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CASE STUDY 1 Mr. Mendes GENDER DISABILITY u uses a whee\chair; needs assistance with activities of daiiy living (ADLs) SOCIOECONOMIC 81 SETTING u Admitted from a rehabilitation health care center SPIRITUAURELIGIOUS Hospital PHARMACOLOGIC Portuguese CULTURAL CONSIDERATIONS Language barrier PREEXISTING CONDITIONS u Use of a medical interpreter ETHICAL u Peripheral vascular disease (PVD); type diabetes; below the knee amputation (BKA, B-K amputation) of left leg two E Use of a medical interpreter weeks ago ALTERNATIVE THERAPY COEXISTING CONDITION Left lower iobe pneumonia COMMUNICATION PRIORITIZATION Non-English speaking DELEGATION THE SKELETAL SYSTEM Level of difficulty: Easy Overview: This case challenges the nurse to identify strategies to help overcome a language barrier and forrn a therapeutic nurse—client relationship. Legal and ethical concerns regarding the use of an interpreter are considered. Stump care for the client with a recent amputation is discussed. Mr. Mendes is an 81-year-old man who speaks only Portuguese. He is quite frail, weighing only 110 pounds. He had a below-the-knee amputation of his left leg two weeks ago. Mr. Mendes has been admitted to the hospital from a rehabilitation center with an acute change in mental status and diminished lung sounds in the left base. Mr. Mendes is diagnosed with left lower lobe pneumonia and antibiotic therapy is prescribed. The nurse assigned to care for Mr. Mendes does not speak Portuguese. Case Study Mr. Mendes requires finish assistance with activities of daily living (ADLs) . A medical interpreter is not assigned to the nursing unit; but, if needed, the nurse can ask a Portuguese-speaking nursing staff member to help interpret what Mr. Mendes is trying to express. However, the nurse still must develop a way of communicating with Mr. Mendes so the nurse can assess Mr. Mendes’s level of comfort, provide care, and identify any needs. Questions I. Briefly discuss the challenges of developing a nurse—client relationship when a language barrier exists between the client and nurse. Explain the difference between a medical “interpreter” and a medical “translator.” Family members are often willing to interpret for the client and are more readily available. Discuss the use of medical interpreters and why, legally and ethically, family members (or friends of the client) Briefly discuss how Mr. Mendes’s past medical history relates to his below-the-knee leg amputation. What is the benefit of havinga below-the-knee (B-K) amputation versus an above-the-knee (A-K) amputation? The interpreter tells the nurse that Mr. Mendes would like the nurse to remove the bed linens from his left foot and raise his leg on pillows. He states, “My foot aches and maybe ifyou put it up it on are not the preferred interpreter(s).some pillows will feel better.” Provide a rationale for 4. Describe a therapeutic nurse—client relationship. Mr. Mendes’s request. Should the nurse elevate his stump on pillows as requested? S’Vhy or why not? 5. The nurse does not speak Portuguese. Discuss nonverbal strategies the nurse can implement 9. Mr. Mendes has not yet been fit for a prosthesis, to help develop a therapeutic relationship with The nurse provides care ofhis stump. Briefly discuss Mr. Mendes. the nurslng interventions Involved in stump care. 6. Provide the most likely explanation for why What outcome goals does the nurse hope to achieve through proper stump care? Mr. Mendes presented with an acute change in mental status. 10, List five nursing diagnoses appropriate to consider for Mr. Mendes’s plan of care. CASE STUDY 2 Mrs. Damerae PHARMACOLOGIC CULTURAL CONSIDERATIONS PREEXISTING Age-related complications CONDITION Osteoporosis COEXISTING CONDITION PRIORITIZATION visiting nurse Potential impact of a hip fracture on quality of life Level of difficulty: Easy Overview: This case requires that the nurse consider appropriate pre- and postoperative nursing interventions for a client with a hip fracture. A new medication is prescribed and teaching is needed. Considerations for recovery related to the client’s age as well as the safety of her home environment are discussed. The nurse is asked to prioritize appropriate nursing diagnoses for the client’s postoperative plan of care. Mrs. Damerae is a 77-year-old woman who was transported to the emergency department following a fall onto her right hip on a snowy morning. “Ijust wanted to check the mail. I was making my way down my front walk slowly. I had my good boots on. But there must have been ice under the snow and I slipped. It all happened so fast. I was up. I was down. And here I am.” Case Study Physical exam reveals that Mrs. Damerae’s right leg is shorter than her left leg and her right leg is externally rotated. There is bruising of her right hip. An X-ray confirms that Mrs. Damerae has an extracapsular fracture of the trochanter region of her right hip. Mrs. Damerae will have an open reduction of the fracture and internal fixation (ORIF) surgery the next morning. Questions 1. Prior to surgery, the health care provider chooses to place Mrs. Damerae’s right leg in Buck’s extension traction). is this Intervention prescribed prior to surgery? 