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CASE Studies FOR Problem Based Learning
Medical Surgical Nursing (HNS B201)
Pwani University
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CASE STUDIES FOR PROBLEM BASED LEARNING (PBL) ACQUIRED VALVULAR HEART DISORDERS – A 78-year-old man was admitted with increasing shortness of breath. He had chest pain in the past but was able to continue with normal activities. He had passed out twice in the past year. On physical examination, a loud systolic murmur could be heard at the left sternal border radiating to the neck. His vital signs were: blood pressure 150/90 mm Hg, heart rate 88 beats/minute and irregular. The electrocardiogram (ECG) showed sinus rhythm with atrial premature contractions and left ventricular hypertrophy (LVH) with strain. A transthoracic echocardiogram showed a hypertrophied left ventricle (LV), and Doppler examination demonstrated severe aortic stenosis (AS) with a gradient of 64 mm Hg, mild aortic insufficiency (AI), and moderate mitral regurgitation (MR). He was scheduled for aortic valve replacement (AVR) and possible mitral valve (MV) repair or replacement. 1. What are the major etiologies of aortic stenosis (AS), aortic regurgitation (AR), mitral stenosis (MS), and mitral regurgitation (MR)? 2. What are the major changes in the loading conditions of the left ventricle (LV) that result from the four different lesions? Why do they occur? What changes result from them? 3. What are the presenting signs and symptoms of the four valvular lesions listed previously? 4. What are diagnostic tests that can be carried it on each of the lessiosn and what result is expected for each? 5. What is the medical and surgical management of the valvular heart disorders? 6. What is the prognosis of each of four lesions? 7. Describe the nursing management for each of the four lesions above 8. What patient education would you give to the patient with valvular disorders? MANAGEMENT OF CARDIOMYOPATHIES – A 53-year-old female presented with a 10-year history of hypertrophic cardiomyopathy (HCM), increasing dyspnea and chest discomfort on exertion, postural lightheadedness, palpitations, and a functional limitation of less than one flight of stairs. Symptoms were initially treated with β blockers, which were not tolerated due to symptomatic hypotension. She was referred for further evaluation and treatment because of worsening symptoms despite taking verapamil 240 mg/day. There was a history of a congenital thyroid disorder, however, the patient was euthyroid on admission. She has three children, ages 30, 28, and 11 years, at the time of admission who are all well. There is no family history of HCM or of sudden death. She stopped cigarette smoking in 1988 and had a 14 pack-year history. 1 1. Differentiate the different types of cardiomyopathy 2. Discuss the pathophysiology for each of the cardiomyopathies 3. Outline the clinical manifestation that you would expect to see in patients with these cardiomyopathies 4. What are the likely diagnostic tests that are likely to be performed on patients with cardiomyopathy 5. Describe the medical and surgical management for these patients 6. What are some of the nursing diagnoses you are likely to develop for patient with cardiomyopathy 7. Describe the nursing interventions for these patients. 8. What are the potential complications for a patient cardiomyopathy INFLAMMATORY AND INFECTIOUS DISEASES OF THE HEART Mr. A, a 42 year old man was admitted unconscious to the intensive care unit, after an out of hospital cardiac arrest and resuscitation by a friend. He had little medical history of note other than that he had had a recent upper respiratory tract infection. He had no risk factors for HIV infection. While in intensive care he had recurrent episodes of ventricular fibrillation requiring multiple dc shocks, but was ultimately managed with intravenous lidocaine, amiodarone, and overdrive pacing. His resting ECG showed non-specific T wave changes with intermittent non-sustained episodes of a broad complex, irregular tachycardia. On assessment it was noted that he had a murmur and a pericardial friction rub. Full blood count, urea and electrolytes, and liver function tests were normal. Transthoracic echocardiography showed normal left ventricular function and size. He gradually recovered without any sequelae. Electrophysiological testing revealed inducible non-sustained polymorphic ventricular tachycardia. Coronary angiography was entirely normal. A right ventricular biopsy was taken which subsequently showed healing myocarditis. 