Pharmacology Reasoning
Bradycardia
Suggested Answer Guidelines
Marilyn Fitch, 78 years old
Medication Categories:
Antidysrhythmics
ACE Inhibitors
Beta Blockers
Statins
Oral Anticoagulants
Diuretics
Electrolytes
NCLEX Client Need Categories
Concepts/Content:
Assessment
Drug-drug interactions
Evaluation of desired outcomes
Monitoring for adverse effects
Emergency treatment of dysrhythmias
Client education
Psychosocial support
Percentage of Items from Each
Category/Subcategory
Covered in
Case Study
Safe and Effective Care Environment
• Management of Care
• Safety and Infection Control
17-23%
9-15%
X
X
Health Promotion and Maintenance
6-12%
X
Psychosocial Integrity
6-12%
X
Physiological Integrity
• Basic Care and Comfort
• Pharmacological and Parenteral Therapies
• Reduction of Risk Potential
• Physiological Adaptation
6-12%
12-18%
9-15%
11-17%
X
X
X
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I. Initial Presentation:
Marilyn Fitch is a 78-year-old Caucasian woman with a history of hypercholesteremia, hypertension, and heart
failure and has NKDA. She was brought in by her daughter after Marilyn complained of feeling dizzy several
times this morning and then almost passed out at home. Marilyn has a six-month history of paroxysmal atrial
fibrillation. Her heart rate has been regular and she has had no episodic dizziness since she had a synchronized
cardioversion one week prior to this visit. Her initial VS in triage were: T: 98.9 F/37.2 C (oral) P: 52 R: 16 BP:
94/52 and O2 sat: 98% room air.
Personal/Social History:
Marilyn is a widow and lives alone in her own home. She denies smoking and admits to drinking one glass of
wine with her dinner.
1. What data from the histories are RELEVANT and must be NOTICED as clinically significant by the
nurse?(NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential)
RELEVANT Data from Present Problem:
Clinical Significance:
Hypercholesteremia
Hypertension
Heart failure
dizzy several times/almost passed out
6-month dx paroxysmal atrial fibrillation
Bradycardia & hypotension
Older adult client with various cardiac related illnesses
presenting with hypo-tension and bradycardia. I would
need baseline bloodwork, history of each dx and
current medication history as well as an EKG.
RELEVANT Data from Social History:
Clinical Significance:
Lives alone
If something were to happen to her, how would
authorities be alerted?
Drinks 1 glass of wine with dinner
She may be on various medications that could interact
with even this 1 glass of wine. How big is the glass?
As the nurse responsible for this patient, you promptly review the medical
history and current home medications in the medical record:
2. What is the RELATIONSHIP of the past medical history and current medications? Why is your patient
receiving these medications? (Which medication treats which condition? Draw lines to connect)
Medical History (PMH):
Hypercholesteremia
Hypertension
Heart failure
Atrial fibrillation
Home Medications:
Apixaban 2.5 mg po bid - Anticoagulant / Afib
Captopril 100 mg po BID daily - AceInhib. / Hypertension
Amiodarone 100 mg po bid -Antiarrhythmic-heart failure
Hydrochlorothiazide 50 mg po daily -Diuretic for Htn
Atorvastatin 10 mg po daily-Antihyperlipidemic for Chol.
Carvedilol 6.25 mg po bid-Beta Blocker for Htn
Applying your knowledge of pharmacology, to provide safe
patient care, answer the following essential information:
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3. List each home medication from the scenario and answer the following:
(NCLEX Pharmacologic and Parenteral Therapies)
Home
Medication:
Pharm.
