Health Care Delivery and Evidence-Based Nursing Practice

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Case Study, Chapter 1, Health Care Delivery and Evidence-Based Nursing Practice

Suzanne Jones, 76-year-old patient with COPD is admitted to the ICU. Mrs. Jones is placed on mechanical ventilation to assist with her breathing. After

2 days on the ventilator, Mrs. Jones is extubated and then transferred to a medical-surgical unit. The medication regimen is adjusted during the

hospitalization. Mrs. Jones is discharged home after 6 days. She and her family are pleased with the care she receive in the hospital. (Learning Objectives

3 and 6)

Describe the quality performance tools that may be used to demonstrate that the care and treatment rendered are both cost-efficient and of high quality.

Describe the quality performance tools that may be used to demonstrate that the nursing care utilized is evidence-based care and high quality, resulting

in patient satisfaction and good patient outcomes.

Case Study, Chapter 2, Community-Based Nursing Practice

Mrs. Johnson, a 67-year-old female patient, has recently been discharged from the hospital following an admission for COPD. She has a past medical

history of a colon resection related to acute diverticulitis. She developed a surgical wound infection that requires daily wet to dry wound packing and IV

Zosyn. Mrs. Johnson was discharged with home oxygen. To manage her care at home, home care visits were ordered. (Learning Objective 5)

What would be involved in setting up the first home care visit?

Describe the nursing assessments and management that would occur during the visit.

Case Study, Chapter 3, Critical Thinking, Ethical Decision Making, and the Nursing Process

The nurse receives a 12-year-old girl from the operating room after an emergent appendectomy due to ruptured appendix. Upon arrival to the

postanesthesia care unit, the patient is drowsy, but arousable to voice; she was extubated in the operating room and is receiving oxygen by facemask at

40%. She has two peripheral IVs in her left arm that are infusing Lactated Ringers solution at 100 mL/hr. A nasogastric tube is attached to low constant

suction, and a small amount of aspirate is noted. She has a urinary catheter that is draining clear, yellow urine. Her abdominal dressing is dry and intact.

Upon arousal, she complains of abdominal pain. (Learning Objective 5)

What NANDA-approved nursing diagnoses may be relevant to this patient?

Once the nursing diagnoses are determined, what steps does the nurse take to complete the Planning Phase of the Nursing Process?

What is the difference between nursing diagnoses and collaborative problems?

Case Study, Chapter 4, Health Education and Health Promotion

Mr. Smith, a 57-year-old patient, presents at a health fair asking questions about the age-appropriate health maintenance and promotion considerations

he should be concerned about. He stated that he only goes to his physician when he is sick and the last time he saw his physician was 2 years ago when

he had a sinus infection. (Learning Objectives 7 to 9)

What further assessment does the nurse need to make before designing a teaching plan?

What topics does the nurse need to include for Mr. Smith based on current medical recommendations?

Design a teaching plan that covers the topics.

Case Study, Chapter 5, Adult Health and Nutritional Assessment

The registered nurse prepares to conduct a nutritional assessment on Mrs. Varner, a 52-year-old Caucasian female who describes herself as “overweight

most of my adult life.” The client states that her health is good. She works part time as a receptionist and volunteers about 10 hours per week in her church.

The nurse obtains Mrs. Varner’s height as 64 inches and her weight as 165 pounds. (Learning Objective 8)

What is the rationale for computing body mass index? What is Mrs. Varner’s BMI?

Calculate her ideal body weight. What is your assessment of her BMI and weight?

Based on Mrs. Varner’s BMI and weight, the nurse measures her waist circumference. Describe the proper procedure for this assessment.

Mrs. Varner’s waist circumference is 38 inches. What is your assessment?

What laboratory values would the nurse review to evaluate Mrs. Varner’s protein levels?

