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Complex Case Studies

Case Study 1

Mr. T is a 64-year-old who was recently diagnosed with diabetics. He has been admitted for blood sugar control. He weighs 240 pounds and is 5 feet 11 in. tall. His BMI is 34. He also has a history of peptic ulcer disease, which the physician wants to prevent from worsening because of stress from hospitalization. On his admission labs, Mr. T was diagnosed with hypothyroid, a new diagnosis for him.

The physician's orders are as follows:

• Start IV and run one liter of normal saline every 8 hours.

• Administer NPH insulin 22 u q a.m. and 15 u q p.m. with a sliding scale of regular insulin qd prn

• Administer ranitidine 50 mg in 100 ml D5W to run over 15 minutes q 6 hours.

• Administer levothyroxine 0.5 mg qd

Answer the following questions:

• Calculate the drip rates for his maintenance IV and for the ranitidine.

• What will you teach Mr. T about the insulin he is receiving and about his new medication, levothyroxine?

• Mr. T wants to know how long it will take for the levothyroxine to make his thyroid function normal so he can stop taking the drug. How will you reply?

• At what times of the day is he most likely to have a reaction from the two doses of NPH?

Mr. T's blood sugars normalize in 2 days. On the third day, he is switched to metformin 1 gm bid. The ranitidine failed to control his dyspepsia, so the physician switched him to omeprazole 20 mg qhs.

Answer the following questions.

• You have on hand metformin 500 mg tablets. How many tablets will you give your patient at each dose?

• In terms of the drug action, how does ranitidine differ from omeprazole? How does insulin differ from metformin?

• What patient variables make metformin preferable to insulin for Mr. T's long-term diabetes management?

• What will you teach your patient about omeprazole and metformin?

• What are the pharmacokinetics (precautions, adverse effect, interactions, absorption, distribution, metabolism, and excretion) and pharmacodynamics of each medication?

• How will the side effects of each medication listed influence your physical assessment of the patient?

• Describe nursing interventions to enhance the therapeutic effects and decrease adverse effects of the drugs. Indicate at least two safety issues, per medication, pertinent to the patient’s diagnosis. Assume that you adhered to the five rights of medication administration. Include your rationale for your choices.

• What educational information should you provide for the patient and her family on gastrointestinal and endocrine drugs?

Case Study 2

Mrs. S is a 48 year-old woman who is morbidly obese and has poorly controlled type 2 diabetes mellitus. She has been hospitalized for pneumonia complicated by vomiting and diarrhea. She was initially started on Augmentin™ 875 mg bid 7 days ago by her primary care physician. The diarrhea started 2 days ago and the vomiting began this morning. Occasionally, she coughs so hard that she vomits. Both problems are thought to be side effects of the Augmentin™, which has been stopped. She is admitted for dehydration, control of her blood sugars, and IV antibiotics. As she arrives at your unit, she has one hanging liter of normal saline with insulin, which is almost empty.

Her vital signs are

• Height: 5 feet 2 in.

• Weight: 227 pounds

• BMI: 42

• Temperature: 99 degrees po

• BP: 120/88

• P 98

Your initial assessment of her heart reveals a regular rate and rhythm without murmurs. Listening to her lungs you note inspiratory and expiratory wheezes with crackles at both bases. Her abdomen is soft, tympanic, with diffuse tenderness on palpation. Her skin is warm and dry.

Prior to admission, her routine medications include

• Novolin 70/30 insulin

• Metoclopramide 10 mg 30 minutes ac & hs

• Lisinopril 10 mg qd

Her admitting labs are

• Glucose 450

• BUN 20 (5-20mg/dL)

• Creatinine 1.0 (0.5-1.1)

• Sodium 145 (136-145meq/L)

• Potassium 3.0 (3.5-5.3 mEq/L)

Her initial admitting orders are

• One liter NS with 20 mEq potassium to run every 8 hours

• Promethazine 12.5 - 25 mg slow IV push q 6 hours prn nausea

• Albuterol MDI 2 puffs qd and q 4 hours prn

• Hold metoclopramide for now

• Hold lisinopril for now

• Rocephin™ 1 gm IV q 12 hours

• Accu-Chek® q 6 hours & prn

• NPH 20U SQ bid (6 p.m. and 6 a.m.)

• Regular insulin sliding scale q 6 hours:

o 2 U SQ for BS 200–249

o 4 U SQ for BS 250–299

o 6 U SQ for BS 300–349

o 8 U SQ for BS 350–399

o 10 U SQ for BS 400–449

o Call if blood sugar > 500

• Serum glucose and electrolytes now and q a.m.

• Stool for WBC, Clostridium difficile, ova and parasites x 3, blood

Answer the following questions:

• You must hang another IV. How many milliliters per hour will the patient receive? Using a regular drip chamber, how many drops per minute should she receive?

• The patient was taking Novolin 70/30™ insulin prior to admission. Why do you think the physician changed her over to NPH with a sliding scale for regular insulin?

