History of Present Problem: E.W., a 76-year-old white man, comes to the emergency department
after a syncopal episode and complaint of mild chest discomfort at a local restaurant. He is accompanied
by two friends.
Subjective Data
 Has been feeling weak for a few days
 Became dizzy and fainted while awaiting his dinner
 Takes one medication, a “water pill” for high blood pressure
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
76 years old
Geriatric age- risk for falls, may need more support. We don’t know
his psychosocial status.
Syncopal episode
BP low, this may be due too much medication or some other reason
that needs to be addressed. Did he hurt himself when he passed out?
Feeling weak for a few days
May have an undiagnosed illness, infection. May not be eating well at
home.
Takes one med- a “water pill” for HTN
If he is taking Lasix, may have low potassium. Could be developing
heart failure with possible chronic HTN
Patient Care Begins:
Current VS:
T: (oral) 98.2 F
P: (irregular) 110
R: (regular) 24
BP: 92/50
O2 sat: 92 %
P-Q-R-S-T Pain Assessment (5th VS):
Provoking/Palliative: Discomfort
dull
Quality:
Left chest area, no radiation
Region/Radiation:
2/10
Severity:
Over last few days
Timing:
What vital signs are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT VS Data:
Clinical Significance:
Temp 98.2 slightly low
Pt may be cool from the drop in BP. Geriatric patients can have an infection
and not have a fever. It needs to be evaluated.
Pulse is irregular and tachycardia
at 110
Can cause decreased cardiac output, so less blood supply to organs such as the
brain. Is the irregular pulse normal for him? If not, what is causing it?
Resp 24 slightly elevated
Compensation for low oxygenation.
BP low 92/50
Low BP can make a person faint, less perfusion to organs. He may be dizzy
getting up and needs to be monitored.
O2 sat: 92%
Oxygenation is below normal. May need supplemental oxygenation
© 2016 Keith Rischer/www.KeithRN.com (Case study adapted 1/2/2020 MK, Updated 7/28/2020 KLW)
Current Assessment:
GENERAL
APPEARANCE:
RESP:
CARDIAC:
NEURO:
GI:
GU:
SKIN:
White, male, slightly anxious
Lungs clear in all fields
S1 S2 Irregular, Tachycardia, Radial and pedal pulses weak. No edema
Alert and oriented,
Abdomen soft, bowel sounds active. Denies any problems
Voiding yellow urine
Dry, pale, cool
What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Assessment Data:
Clinical Significance:
Patient is anxious
Need to find out why he is anxious. Is it due to low oxygen saturations or
is it fear about his health or something else?
Heart rhythm is irregular
May not putting out enough blood to bring oxygen and nutrients to cells.
The reason for this needs to be evaluated.
Radial and pedal pulses weak
Heart not pumping well
Skin pale and cool
Circulation is not good to skin
What other health history questions will the nurse need to ask?
Is he currently experiencing any angina, syncope, weakness, palpitations, or shortness of breath?
Does he have a history of heart disease?
When did he last take the “water pill”?
Does he have family members that need to be notified of his treatment in the emergency department?
How long has he been feeling weak?
Has he ever fainted before?
Lab/diagnostic Results:
Labs (normal)
Sodium (135–145 mEq/L)
Potassium (3.5–5.0 mEq/L)
Glucose (70–110 mg/dL)
Creatinine (0.6–1.2 mg/dL)
BUN (7-20 mg/dL)
Hgb (13.5-17.5 g/dL for men; 12.015.5 g/dL for women)
Current:
137
3.2
85
1.3
23
16
High/Low/Normal?
High- Normal
Low
Normal
Slightly elevated
Slightly elevated
Normal
© 2016 Keith Rischer/www.KeithRN.com (Case study adapted 1/2/2020 MK, Updated 7/28/2020 KLW)
Hct (45-52% for men; 37-48% for
women)
47
Normal
Other labs
Troponin (0-0.4 ng/mL)
BNP (0-100 pg/mL)
PT (11-13.0 seconds)
INR (1.0-1.5)
Current:
<0.1
87
11.3
1.15
High/Low/Normal?
Normal
Within normal range
Normal
Normal
Discuss abnormal labs and what clinical significance it has for nursing care.
Labs:
Clinical Significance:
Sodium normal
High end of normal, patient may be dehydrated
K+ low
Patient may be taking Lasix and not taking a potassium supplement. This can cause and
arrhythmia. This will need further evaluation.
Glucose normal
Patient does not appear to be a diabetic. Had been eating when he passed out.
BUN & Creatinine
slightly elevated
Due to history of HTN, are the kidneys being affected?
Hgb/Hct
These are normal so patient not bleeding or experiencing anemia.
Troponin normal
Pt does not appear to be having a heart attack.