Case Study, Chapter 6, Individual and Family Homeostasis, Stress, and Adaptation

Mr. Smith, a 52-year old patient, is admitted to the coronary care unit with the diagnosis of acute inferior myocardial infarction. The patient has a history

of smoking two packs per day of cigarettes for 35 years, and he drinks a six-pack of beer on weekend nights, but does not drink the rest of the week. He is

the sole financial support for his family. He is a consultant for a company and is out of town during week days. Over the past year, Mr. Smith has gained 20

pounds. He is 5 foot 6 inches, weighing 200 pounds. His diet consists mostly of fast food. He rarely exercises. His wife cares for their three teenage

children. The eldest son, 17 years of age, totaled the family car when drinking and driving 2 days ago and he is in the local children’s hospital in the

intensive care unit in critical condition. Mr. Smith developed chest pain and slumped over in his chair during an argument with his wife about their teenage

daughter, who is 15 years of age and wanted to get birth control pills. The wife is in the waiting room while the nurses settle Mr. Smith into his room. The

youngest son, 13 years of age, is at a friend’s house. The teenage daughter is staying at the bedside of the critically ill eldest son. The wife blames her

eldest son for her husband’s heart attack and told the emergency department nurse that she does not care to see her son at all. (Learning Objectives 6, 10,

and 11)

What maladaptive responses to stress may have contributed to Mr. Smith’s development of an illness?

Based on the case study, what family assessment data may be used to determine coping strategies being currently used by the family in crisis?

What nursing interventions should be used to promote effective coping for the patient and his family?

Case Study, Chapter 7, Overview of Transcultural Nursing

Mrs. Perez, 32 years of age, is a Hispanic patient who is admitted for early stage cancer of the uterus. The surgeon stated that in order to treat Mrs.

Perez’s cancer successfully, the uterus will need to be removed surgically through a procedure called a simple hysterectomy leaving the ovaries, fallopian

tubes, and vagina. The surgeon requests that the nurse make arrangements for an interpreter, so they can both use the interpreter’s services. The patient

only speaks Spanish, but her mother and one of the patient’s sisters are bilingual. They are currently visiting the patient. Her husband is also visiting and he

only speaks Spanish. The patient’s two children are with her sister Maria. The family stated they are devout Catholics and request to see a priest while in

the hospital. Today is Ash Wednesday. (Learning Objective 4)

Which interpreter is the most appropriate choice to communicate with Mrs. Perez and why?

After critically analyzing the cultural influences, what nursing actions are appropriate for the patient?

Case Study, Chapter 8, Overview of Genetics and Genomics in Nursing

A patient who is 38 years of age is diagnosed with autosomal dominant polycystic kidney disease, a hereditary disease that results in fluid-filled cysts

occupying space in the kidneys. The cysts can interfere with the function of the kidney and may burst and cause bleeding inside the kidney. The patient with

polycystic kidney disease may or may not have a berry aneurysm of a blood vessel in the brain that could lead to bleeding and death, cysts on the ovaries,

and a mitral valve prolapse (in females) that can lead to dysrhythmias (irregular heart rhythms), or diverticula (outpouching of the bowel) that are

susceptible to infection and inflammation and may lead to gastrointestinal bleeding. The patient is susceptible to retaining fluid in the abdomen so the

abdomen is large to constipation, and to hypertension. There is no cure for the disease. The patient receives supportive care for the various symptoms or

complications the patient may have. (Learning Objectives 1 to 3)

When explaining to the patient and family about polycystic kidney disease, the nurse should explain what characteristics about an autosomal dominant

genetic disease?

How does variable expression of genetic characteristics play a role in the course of polycystic kidney disease and how can the nurse further predict the

level of the disease?

Identify the roles of the nurse in integrating genetics in the nursing care provided for the patient.

Case Study, Chapter 9, Chronic Illness and Disability

Mr. Edwards is 20-year-old male patient who is admitted for treatment of recurring pyelonephritis (kidney infection) and surgical treatment of a urinary

stricture, which has decreased the urinary stream. Mr. Edwards has paraplegia; he is paralyzed from the waist down secondary to an automobile accident

when he was 16. He came by ambulance to the hospital, leaving his wheelchair and wheelchair pressure-relieving cushion at home. According to the

nursing history, the patient is a nonsmoker and he does not drink alcohol or take any illegal drugs. (Learning Objective 5)

What nursing considerations should be made for Mr. Edwards related to his disability?

