Chapter 22: Case Study: Evolve, Chapter 22 Case Study , Chapter 22 Case Study , Postpartum evolve case study, Chapter 22 Case Study, CH 22 Case Study

With Ms. Rodrigues' overweight condition and family history of diabetes, she may have type 2 diabetes mellitus. You should ask her about polyuria, polydipsia, changes in vision, itching skin rash or ulcers, vaginal discharge, recent history of frequent urinary tract infections, paresthesias, and intermittent claudication. These questions address manifestations of hyperglycemia and of complications of long-term diabetes, which may be present by the time type 2 diabetes is diagnosed.

1. In addition to questions about her chest discomfort, what other assessment questions should you ask Ms. Rodrigues? Why?

She may have hypertension. Her paresthesias indicate some degree of peripheral neuropathy.

Ms. Rodrigues has polyuria, paresthesias in her feet, an itching rash in her groin, and blurry vision. Why is it important to measure her blood pressure and the pain and vibration sensation in her hands and feet?

Both blood glucose and HBA1, will be elevated. Indeed, they were elevated, and she was diagnosed with type 2 diabetes.

Her nurse practitioner ordered blood tests for glucose and HbAle What do you expect these values to be if Ms. Rodrigues has type 2 diabetes?

Hyperglycemia impairs WBC function, including chemotaxis and phagocytosis. Elevated glucose in the tissue also provides a culture medium for pathogen growth and vascular disease reduces tissue blood supply.

Ms. Rodrigues's evaluation reveals Candida infection and mild coronary artery disease. Why does diabetes increase the risk of infection?

Changes in the polyol pathway of sugar metabolism cause conduction defects and nerve degeneration. Microvascular disease also reduces blood supply to peripheral neurons.

Which physiological mechanisms contribute to peripheral neuropathy in type 2 diabetes?

Complications of long-term diabetes include diabetic retinopathy and cataracts.

Why did her nurse practitioner refer Ms. Rodrigues to an ophthalmologist?

Close glucose control will help reduce the onset, and possibly the progression, of the complications of long-term diabetes.

Why is it important to teach Ms. Rodrigues about diet, weight loss, and appropriate exercise, home glucose monitoring, and other ways (possibly including medications) to manage her blood sugar?

1. The healthcare professional explains that Parkinson's disease is characterized by which of the following?

A. Continuous seizures without regaining consciousness between the seizure.

B. Progressive decline in cognitive function with increasingly severe impairment in social and occupational functioning.

C. Fine, slowly spreading muscle tremors; and generalized slowness of movement, called Bradykinesia.

D. Recurrent proximal disorder of brain function, characterized by sudden attacks of altered, consciousness, motor activity, or sensory impairment.

C. Fine, slowly spreading muscle tremors; and generalized slowness of movement, called Bradykinesia.

2. What is the treatment goal for Abrienda?

A. Provide enough energy to exercise.

B. Control seizures without oversedation.

C. Relieve the cholinergic system and improve function.

D. Relieve symptoms and maintain mobility.

D. Relieve symptoms and maintain mobility.

3. Abrienda read more on Parkinson's disease and learns that levodopa crosses the blood brain barrier, where it is converted to:

A. Dopamine.

B. Acetylcholine.

C. Serotonin.

D. Epinephrine.

A. Dopamine

4. A healthcare professional explains to Abrienda that combining levodopa and carbidopa in one medication:

A. Differs the process of neurotransmitters at the synapse.

B. Promotes the cholinergic affect.

C. Postpones the progression of the nerve impulses in there for reduces the adverse reactions.

D. Increases the therapeutic effect of dopamine in the CNS and reduces its adverse reactions.

D. Increases the therapeutic effect of dopamine in the CNS and reduces its adverse reactions.

5. The healthcare professional explains to Abrienda that catechol-O-methyltransferase (COMT) inhibitors allow the patient does of levodopa to be lowered and decreased the incidence, and/or severity of dose-related side effects of levodopa. Which medication is a COMT inhibitor?