BNP 87
Pt at risk for heart failure
Normal PT/INR
Shows that the patient is not on Warfarin already
Cardiac Telemetry Strip
Interpretation: what
is this rhythm?
Pathophysiology and Clinical Significance: How will this rhythm affect the
patient?
© 2016 Keith Rischer/www.KeithRN.com (Case study adapted 1/2/2020 MK, Updated 7/28/2020 KLW)
Atrial fibrillation is characterized by a total disorganization of atrial electrical activity
due to multiple ectopic foci, resulting in loss of effective atrial contraction. (Lewis,
chapter 35)
Because of the decrease in CO with ineffective atrial contractions and/or a rapid
ventricular response, E.W. is at risk for angina, heart failure, and developing a more
serious dysrhythmia. Thrombi may form in the atria because of blood stasis; an
embolized clot may develop and pass to the brain, causing a stroke. (Lewis, chapter 35)
Atrial fibrillation
Collaborative Care: Medical Management
State the rationale for the provider’s orders.
Care Provider Orders:
Rationale:
Warfarin 5 mg po
Warfarin, an anticoagulant, is used to prevent development of blood clots in
the fibrillating atria of the heart
Amiodarone 400 mg po
Amiodarone is used to restore and maintain a normal heart rhythm in patients
twice daily x1 month, then with atrial dysrhythmias.
200 mg daily
Potassium chloride 20 meq
po BID
Potassium replacement is important for body function, especially the heart
muscle function.
Chest X-ray
Evaluate for possible lung infection, heart enlargement, reason for patient
having tachypnea
Titrate oxygen to keep O2
sats > 93%
Keep enough oxygen going to cells
1. What two psychosocial/holistic care PRIORITIES need to be addressed for this patient? The patient may
be nervous about another medical condition, about ability to care for himself. He may be fearful of dying.
2. List two ways you can engage and show this patient matters to you? Speak directly to the patient,
listen to his concerns. Make eye contact. Evaluate if he has a support system and if someone needs to be
contacted.
Develop 2 Nursing Care Plans for this patient
(These are options. The students may come up with other answers that are also appropriate.)
Priority Nursing
Diagnoses
Decreased cardiac
output or
Impaired cardiac
function
related to alteration in
heart rate and rhythm
Goals (one goal per
diagnosis)
Interventions (list at least 2
interventions)
Evaluation (write what
you would imagine could
happen)
Goal met: Patient’s heart
rate was <100.
Pt’s rhythm was regular
for two shifts.
Pt’s heart rate will be
under 100 bpm by end
of hospital stay.
Pt’s rhythm will be
regular by discharge.
-Assess heart sounds and vitals
every 4 hours.
-Monitor telemetry for change in
rhythm and heart rate.
-Monitor labs
-Administer meds (amiodarone) to Goal not met: Pt’s rhythm
help normalize heart rhythm.
was still irregular.
© 2016 Keith Rischer/www.KeithRN.com (Case study adapted 1/2/2020 MK, Updated 7/28/2020 KLW)
as evidenced by heart
rate 110, irreg.
Impaired gas exchange
related to altered blood
flow/heart rhythm
As evidenced by oxygen
sats 92% and
respiratory rate of 24.
Ineffective tissue
perfusion related
alteration in heart
rhythm as evidenced by
weak peripheral pulses
and cool skin
Knowledge deficit of
atrial fibrillation and
care related to new
diagnosis as evidenced
by patient states “what
is going on with my
heart?”
Patients will have
oxygen sats> 93% by
1 hour
Patient’s sats will
remain above 93%
during
hospitalization.
Patient will not
require oxygen by
discharge.
Pt’s respiratory rate
will be within normal
range by discharge.
Pt’s peripheral pulses
will be normal by
discharge.
-Monitor O2 sats every 4 hours
-Administer oxygen to keep
saturation over 93% and monitor
for effectiveness.
-Auscultate lung sounds every 4
hours.
-Elevate head of bed
-Encourage position changes and
deep breathing.
Goal met: Patient’s O2 sats
were >93% on room air by
discharge.
Respiratory rate was
within normal range by
discharge.
Assess for peripheral pulses every
4 hours, noting strength and
quality of pulses.
Goal met: Peripheral
pulses were strong.
Pt verbalizes what
atrial fibrillation is,
when to call the
physician, and what
new medications he
will be taking
Assess readiness for learning.
Teach patient the basic
physiology of atrial fibrillation.
Teach the patient about meds,
reasons for taking the med, side
effects, etc.
Teach patient signs and symptoms
that need to be reported to the
physician.
Goal not met: Pt’s with
more questions about
treatment for a-fib.
© 2016 Keith Rischer/www.KeithRN.com (Case study adapted 1/2/2020 MK, Updated 7/28/2020 KLW)