How to Answer Medical Surgical Case Questions (Complete Guide)

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Original Question

MEDICAL SURGICAL CASE STUDY Objectives -Prioritization -Evaluate – Describe -Evaluate -Identify Subject Sandy Werthal is a 60 yo sales representative who suffered a stable fracture of the pelvis in a motor vehicle crash 4 days ago. Her past medical history is osteopenia and hypothyroidism. She has multiple areas of soft tissue trauma to her legs, as evidenced by large hematomas over the entire left leg and right thigh. She also has several facial fractures from hitting the steering wheel during the crash. She is being treated by immobilization with bedrest. Her medication orders include enoxaparin 40mg SQ daily, levothyroxine 100mg daily,alendronate 70mg PO weekly, oxycodone/acetaminophen 2 tablets q4hrs prn, and psyllium (Metamucil) 2 tsp twice daily.` Your morning assessment findings include the following: blood pressure 128/82 mm Hg, heart 82 beats/min, respiratory rate 16 breath/min, 94% SPo2 on room air, and temperature 98.2 F (36.8 C), A&O X 4, swelling and ecchymosis noted on right side of face; lung sounds clear but diminished in bilateral lower lobe, normal S1 and S2 heart sounds; bowel sounds active in all four quadrants, moves lower extremities with difficulty; states pain at an acceptable level but says her legs are very sore. Pedal pulses 2+ bilaterally; +1 edema around both ankles; legs warm and ecchymotic. She is eating a regular diet and drinks fluids well. Mrs.Werthal pushes the call bell a few hours later and you find her struggling to sit up in bed and holding her chest. She tells you that she has severe chest pain and can not breathe. A quick assessment of her vital signs reveals a blood pressure of 102/66 mm Hg, HR of 110 beats/min, and a respiratory rate of 38 breaths/min, and SPO2 of 78%. Sandy A&O X4. Chest auscultation reveals bilateral crackles. She coughs and her sputum is frothy and red. Evaluation Your first action after this initial assessment is to: Notify the provider Apply nasal cannula O2 Position her in a high fowler’s position Call the laboratory for stat ABGs You notify the health care provider and and receive orders for stat arterial blood gases (ABGs). Pulse oximetry, continuous oxygen to maintain SpO2 greater than 93% insertion of a second IV catheter and a stat ECG. ABG results that would reflect the presence of a PE include: pH 7.32, PaO2 64mm Hg, PaCO2 52mm Hg, HCO3 24 mEq/L pH 7.40, PaO2 76 mm Hg, PaCO2 45mm Hg, HCO3 26 mEq/L pH 7.46, PaO2 54 mm Hg, PaCO2 30 mm Hg, HCO3 22 mEq/L pH 7.48, PaO2 66 mm Hg, PaCO2 58 mm Hg, HCO3 28 mEq/L The `health care provider arrives and examines Mrs. Werthal and requests her to transfer to the intensive care unit after she has a spiral (helical) CT scan. The CT scan identifies multiple pulmonary emboli obstructing perfusion to approximately 60% of the lung. The health care provider orders a continuous IV heparin drip in D5W using a weight-based nomogram. Based on Mrs Wethal’s weight she will receive a bolus of 5000 U of heparin followed by a drip rate of 1200 U/hr. You know that the thrombolytic therapy is useful in the treatment of PE, but also recognize that thrombolytic therapy is contraindicated for Mrs.Werthal because; She has experience recent trauma At her age, she is at risk for a cerebral bleed Her blood pressure is below the recommended parameters It has not been approved for use in treating Pulmonary emboli Prior to the start of fibrinolytic therapy, the nurse should perform a baseline assessment on which body system? Neurological Respiratory Gastrointestinal Cardiac Based on the ABG results identified in question 2, you recognize that the type of respiratory failure Mrs. Werthal has isp; Alveolar hypertension Hypoxemic respiratory failure Ventilatory failure Hypercapnic respiratory failure Based on the finding of the CT, you recognize that the primary mechanism of respiratory failure that is present in Mrs.Wethal is: Diffusion limitation V/Q mismatch Shunt Alveolar hypoventilation Select all the additional orders that would be appropriate upon Mrs.Werthal’s transfer to the intensive care unit. Select all that apply Repeat ABG in 4 hours Albuterol nebulization with 2.5mg/ 5 mL NS q 2hr dyspnea Call if BP less than 110/60 mm Hg Continuous ECG monitoring Cefazolin 2 grams IV q8hr Morphine 4 mg IV q 2hr prn pain aPTT q 6 hr and titrate heparin drip according to nomogram What is a possible complication of a PE, based on the symptoms and type of PE this patient has. Pulmonary hypertension Sinus sick syndrome Pulmonary hypotension Congestive heart failure You evaluate that Mrs.Werthals condition is improving when her… Arterial pH decreases Arterial PaO2 increases Urinary output increases Blood pressure increases Mrs.Werthal is better, and is preparing to discharge. You recognize the importance of patient teaching regarding long-term warfarin therapy for Mrs.Werthal. Select those statements that would be appropriate to teach Mrs.Werthal. Select all that apply Frequent laboratory testing for INR values will be necessary for accurate dosing An increased dietary intake of green, leafy vegetables will increase the effects of warfarin. A diet in vitamin E and calcium is essential for adequate coagulation Encourage proper hydration to prevent additional hypercoagulability of the blood Instruct patient to report any signs of bleeding (e.g., black or bloody stools, bloody urine, coffee-ground or bloody vomit, nosebleeds) Teach patient to use a firm toothbrush in order to maintain oral hygiene A limited dietary intake of green, leafy vegetables will decrease the effects of warfarin.

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