Case Studies Test Questions – Flashcards

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question
R.T., a 16 year old male, is involved in a serious ATV accident in which he is the only survivor. Two ATVs collided, causing an explosion and fire in which RT is severely burned. He has full thickness burns covering 90% of his body, including his face. RT is flown to the QEII Health Sciences Centre and admitted to Intensive Care. 1.1) How is RTs "first line of defense" against foreign invaders affected by his burns? What type of cellular damage does this now place RT at risk for?
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-his skin has been damaged -open wounds makes me susceptible to infection due to bacteria
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RT has now been in Intensive Care for several days. He edematous, has a temperature of 39.2 and is requiring high levels of narcotics to manage his pain. He is unable to move his own body at all in bed. His WBC count is elevated at 22.1 and RT is oozing blood from all of his wound beds, causing his hemoglobin to drop to 68 and his blood pressure to be low at 82/40. 1) As the bedside nurse caring for RT, what symptoms of inflammation do you note RT is experiencing? Why is RT requiring high levels of narcotics to manage his pain?
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-he is experiencing edema (swelling and fluid shift due to leakage of cellular material as cell death occurs), immobility/loss of function, high pain (reason for narcotics)
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2) What blood products might you administer to help stop the oozing of blood from RTs wounds?
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-plasma and platelets -assist with clotting and slow oozing from wounds; restore loss of fluids and low platelet count
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3) The blood is taking a while to arrive onto the unit from the blood bank. You need to administer some IV fluid to help support RTs blood pressure until the blood product arrives. Would you administer 0.9 NS (isotonic IV solution), D5W (hypotonic IV solution), or 3% Saline (a hypertonic IV solution)?
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-isotonic solution (normal saline or ringers lactate) will stay in arteries and veins/vasculature and not leak into tissues. -hypotonic solution would allow more fluid to ooze into tissues and increase edema; hypertonic solution would pull fluid into vasculature (ie. albumin); 3% saline howevere can have serious effects on brain
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4) As a RN, what are some other important considerations to keep in mind in order to ensure optimal healing of RTs wounds?
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-pain control -appropriate dressing changes to wounds -nutritional status -infection control (place in reverse isolation to protect RT)
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If RT was to have a transfusion reaction in the future, what type of hypersensitivity reaction would he be experiencing?
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-Type 11/ antibody mediated hypersensitivity
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As the bedside nurse, if you noted RT was having a transfusion reaction, what would be the very first action you would take to stop the reaction?
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-stop the transfusion
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EK, a 22 year old university student, presents to the Emergency Department. She complains of a very stiff and sore neck, fever, chills and exhaustion, a headache and feeling "like she is going to throw up". She also complains that "the lights are way too bright in here" and seems extremely irritable. Upon you physical assessment of EK you note that she is unable to touch her chin to her chest or fully turn her head side to side. You also note that her deep tendon reflexes appear to be exaggerated and that when you attempt to flex EK's neck she passively flexes her lower limbs (positive Brudzinski's sign). During your physical assessment EK informs you that she has had a sinus infection for the past two weeks, which she had been taking antibiotics for. EK has a temperature of 39.2 and her heart rate is elevated at 114 bpm. 1) Based on your physical assessment and what EK has told you, what do you suspect the cause of EK's symptoms to be?
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Meningitis due to bacterial sinusitis
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2)What tests or procedures, if any, would you be prepared to do or assist with as EK's nurse in the emerg department?
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-xray or CT to see if there is an abscess from her sinuses into her skull and brain -lumbar puncture to send CSF for C&S -blood, urine and sputum culture, CBC and electrolytes because of signs of infection
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The ERP (emergency room physician) has completed a lumbar puncture and while you are assisting her in collecting the CSF (cerebral spinal fluid), you note that EK's CSF looks cloudy and appears to be slightly thick.
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-CSF should not be cloudy but clear and bubbly, she may have bacteria in it as well as increased WBCs
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2)You are filling out the requisition to have the CSF processed in the lab. What tests will you check off to have run on the CSF?
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-check for culture and sensitivity, WBC count, RBC count (she should have none in CSF)
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The ERP would like EK to be admitted for observation. There is no bed available at this time, so EK must stay in your pod in emerg and you must monitor her as well as care for the other patients that are coming and going. While you are busy helping an elderly lady to the toilet, EK vomits and then falls asleep on the stretcher. When you go to check on her, she is very difficult to wake up and unable to keep her eyes open to focus on you. 1)What is your primary concern for EK?