Class:
Apixaban
2.5 mg po
bid
Anticoagulant
Captopril
150 mg po
daily
Ace Inhibitor
Amiodarone
100 mg po
bid
Antiarrhythmic
Hydrochloro
thiazide 50
mg po daily
Thiazide
Diuretic
Carvedilol
6.25 mg po
bid
Nursing
Assessments:
Liver
Skin Bruising
Risk bleeding
Monitor PTT,
monitor for
bleeding s/s of
anbormal
bleeds
Heart &
Liver
Fainting,
dizziness, low
bp,
Hyperkalemia
Monitor vitals,
electrolytes
and kidney
function
it is used to restore
Heart
normal heart rhythm and
maintain a regular, steady
heartbeat
Numbness
Tingling
Dizziness
assess
circulation so
cap refill,
pulses,
hemodynamics
Reduces sodium
reabsorption
Thirst
Monitor
Dry Mouth
I&O
Muscle Cramps
Confusion
Mechanism of Action
In OWN WORDS:
Prevent blood
clots
Interferes with
conversion of
prothrombin to thrombin
Inhibits Angiotension
converting enzyme
Hypertension
irregular hr
beta blocker
Common
Side Effects: (13)
Indication(s):
Treats htn
Treats htn
Atorvastatin antiLowers bad
10 mg po
hyperlipidemia cholesterols
daily
med
Body
System
Impacted
Kidney
Blocks beta1 adrenergic Heart
receptor
Dizziness
Lightheadedn
ess
Drowsiness
Neuro/
and cardiac
assessment
Reduces cholesterol
synthesis
Yellowing of
the sclera,
amber colored
urine
Urine
assessment &
liver function
tests
Liver
4. Based on this patient’s home medication list, does the nurse need to address the clinical concern of
polypharmacy with the primary care provider?
Yes
5. Based on this patient’s home medication list, are there any concerning medication interactions that the
nurse needs to communicate to the primary care provider?
Amiodarone and Hydrochlorothiazide when taken together they can increase the risk of an
irregular heartbeat.
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II. Present Problem:
Recognizing a potential problem, you place Marilyn on a
cardiac monitor, collect a full set of vital signs and complete
a nursing assessment:
Cardiac Telemetry Strip-Six Seconds:
Regular/Irregular: Regular/rate
Interpretation:
P wave present?
PR:
QRS:
Sinus Brady
Clinical Significance:
This may be why the patient is experiencing dizziness
.
Current VS:
T: 98.8 F/37.1 C (oral)
P: 54 (reg)
R: 14 (reg)
BP: 94/58
SpO2: 94% on room air
P-Q-R-S-T Pain Assessment: Denies and pain or discomfort
Provoking/Palliative:
Quality: DENIES PAIN
Region/Radiation:
Severity: 0/10
Timing:
1. What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?
(NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential)
RELEVANT VS Data:
Clinical Significance:
BP
O2
The BP is low
Dropping on room air from admittance
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Current Assessment:
GENERAL SURVEY:
NEUROLOGICAL:
HEENT:
RESPIRATORY:
CARDIAC:
ABDOMEN:
GU:
INTEGUMENTARY:
Pleasant, well-nourished older adult in no apparent distress. In semi-Fowler’s position on
gurney, quietly talking with daughter.
Alert, oriented x4 (to person, place, time, and situation). PERRLA. Muscle strength 5/5 in
both upper and lower extremities bilaterally.
Head normocephalic with symmetry of all facial features. Sclera white. Lips, tongue, and
oral mucosa pink and moist
Bibasilar crackles posteriorly, otherwise clear with equal aeration throughout lung fields.
Respiratory effort nonlabored. Denies dyspnea at rest on room air.
Skin pink, warm & dry, with 1+ ankle edema bilaterally. Radial, pedal. And post-tibial
pulses +1 pulses on palpation. Cap refill <2 seconds. Heart tones regular, S1, S2, and S3
noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD
noted at 45 degrees. Cardiac monitor: sinus bradycardia.
Abdomen round, soft, and nontender. BS active in all 4 quadrants
Voiding without difficulty, urine clear amber. Genital exam deferred.
Skin warm, dry, intact, normal color for ethnicity. Decreased skin turgor: recoil 2 secs.
No clubbing of nails. Hair soft, distribution normal for age and gender.
2. What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse?
(NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential)
RELEVANT Assessment Data:
Clinical Significance:
Crackles
Edema
Decreasing skin turgor
Pulmonary edema could be a possibility since the patient has a
history of heart failure.
