed alarm begins to sound on the confused patient. Explain your nursing actions here.

2.

69 year old AKA; Dr. Hatchet E.B., a 69-year-old man with type 1 diabetes mellitus (DM), is admitted to RHJ VAMC complaining of severe pain in his right foot and lower leg. The right foot and lower leg are cool and without pulses (absent by Doppler). Arteriogram demonstrates severe atherosclerosis of the right popliteal artery with complete obstruction of blood flow. Despite attempts at endarterectomy and administration of intravascular alteplase (tissue plasminogen activator [TPA]) over several days, the foot and lower leg become necrotic. Finally, the decision is made to perform an above-the-knee amputation (AKA) on E.B.'s right leg. E.B. is recently widowed and has a son and daughter who live nearby. E.B. returns from surgery with the right stump dressed with gauze and an elastic wrap. The dressing is dry and intact, without drainage. He is drowsy with the following vital signs (VS): 142/80, 96, 14, 97.9 ° F (36.6 ° C), SpO2 92%. He has a maintenance IV of D5NS infusing at 125 mL/hr in his right forearm. The surgeon has written to keep E.B.'s stump elevated on pillows for 48 hours; after that, have him lie in a prone position for 15 minutes, four times a day. In teaching E.B. about his care, how will you explain the rationale for these orders?

3.

In reviewing E.B.'s medical history, what factors do you notice that might affect the condition of his stump and ultimate rehabilitation potential?

4.

What is causing E.B.'s pain?

5.

84 Year old confused patient with UTI; Dr. C. M. Pea.The LPN comes to tell you that the patient is very confused, trying to get out of bed..."was a little confused at the beginning of the shift, but nothing like this." What is the FIRST nursing action to ensure the patient's safety?

A.

Re-orient the patient and activate the bed alarm
B.

Call the physician for an order for restraints
C.

Call the physician for an order for Ativan
D.

After making your nursing rounds, go in and check on the patient

Correct Answer
A. Re-orient the patient and activate the bed alarm

Explanation
The first nursing action to ensure the patient's safety in this scenario is to re-orient the patient and activate the bed alarm. This is important because the patient is confused and attempting to get out of bed, which puts them at risk for falls or injury. By re-orienting the patient, the nurse can help them regain their orientation and understanding of their surroundings. Activating the bed alarm will alert the nursing staff if the patient tries to get out of bed, allowing for prompt intervention and prevention of falls.

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6.

57 year old patient GI bleed/alcohol intoxication; Dr. Shake J.G., a 57-year-old man, was seen in the emergency department (ED) 2 days ago, diagnosed (Dx) with alcohol intoxication, and released after 8 hours to his brother’s care. He was brought back to the ED 12 hours ago with an active gastrointestinal (GI) bleed and is being admitted; his diagnosis is upper GI bleed and alcohol intoxication. According to the report received, his admission vital signs (VS) were 84/56, 110, 26, and he was vomiting bright red blood. His labs were remarkable for Hct 23%, alanine transaminase (ALT) 69 IU/ml, aspartate transaminase (AST) 111 IU/ml, and serum alcohol (ETOH) 271 mg/dl. He was given IV fluids and transfused 6 units of packed RBCs (PRBCs) in the ED. On initial assessment, you note that J.G.’s VS are blood pressure (BP) 180/110 mm Hg, pulse 120 beats/min; he has a slight tremor in his hands, and he appears anxious. He complains of a headache and appears flushed. You note that he has not had any emesis and has not had any frank red blood in his stool or “black tarry stools” over the past 5 hours. In response to your questions, J.G. denies that he has an alcohol problem but later admits to drinking approximately a fifth of vodka daily for the past 2 months. He reports having been drinking just before his admission to the ED. He admits to having had seizures while withdrawing from alcohol in the past.Which data from your assessment of J.G. are of concern to you? [Select all that apply]

A.

Elevated BP and heart rate
B.

Tremor, appearing anxious and flushed
C.

Headache
D.

Amount and frequency of alcohol use
E.