1. Compare and contrast risk factors associated with inflammatory heart disorders. 2. Analyze the etiology and pathophysiology for the following disorders: Endocarditis – Rheumatoid and Infectious Myocarditis Pericarditis 3. Analyze the signs and symptoms and complications of the following disorders: Endocarditis - Rheumatoid and Infectious Myocarditis: Pericarditis: 2 MANAGEMENT OF ARTERIAL DISORDERS – Mr. Jiminez is a 76 year old man admitted to the hospital with resting pain in his foot. He has a non-healing ulcer of the great toe on the right foot. Subjective data: history of MI, stroke, and arthritis left femoral-popliteal bypass 5 years ago smoking history 45 pack years NIDDM 30 years Intense right foot pain last six weeks sleep in recliner with right leg in dependent position Objective data: diminished right femoral pulse with no palpable pulses in right foot small necrotic ulcer on tip of right great toe thickened toenails, no hair on foot, shiny tight skin atrophy of right calf muscle Acute Arterial Occlusive Disorders 1. Describe the etiology, pathophysiology, and assessment of acute arterial disorders. o Name the six "Ps" of assessment. 2. Identify the purpose and side effects of collaborative management of an acute arterial disorders. o Heparin o Embolectomy o Streptokinase; r-tPA; urokinase 3. For the nursing diagnosis Ineffective Tissue Perfusion: Peripheral, name the major nursing interventions. 4. Compare and contrast manifestations of peripheral vascular disease (atherosclerosis) with manifestations of venous circulation disorders. (Color of extremity in a dependent position, cool or warm, etc.) 5. Discuss the various types of arterial aneurysms 6. Outline the various aetiologies of arterial aneurysms 7. Describe the clinical manifestations of the following aneurysms a. Thoracic aorta aneurysm b. Abdominal aorta aneurysm 8. Describe the medical, surgical and nursing management of the above mentioned aneurysms 9. What is Aortic dissection? 4 Chronic Arterial Occlusive Disease 1. Discuss the etiology and pathophysiology of thromboangiitis obliterans (Buerger's disease), and Raynaud's phenomenon (disease). 2. Differentiate the assessment of the client with Buerger's disease and Raynaud's phenomenon. 3. Discuss nursing interventions in the collaborative management of Buerger's disease and Raynaud's phenomenon. 4. Discuss the nursing interventions in the management of the client with Buerger's disease and Raynaud's phenomenon. 5. Identify the data for the evaluation of the care of the client with Buerger's disease and Raynaud's phenomenon. MANAGEMENT OF VENOUS DISORDERS Mr. Luke is a 58-year-old man who is currently a client on an outpatient rehabilitation unit following a left total knee replacement (TKR) five days ago. This afternoon during physical therapy he complained that his left leg was unusually painful when walking. His left leg was noted to have increased swelling from the prior day was sent to the emergency department to be examined. Mr. Luke’s vital signs are temperature 98°F (36°C), blood pressure 110/50, pulse 65, and respiratory rate of 19. His oxygen saturation is 98% on room air. The result of a serum D-dimer is 7 μg/mL. Physical exam reveals that his left calf circumference measurement is ¾ of an inch larger than his right leg calf circumference. Mr. Luke’s left calf is warmer to the touch than his right. He will have a noninvasive compression/doppler flow study (doppler ultrasound) to ruleout a DVT in his left leg. 1. Differentiate between the following venous vascular disorders: a. Thrombophlebitis – superficial and deep vein thrombosis b. Venous stasis ulcers c. Varicose Veins 2. Discuss risk factors that predispose an individual to develop each of these venous disorders. 3. Discuss signs and symptoms of venous vascular disorders. 4. The health care provider in the emergency department chooses not to assess Mr. Luke for a positive Homan’s sign. What is a Homan’s sign and why did the health care provider defer this assessment? 5. Discuss the diagnostic cues gathered during Mr. Luke’s examination in the emergency department that indicate a possible DVT. 6. Discuss Virchow’s triad and the physiological development of a DVT. 7. The nurse who cared for Mr. Luke immediately following his knee surgery, when writing the postoperative plan of care, included appropriate interventions to help prevent venous thromboembolism. Discuss five non-pharmacological interventions the nurse included in the plan. 5
CASE Studies FOR Problem Based Learning
Course: Medical Surgical Nursing (HNS B201)
University: Pwani University