What health promotion and prevention education does Mr. Edwards need?

Case Study, Chapter 10, Principles and Practices of Rehabilitation

Mrs. Adams, 72 years of age, is admitted to the rehab unit with the diagnosis of stroke. The stroke affected the limbic area in the brain, which has caused

the patient to have emotional labiality (her mood changes rapidly because she misinterprets situations). As a result of the emotional labiality, she sometimes

refuses to be repositioned or to participate in physical or occupational therapy. She sometimes also refuses to eat and drink. The patient’s right side is

paralyzed and flaccid. She has no feeling on her right side. She has reddened areas on her coccyx and both heels at least 1 cm in diameter that do not go

away with repositioning. She is incontinent of urine and stool. She has problems with communication called global aphasia (difficulties understanding

speech and the written word and difficulties with speaking and writing). She is 5 feet tall and weighs 178 pounds. She has a tendency to develop skin tears

because her skin is thin, and she has several bandages on her arms. The family states they are concerned because the staff on the previous medicalsurgical

unit would drag their mother up in bed when she slid down. The staff would chart when their mother refused to be repositioned and then would not

reposition her for hours. (Learning Objectives 2 and 4)

Explain the pathophysiology of the risk factors that predispose Mrs. Adams to developing pressure ulcers?

What nursing measures need to be instituted for Mrs. Adams based on the information presented in the case study?

Case Study, Chapter 11, Health Care of the Older Adult

The nurse working at the senior center notices Mrs. Jones, a 78-year-old, crying. The nurse approaches Mrs. Jones and asks if she needs help. Mrs.

Jones states “I am so embarrassed. I had another accident and my pants are all wet. It’s like I’m a baby. I never should have come to the senior center.”

(Learning Objectives 3 and 4)

What factors may be contributing to the urinary incontinence?

How should the nurse respond to Mrs. Jones?

Case Study, Chapter 12, Pain Management

Mr. Will, a 67-year-old patient, is postoperative day 2 after a coronary artery bypass graft operation to revascularize his coronary arteries that were

significantly blocked. He has a midline incision of his chest and a 7-inch incision on the inner aspect of his right thigh where a saphenous vein graft was

harvested and used to vascularize the blocked coronary artery. The surgeon ordered Oxycodone 5 mg every 4 hours PRN for moderate pain and

Oxycodone 10 mg every 4 hours PRN for severe pain. (Learning Objectives 7 and 8)

Considering the patient’s age, what medication administration considerations should the nurse incorporate into the pain management plan and why?

What measures should the nurse provide the patient to prevent adverse effects of analgesic agents from occurring?

What nonpharmacologic pain management methods should the nurse teach to Mr. Will to assist with pain management?

Case Study, Chapter 13, Fluid and Electrolytes: Balance and Disturbance

Mrs. Dean is 75-year-old woman admitted to the hospital for a small bowel obstruction. Her medical history includes hypertension. Mrs. Dean is NPO.

She has a nasogastric (NG) tube to low continuous suction. She has an IV of 0.9% NS at 83 mL/hr. Current medications include furosemide 20 mg daily

and hydromorphone 0.2 mg every 4 hours, as needed for pain. The morning electrolytes reveal serum potassium of 3.2 mEq/L. (Learning Objective 4)

What are possible causes of a low potassium level?

What action should the nurse take in relation to the serum potassium level?

What clinical manifestations might the nurse assess in Mrs. Dean?