• The patient begins vomiting soon after arriving on your unit. You check the ER record and learn that the patient received promethazine 12.5 mg IV push 3 hours ago. What will you do and why? You have on hand promethazine 25mg/cc. If you opt to give her another dose, how many milligrams and milliliters will you administer?

• Thirty minutes after you administer the second dose or promethazine, the patient begins to grimace, show involuntary limb movements, and rhythmically protrude and retract her tongue. What is your assessment of these symptoms and plan? What medications might the physician order to reverse this process?

• After 24 hours, the patient's lisinopril and metoclopramide are restarted and she remains on IVs since she is not tolerating po fluids very well. What potential electrolyte imbalance can occur when patients received an ACE inhibitor along with a potassium supplement?

• What was the physician most likely treating with the metoclopramide in this patient? Why was it stopped initially? What nursing assessment is appropriate now that it has been restarted?

• At 6 p.m. that evening, the patient's insulin check is 288. She is also due for her dose of NPH insulin. How much insulin will you give her? Can you mix these insulins in the same syringe? If yes, which do you draw up first and why?

• That evening Mrs. S. is unable to keep her clear liquid dinner down and she vomits 30 minutes after the meal. Knowing she received the dose of insulin noted in in the previous question at 6 p.m., at what times would the prudent RN concerned about hypoglycemia recheck her blood sugar? What symptoms would you question the patient about? What signs would you look for?

• Mrs. S. complains that her "heart pounds" after using the MDI and she refuses to use it again. What information can you give her to help her understand why she needs the medication and why she is experiencing these symptoms?

• One of the side effects of lisinopril is cough. What data on this patient eliminates that as the cause of her cough?

Case Study 3

A 62 year-old male with a long-standing history of poorly controlled hypertension and chronic deep vein thrombosis (DVT) presents to your emergency room complaining of shortness of breath increasing over the past week. His initial EKG revealed normal sinus rhythm (NS) with a rate of 104 and non-specific ST wave changes. His troponin and creatine kinase (CK-MB) bands were normal as was his VQ scan and D-dimer lab test. His exam revealed the following information:

• BP 170/104, p- 104 and regular

• Heart regular rate and rhythm with a 2/6 systolic murmur heard best at the 5th intercostal space, along the sternal border and an S3 and S4 gallop

• Lungs crackles in both bases (bibasilar)

• Extremities 3+ pitting edema of feet and ankles

This exam is consistent with acute congestive heart failure. The physician speculates that he had a silent MI months ago. His echocardiogram shows moderate mitral regurgitation and with a 25% ejection fraction (normal is > 65%), which means his cardiac output is severely decreased.

The patient was taking the following medications prior to admission:

• Clonidine 0.1 mg bid

• Dyazide™ (triamterene 50mg and hydrochlorothiazide 25 mg) 1 tablet qd

• Prozac™ 20mg qd

• Coumadin™ 2.5 mg qd

The following are the admission orders:

• Admit patient to the ICU

• Insert IV with buff cap

• I & O

• Furosemide 40mg IV push on arrival in unit then Lasix™ 40mg po q am

• Start lisinopril 10 mg po qd first dose stat

• digoxin 400 mcg IV now and start digoxin 0.125mg po qd in am

• Clonidine 0.1mg q hs times 2 then D/C

• D/C Dyazide™

Answer the following questions:

• Why was the clonidine not stopped abruptly?

• What are the pharmacodynamics of furosemide, lisinopril, and digoxin?

• What relevant core patient variables should be monitored before and after starting these drugs?

• What aspects of the pathophysiology of CHF do these specific drugs fix?

• The physician ordered digoxin 400 mcg IV push. You have on hand 0.5 mg in 2 ml. How many milliliters will you give the patient?

• You have furosemide 80mg/cc on hand. How much will you give the patient?

After 12 hours, the patient diuresed well and his bibasilar crackles and S3 resolved. His blood pressure stabilized at 130/80 with a pulse of 80. However, on the second hospital day, his pulse became irregular and the monitor showed atrial fibrillation with a ventricular response of 90 beats per minute.

• His physician wrote the following orders:

• Increase Coumadin™ to 5 mg qd

• Increase digoxin 0.25mg po qd

• PT/INR in am

The next day his INR was 2.5 and the physician decided to try to medically convert his rhythm to normal sinus rhythm (NSR). Your text is not up to date, since amiodarone has been FDA approved for treating atrial fib and atrial flutter and it is frequently used in the clinical arena for these common arrhythmias.

The physician orders the following:

• Load patient with amiodarone as follows:

• Amiodarone 360 mg over the NEXT 6 hours (1 mg/min) then 540 mg over the REMAINING 18 hours (0.5 mg/min). The pharmacy sends up the amiodarone labeled as follows: amiodarone 900 mg in 500 mg D5W (1.8mg/ml)

o Infuse 200 cc in first 6 hours (360 mg = 1mg/ml)

o Infuse 300cc in 18 hours (540 mg = 0.5mg/ml).

