Adult Health II Clinical Case Study

NURS 453 - Clinical Management of Adult Health Nursing II

Purpose of Assignment
The purpose of the case study is to use my skills and knowledge to plan, implement, and
evaluate holistic care provided to my patient, during her stay in the acute care hospital facility.
This paper examines the pathology of my patient's disease process, her presenting signs and
symptoms, my nursing diagnosis, our perceived outcomes, interventions, and an evaluation of
her progress.

Student Approach to Assignment

The patient I chose for this assignment had various factors affecting her health, including
physical and psychosocial elements that were evaluated in my plan of care. I acquired a strong
foundation in medical-surgery nursing by providing care to this patient. The patient was
morbidly obese, had a history of AM, a fib and DM. She was admitted with a-fib with a rapid
ventricular response and was on IV metoprolol when I cared for her.

Reason for Inclusion of the Assignment in the Portfolio

This assignment is included in the portfolio since it highlights the care I provided to a
patient with multiple issues, including wound care, telemetry monitoring, and psychosocial
aspects.

 Critical Thinking
 Uses nursing and other appropriate theories and models to guide professional practice.
 Example: In this case study, I used I chose Dorothea Orem's Self-Care Theory and
Virginia Henderson's Need Theory to support my priority diagnosis of Decreased
cardiac output and plan for my patient's care. Orem proposed that patients are
responsible for their own well-being and have a responsibility to help themselves
recover. My patient was in a state of distress and suffering where she was unable to
help herself and relied on the help of the professional healthcare staff to intervene.
She was in critical condition as she continued to have shortness of breath,
palpitations, dyspnea, syncope, and nausea while in the telemetry unit. Her heart rate
was also still elevated in the 130-140's. She was unable to reposition herself in bed,
toilet on her own, eat, or sleep. This leads me to Henderson's Need Theory because
my role in assisting my patient was to help her improve her condition so that she
could meet her basic needs. Henderson proposed that nurses can help the patient
recover by increasing their patient's independence by helping them meet their basic
needs. Basic needs that were not being met were physiological such as the ability for
my patient to breath efficiently and to pump blood through her heart so that the rest of
her body could be perfused. Her heart's inability to pump efficiently also caused her
to retain fluid and her upper and lower extremities were edematous.
 Uses decision-making skills in making clinical or professional judgments.
 Example: In this case study, I created a care plan for the patient and found that her
decreased cardiac output was my priority nursing diagnosis. Additionally, I also made
note of other relevant nursing diagnoses. My patient had Decreased cardiac output
related to alteration in heart rate and rhythm as evidenced by her EKG; a heart rate in
the 110-140s; and a blood pressure of 144/92; palpitations; Cardizem (diltiazem
 hydrochloride) 30mg daily; and syncope. Other nursing diagnoses that I found
relevant to this patient include Activity intolerance, Risk of Falls, Deficient
knowledge, and Anxiety: Activity intolerance related to imbalance between oxygen
supply and demand, evidenced by her inability to get out of bed without c/o dizziness
or nausea; dyspnea upon exertion; and weakness. Risk of falls as related to syncope;
dyspnea upon exertion; history of falls; impaired mobility; unsteady gait; dependence
on a cane and wheelchair; and a pain level of 7/10 from the wound of her left lower
extremity. Deficient knowledge related to emotional state regarding learning, as
evidenced by refusal of physical therapy; nonadherence to a cardiac, low-fat diet;
BMI of 42.6; and a blood glucose of 157. Anxiety related to the complication of her
illness, as evidenced by Ms. I. I. stating, "I feel anxious"; restlessness; increased
blood pressure of 144/92 mmHg; irregular tachycardic pulse of 110-140 bpm; and a
high respiration rate of 20 per minute.