A. Ropinirole(Requip)

B. Trihexyphenidyl (Artane)

C. Entacapone (Comtan)

D. Benztropine (Cogentin)

C. Entacapone (Comtan)

6. What is the primary characteristic of a partial seizure?

A. Bilateral seizures.

B. Loss of consciousness for 10 to 20 seconds.

C. Loss of bowel and bladder control.

D. Rapid movement of the arms and legs.

B. Loss of consciousness for 10 to 20 seconds.

7. What is the drug of choice for management of partial seizures?

A. Phenytoin (Dilantin)

B. Ethosuximide (Zarontin)

C. Cartamazepine (Tegretol)

D. Valproic acid (Depakene, Depakote)

B. Ethosuximide (Zarontin)

8. Ethosuximide (Zarontin) is prescribed. What is a primary side effects of this medication?

A. Gingivitis.

B. Blurred vision.

C. Constipation

D. Sedation.

D. Sedation

9. What instructions should Naara receive concerning the effects of Zarontin, especially until the dosage is regulated?

A. The medication may produce generalized seizures.

B. Avoid taking the medication with grapefruit juice.

C. The medication will also affect generalized seizures. Should she have them.

D. Drive with caution.

D. Drive with caution.

10. If Zarontin is not effective in treating Naara's seizures, which other medication should she be prescribed?

A. Valproic acid(Depakote) and clonazepam(Klonopin).

B. Fosphenytoin (Cerebyx).

C. Gabapentin(Neurontin).

D. Phenytoin (Dilantin).

A. Valproic acid(Depakote) and clonazepam(Klonopin).

Peggy G. is a 35-year-old female patient who is 10 weeks pregnant. She tells you that she has constant morning sickness and has lost weight. She has acute gingival and dental pain and a probable endodontic lesion on tooth #29, which requires immediate treatment. Her gingiva is erythematic, and bleeding occurs upon brushing.

...

1. Which medications would be safest for Peggy to take for her pain?

a. Aspirin

b. Ibuprofen

c. Acetaminophen

d. Codeine

d. Codeine

2. What recommendations should be given regarding antibiotics for Peggy's endodontic lesion?

a. Amoxicillin should be prescribed if the infection does not resolve.

b. Amoxicillin should be prescribed prophylactically.

c. Incision and local drainage is preferable to antibiotic use.

d. Cephalosporins should be prescribed.

e. Metronidazole should be prescribed.

f. a and c only

g. a and d only

h. a and b only

f. a and c only

3. Which would be the safest local anesthetic to use for Peggy?

a. Bupivacaine

b. Mepivacaine

c. Lidocaine

d. Benzocaine

c. Lidocaine

Which special considerations should be made for Peggy's dental treatment?

a. Afternoon appointments to avoid morning sickness

b. Avoidance of all unnecessary radiographs

c. Emphasis on oral hygiene to prevent a low birth weight and preterm delivery

d. Delay in elective treatment to the second trimester

e. a and b only

f. a and c only

g. All of the above

h. None of the above

g. All of the above

5. Peggy confides to the dental hygienist that she really misses her evening glass of wine, and that she doesn't think that one glass of wine could hurt the baby. What information should the dental hygienist share with Peggy?

a. One drink a day is considered safe for pregnant mothers

b. Once the first trimester is completed, there is little risk to the baby. *c. There is no safe threshold for alcohol in the pregnant patient

d. Cleft lip and palate occur commonly with alcohol use in pregnancy

*c. There is no safe threshold for alcohol in the pregnant patient

1. Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most important for the nurse to obtain?

Uterine firmness

2. What is the priority nursing diagnosis for Marie, who is experiencing residual effects of epidural anesthesia?

Risk for injury

3. What is the priority nursing action to address Marie's needs related to the repair of her 4th degree perineal laceration?

Apply perineal ice packs consistently for the first 24-48 hours.

What is the sequence of nursing actions to assess Maureens 4th degree perineal laceration? (order)

put on gloves

ask the client to turn on her side and flex upper leg

examine laceration for REEDA

observe anus for edema

apply clean peripad

dispose of soiled materials

4. Considering Marie's history, for which postpartal complication is she most at risk?

Hemorrhage

When assessing maureens blood loss utilizing perineal pad saturation, the nurse weights a saturated pad and subtacts the weight of a dry pad. The difference is 8 grams. How many mL does the nurse record?