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-her LOC as well as any changes in wakefulness, mood and behaviour
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2) What do you suspect may have caused her to vomit and become so difficult to rouse?
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-meningitis is an infection and will therefore cause inflammation -since the brain is house in an enclosed case, if either blood or CSF increase the other two must accomodate to make room for and protect the brain. -her brain size has increased due to infection, increased ICP (as shown by vomiting and decreased LOC)
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EK is transferred to the neurosurgery IMCU. What do you think will be the course of her treatment there?
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-antibiotics to treat bacterial meningitis -meds for pain and nausea -vital signs especially neurovitals will be closely monitored
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M.K, a 38 year old mother of two, is diagnosed with stage 4 breast cancer. She is a non smoker and breast fed both of her children for one year. Both her mother and grandmother died of cancer that originated in their breasts. She undergoes a double mastectomy, treatment with chemotherapy and some radiation to the surgical sites post operatively. The surgeons remove the lymph nodes in her axilla as well as her breasts. 1) What are the defining characteristics of stage four cancer?
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-stage 4 means that cancer has spread to other parts of the body beyond the primary site and lymph nodes
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2)What risk factors did MK have for developing breast cancer? Specifically genetic risk factors.
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-she may carry breast cancer gene (BRCA1 and BRCA2); pregnancy and breastfeeding are protective against breast cancer
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3)What failed to happen in MK's immune system when she developed this cancer?
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-in a healthy immune system, tumor supressor genes encode proteins that inhibit cellular growth; a mutation in this gene allows for unregulated cell growth
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4)What types of treatments were given to MK? What are the side effects and potential complications of these treatments?
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-surgery (risk for infection, inflammation and pain) -chemo (targets rapidly dividing cells which kills cancer cells but also hair cells and cells in GI tract-hair loss, ulcers, vomiting and diarrhea) -radiation (carcinogenic so must be administered in exact dose, causes nausea, vomiting and hair loss)
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One year post treatment and into remission, MK begins to notice she is having difficulty breathing and that she is again rapidly losing weight. One night after playing with her children she becomes acutely short of breath and her husband has to take her to the emergency department. A chest XRay shows that MK has a large pleural effusion on her left lung that is restricting her ability to breathe. A chest tube is inserted to drain the effusion and immediately upon insertion it drains one litre of pleural fluid mixed with a bit of blood. MK is admitted to thoracic surgery and a PET scan shows that she has a large tumor in her left lung, as well as metastasis to her liver and bones. MK's prognosis is very poor and she opts for no further surgery or aggressive treatment. She is offered radiation to shrink the tumour to help with her breathing as well as pain related to the bone mets, and a permanent type of chest tube called a Tenckoff catheter that she can use at home to drain her pleural effusion when she becomes short of breath. 1)What type of treatment is MK now receiving for her cancer? Specifically, what are the goals of care for MK?
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-palliative treatment for comfort; curing is not the priority easing the symptoms is
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2)What is the primary source of cancer in the MK's body?
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breast cancer
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Describe what metastasis is and how the cancer may have spread throughout MK's body.
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-cancer is spread by movement of tumor cells into adjacent organs and tissues; this can also occur by seeding which is proliferation into the peritoneal or pleural cavity surrounding tumor
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BL, an active 23 year old male, is taken to emergency following an accident in which while swimming intoxicated, BL dove into the shallow area of the lake and severely jarred his head and neck. BL is alert, has labored breathing with excessive accessory muscle to his shoulders, and is not moving below his nipple line. He tells you that he "can't feel anything" under his clavicle. You are relieved to note that BL is wearing an aspen collar and is on a backboard to keep him immobile. BL's heart rate is 43 and his blood pressure is 85/50. 1) What injury do you suspect BL to have and at what level of his spinal column? Most importantly, why might BL be having difficulty breathing?
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-spinal cord injury at C6/T1; may have difficulty breathing because he is relying solely on shoulders and diaphragm to breathe
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2) Why are you relieved to note BL's neck is immobilized and he is on a back board?
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-immobilizing the neck prevents further damage to the spinal cord
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3) What tests, specifically imaging, will BL need to diagnose his injury
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MRI and CT
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BL's CT scan shows him to have a complete cord injury at the level of C6. Currently he has some gross motor movement of his shoulders. 1) What is BL's treatment now that he has a diagnosis?