 Nursing Practice
 Applies appropriate knowledge of major health problems to guide nursing practice.
 My patient was a 66-year-old African American female was admitted to the
emergency department (ED) three days ago with chief complaints of difficulty
breathing and dyspnea on exertion. My patient. said she recalled falling and hit the
back of her head while transferring from her bed to a wheelchair. During her fall, she
sustained a laceration to her right occipital region of her head and had two staples
placed. An electrocardiogram (EKG) done in the ED identified she was experiencing
atrial fibrillation with rapid ventricular response. She put on a Cardizem intravenous
(IV) fluid infusion and her heart rate returned to baseline, so her medication was then
changed to Metoprolol. Further assessment identified that she also had a 4.9 x 6.2-
inch open wound on her lower left shin from a previous fall. My patient had never
been married and had one child. She cohabitates with a female in a two-bedroom
apartment. Her medical history includes a history of atrial fibrillation, diabetes,
congestive heart failure, hypertension, morbid obesity, anemia, gout, a history of
falls, and anxiety.
 Performs therapeutic interventions that incorporate principles of quality management
and proper safety techniques
 This patient required insulin as she was diabetic and had a high blood glucose levels
in the 180 range at mealtime. To administer this correctly and safely, as well as
adherence to hospital policy, two nurses were required to do the 5 rights of
medication checks including glucose level verification. This was done prior to giving
insulin and required that both nurses sign off the medication in the computer.
Additionally, we verified HR and BP parameters as a response to her metoprolol.
 Implements traditional nursing care practices as appropriate to provide holistic health
care to diverse populations across the life span.
 Example: Traditional nursing care practices that I used in caring for this complex
cardiac patient at the telemetry unit included monitoring the patient's last bowel
movement and ensuring she was toileting safely. Since the patient's last bowel
movement was 3 days earlier, I gave her Dulcolax, a stool softener and laxative
combination to prevent the patient from straining or doing the Valsalva maneuver
while defecating, which can lead cardiac malfunctioning such as dysrhythmias. We
 also placed a commode near the bed to promote her getting out of bed and to reduce
complications of immobility, while stressing the importance for her calling the nurse's
station for assistance prior to getting out of bed.
 Demonstrates an awareness of complementary modalities and their usefulness in
promoting health.
 Example: I used complementary modalities to promote the health of my patient. I
taught the patient to self-manage anxiety by using deep breathing techniques because
deep breathing allows the lungs to more fully expand. I also put a serene music
channel on the television because music is therapeutic and calming. I also
recommended that we could teach her about guided imagery to help her visualize
being stress free. Additionally, we could also teach her about exercise to reduce
stress. I also noted that we could provide her with resources for cognitive-behavioral
therapy to help her reevaluate her stressors.
 Establishes and/or utilizes outcome measures to evaluate effectiveness of care
 Example: The patient had discomfort and pain in her lower back on a scale of 7/10
and pain in her shin area of 9/10 from a festering wound. I administered an analgesic
oral med to reduce her pain level and also helped the wound care team with
debridement and irrigation and then a topical analgesic. I assessed her pain at a half
hour to determine if the analgesic was effective and found that her pain level was
reduced.

 Communication
 Uses therapeutic communication within the nurse-patient relationship.
 Example: In this case study, I encouraged therapeutic communication by holding the
patient's hand when I came into the room to talk to her about how she was feeling,
and in a calm demeanor I explained the medications that I would be administering,
asked her if she had any questions or concerns, and listened to her responses.
 Demonstrates skills in using technology, informatics, and communication devices that
support safe nursing practice
 Example, in providing care to my patient, I used the patient's EMR to review doctor
notes and medication orders, patient allergies, and recent blood glucose values and
vital signs taken by the care partner as well as a tool called Glucommander to guide
me in administering maintenance and meal bolus dosages of insulin. Glucommander
is a software program that calculates the expected insulin need based on the patient's
ingestion of carbs, current blood glucose level and response to the last insulin dose.
 Accesses and utilizes data and information from a wide range of sources to enhance
patient and professional communication.
 Example: Utilized the ODU Library Portal to access CINHAL, a research tool for
nursing and health professionals, to access nursing evidence-based research that was
relevant to my patient. Provided patient with care that was congruent to established
evidence-based practice and hospital protocol by using the numeric scale to
communicate the patient's rating of her pain level and reassess her pain within 30 min
using the same scale after administering analgesic.

 Teaching
  Provides teaching to patients and/or professionals about health care procedures and
technologies in preparation for and following nursing or medical interventions.
 Example: A patient that had low hemoglobin and hematocrit levels was to undergo a
blood transfusion. When we provided her with the informed consent, we informed her
about the procedures risks and benefits, what to expect during the transfusion, signs
and symptoms of a reaction, and when to call for assistance. We then gave her time to
ask questions. After the procedure was completed, we assessed the patient for adverse
reactions and asked her to report itchiness, fever, and pain in addition to any
suspected adverse reaction.
 Provides relevant and sensitive health education information and counseling to patients,
and families, in a variety of situations and settings
 Example: In this case study, I educated my patient about a cardiac diet and how it
could benefit her since she had hypertension and diabetes. I explained that research
showed a diet rich in nutrients, but low in sodium and fat could help her control her
weight, blood pressure, and cholesterol.
 Example: In this case study, I recommended referring my patient to a nutritionist or a
cardiac rehabilitation center and assessing the psychosocial barriers that may impede
her from getting proper health care or from eating a healthy diet. Therefore, I also
recommended providing the patient with resources about SNAP and free health
clinics that are near her. I also recommended teaching the patient about stress
reduction through complementary alternative medicine and send her home with
resources to encourage her to change her activity level. Also, teaching the client the
importance of consistently taking cardiac medications and knowing the actions and
side effects of the medications because she is a senior citizen that fits the criteria for a
Beers review.
 Uses information technologies and other appropriate methods to communicate health
promotion, risk reduction, and disease prevention across the lifespan.
 Example: Utilized EMR to review patient medications and found she regularly took
the prescribed anticoagulant Warfarin reduce risk of stroke. Communicated to patient
that she would be on heparin subQ injections in the hospital for stroke risk reduction.
 Uses information technologies and other appropriate methods to enhance one's own
knowledge base.
 Example: I was responsible for knowing about the meds that I was administering to
my patient as she was prescribed several cardiac medications, particularly blood
pressure meds. To ensure I administered medications correctly, I used Micromedex to
find compatibility information and learned that I was to check the patient's vital signs
prior to administration, especially paying attention to blood pressure values ensuring
they were not already low.

