Alexandria Carlisle is a 72-year-old African American female who presents to the emergency departmen

Alexandria Carlisle is a 72-year-old African American female who presents to the emergency department with severe shortness of breath, which has progressively worsened over the previous week. Mrs. Carlisle states that she had experienced chest discomfort rated a 4 out 0-10 pain scale on five occasions last week, usually when walking to the mailbox or upstairs. She also states “My legs are as big as tree trunks. I have lost my ankles.” Past medical history includes hypertension, Diabetes Mellitus Type 2 with the onset at age 32, duodenal ulcer disease, asthma, and obesity and had a gastric bypass 18 years ago. Lipid profile unknown. Social History: smoking ~ 1 pk /day for 25 years but she quit 10 years ago, partner died 6 months ago, mother of one child and grandmother of three that all live out of state, retired 7 years ago from office manager position for a small business, and currently lives alone in a stand-alone house. Current meds: DiaBeta 5 mg daily, Glucophage ER 1,000 mg BID, captopril 25 mg daily, torsemide 80 mg daily, enteric-coated aspirin 81 mg daily, K-Dur 60 mEq daily, and famotidine 40 mg BID. Insurance: Medicare, no coinsurance. Mrs. Carlisle states that it has been almost 2 years since she saw her primary care provider. She was worried about “catching COVID so I didn’t go” and she has run out of her medications without the new prescriptions. She thinks her last doses were about 5 months ago. Allergies: Amoxil, pineapple, and peanuts which all of which give her a rash; morphine makes her depressed.Religion: Jehovah’s Witness.Upon admission to the ER, the following vital signs are obtained: Weight: 180 lbs., reported Height 5 ft. 9 in; computed BMI 26.6; T. 101.8 °F; B/P 172/96; P 112 and irregular; RR 28; Pulse Ox on room air 90%. Admission assessment reveals: Well-developed, female in moderate distress, skin dry and hot, PERRL, CN II-XII intact; Neurological exam: no deficits noted; Cardiac: S2 and S1 clearly audible, with S3 audible with client lying on left side, Grade 4 diastolic murmur audible at apex, irregular rhythm, peripheral pulses palpable 4+; Pulmonary: Wheezing heard throughout A&P, with coarse crackles in bases bilaterally; Abdomen: no tenderness noted, bowel sounds audible x 4; G/U: deferred; Extremities: 4+ pitting edema lower extremities, upper extremities 2+ edema. Skin: Braden scale: 15, yellowish bruising noted on right forearm and bilateral shinsEmergency department orders: Cardiac Enzymes x 3, Complete Blood Count with differential, Complete Metabolic Profile, HbA1c, Lipid Profile, 12-lead ECG, Stat BG, D-Dimer, pro-BNP, Chest x-ray, Urinalysis, ABGsInitial Laboratory findings: Only abnormal labs reportedCBC: WBC: 23.2 mm³, HCT 28.7 mL/dL, HGB: 9.7 gm/dLCMP: SrCr: 2.8 mg/dl, BUN: 62 mg/dl, K+: 5.8 mEq/L, HbA1c: 13.4Stat bedside glucose: BG 352 mg/dl              pro-BNP: 10,725Lipid Profile: Total Cholesterol: 340 mg/dl, LDL: 267 mg/dl, HDL: 34 mg/dl, Triglycerides: 405 mg/dlD-Dimer: positive        Urine: 4+ glucose, TNTC RBCs, TNTC WBCs, 4+ proteinABG: pH: 7.0, PaO2: 50 mmHg; PaCO2: 60 mmHg, HCO3: 22 mEq/LCXR: possible PE         12-Lead EKG: irregular, rate of 112 beats per minute    1. List all problems that this client presents with: (include medical and social issues) (10 points)         Your patient has now been admitted to the ICU for CHF exacerbation, possible PE, possible UTI with the following orders: 2000 calorie, ADA/AHA diet Insert Foley catheterStrict I & O; Daily weightsUA for C & S; Call when urine culture results come backConsult Respiratory Therapy for oxygen therapy managementOxygen therapy, titrate up to 4L NC for SaO2 <92%Medication orders:Stat furosemide 100 mg IVP every 6 hours x 3 dosesGlucose Checks AC & HS Insulin aspart Sliding Scale            150-200  2 units                      301-350  10 units            201-250  4 units                      351-400  12 units            251-300  6 units                      > 400 give 16 units and call MDVancomycin 1.5 g/ 500 ml NS IVPB over 3 hours now and repeat every 12 hrs. Vanc trough with 3rd doseAlbuterol and ipratropium nebs QID and PRN per Respiratory TherapyHeparin bolus IVP 60 units/ kg/ doseBegin drip at 18 units/ kg/ hr. Bag from pharmacy contains 25,000 units in 500 mL NS. Run this rate for 6 hours, have lab draw aPTT, and follow the protocol below.Heparin protocol PTT (seconds)Re-bolusHold dripChange drip units/ hrRepeat aPTT(after dose adjustment)<or= 35 sec60 units/ kg0 minutesIncrease by 3 units/ kg/ hr6 hours36-45 sec0 units0 minutesIncrease by 2 units/ kg/ hr6 hours46-70 sec0 units0 minutes0- do not change6 hours71-90 sec0 units0 minutesDecrease by 2 units/ kg/ hr6 hours>90 sec0 unitsStop 60 minutesDecrease by 3 units/ kg/ hr6 hours  Questions are to be answered thoroughly, be sure to include all components of the question. For all dosage questions, round to the nearest whole number. 