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-surgery to repair spine and supportive to support breathing and help him rehabilitate -he may regain some function but will likely live as a quadripelegic
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2) Based on the dermatome chart in your lecture, where do you expect BL's sensation will end on his body?
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-he would have sensation to his thumb and first finger and on anterior side of arm -sensation above clavicle only
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GD, a 65 year old man who has a PMHX of a 40 pack year smoking history, COPD, diabetes and chronic renal failure is admitted for an exacerbation of COPD and acute on chronic renal failure. You are told that he reports his urine output has been minimal the last few days, and he hasn't been following his renal diet. GD has been ++ short of breath and wheezy. An arterial blood gas and some electrolytes were sent. You have the result of the ABG and it is as follows: Ph 7.18,pCo2 78,pO2 58,Hc03 34,Spo2 88,K 6.1 1) What type of acid base imbalance does GD's ABG show him to have? Is he in a respiratory or metabolic acidosis? Is it fully or partially compensated (or not compensated at all)? HCO3 is a base.
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-respiratory acidosis; partially compensated because HCO3 is elevated, which shows that body is attempting to correct pH
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You take note of GD's potassium of 6.1. Is this a normal potassium level?
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potassium is elevated
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1) What are some of the possible effects of GD's potassium level that you may see when assessing him?
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-abdominal cramping, flaccid paralysis -change on ECG (peaked T wave) and cardiac arrest
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2) Knowing that GD has an acute on chronic renal failure, and that he reports peeing very little over the last few days and not following his renal diet, what do you suspect the cause of his high potassium level to be?
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-his potassium is not being adequately excreted by kidneys and not following diet could make this worse since he may be consuming food/drink with high potassium content
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What happens to cells that are exposed to an acidic environment? How low can a PH be before it is considered "incompatible with life'?
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-cells will die -below 6.8 or above 7.8
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Mr. T, a 63 year old man presents with severe sob. He reports being unable to breath while lying flat, and states that he has been sleeping in a chair or bent over his table. He is sitting on the edge of the stretcher in the "tripod" position. You note that he is using pursed lip breathing, has accessory muscle use while breathing and has a noticeable barrel chest. Mr T's medical history is hypertension, and he reports smoking "two packs a day since I was a teenager". you hear distant wheezes throughout. Mr T. also has a productive cough which he states he lives with on a regular basis but seems to be a bit worse lately. His arterial blood gas shows that he has a normal PH of 7.36, a elevated PCO2 of 60, an elevated HCO3 of 30 and a low PO2 of 64. 1) Based on Mr. T's history, symptoms and physical appearance, what chronic illness do you suspect he is suffering from?
answer
-COPD -barrel chest, pursed lip breathing and tripod position point to emphysema; chronic productive cough points to chronic bronchitis -hypercapnia and hyperoxemia indicates fully compensated respiratory acidosis -pursed lip breathing assists in fully emptying lungs when they have become enlarged
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2) What other tests would be run on Mr T to ensure he is properly treated?
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-chest xray -sputum culture (to rule out community acquired pneumonia) -pulmonary functions test to diagnose COPD
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3) What would be the goals of care and possible medications/treatments that Mr T. would be given?
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1.symptom management -steroids and anti-inflammatory drugs -bronchodilator puffers or aerosols -steroid puffer -breathing exercises -home oxygen therapy 2.smoking cessation 3.surgical options arent often done
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Mr. T is admitted to the general medicine floor. At 0230 he wakes from sleep and rings his call bell. When the nurse enters the room he is so short of breath he has trouble getting his words out. He is able to tell the nurse he is having crushing chest pain, as if an elephant is sitting on his chest. He feels sick to his stomach and vomits. 1) Again, based on Mr. T's hx of smoking, hypertension and the symptoms he is currently experiencing, do you think is happening to Mr T?
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-MI based on crushing pain and vomiting -smoking and hypertension are two major risk factors
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2) As the nurse, what are the first interventions you would implement to help Mr T?