Case Study, Chapter 14, Shock and Multiple Organ Dysfunction Syndrome

Adam Smith, 77 years of age, is a male patient who was admitted from a nursing home to the intensive care unit with septic shock secondary to

urosepsis. The patient has a Foley catheter in place from the nursing home with cloudy greenish, yellow-colored urine with sediments. The nurse removes

the catheter after obtaining a urine culture and replaces it with a condom catheter attached to a drainage bag since the patient has a history of urinary and

bowel incontinence. The patient is confused, afebrile, and hypotensive with a blood pressure of 82/44 mm Hg. His respiratory rate is 28 breaths/min and the

pulse oximeter reading is at 88% room air, so the physician ordered 2 to 4 L of oxygen per nasal cannula titrated to keep SaO2 greater than 90%. The

patient responded to 2 L of oxygen per nasal cannula with a SaO2 of 92%. The patient has diarrhea. His blood glucose level is elevated at 160 mg/dL. The

white blood count is 15,000 and the C-reactive protein, a marker for inflammation, is elevated. The patient is being treated with broad-spectrum antibiotics

and norepinephrine (Levophed) beginning at 2 mcg/min and titrated to keep systolic blood pressure greater than 100 mm Hg. A subclavian triple lumen

catheter was inserted and verified by chest x-ray for correct placement. An arterial line was placed in the right radial artery to closely monitor the patient’s

blood pressure during the usage of the vasopressor therapy. (Learning Objectives 6 and 7)

What predisposed the patient to develop septic shock?

What potential findings would suggest that the patient’s septic shock is worsening from the point of admission?

The norepinephrine concentration is 16 mg in 250 mL of normal saline (NS). Explain how the nurse should administer the medication. What nursing

implications are related to the usage of a vasoactive medication?

Explain why the effectiveness of a vasoactive medication decreases as the septic shock worsens. What treatment should the nurse anticipate to be

obtained to help the patient?

Explain the importance for nutritional support for this patient and which type of nutritional support should be provided?

Case Study, Chapter 15, Oncology: Nursing Management in Cancer Care

Emanuel Jones, 60 years of age, is male patient diagnosed with small cell carcinoma. He underwent surgery in the past to remove the left lower lobe of

his lung. He is receiving chemotherapy. Two weeks before a round of chemotherapy, a complete blood count with differential, and a renal and metabolic

profile are obtained for the patient. The patient presents to the oncology clinic for chemotherapy with a temperature of 101°F. Further assessment reveals

decreased breath sounds in the right base of the right lung, and a productive cough expectorating green colored mucus. The patient is short of breath and

has a pulse oximetry reading that is SaO2 of 85% on room air. The patient has a history of benign prostate hypertrophy (BPH) and has complaints of

urinary frequency and burning upon urination. The patient is admitted to the oncology unit in the hospital. The oncologist orders the following: blood,

sputum, and urine cultures; and a chest x-ray. An x-ray of the kidneys, ureters, bladder (KUB) is ordered. An arterial blood gas (ABG) on room air, CBC with

differential, and renal and metabolic profile are ordered. Oxygen is ordered to begin with nasal cannula at 2 L/min and titrate to keep SaO2 greater than

90%. A broad-spectrum antibiotic, levofloxacin 500 mg in 100 mL of NS is ordered to be administered IV over 60 minutes once daily. (Learning Objective 8)

After examining the physician orders, in what sequence should the nurse provide the care to the patient admitted to the hospital? Give the rationale for

the sequence chosen.

On what areas should the nurse focus the assessment to detect potential complications for Mr. Jones?

What patient education does Mr. Jones need from the nurse to help prevent the reoccurrence of an infection and to get treatment for an infection

promptly?

Case Study, Chapter 16, End-of-Life Care

Joe Clark, 79 years of age, is a male patient who is receiving hospice care for his terminal illnesses that include lung cancer and chronic obstructive

pulmonary disease (COPD). He developed bilateral pleural effusion (fluid that accumulates in the pleural space of each lung), which has compromised his

lung expansion. He states that he is short of breath and feels anxious that the next breath will be his last. The patient is admitted to the hospital for a

thoracentesis (an invasive procedure used to drain the fluid from the pleural space so the lung can expand). The thoracentesis is being used as a palliative

measure to relieve the discomfort he is experiencing. Low dose morphine is ordered to provide relief from dyspnea or discomfort. The patient is prescribed

Proventil (albuterol) inhaler 2 puffs per day, as needed, and Flovent (fluticasone propionate) inhaler 2 puffs twice a day. The patient has 2 L/min of oxygen

ordered per nasal cannula as needed for comfort. (Learning Objective 9)

What nursing measures should the nurse use to manage the patient’s dyspnea?