8

1.03mL=1gram

5. The nurse finds Marie disoriented and lying on her back in a pool of vaginal blood...what is the priority nursing action?

Massage the fundus

6. What is the best method for the nurse to use to obtain immediate assistance?

Activate the priority call light from the bedside.

7. While waiting for help to arrive, what is the next priority action?

Assess for bladder distention

8. Which task is best delegated to the UAP during this crisis?

Obtain the vital signs and O2 saturation

How many mL of methergine IM should the PN administer to Maureen?

2

at what infusion rate should the IV infusion pump be programmed to deliver the liter of NS with Pitocin 10 units?

250 mL/hr

1000mL divided by 4 hours=250 mL/hr

11. Which finding is most indicative that the medication is reaching a therapeutic level?

Firm fundus

12. Considering the client's history, what etiology is most likely?

Uterine atony

13. What intervention should the nurse implement to communicate the situation to Marie's husband?

Call Mr. Wilson from the nurses' station to inform him of his wife's status and request that he come to the hospital soon, without the children

14. What should the nurse do to prepare for Marie's blood transfusion? (Select all that apply)

-Start an additional IV using a 16 or 18 gauge angiocath

-Prime a new Y-set blood tubing using a new bag of normal saline.

-Explain the blood transfusion process to Marie

15. Marie's infant needs to be fed...what is the best thing for Marie's nurse to do?

Explain Marie's history and request that the infant be fed with formula in the nursery

16. What should the nurse do in response to these assessment findings?

Provide a warm blanket and continue to monitor

17. What is the difference in Marie's intake and output?

205

18. The nurse is aware that while Marie's condition is stabilizing, Marie is still at risk for hemodynamic changes. What action should the nurse take next, based on the assessment data just obtained?

Palpate Marie's bladder for fullness and catheterize if indicated

19. Considering Marie's history, what would be the most likely cause of Marie's headache?

Epidural anesthesia

20. Considering Marie's history and acuity level, who is the best nurse to assign to Marie's care?

Labor and delivery nurse with 12 years of experience, who was called in to work for 4 hours until 2300

21. Who is the best person to speak with Marie's HCP?

Marie's nurse, who has already given the shift report and is preparing to clock out

22. Which task is best for the nurse to delegate to the UAP?

Obtain and document Marie's vital signs

23. What further teaching would be the most important for the nurse to include at this time?

Indications and mechanism of action of caffeine sodium benzoate

24. Based on this information, what is the correct nursing action?

Allow Marie to rest during the blood transfusion, and administer the RhoGam as prescribed at a later time.

25. What priority action should the nurse implement?

Notify the security personnel and direct all staff to report to their assigned exit in the hospital

Peggy G. is a 35-year-old female patient who is 10 weeks pregnant. She tells you that she has constant morning sickness and has lost weight. She has acute gingival and dental pain and a probable endodontic lesion on tooth #29, which requires immediate treatment. Her gingiva is erythematic, and bleeding occurs upon brushing

1. Which medications would be safest for Peggy to take for her pain?

a. Aspirin

b. Ibuprofen

c. Acetaminophen

d. Codeine

ANS: C. Acetaminophen

In normal doses, acetaminophen is considered safe during pregnancy. In large doses, it may be associated with renal changes in the fetus like those that occur in adults. Aspirin taken in the third trimester can prolong gestation, complicate delivery, decrease placental efficiency, and increase the risk of hemorrhage to both mother and baby; premature closure of the patent ductus arterious may also occur. These effects have been reported with long-term use of high doses of aspirin. Abuse of aspirin may increase the risk of stillbirth or neonatal death. Ibuprofen has similar effects as aspirin; if they are given near term, the fetal outcome would be expected to be the same. NSAIDs also potentiate vasoconstriction in a patient with hypoxia. All NSAIDs carry a warning to avoid use during pregnancy. Opioids given near term may cause respiratory depression in the infant or, in an addicted mother, withdrawal symptoms after birth.

