Case Study 6 Coronary Artery Disease and Heart Failure X Scenario You are working in the internal medicine clinic of a large teaching hospital. Today…

Question Answered step-by-step Case Study 6 Coronary Artery Disease and Heart FailureX ScenarioYou are working in the internal medicine clinic of a large teaching hospital. Today your first patient is 70-year-old J.M., a man who has been coming to the clinic for several years for management of coronary artery disease (CAD) and hypertension (HTN). A cardiac catheterization done a year ago showed 50% stenosis of the circumflex coronary artery. He has had episodes of dizziness for the past 6 months and orthostatic hypotension, shoulder discomfort, and decreased exercise tolerance for the past 2 months. On his last clinic visit 3 weeks ago, a chest x-ray (CXR) showed cardiomegaly, and a 12-lead electrocardiogram (ECG) showed sinus tachycardia with left bundle branch block (LBBB). You review his morning blood work and initial assessment. ■ Chart View 1. As you review these results, which ones are of possible concern, and why? The blood pressure and pulse are slightly elevated, with several possibilities, including worsening of his CAD, HTN, or possibly heart failure (HF). More testing is needed to verify. His Hgb and Hct are slightly decreased, and further testing is needed to determine whether an iron deficiency or vitamin B 12 deficiency exists. Laboratory Testing Chemistry Sodium 142 mEq/L Chloride 95 mEq/L Potassium 3.9 mEq/■ Chart View 1. As you review these results, which ones are of possible concern, and why? The blood pressure and pulse are slightly elevated, with several possibilities, including worsening of his CAD, HTN, or possibly heart failure (HF). More testing is needed to verify. His Hgb and Hct are slightly decreased, and further testing is needed to determine whether an iron deficiency or vitamin B 12 deficiency exists. Laboratory Testing Chemistry Sodium 142 mEq/L Chloride 95 mEq/L Potassium 3.9 mEq/L Creatinine 0.8 mg/dL Glucose 82 mg/dL BUN 19 mg/dL CBC WBC 5400/mm 3 Hgb 13 g/dL Hct 41% Platelets 229,000/mm 3 Initial Assessment Complains of increased fatigue and shortness of breath, especially with activity, and “waking up gasping for breath” at night, for the past 2 days. Vital Signs Temperature 97.9° F (36.6° C) Blood pressure 142/83 mm Hg Heart rate 105 beats/min Respiratory rate 18 breaths/min1. As you review these results, which ones are of possible concern, and why? The blood pressure and pulse are slightly elevated, with several possibilities, including worsening of his CAD, HTN, or possibly heart failure (HF).2. Knowing his history and seeing his condition this morning, what further questions are you going to ask J.M. and his daughter?CASE STUDY PROGRESS J.M. tells you he becomes exhausted and has shortness of breath climbing the stairs to his bedroom and has to lie down and rest (“put my feet up”) at least an hour twice a day. He has been sleeping on two pillows for the past 2 weeks. He has not salted his food since the physician told him not to because of his high blood pressure, but he admits having had ham and a whole bag of salted peanuts 3 days ago. He denies having palpitations but has had a constant, irritating, nonproductive cough lately.3. You think it’s likely that J.M. has heart failure (HF). From his history, what do you identify as probable causes for his HF?4. You are now ready to do your physical assessment. For each potential assessment finding for HF, indicate whether the finding indicates left-sided heart failure (L) or right-sided heart failure (R).• Fatigue, weakness, especially with activity• Jugular (neck) vein distention 3. Dependent edema (legs and sacrum)• Hacking cough, worse at night • Enlarged liver and spleen• Exertional dyspnea• Distended abdomen• Weight gain• S3/S4 gallop• Crackles/wheezes in lungs■ Chart View CASE STUDY PROGRESS The physician confirms your suspicions and indicates that J.M. is experiencing symptoms of early left-sided heart failure. Medication orders are written.5. For each medication listed, identify its class, and describe its purpose for the treatment of HF. Enalapril (Vasotec):Furosemide (Lasix): Loop diuretic. Loop diuretics are given to decrease fluid volume (preload).Carvedilol (Coreg.Digoxin (Lanoxin):Potassium chloride (K-Dur): .Medication Orders Enalapril (Vasotec) 10 mg PO twice a day Furosemide (Lasix) 20 mg PO every morning Carvedilol (Coreg) 6.25 mg PO twice a day Digoxin (Lanoxin) 0.5 mg PO now, then 0.125 mg PO dailyPotassium chloride 10 mEq tablet PO once a day6. When you go to remove the medications from the automated dispensing machine, you see that carvedilol (Coreg CR) is stocked. Will you give it to J.M.? Explain.7. As you remove the digoxin tablet from the automated medication dispensing machine, you note that the dosage on the tablet label is 250 mcg. How many tablets would you give?8. Based on the new medication orders, which blood test or tests should be monitored carefully? Explain your answer.9. When you give J.M. his medications, he looks at the potassium tablet, wrinkles his nose, and tells you he “hates those horse pills.” He tells you a friend of his said he could eat bananas instead. He says he would rather eat a banana every day than take one of those pills. How will you respond?CASE STUDY PROGRESS This is J.M.’s first episode of significant HF. Before he leaves the clinic, you want to teach him about lifestyle modifications he can make and monitoring techniques he can use to prevent or minimize future problems.10. List five suggestions you might make and the rationale for each11. You tell J.M. the combination of high-sodium foods he had during the past several days might have contributed to his present episode of HF. He looks surprised. J.M. says, “But I didn’t add any salt to them!” To what health care professional could J.M. be referred to help him understand how to prevent future crises? State your rationale.12. You also include teaching about digoxin toxicity. When teaching J.M. about the signs and symptoms of digoxin toxicity, which should be included? (Select all that apply.) a. Dizziness when standing up b. Visual changes c. Loss of appetite or nausea d. Increased urine output e. DiarrheaCASE STUDY OUTCOME J.M.’s condition improves after 5 days of treatment, and he is discharged to home. He has a follow-up appointment with a cardiologist in 2 weeks. Health Science Science Nursing Share QuestionEmailCopy link Comments (0)

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