Dewayne Lee
Fundamentals of Nursing
Case Study 1
You are a cardiac nurse with 12 years’ floor experience, caring for a patient who is 2 days
postoperative extensive cardiac bypass. The previous shift’s nurse reports that the patient was
resting comfortably---an unremarkable shift. As you begin your first assessment, “something”
prompts you that this could be an eventful shift with this patient. The patient is off the
ventilator, conversing with you and his family. Everything seems to be fine, but you just can’t get
rid of the feeling that something may happen.
A. What data in this scenario Are pertinent ?
The patient is on the second day after a very extensive surgery even though a cardiac bypass surgery
has a 98 percent chance of success and over a half million is done in the USA, we still need to
observe patient thoroughly .
B. The something that the nurse is feeling is the fact that it’s the post operative day and she knows
that something can goes wrong, some common side effects of cardiac bypass is.
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Dysrhythmias- abnormality especially in the activity of brain and heart
Ventricular dysrhythmias- are abnormal heart rhythms that make the lower chambers of
your heart twitch instead of pump.
Supraventricular dysrhythmias- a faster than normal heart rate beginning above the
heart’s two lower chambers.
Some additional problems that can take place are blood clots , infection at the incision site ,
pneumonia and breathing problems, these are the things that’s on my mind as a nurse.
C. The steps I would take to link to my thinking are as follows.
 Monitor the patient.
 Check blood pressure and cardiac output.
 Monitor temperature for any hypothermia.
 Electrolyte imbalance
D. In this situation you could find help from a dynamic nursing team by working with everyone and
the attending surgeon.
Nursing process- Assessment
Question 2
a. What data in the scenario are pertinent? The data that’s important is as follows shortness of
breath , weight loss, shortness of breath increase with talking , because of oxygen use via nasal
cannula suggest dyspnea at rest.
b. What type of nursing assessment would you expect to complete and why? The nurse can monitor
and take control of the outcome by monitoring and maintaining the blood oxygen level if condition
worsen the nurse can also attached an oxygen tank and make sure its ready and prep to go for any
sudden fall in oxygen saturation
c. Why would you need to establish assessment priorities? You would need to set priorities because this
is considered a top priority in nursing because the client has trouble breathing , if the patient is not able
to breathe or get back the patient stable, she will die so establishing assessment is a must.
d. What patient factors would assist in identifying and prioritizing data? I would do a new set of vitals to
set a baseline line to work with. I would take the patient’s blood pressure, pulse and o2 saturation.
e. What challenges might the nurse encounter during data collection? One of the problems is
desaturation during questioning , since the client is not stable, I would stop questioning the client I
would also make sure that the client is in a semi fowler position to promote breathing and try to get her
health care provider on the phone.
3)You are a nurse preparing to receive a new patient, fresh from surgery to your unit. The patient is a 71year-old man who underwent a surgical repair of a fractured femur. As you receive a
report from the post anesthesia recovery unit, you learn that his medical history includes
hypertension, 40 pack-years of smoking, and COPD. His surgical repair was successful but
complicated by excessive bleeding, and he is receiving IV fluids to compensate. He is widowed,
and his three children are scattered throughout the United States. He lives alone, receives Meals
on Wheels, and pays a cleaning service to keep his home clean.
a. What potential collaborative problem(s) could be applicable in this situation? The patient just came
out of surgery, and it’s mentioned that he is losing blood, a potential problem might be patient losing
too much blood then goes into shock. Patients also suffer from hypertension which could make the
situation worse all around.
b. Which nursing diagnoses would you expect to be applicable regarding the medical
procedures in this situation? Higher risk of sudden dyspnea due to pulmonary embolism
from fractured femur
Risk of stroke due to embolism and hypertension
Emotional breakdown due to anxiousness of the old age patient.
High risk of infection
High risk of nonunion femur neck
Higher risk of accidental fall due to old age
c. Which nursing diagnoses would you expect to be applicable regarding the
nursing/medical history in this situation? High risk of blood loss anemia due to excessive blood
loss during surgery , patient history of hypertension, copd. Patient loneliness being single.
Patients old age cause more risks of embolism, DVT and infection, also risk of falling from chair,
bed etc.
d. Which nursing diagnoses would you expect to be applicable regarding the discharge
planning in this situation? Strict monitoring of IV fluid given and urine output
Measuring of hemoglobin levels and arterial blood gas analysis
Early mobilization of the patient
Measuring BP, pulse rate, respiratory rate, and vitals regularly.
Measuring trigger points of hypertension and stress
4) Planning
A. General priority can be taken
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Management of surgical wound, proper care of the old age patient physical and mental
Regular monitor for his vitals
B.
Sudden dyspnea due to pulmonary embolism from fracture femur
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Risk of stroke due to embolism and hypertension
Emotional breakdown due to anxiousness of old age patient
High risk of infection
High risk of non-union femur neck
C. information that would be included in evidence-based nursing interventions
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Old age put patients at higher risk of embolism.
History of hypertension
High risk blood loss
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Strict monitoring of iv fluid given urine output
Hemoglobin levels and arterial blood gas levels
Early mobilization of patient
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Challenges to care plan
History of hypertension cab cause problems
history of copd can cause complications.
D
E
5) implementation
A. We would expect the client to have increased risk of blood clots , dvt
b. Expected patient outcome would be at risk for hypertension and high blood pressure.
c. Evaluate outcome by having a baseline occasionally do vitals and compare.
d. Interventions can be evaluate by getting patient stable and stop bleeding
6) Evaluation