3. Interpreting relevant clinical data, identify potential problems. What additional data is needed to identify
the priority problem and nursing priorities? (NCSBN: Step 2 Analyze cues/NCLEX Management of Care/Physiologic
Adaptation)
Likely Problems:
Additional Clinical Data Needed:
Pulmonary Edema
Dehydration
Hypoxia
Sinus Brady
We would need labs, ABGs, BMP and imaging to be able to assess the
total picture.
As you complete your assessment, Marilyn’s high priority alarm goes off
and the telemetry monitor reveals the following strip below.
Marilyn lies back and complains of feeling faint. This abnormal rhythm
spontaneously resolves and returns to sinus bradycardia with a HR of 56.
You immediately reassess her BP, which is 82/50.
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Cardiac Telemetry Strip:
Interpretation:
Afib
Clinical Significance:
All of the warning signs like dizziness point to afib. This patient is at risk for clots.
Recognizing that a problem is present, use SBAR concisely to
communicate your concern to the emergency department physician.
Situation:
Name/age:
MF 78 y/o female
BRIEF summary of primary problem:. Dizziness, Afib, Sinus Brady
Background:
Primary problem/diagnosis:
Afib / Heart Failure
RELEVANT past medical history: htn/heart failure, history of cardioversion
patient lives alone
RELEVANT background data:
Assessment:
Most recent vital signs: HR 56 BP 82/50 T 98.8 RR 14 SpO2 94%
RELEVANT body system nursing assessment data: Bilateral crackles, edema in extremities
RELEVANT lab values:
No labs to reference
TREND of any abnormal clinical data (stable-increasing/decreasing): BP and oxygen are both dropping
INTERPRETATION of current clinical status (stable/unstable/
unstable
worsening):
R
ecommendation:
Suggestions to advance the plan of care: Oxygen, chest xray, full lab workup, abgs.
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The emergency department physician agrees with
your recommendations and orders the following:
The physician then orders the following:
4. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies)
Orders:
Rationale:
1. Oxygen 2L per nasal cannula.
Titrate to keep O2 sat >95%
2. Stat 12 lead EKG
3. Stat labs: Basic Metabolic
Panel (BMP), cardiac
enzymes, complete blood
count (CBC), and Brain
Natriuretic Peptide (BNP).
Mag level
4. Stat portable chest x-ray
(CXR)
5. Insert peripheral IV catheter to
saline lock.
6. Continuous monitoring of
telemetry, BP, and O2 sat.
Expected Outcome:
Oxygenation
Improved oxygenation
Monitor the heart
To get a better picture of what is going on with
my patient.
Chest x-ray to evaluate pulmonary edema
A better understanding of
the patients heart
function and other body
systems.
IV for meds/possible rescue meds
Monitoring Q15 or Q1HR until patient stabilizes
Patient is a fall risk
Crash cart in case the afib turns into vfib/vtach
7. Bedrest
8. Crash cart/defibrillator to
bedside.
12 Lead EKG
Clinical Significance:
T-wave inverted, possible pulmonary embolism
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Thirty minutes later, the following diagnostic test
results just posted in the electronic health record:
Results:
Results: Mild cardiomegaly and
small bilateral pleural effusions.
Evidence of heart failure.
Radiology: Chest X-Ray
Clinical Significance:
Blood is building up backing into the heart and fluid is filling in the
spaces
Current:
WBC
9.5
Complete Blood Count (CBC)
HGB
HCT
10.2
28
PLTs
168
Current:
Na
145
Basic Metabolic Panel (BMP)
K
Gluc.
3.1
85
Creat.
1.05
Current:
Troponin
0.01
MCV
70
Cardiac & Magnesium
BNP
Magnesium
410
1.1
5. What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
(NCSBN: Step 1 Recognize cues/NCLEX: Reduction of Risk Potential Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Lab(s):
Clinical Significance:
HGB and HCT
PLT
BNP
HGB and HCT are low
High risk for a blood clot
Heart Failure
You call the emergency physician and report the relevant results of the
diagnostic testing and current VS: BP 90/58, HR 56 sinus bradycardia.