You want to know how many microdrops/min to infuse the fluid. You know the following formula:

• Milliliters per hr = Total ml fluid to be given / hours to run

• Milliters per min = milliliter per hour / 60 minutes

• Drops per min = ml per min x drop per ml

You plug in the following data:

• 200 ml in 6 hours = 200/6 = 33 ml in an hour

• 33 ml /60 minutes = 0.55 ml per minute

• 0.55 x 60 microdrops per minute = 33 drops per minute

Answer the following question:

• How many drops per minute will you run the remaining 300cc over the next 18 hours? Hint. Use the preceding formula and repeat the same process. Do not be confused by all the mg/min data, as the pharmacist has already calculated how much fluid you need to infuse to give the appropriate dose.

After the first 24 hours of amiodarone loading, the patient converts to NSR. Fortunately, he is adequately anticoagulated and he does hot "throw a clot" and have a stroke. The addition of the amiodarone decreases the patient's now regular pulse to 64 beats per minute with a BP of 120/78.

Answer the following question:

• What potential drug interactions should the RN consider in a patient on digoxin, amiodarone, lisinopril, fluoxetine, and furosemide?

The patient's discharge orders include:

• digoxin 0.125 ng qd

• Lisinopril 10 mg qd

• Amiodarone 200 mg qd

• Coumadin™ 5 mg qd

• Furosemide 40 mg qd

• Prozac™ 20 mg qd

Answer the following questions:

• What core patient variables (health status; life span and gender; lifestyle, diet and habits; and culture) are appropriate to assess for this patient?

• As the patient is ready for discharge, what information do you need to convey to him about his medications?

Case Study 4

Tim, a 21-year-old male college student is brought to the emergency room after having a grand mal seizure. The paramedics were called to a local party by his friends after he began to seize. The paramedics tell you this is his third seizure since they made contact with the teen. His friends told the paramedics he had been using Ecstasy (MDMA) for the first time and may have used too much. He stops seizing soon after arrival in your ER after having been given Valium™ 10 mg, 5mg IV and 5mg IM. The patient is somnolent and responsive to only painful stimuli now.

He looks to be about 6' tall and weighs about 165 pounds.

His current medications include:

• Fluoxetine 20 mg qd

• Alprazolam 0.5 mg t.i.d

• Motrin™ 600 mg t.i.d for the past 4 weeks for a sprained ankle

• He has no known medication allergies

The ER doctor's orders are

• Start IV with normal saline running over 8 hours

• Cardiac monitoring

• Dilantin™ 1000mg IV push now (which the physician administers)

• Admit to telemetry when seizure free for 4 hours

• Dilantin™ 100mg t.i.d starting tomorrow

• Dilantin™ level in a.m.

He is admitted to the medical unit and begins to wake up 4 hours later without having another seizure. During your assessment later that night, you discover that he has been ill with a respiratory infection for the past 2 weeks. He is blowing green mucous from his nose and coughing up green sputum as well. He has felt very tired lately and has not attended school. He notices that he is short of breath when he walks fast and hasn't been able to play basketball since before he got sick.

Your exam reveals a groggy 21-year-old with a BP of 110/60 and a regular pulse of 90. His oral temperature is 100.8 °F. His heart is regular rate and rhythm with a normal S1 and S2. Examining his lungs, you hear crackles at the left base with positive egophony on that side as well. His abdomen is soft, tympanic, and without tenderness. His skin is warm and dry. He has mild facial acne. Your neuro exam reveals PERLA, normal visual fields, good muscle tone in all extremities, and symmetrical reflexes graded 2+. He is alert and oriented to person, place, and time. His responses to your questions are a bit slow, however.

His physician makes rounds and confirms your suspicion. Tim has a left lower lobe pneumonia and needs IV antibiotics.

His physician writes the following orders:

• Cefoxitin 2 Gms IV q 8 hours

• Tylenol™ 325 mg 2 tablets q 4 hours prn fever > 100 degrees

• Fluoxetine 20 mg qd

• Ibuprofen 600 mg t.i.d with food

Answer the following questions:

• Tim tells you he has been on alprazolam for several years for his panic disorder. The physician did not order it to be given while Tim is hospitalized. You plan to call the physician and ask her to order it. What problem can abrupt cessation of alprazolam cause?

• You call the physician and she agrees to start the alprazolam 0.5 mg t.i.d. What should the RN know about concomitant administration of alprazolam and phenytoin?

• The physician tells Tim he will be on phenytoin 300 mg qd for at least 6 months. What will Tim need to know about this drug? Considering the other medications he is on, what should your education program include for Tim's discharge?

• How will fluoxetine affect phenytoin? What lab parameters should be monitored to avoid problems?

• Because of effects on organs, what lab parameters will need to be monitored? How does the fact that the patient is also taking ibuprofen add to the importance of monitoring lab parameters?

• What is the mechanism of action of ibuprofen? What side effects will you educate Tim to watch for?

• What class of antibiotics does the antibiotic Mefoxin™ (cefoxitin) belong to? Mefoxin™ is dispensed as 2 Gm/50ml of D5W. The physician has ordered it to run over 30 minutes. Using a regular macrodrip chamber, how many drops per minute will deliver this drug in 30 minutes?

• What side effects will you assess Tim for while he is receiving IV Mefoxin™?

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