2. A trochanter roll is another option for Mrs. Darnerae. What is ætrochanter roll and how would it be useful? 3, How might Mrs. Damerae’s age affect her hospitalization and recovery? Briefly discuss how Mrs. Damerae’s past medical history played a role in her injury. Mrs. Damerae’s surgeon informs her of the potential complicaüons of hip surgery. Identify at least three complicaüons the surgeon wrill address. Prioritize five nursing diagnoses appropriate for Mrs. Damerae following surgery. Explain how the nurse should move Mrs. Damerae in order to position her sdely on her side to wash her back Thu nurse applies graduated compression stockings (TEDs) and sequential compression J.deviCes (SCDs) as prescribed. is the rationale foy these intententions? Mrs. Damerae asks for assistance to the bathroom. The nurse checks to see that the appropriate equipment is available m the bathroom before assisting the client to ambulate. What is the nurse looking for in the bathroom? Mrs. Damerae is assisted back to bed. She asks that the head of her bed be raised-so she can read. How high should the head of the bed be raised and why? Mrs.-Damerae is seated In a.reclining chair. What reminders will the nurse give Mrs. Damerae regarding positioning while sitting and why is positioning so important? Identify the indications of a possible hip dislocation that the nurse should watch for. If the nurse notices any of the above signs, discuss the appropriate action for the nurse to take. Alendronate sodium is prescribed for Mrs. Darnerae. What is the rationale for the use of alendronate sodium? Discuss the client education regarding proper administration to maximize the benefits of alendronate sodium and adverse effects. 15. Following discharge from a rehabilitation unit, a visiting nurse will provide follow-up care for Mrs. Damerae. On the first home visit, the nurse conducts a home safety assessment. Identify at least five components of a safe home environment. CAS 3 Mr. Lourde PHARMACOLOGIC ETHNICITY Hospitai Linezoiid (Zyvox); fondaparinux u White American (Arixtra); hydrocodone bitartrate/ acetaminophen (Vicodin); CULTURAL CONSIDERATIONS acetaminophen (Tylenol); docusate sodium (Colace) PREEXISTING CONDITIONS PRiORITlZATlON u Left hip replacement buo years ago; septic shock with ieft hip osteomyelitis last year with subsequent removal of the hip replacement prosthesis; allergies to meperidine hydrochloride (Demerol), morphine sulfate (MS Contin), and vancomycin hydrochloride (Vancocin) COEXISTING DELEGATION CONDITION COMMUNICATION THE SKELETAL SYSTEM Level of difficulty: Moderate Overview: This case requires that the nurse understand the risk associated with postoperative wound infection following a hip replacement. The manifestations characteristic of osteomyelitis are discussed. The nurse must care for the surgical incision site with a daily dressing change and maintenance of a HemoVac drainage system, The client’s prescribed medications are reviewed for purpose and potential adverse effects. The purpose and potential complications of a peripherally inserted cent-ral catheter (PICC) are explained, Mr. Lourde is a 73-year-old man whose wife noticed a lump on his left hip that has increased in size over the past two weeks. The skin around the lump is red and swollen. Mr. Lourde complains of increasing discomfort in his left hip. His wife became concerned when he felt warm and his temperature was 101 OF (38.30C) so she brought him to the hospital. Mr. Lourde is diagnosed with an abscess of his left hip. A needle aspiration of the abscess reveals 30 mL of purulent exudate. Mr. Lourde is admitted for surgical incision and drainage of a suspected recurrence of osteomyelitis and for intravenous antibiotic therapy. Case Study A surgical incision and drainage is performed to remove necrotic tissue, sequestrum, and surrounding granulation tissue. A bacterial infection is identified as Enteroco«us faecalis. The nurse reviews the client’s kardex and notes the dressing change prescribed is a dry sterile dressing to the left hip daily with reinforcement as needed. The nurse medicates Mr. Lourde with hydrocodone/acetaminophen (Vicodin) thirty minutes prior to the dressing change. While changing the hip dressing, the nurse notes there are seven intact sutures along the incision line, and a HemoVac drain is in place. Minimal drainage is noted at the incision site. The site is slightly swollen, but there are no signs of infection. The HemoVac has drained 30 mL of dark red blood. Mr. Lourde tolerates the dressing change with minimal discomfort. He is afebrile at 980F (36.70C). Questions I. Discuss the time frame within which signs of an infection at the site of a hip replacement usually occur. possible complications are of concern when a client develops an infection at the site of a hip replacement? 