The patient complains that he has no appetite and struggles to eat and breathe. What nursing measures should the nurse implement to manage this

physiologic response to the terminal illnesses?

Case Study, Chapter 17, Preoperative Nursing Management

Joan Arnold, 67 years of age, is a female patient who underwent a coronary angiogram that diagnosed severe coronary artery disease in three of her

coronary arteries, the left anterior descending, the left circumflex, and the right coronary artery. She is scheduled for a coronary artery bypass graft

operation tomorrow. The nurse provides patient education for Mrs. Arnold and her husband, which includes watching a hospital video on the operation, the

intensive care environment, what to expect after the surgery, the recovery period, and cardiac rehabilitation. The video also covered the importance of

coughing and deep breathing, using an incentive spirometer, splinting, early ambulation, pain medication, and how to position oneself safely. The video

stressed the importance of not rolling onto the side that the chest tube may be in place postoperatively. The video also discussed the preoperative

preparation. The nurse also provided a booklet on the subject material. The nurse had a session with the patient and her husband to assess their

understanding and to answer any questions they may have had. (Learning Objectives 6 to 8)

What specific preoperative nursing measures should the nurse review with the patient to help decrease the risk for postoperative complications?

Explain the role of the nurse when implementing the immediate preoperative preparation the day before surgery and the morning of the surgery?

Case Study, Chapter 18, Intraoperative Nursing Management

Pearl Richards, 69 years of age, is a female patient who is in the operating room for a repair of an abdominal aortic aneurysm. The patient has a history

of hypertension controlled with medications, osteoporosis, chronic obstructive pulmonary disease, and has smoked two packs of cigarettes per day for 40

years. (Learning Objectives 2, 6, and 9)

What nursing interventions are instituted to reduce the surgical risk factors related to the patient’s age?

Explain the role of the nurse in providing patient safety measures during the intraoperative period.

Case Study, Chapter 19, Postoperative Nursing Management

Rita Schmidt, 74 years of age, is a female patient who was admitted to the surgical unit after undergoing removal of a section of the colon for colorectal

cancer. The patient does not have a colostomy. The patient has several small abdominal incisions and a clear dressing over each site. The incisions are

well approximated and the staples are dry and intact. There is a Jackson-Pratt drain intact with minimal serous sanguineous drainage present. The patient

has a Salem sump tube connected to low continuous wall suction that is draining a small amount of brown liquid. The patient has no bowel sounds. The

Foley catheter has a small amount of dark amber-colored urine without sediments. The patient has sequential compression device (SCD) in place. The

nurse performs an assessment and notes that the patient’s breath sounds are decreased bilaterally in the bases and the patient has inspiratory crackles.

The patient’s cardiac assessment is within normal limits. The patient is receiving O2 at 2 L per nasal cannula with a pulse oximetry reading of 95%. The

vital signs include: blood pressure, 100/50 mm Hg; heart rate 110 bpm; respiratory rate 16 breaths/min; and the patient is afebrile. The patient is confused

as to place and time. (Learning Objectives 4 and 7)

Explain the assessment parameters used to provide clues to detect postoperative problems early and the interventions needed.

What gerontological postoperative considerations should the nurse make?

Mr. John Smith is admitted to the hospital for surgical incision and drainage (I&D) of an abscess on his right calf, which resulted from a farm machinery

accident. The right calf has an area 3 cm × 2.5 cm, which is red, warm and hard to touch, and edematous. (Learning Objective 5)

Explain the wound healing process according to the phase of Mr. Smith’s wound?

The surgeon orders for wet-to-dry sterile saline dressing twice a day with iodoform gauze to the wound, covered with the wet-to-dry dressing. Explain

how to perform this dressing change.

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