History of seizure with withdrawal from alcohol

Correct Answer(s)
A. Elevated BP and heart rate
B. Tremor, appearing anxious and flushed
C. Headache
D. Amount and frequency of alcohol use
E. History of seizure with withdrawal from alcohol

Explanation
The elevated blood pressure and heart rate, tremor, appearing anxious and flushed, headache, and history of seizure with withdrawal from alcohol are all concerning findings in the assessment of J.G. These symptoms suggest that J.G. may be experiencing alcohol withdrawal syndrome, which can be life-threatening if not managed properly. The high blood pressure and heart rate may indicate autonomic hyperactivity associated with withdrawal. The tremor, anxiety, and flushed appearance are also consistent with alcohol withdrawal symptoms. Additionally, J.G.'s history of seizures with alcohol withdrawal further supports the concern for alcohol withdrawal syndrome. The amount and frequency of alcohol use are also important to assess in order to determine the severity of J.G.'s alcohol dependence and guide appropriate treatment.

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7.

After not having any emesis and not having any frank red blood in his stool or “black tarry stools” over the past 5 hours, you contact the physician about the other symptoms the patient is displaying. You anticipate the physician starting what protocol?

A.

Stroke
B.

Chest Pain
C.

CIWA
D.

None of these

Correct Answer
C. CIWA

Explanation
Based on the given information, the patient is not experiencing symptoms related to stroke or chest pain. The mention of CIWA (Clinical Institute Withdrawal Assessment) suggests that the patient may be displaying symptoms of alcohol withdrawal. CIWA is a protocol used to assess and manage alcohol withdrawal symptoms.

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8.

You are reviewing the plan of care for E.B. Which of these care activities can be delegated to the LPN? (Select all that apply.)

A.

Rewrapping the stump bandage
B.

Checking E.B.'s vital signs
C.

Changing E.B.'s PICC line dressing
D.

Assisting E.B. with repositioning in the bed
E.

Asking E.B. to report his level of pain on a 1-to-10 scale

Correct Answer(s)
A. Rewrapping the stump bandage
B. Checking E.B.'s vital signs
D. Assisting E.B. with repositioning in the bed
E. Asking E.B. to report his level of pain on a 1-to-10 scale

Explanation
The LPN can rewrap the stump bandage, check E.B.'s vital signs, assist E.B. with repositioning in the bed, and ask E.B. to report his level of pain on a 1-to-10 scale. These activities do not require advanced nursing skills and can be safely delegated to the LPN. Changing E.B.'s PICC line dressing, on the other hand, requires a higher level of expertise and should be performed by a registered nurse.

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9.

On the evening of the first postoperative day, E.B. becomes more awake and begins to complaining of (C/O) pain. He states, “My right leg is really hurting; how can it hurt so bad if it's gone?” What is your best response?

A.

“That is a side effect of the medication.”
B.

“You can't be feeling that because your leg was amputated.”
C.

“Don't worry, that sensation will go away in a few days.”
D.

“Are you able to rate that pain on a scale of 1 to 10?”

Correct Answer
D. “Are you able to rate that pain on a scale of 1 to 10?”

Explanation
The best response is to ask the patient to rate the pain on a scale of 1 to 10. This allows the healthcare provider to assess the severity of the pain and determine the appropriate course of action. It also shows empathy and concern for the patient's well-being.

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4bs Fy15 Case Study

57 year old patient with GI Bleed/alcohol intoxication; Dr. ShakeThe patient calls you in to tell you that someone is watching him through the 2-way mirror and begins screaming. At the same time, the bed alarm begins to sound on the confused patient. Explain your nursing actions here.

In reviewing E.B.'s medical history, what factors do you notice that might affect the condition of his stump and ultimate rehabilitation potential?

What is causing E.B.'s pain?

84 Year old confused patient with UTI; Dr. C. M. Pea.The LPN comes to tell you that the patient is very confused, trying to get out of bed..."was a little confused at the beginning of the shift, but nothing like this." What is the FIRST nursing action to ensure the patient's safety?

After not having any emesis and not having any frank red blood in his stool or “black tarry stools” over the past 5 hours, you contact the physician about the other symptoms the patient is displaying. You anticipate the physician starting what protocol?

You are reviewing the plan of care for E.B. Which of these care activities can be delegated to the LPN? (Select all that apply.)

On the evening of the first postoperative day, E.B. becomes more awake and begins to complaining of (C/O) pain. He states, “My right leg is really hurting; how can it hurt so bad if it's gone?” What is your best response?