2, Discuss the pathophysiology of osteomyeliås. Include an explanation of a sequestrum, involucrum, and Brodie’s abscess. Discuss the clinical manifestations of osteomyeliüs. The health care provider suspects a recurrence of Mr. Lourde’s osteomyelitis. How will the health care provider confirm this diagnosis? Discuss the treatmenvoptions if Mr. Lourde has osteomyeiitis of his left hip. Mr. Lourde will require at least three to eight weeks of high-dose intravenous antibiotic therapy. The health care provider has requested that a PICC be inserte& ExpIain what a PICC is and the potential complications associated with this device. t information should be included in the nurs documentation of the dressing change? Explain why the nurse does not document the stage of the left hip wound. Write two expected outcomes for the duration of time that a HemoVac drainage reservoir system is in place. How often should the nurse empty the drain and how will the nurse ensure that the system is working correctly to drain the incision site? Each of the medications below is prescribed for Mr. Lourde. For each, provide the therapeutic drug classification and discuss the purpose of the medicaton for Mr. Lourde and potential adverse effect(s) that the nurse should monitor. Fondaparinux I. Linezolid Hydrocodone bitartrate/acetaminophen Acetaminophen 5, Docusate sodium Il, Help the nurse generate three appropriate nursing diagnoses for Mr. Lourde. CAS Mrs. Bagent u Retired veterinarian; lives at home SETTING ETHNICITY 74 intensive care unit z White American CULTURAL CONSIDERATIONS ETHICAL PREEXISTING CONDITIONS Chronic obstructive pulmonary disease (CORD); hypertension; myocardiai infarction (MI) 2 years ago; type 2 diabetes DELEGATION CONDITION DISABILITY 129 u MULTI-SYSTEM FAILURE Mrs. Bagent was admitted to the medical unit of the hospital 3 days ago with pneumonia and heart failure. Upon admission, the client was having difficulty breathing and had an elevated temperature and white blood cell count (WBC). Claforan IV was ordered to treat the pneumonia. Her weight had increased by 6 pounds in the 5 days preceding admission and she had significant swelling in her lower extremities. Mrs. Bagent was receiving IV furosemide (Lasix) twice a day. She became very short of breath while ambulating to the bathroom. To promote rest, an indwelling urinary catheter was inserted. During the last 24 hours her condition deteriorated and she was u-ansferred to the intensive care unit (ICU). Case Study Mrs. Bagent was admitted to the ICU seven hours ago in septic shock. Her last set of vital signs were blood pressure 82/66, pulse 82, labored respirations of 32 per minute, tympanic temperature 101.20F (38.40C) and her oxygen saturation is 90% on 6 liters of oxygen via mask. Mrs. Bagent’s skin is pale and moist, her radial pulse is rapid and thready, capillary refill is 3 seconds, and she is complaining of nausea. The nurse auscultates crackles and wheezes in all lung fields and her bowel sounds are hypoactive. Mrs. Bagent is restless and has difficulty answering questions at times because of slight confusion. The physician has ordered her urine output to be measured every hour, her last hourly output was 18 mL. Questions I. Define shock. Discuss the potential causes of septic shock; and state at least 3 risk factors for developing septic shock. 2. Shock affects all body systems. Discuss the signs and symptoms shock produces in the following of Dopamine 800 mg m 500 mL of 0.9% NaCl. Mrs. Bagent’s weight is 135 pounds. At what rate should the nurse program the IV pump to run (mL/hr)? 6. Mrs. Bagent’s urine output is being monitored systems: respiratory, cardiovascular, neurological, every hour. Her last hourly urine output (UO) and hematological. Elaborate on the specific was 18 ml-. M7hat is a goal UO? Discuss why her considerations for Mrs. Bagent in regard to UO is low. each system.•7. List five priority nursing diagnoses for -3. The physician evaluating Mrs. Bagent asks the.Mrs, Bagent. nurse what her pulse pressure is. is a pulse 8. Nutritional support is very important for pressure and why is it of concern?Mrs. Bagent. Discuss why a dietician consult IS a Discuss the cellular changes that occurwhen a priority and why nutritional support should occur •patient is in shock.as soon as possible. A Dopamine drip has been ordered. 9. Multiple Organ Dysfuncåon Syndrome (MODS) Part A: Discuss what this medication is for, and can occur in septic shock if perfusion to tissues side effects that the nurse must monitor for. cannot be restored. Discuss the signs and symptoms of MODS and treatment options. Part n: The physician orders Dopamine 8 mcg/ kg/minute. Pharmacy brings the nurse a bag

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