CASE STUDY 1

Congestive Heart Failure

Patient profile
Mrs. E, a 62-year-old Hispanic woman, was admitted to the medical unit with complaints of
increasing dyspnea on exertion.

Subjective Data
 Had a severe MI at 58 years of age.
 Has experienced increasing dyspnea of exertion during the last 2 years
 Had a respiratory tract infection, frequent cough and edema in legs 2 weeks ago
 Cannot walk two blocks without getting short of breath
 Has to sleep with head elevated on three pillows
 Does not always remember to take medication

Objective Data
Physical Examination
 Elderly woman in respiratory distress
 Heart murmur
 Moist crackles in both lungs
 Cyanotic lips and extremities

Diagnostik Studies
 Chest x-ray results: cardiomegaly with right and left ventricular hypertrophy; fluid in lower lobes
of lungs

Collaborative Care
 Digoxin 0,25 mg qd
 Furosemide (Lasix) 40 mg bid
 Potassium 40 mEq PO bid
 Enalapril (Vasotec) 5 mg PO qd
 2 g sodium diet
 Oxygen 6 L/menit

Critical Thinking Questions

1. Explain the pathophysiology of Mrs. E heart disease
2. What clinical manifestations of heart failure did Mrs. E exhibit?
3. What is the significance of the findings of the chest x-ray?
4. Explain the rationale for each of the medical orders prescribed fos Mrs. E?
5. What are appropriate nursing interventions for Mrs. E?
6. What teaching measures should be instituted to prevent recurrence of an acute episode of heart
failure?
7. Based on the assessment data presented, write one or more appropriate nursing diagnoses. Are
there any collaborative problems?
CASE STUDY 2
Acute Respiratory Distress Syndrome

Patient Profile
Mr. J is a 35-yaer-old man who was admitted 32 hours ago to a general surgical unit after surgery for
multiple gunshot wounds in the abdomen. The surgical procedure involved extensive abdominal
surgery to repair a perforated colon, remove bullets, and repair a torn mesenteric artery. During
transport to the hospital and during surgery his systolic blood pressure dropped to 70 mmHg. Ten
units of packed red blood cells and 6 L of normal saline were administered intravenously to restore
blood loss and volume. He is receiving 60% oksygen through an aerosol face mask. He is being
monitored with a cardiac monitor and pulse oximeter. He has a central intravenous catheter in place
and is receiving 0,9% normal saline intravenously at 125ml per hour. A urinary catheter is in place.

Subjective Data
 Complain of shortness of breath, inability ti lie flat, and diffuse abdominal pain

Objective Data
Physical Assessment
 General: alert, well-nourished man who appears restless and anxious; head of bed elevated 45
degrees; skin cool with moderate diaphoresis
 Respiratory: no accessory muscle use, retraction paradox breathing, repiratory rate 28 breath
SpO2 88%; fine crackels at lung bases
 Cardiovascular: blood pressure 100/60 mmHg; cardiac monitor shows sinus tachycardia at 120
beats/min, which correlates with his apical pulse rate; temperature 38⁰ C
 Gastrointestinal: surgical dressing dry and intact, sharp pain on palpation over incisional area
 Urologic: urinary catheter draining concentrated urine

Diagnostic Findings
 Chest x-ray shows scattered interstitial infiltrates compatible with an ARDS pattern as interpreted
by the radiologist

Critical Thinking Questions

1. How does the pathofisiology of ARDS predispose to the development of refractory hypoxemia?
2. What clinical manifestations does Mr. J exhibit that support a diagnosis of ARDS?
3. What are the possible causes of ARDS in Mr. J?
4. What are the possible complications Mr. J is at risk for developing secondary to ARDS?
5. What respiratory care interventions might be implemented to improve Mr. J’s hypoxemia?
6. Based on the assessment data presented, write one or more appropriate nursing diagnoses. Are
they any collaborative problems?
CASE STUDY 3
Head Injury

Patient Profile
Jason B., a 22-year-old unrestrained driver, was involved in a head-on collision. He was found at the
scene of a motor vehicle accident trapped inder the steering wheel of his car. He is admitted to the
emergency department with a diagnosis of traumatic brain injury and open fracture of the right
humerus and femur.

Subjective Data
 Paramedic reported that patient was unconscious at the scene, normotensive with Cheyne-Stoke
respirations

Objective Data
At the Scene
 Slight decerebration with the left arm

In the Emergency Department

 Pupils equal, 2 mm, and fixed
 Vital signs within normal limits
 Glasgow Coma Scale = 5; ICP and CPP average 20 mm Hg and 60 mmHg, respectively
 Fractured right femur and humerus
 Multiple lacerations and contusions

Diagnostic Findings
 Brain Ct scan reveals fracture along lateral wall of right maxillary sinus, subarachnoid
hemorrhage, generalized brain sweeling, and slit ventricles

Critical Thinking Questions

1. What sould be the cause of Mr. B.’s nonresponsive neurologic condition based on his initial
clinical condition and Ct scan?
2. Discuss conditions of the injury and the pathophysiologic changes that can occur from the injury
in relation to Mr. B.’s neurologic status.
3. What do the signs and symptoms suggest for Mr. B.’s area of brain involvement?
4. What are the priority interventions based on the nursing assessment?
5. Write one or more appropriate nursing diagnoses based on the assessment data. Are there any
collaborative problems?