2. What recommendations should be given regarding antibiotics for Peggy's endodontic lesion?

a. Amoxicillin should be prescribed if the infection does not resolve.

b. Amoxicillin should be prescribed prophylactically.

c. Incision and local drainage is preferable to antibiotic use.

d. Cephalosporins should be prescribed.

e. Metronidazole should be prescribed.

f. a and c only

g. a and d only

h. a and b only

ANS: F. a and c only

Antiinfective agents should only be used when a definite indication for their use exists. Experts generally agree that amoxicillin is safe to use during pregnancy, and if incision and local drainage are unable to control the dental infection, its use would be acceptable.

3. Which would be the safest local anesthetic to use for Peggy?

a. Bupivacaine

b. Mepivacaine

c. Lidocaine

d. Benzocaine

ANS: C. Lidocaine

Lidocaine is the local anesthetic of choice for the pregnant woman because of its low risk for both the mother and developing fetus, and it is not associated with methemoglobinemia (as is prilocaine) and is not highly lipid soluble (as is etidocaine), which would prolong its effect. Low doses of a local anesthetic given by careful, slow injection have not been associated with any problems in the fetus.

Small doses of epinephrine, administered with appropriate care, are similar to those produced endogenously. If procedures are to be short, then local anesthetics without epinephrine are preferred.

4. Which special considerations should be made for Peggy's dental treatment?

a. Afternoon appointments to avoid morning sickness

b. Avoidance of all unnecessary radiographs

c. Emphasis on oral hygiene to prevent a low birth weight and preterm delivery

d. Delay in elective treatment to the second trimester

e. a and b only

f. a and c only

g. All of the above

h. None of the above

ANS: G. All of the above

All the recommendations are good for maximizing Peggy's oral health and protecting her unborn child.

5. Peggy confides to the dental hygienist that she really misses her evening glass of wine, and that she doesn't think that one glass of wine could hurt the baby. What information should the dental hygienist share with Peggy?

a. One drink a day is considered safe for pregnant mothers

b. Once the first trimester is completed, there is little risk to the baby.

c. There is no safe threshold for alcohol in the pregnant patient

d. Cleft lip and palate occur commonly with alcohol use in pregnancy

ANS: C. There is no safe threshold for alcohol in the pregnant patient

Pregnant patients should be encouraged to abstain from alcohol ingestion throughout their pregnancies, especially in the first trimester when fetal organ systems are developing. There is strong evidence for the teratogenicity of alcohol, and no safe threshold of drinking has been established. Fetal alcohol syndrome is linked to growth retardation, CNS abnormalities, and facial dysmorphology. Drinking throughout pregnancy is linked to tremors, hypertonia, restlessness, crying, and abnormal reflexes after birth.

Case Study

CASE REPORT 1: MAJOR DEPRESSION

Mrs. Carr, a 58-year-old widow, was brought to an emergency ward by her daughter, who found her at home in bed in the middle of the day. For a period of months, Mrs. Carr had become increasingly withdrawn and dysphoric, without any precipitating events. She had become progressively less active and even required encouragement to eat and perform her daily tasks. Her daughter and son-in-law became alarmed but did not know what to do. Mrs. Carr's medical history was unremarkable, but her psychiatric history revealed an episode of postpartum depression following the birth of one of her children.

On examination, the ER physician noted that Mrs. Carr was withdrawn and negativistic, refusing to cooperate with the examination, and even refusing to open her mouth. There were signs of acute dehydration and decline in personal hygiene and grooming.

Further questioning of Mrs. Carr's daughter revealed that Mrs. Carr had become increasingly paranoid and had delusions of sinfulness and guilt. Recently, she had shown signs of increasing mutism.

The physician recognized signs of major depression and arranged for immediate hospitalization. Mrs. Carr responded favorably to combined use of an antipsychotic and an antidepressant drug. An alternative treatment would have been a course of electroconvulsive therapy, which also produces favorable results.

Postpartum depression is an example of a

Mood disorder

A term that best describes one of Mrs. C's symptoms is

Apathy

Mrs. C's dysphoria meant that she was

depressed

An example of an antidepressant drug is

Prozac