 Research
 Differentiates between descriptive nursing literature and published reports of nursing
research.
 Example: In this case study, I used three nursing research articles to provide examples
of evidence-based practice that could be implemented in my care. One of the articles
discussed the success of interventions on African Americans reported adherence to a
DASH (Dietary Approaches to Stop Hypertension) diet compared with Whites.
 Another examined the effectiveness of advanced nurse practitioner managed
reconciliation of elderly cardiac patients (65+) discharged from a rural community
hospital. The next study was conducted on 64 patients, 45-81 years old, awaiting
coronary angioplasty to examine the effects of music therapy on reducing anxiety.
 Applies research-based knowledge from nursing as the basis for culturally sensitive
practice.
 Example: In this case study, I identified that my patient did not adhere to a cardiac
diet. I discussed a study that evaluated the success of interventions on African
Americans reported adherence to a DASH (Dietary Approaches to Stop
Hypertension) diet compared with Whites. The study found that based on the
differences in dietary fat, carbohydrate, fruit, and vegetable consumption among
African Americans compared to Whites, dietary interventions should be culturally
specific and tailored (Goode et al., 2017).
 Evaluates research that focuses on the efficacy and effectiveness of nursing interventions.
 Example: In this case study, I used research studies to support my nursing
interventions. I found a recent study that showed music therapy was effective in
reducing anxiety levels. Since my patient was anxious, I put a serene music channel
on the television because music can be therapeutic and calming. In a later evaluation
her anxiety, my patient told me she felt less anxious.

 Leadership
 Articulates the values of the profession and the role of the nurse as member of the
interdisciplinary health care team.
 Example: In this case study, I described how a collaborative group of professionals
including nurses, physicians, pharmacists, nutritionist, physical and occupational
therapist worked together to develop a plan of care. Dependent, independent, and
collaborative interventions were implemented. Collaborative interventions
implemented for my patient's diagnosis of Decreased Cardiac Output included consult
with cardiology, cardiac rehabilitation, and nutrition services. The patient was placed
on a low sodium, low-cholesterol, cardiac diet to help decrease fluid volume excess
and hypertension. In my nursing care, I monitored the patient for symptoms of heart
failure and decreased cardiac output, such as assessing for strength of peripheral
pulses, diaphoresis, cyanosis, increased respiratory rate, asking her about paroxysmal
nocturnal dyspnea or orthopnea, increased heart rate, jugular vein distention, level of
consciousness, and edema because these would be signs of decreased cardiac output
and heart failure.

 Professionalism
 Differentiates between general, institutional, and specialty-specific standards of practice
to guide nursing care.
 Example: In this case study, the care to my patient was guided by general standards of
practice such as HIPAA since I was careful not to disclose confidential patient
information while reviewing her electronic record. I also implemented the hospital's
institutional standards of practice such as using the fall risk assessment tool and
administering insulin using a two-nurse protocol. I also practiced specialty-specific
standards of practice, such as using evidence-based practice as support for
 interventions; I was conscious of reducing environmental stressors to my patient by
limiting lighting in my patient's room and using cluster care to reduce her anxiety
levels.

 Culture
 Articulates an understanding of how human behavior is affected by culture, race,
religion, gender, lifestyle and age.
 Example: In this case study, I explained that I communicated with my patient about
her cultural and spiritual beliefs. I helped my patient identify triggers of her anxiety
and coping mechanisms that worked for her in the past since having insight into the
problem and solutions could minimize anxiety. Praying worked for her in the past,
therefore it was likely to work in the future. Later on, she was able to tell me that she
felt "less anxious" and she was coping with prayer.