2. How many units of insulin aspart are administered upon admission: (1 point)a) ________________________The next glucose check registers 288 mg/dl, how many units are administered now? (1 point)b) ________________________What are possible rationales for why the blood glucose is high? (1 points)c) ____________________________________________________________________3. How many minute(s) will it take to administer a single dose of the ordered furosemide? (1 point)________________________ 4. Calculate for this client the a) heparin bolus in units, b) heparin hourly dose rate in units/hr, and c) heparin infusion rate in mL/hr. (1 point each)a) __________________b) __________________c) __________________ 5. Identify all abnormal laboratory findings and diagnostic studies for this client. Link abnormal labs and diagnostics to the client’s current condition/findings. Provide a rationale for the abnormality. (10 points)       6. After running the heparin drip for 6 hours at the original order rate of 18 units/ kg/ hr, the aPTT is 74 seconds. (2 points each)a) What does the protocol state to do now? _____________________________________________________________________________b) Calculate the bolus dose due now. ______________________c) How many mL/hr will the nurse now set the infusion pump for the delivery of heparin per the protocol orders? __________________________________  The primary healthcare provider has now ordered a stat CT of the chest with contrast to rule out a PE. 7. What, if any, concerns do you have about this order? Explain your rationale. (3 points)     The client’s CT was positive for a PE. Over the next 10 days, Mrs. Carlisle slowly improves and plans for discharge are made. Her discharge diagnoses include CHF, HTN, DM type 2, UTI resolved, dyslipidemia, peptic ulcer disease, PE, sleep apnea, and asthma.Discharge orders: ADA/AHA diet, exercise 3-5 times per week, limit fluid intake to no more than 2 liters per day, follow up with PCP in 1-2 weeks, follow up with cardiologist in 1 week, follow up with endocrinologist in 1-2 week, follow up with pulmonologist in 1-2 weeksDischarge Medications: Digoxin 250 mcg PO daily, Furosemide 40 mg PO daily, Insulin glargine 18 units SC HS, Amlodipine 30 mg PO BID, Metoprolol 50 mg PO BID, Simvastatin 40 mg PO HS, Liraglutide 1.2 mg SC daily, Aspirin 325mg PO HS, Warfarin 6 mg PO HS, Lansoprazole 60 mg PO BID 8. Develop a discharge teaching plan for Mrs. Carlisle based on the discharge medications listed above. Include in this discharge plan specifics regarding 1) timing of administration, 2) indications for each order, 3) mechanism of action/how the drug works, 4) dietary restriction/inclusions and/or pertinent lab monitoring/diagnostic tests, 5) adverse drug reactions/contraindications/black box warnings, and 6) associated monitoring/teaching education for the client. Keep in mind this discharge teaching plan should be written so that the client is able to understand it. (26 points)    Download and read the following articles from Canvas:Amakali, K. (2015). Clinical care for the client with heart failure: A nursing care perspective. Cardiovascular Pharmacology, 4(2). https://www.doi.org/10.4172/2329-6607.1000142 Fabbri, M., Yost, K., Finney Rutten, L. J., Manemann, S. M., Boyd, C. M., Jensen, D., Weston, S. A., Jiang, R., & Roger, V. L. (2018). Health literacy and outcomes in patients with heart failure: A prospective community study. Mayo Clinic Proceedings, 93(1), 9-15. Powers, M. A., Bardsley, J., Cypress, M., Duker, P., Funnell, M. M., Fischl, A. H., . . .  Vivian, E. (2017). Diabetes self-management education and support in type 2 diabetes: A joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. The Diabetes EDUCATOR 43 (1), 40-53. https://doi.org/10.2337/dc15-0730 Sherer, A. P., Crane, P. B., Abel, W. M., & Efird, J. (2016). Predicting heart failure readmissions. Journal of Cardiovascular Nursing, 31(2), 114-120. Stella, L. B. (2013).Understanding core measures for heart-failure treatment. American Nurse. https://www.myamericannurse.com/understanding-core-measures-for-heart-failure-treatment/  Using the above articles, answer the following questions in relation to this client.  Analyze the admission orders and discharge medications and instructions using the American Nurse Core Measures for Heart Failure guidelines. Which component(s) was not addressed either during the hospital stay or within the discharge orders for Mrs. Carlisle? (8 points)_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________  Health Science Science Nursing NURS 3000 Share QuestionEmailCopy link Comments (0)

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