Case study for Afib/CHF Case study for Atrial fibrillation and Congestive Heart Failure

1a. Mr. F, an obese 68 year old man presents to the ED triage. He tells you, the triage nurse, that he has been feeling li e he !an"t !at!h his breath and his !hest #feels funny.$ He tells you that it started this morning %hen he %as out %ashing his !ar in the dri&e%ay. He %ent inside to rest on the !ou!h and felt #a little better.$ As some time %ent on he felt in!reasingly '() and li e his #!hest %as going to *ump out of his !hest.$ He as s you, #Am + ha&ing a heart atta! , Am + going to die, 1b. -ast medi!al history. DM, H/0 (besity %ith sleep apnea. E/(H abuse (ne pa! a day smo er He sleeps %ith a C-A- ma!hine at night. 1c. -hysi!al Assessment. 'herry, + %ant ea!h of these to be on a note !ard. + %ant the student to a!tually ta e his &ital signs in 'e!ond life and get ea!h of these signs. /hen, asses his neurologi!al status and get this note !ard, then loo at a !ardia! monitor and see this rhythm, et!. Can %e meet to tal this through on 1ednesday %hen %e get together %ith Hope, 2'. )/- 345/66, H7 388, / 9:, 77 99, -ulse (; 88< on 6=n/! 0euro. AA(>9, an;ious, #feeling of doom$ and !/o di??iness Cardia!. 7apid Atrial fib on the monitor, %ea peripheral pulses -ulmonary. '(), C/A @+. Abdomen soft, non distended. A )' @B. 2oiding !lear urine. 0o abnormalities noted ' in. Clammy, !ool, pallor M'. 10= 1d. 1hat is your priority assessment, 1hat physi!al findings should you be e;pe!ting and on the alert for , Cno%ing that this man is in a rapid Atrial fib, %hat is he also at ris for,

Case study for Afib/CHF

1e. Dou re!ei&e the do!tor"s orders. a. b. !. d. e. f. g. 'tat 35 lead EC@ C)C /hyroid panel Hepati! panel 7enal fun!tion E!ho!ardiogram C>7

1hy are EACH of these tests ordered, 1f. =ab %or that has resulted from the ED /roponin. slightly ele&ated =ipid -anel. in!reased =D= C-C. slightly ele&ated C)C. slightly ele&ated 1)C Chemistry. -otassium 9.5, Mag le&el 3.4 Homo!ysteine. E35 C 7ea!ti&e -rotein. 5mg/= Myoglobin. E394 Fnormal is GH5I Are there any labs results that !on!ern you, +f so,%hy, 1g. Mr. F has been stabili?ed in the ED and is no% transferred to the telemetry floor. Dou are %or ing the night shift and he is one of your 34 patients. Dou hear the !ardia! monitor alarming in the hall%ay and note that he is in a '7, ho%e&er, you noti!e that he is thro%ing lots of -2Cs . 'herry, here + %ant the students to see the rhythm on the monitor. + %ant it to be dar in the hall%ay, li e a night shift really is and hear the noises li e in real life. Can %e do this, 1hy does this !on!ern you, 1hat !ould happen,

Case study for Afib/CHF 1h. /he ne;t thing you see on the monitor is 2 ta!h %ith a rate of 386. )eing the astute 'B0D Blster nurse that you are you immediately go to assess him and your fo!used physi!al assessment is as follo%s. Again, here + %ant the students to perform the assessment and get note !ards for ea!h assessment. 0euro. de!reased le&el of !ons!iousness, !onfusion Cardia!. e;hibiting !hest pain 6/34 ' in. pale, !ool, !lammy -ulmonary. 7ales audible bilaterally 5/9 the %ay up, using a!!essory mus!les, blood tinged frothy sputum. 2'. H7 386, )/- 84/86, / 9:, 77 58, -ulse (; 86< 1hat is happening to this patient, 1hat is your priority, 1hat are the nursing inter&entions for this patient, 1i. Dou perform a su!!essful defibrillation follo%ing AC=' proto!ols and he is no% ba! in a sinus rhythm but is no% on a &entilator. Dou reassess your patient. Dour fo!used physi!al assessment re&eals. 0euro. sedated at a ramsay J9 Cardia!. 'inus rhythm ' in. pale, !ool, !lammy -ulmonary. 7ales audible bilaterally 5/9 the %ay up, using a!!essory mus!les, blood tinged frothy sputum 2'. H7 8:, )/- 89/85, / 9:, 77 38, -ulse o; H8< on the &entilator Again, here + %ant the students to perform the assessment and get note !ards for ea!h assessment.

1j. Dou put a !all out to the physi!ian and re!ei&e the follo%ing orders. a. =asi; 84 mg +2 push no% b. Morphine sulfate 8mg+2 push ;3 no% and then morphine sulfate 5mg +2 push K5 hours !. Digo;in 4.58 +2 push no% and then 4.358 K day d. /ransfer to the +CB Ho% %ill you prioriti?e these orders, )ased on your assessment %ill you !arry out all of these orders or %ill you Luestion some of the orders %ith the MD,

Case study for Afib/CHF 1k. +t is 5 days later and Mr. F is transferred ba! to your unit. Dou ha&e re!ei&ed %ord that he is going to be dis!harged the &ery ne;t day. Cno%ing that Mr. F had an M+, %hat types of medi!ations !an you anti!ipate the patient to be pres!ribed for dis!harge, 1hy are these medi!ations indi!ated, 1hat dis!harge tea!hing %ill be important to do prior to his dis!harge,