The following orders are given:
6. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies)
Orders:
Rationale:
Expected
Outcome:
Stat magnesium sulfate 1 Gm IV bolus. Give
over 10 minutes.
Her mag level is low
prevents seizures
potassium and
mag are both
within normal limits
Administer potassium 20 mEq in 100 mL NS IV Potassium level is low
over 2 hours.
Basic metabolic panel (BMP) after magnesium
and potassium infusions complete.
To get updated levels after mag and
potassium are given.
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If Mg < 1.5, repeat 1 Gm IV bolus.
hold this med and give the magnesium
first.
Hold amiodarone.
7. State the rationale and expected outcomes for the medical plan of care. (NCLEX Pharm. and Parenteral
Therapies)
Medication:
Pharm.
Class:
Indication(s):
Mechanism of Action
In OWN WORDS:
Magnesium
sulfate
mag
sulfate
Potassium
chloride
Electrolyte potassium level It helps with nerve total
was low
function and muscle
contraction.
Prevents
seizures
supporting muscle
and nerve function
and energy
production
Common
Side Effects:
(1-3)
Body
System
Impacted
CNS
Flushing
Sweating
Confusion
Weakness
Nausea
Vomiting
Diarrhea
Nursing
Assessments:
Neuro
muscular
checks
Vitals
Hemodynamics
III. Put it All Together to THINK Like a Nurse!
1. Interpreting all clinical data collected, what is the priority problem? What is the pathophysiology of the priority
problem? (NCLEX Management of Care/Physiologic Adaptation)
Priority Problem:
Pathophysiology of Problem in OWN Words:
Heart Failure
The patient is having heart failure which occurs when the heart muscle doesn't
pump as much blood as it should.
2. What nursing priority(ies) and goal will guide how the nurse RESPONDS to formulate a plan of care? (NCSBN: Step
4 Generate solutions/Step 5: Take action/NCLEX Management of Care)
Nursing PRIORITY:
GOAL of Care:
Perfusion
Improved cardiac function
Nursing Interventions:
Rationale:
Expected Outcome:
Oxygen
Vitals
Frequent Assessments
Oxygenation for poor perfusion
To monitor the patient and hope that she
starts to improve.
Perfusion and
improvement in
vital signs and labs
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IV. Evaluation: Two hours later…
You collect the following data just before calling
report to the nurse that will be caring for Marilyn in
the intensive care unit. Interpret the following data to
determine the current status of your patient:
1. After implementing the medical and nursing plan of care, EVALUATE by INTERPRETING relevant current
clinical data to determine if status is improving, declining, or reflects no change.
(NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care)
Assessment Finding:
Potassium 3.5
Magnesium 1.5
Telemetry: sinus brady, no further episodes of torsades de
pointes
S3 gallup auscultated over apex
1+ pedal edema
Bibasilar posterior crackles
O2 sat 96% on 2L NC
BP 98/56, HR 56
Improving:
Declining:
No Change:
xx
xx
xx
xx
xx
xx
xx
xx
2. Has the overall status of your patient improved, declined, or remain unchanged? If your patient has not improved,
what other interventions need to be considered by the nurse?
(NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care)
Overall Status:
Additional Interventions to Implement:
Expected Outcome:
Very Small
Improvements
Assess for dyspnea, shortness of breath, fatigue, and edema. Improved lung function and
Assess for sleep disturbances, especially sleep suddenly
perfusion
interrupted by shortness of breath.
Explore the patient’s understanding of HF, self management
strategies, and the ability and willingness to adhere to those
strategies.
3. To develop clinical judgment, reflect on your thinking by answering the following questions:
What did you do well in this case study?
What knowledge gaps did you identify?
I think I did "ok" as far as interpreting what was I identified disease processes
going on as I was reading it.
What did you learn?
How will you apply learning caring for future patients?
I learned more about heart failure through
research
I will be more aware of what to watch for with patients
in the future that may be experiencing heart failure.
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form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of KeithRN