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-call doctor then perform ECG to assess for rhythm changes (ST depression or elevation) -draw bloodwork (are CK or troponin elevated?) -MONA (MORPHINE to relieve pain and heart workload, apply or increase OXYGEN, NITRATES relax vessels, ASPIRIN decreases adverse events related to MI-325 mg) -may need a CABG (coronary artery bypass graft) or a stent
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You are working a nightshift in the neurosurgical stepdown unit and are caring for a patient that was admitted from the operating room late on the dayshift. This patient is 54, and has had surgery on her pituitary gland to remove a tumor. The surgery was done via a transphenoidal approach (through the patients nose) and both the anterior and posterior portions of the gland were affectes. You note when reviewing her medication record that you are to begin admininstering her several medication. One of these is a steroid, methylprednisone. Another is synthetic form of thyroid hormone, levothyroxine. The neurosurgeon who did the surgery seems very adamant and concerned that the patient receives these medications promptly and exactly as ordered. 1) You have seen similar medications ordered for other patients you have cared for. Why is it so important that this particular patient receives these medications promptly and exactly as ordered?
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-she will no longer produce adrenocorticosteroids or thyroid hormones; her pituitary gland wont function properly and produce the hormones necessary for these hormones to be excreted from the thyroid and kidneys -not giving meds could have lethal consequences
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2) The neurosurgeon tells you that this patient will be on these steroids and synthetic thyroid hormone for the rest of her life. Why is this?
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-pituitary will never regain function and likely was already damaged to begin with and she should have been on HRT before
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At four in the morning you note when you are doing the intake and output for your shift you note that your post op pituitary tumour patient has had very high urine output. Her urine is extremely clear and colorless. You also have sent some bloodwork on this patient and note that her serum sodium is climbing (it was 142 six hours ago, it is now elevated at 148). 3)Based on the patients surgery and what it can affect in her body, what are concerned may be happening to your patient? I.e. why is she having high urine output and high serum sodium.
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-pituitary is not producing enough ADH to signal to kidney to slow urine production -she is becoming dehydrated from large volume of urine and serum sodium is increasing (Diabetes Insipidus)
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What do you suspect may be ordered by a physician to treat this condition?
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-fluids (drinking and IV of a hypotonic solution such as 5% dextrose) -synthetic ADH/ vasopressin -nurse will monitor patient it case urine output becomes too low
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Explain the hormonal changes that occur during the menstrual cycle and cause the onset of menstruation (endometrial sloughing). 1) Follicular Phase
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-menstrual bleeding -caused by decreases of estrogen and progesterone -FSH will rise, triggering development of follicles-only one of which will be ovulated and release estrogen
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Ovulatory Phase
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-follicle is developed -surge of LH and FSH stimulates ovum release from follicle -estrogen peaks and progesterone begins to rise
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Luteal Phase
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-LH and FSH decrease once ovum is released -ruptured follicle forms corpus luteum which produces progesterone -high progesterone and estrogen causes endometrium to thicken -if ovum isnt fertilized the corpus luteum breaks down and stops producing progesterone; estrogen also decreases
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Mrs. K, a 82 year old widow who lives alone on a fixed income has presented to the emergency department with a complaint of nausea and cramping. She has had a significant weight loss in the last year and reports her daily food intake consists mainly of tea and toast. Her abdomen is distended and when asked she reports her bowels haven't moved in over a week. An abdominal flat plate XRay is done and fecal overload is noted on the XRay. Some blood work is done and it shows that Mrs. K has a high serum osmolality of 315 and a low prealbumin of 71. 1) What are some possible reasons that Mrs. K food intake is so low and she is eating mainly toast and drinking mainly tea?
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-low appetite is due to aging process (diminished taste) -may have tight budget since she has fixed income -may be socially isolated and depressed which also impacts appetite
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2) What is the possible cause of Mrs. K's fecal overload (severe constipation) and why is she nauseas?
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-bowel motility decreases with age making constipation more common -low food intake slows motility as does lack of fiber and fresh food (required for healthy bowel) -tea can cause dehydration, she needs to consume water and stay hydrated for bowel function
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3) Why are Mrs. K's osmolality and prealbumin significant?
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-high concentration would indicate dehydration; low pre-albumin means she is undernourished
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4) What are some possible treatments for Mrs. K's constipation and if her constipation is not resolved what is she at risk for?
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-hydration -increasing diet (progress slowly due to nausea and risk of re-feeding syndrome which can causes serious electrolyte imbalance) -oral laxatives (stool softeners, peristaltic agents, osmotic laxatives, rectal suppositories, enemas) -manual disimpaction of lower rectum -at risk for developing a bowel obstruction which causes nausea, vomiting and perforation of bowel which is life threatening
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