NRNP 6566F Week 4 Scenario 84 Year Old Female With Confusion And Lethargy

Week 4: Hypertension And Shock

Issues with the heating and cooling system of your home can be relatively benign matters that are addressed easily enough with the help of a visiting technician. But in cases of extreme weather conditions or delayed attention, these matters can seriously threaten the health of the home or its occupants.

Similarly, extreme cardiovascular conditions can pose very serious health risks. Hypertension can lead to severe health complications and increase the risk of heart disease, stroke, and sometimes death. Shock can damage the body’s organs and can also be life-threatening. Effective diagnosis and treatment of hypertension and shock can, therefore, be a critically important and even life-saving endeavor.

This week, you will assess and develop management plans for patients with hypertension, including urgent and emergent conditions. You will review how to differentiate shock states and examine hemodynamic values for those shock states when evaluating treatment goals.

Objectives

Students will:

  • Distinguish between hypertensive urgencies and emergencies
  • Develop a management plan for hypertensive emergencies
  • Apply current clinical practice guidelines to address acute and chronic management of hypertension
  • Distinguish shock states
  • Develop patient treatment plans for shock
  • Analyze pharmacologic treatments of shock
  • Evaluate normal and abnormal hemodynamic monitoring values
  • Develop appropriate treatment plans, including diagnostics and laboratory orders for patients with hypertension and shock
  • Identify concepts related to hypertension and shock

Learning Resources

Required Readings (click to expand/reduce)

  • Barkley, T. W., Jr., & Myers, C. M. (2020). Practice considerations for the adult-gerontology acute care nurse practitioner (3rd ed.). Barkley & Associates.
  • Chapter 12, “Hypertension” (pp. 131–145)
  • Chapter 15, “Adjunct Therapies” (pp. 185–200)
  • Chapter 76, “Management of the Patient in Shock” (pp. 982–1012)

Assignment: Branching Exercise: Cardiac Case 2

For this Assignment, you will review the interactive media piece/branching exercise provided in the Learning Resources. As you examine the patient case, consider how you might assess and treat patients with the symptoms and conditions presented.

To prepare:

  • Review the interactive media piece/branching exercise provided in the Learning Resources.
  • Reflect on the patient’s symptoms and aspects of disorders that may be present in the interactive media piece/branching exercise.
  • Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the interactive media piece/branching exercise.
  • You will be asked to develop a set of admission orders based on the patient in the branching exercise.

The Assignment

Using the Required Admission Orders Template, write a full set of admission orders for the patient in the branching exercise.

  • Be sure to address each aspect of the order template
  • Write the orders as you would in the patient’s chart
  • Make sure the order is complete and applicable to the patient
  • Any rationale you feel the need to supply should be done at the end of the order set – not included with the order
  • Please do not write per protocol. We do not know what your protocol is and you need to demonstrate what is the appropriate standard of care for this patient.
  • A minimum of three current, evidenced based references are required.

By Day 7 Of Week 4

Submit your completed Assignment by Day 7 of Week 4 in Module 2.

Week 4 Sample Answer

Greetings Students,

Welcome to week 4,

Great job on your 1st knowledge check. If anyone would like to review, please send me an email and I will be happy to go over your answers.

This week you all will be learning more about arrhythmias, shock and hypertension.

Please utilize the information provided under the learning resources.

For your assignments there will be another branching exercise and your second knowledge check. Both of these assignments are due March 29th @ 0159 est.

Please remember to review the rubric and the comments I have made on your previous branching exercise to improve and receive maximum points.

Here is the information for your branching exercise:

84 y/o Female

Code Status: DNR

PMH: HTN, DM

Home meds: Metoprolol/Insulin/ASA/ Calcium

Wt: 62kg, Ht 5’5 NKDA

Critically think about where you would send this patient from the ER and write admissions orders for that unit. Remember to be specific with your orders. Especially with your nursing orders.

Remember Oxygen is a drug. We shouldn’t be placing oxygen on patients just to place it or if they have a normal O2 sat, ie: 94%. If they have an O2 sat of 92% and above O2 is not indicated. Remember if you just put oxygen on a patient routinely, if something really is going on, it could mask a problem that may warrant an investigation.

Please email me with any questions, comments, concerns. If you would like to have a zoom meeting or phone conference, please email me and we can schedule a time.

Best,

Scenario #3 84 Year Old Female

BACKGROUND

  • An 84-year-old female is brought in by family with complaints of increased confusion and lethargy.
  • Patient usually lives alone and is fully functional.
  • Son reports that she has been increasingly confused and sleeping a lot at home.
  • Son denies any fever.
  • Patient complains of pain “all over” and responds to repeated questions with “I think I’m sick”

VITAL SIGNS

  • BP 105/64, HR 115, RR 24, T 96°F, SpO2 92% Room Air
  • Patient is alert, and oriented to person but thinks is it 1990
  • PMH: HTN: Metoprolol
  • DM: Insulin
  • Other meds: ASA, Calcium

Decision Point One

12 lead ECG, CBC, CMP, urinalysis, Chest x-ray

RESULTS OF DECISION POINT ONE: Correct!

  • Initial 12 lead EKG to assess myocardial function
  • CBC to assess WBC and potential anemia
  • BMP to assess electrolyte disturbance and potential for DKA
  • Urinalysis to assess for potential infection
  • Chest x-ray to assess for potential infection

RESULTS OF INDICATED TESTS

Complete Blood Count (CBC)

WBC 3.4 k/UL

Hgb 9.3 g/dL

Hct 28%

Platelets 250 k/UL

Differential

Neutrolphil 90%

Bands 10%

Eosinophil 0%

Basophil 0%

Lymphocyte 2%

Monocyte 3%

Basic Metabolic Profile (BMP)

Na+ 132mEq/L

K+ 3.7mEq/L

HCO3 27mEq/L

Cl- 101mEq/L

Glucose 1766 mg/dL BUN 55 mg/dL

Creatinine 2.0 mg/dL

Urinalysis (U/A)

Color Yellow

Clarity Dark/Cloudy Sp gravity 1.042

pH 6.2

Total Protein negative

Glucose positive

Ketone negative

Bilirubin negative

Hematuria positive

Leuk. Est. +++

Nitrite +++ NRNP 6566F Week 4 Scenario 84 Year Old Female with Confusion and

Lethargy

Decision Point Two

Urinary Tract Infection

RESULTS OF DECISION POINT TWO

  • Urinalysis shows hematuria, positive nitrate, positive leukocyte esterase which all are indicative of a UTI.
  • Elderly frequently have a low WBC and low body temperature in the presence of
  • infection.
  • Chest x-ray is clear and EKG shows tachycardia but no arrhythmia or myocardial hypoxia.
  • The patient remains confused and is becoming more lethargic. Follow up BP is 82/42. Serum lactate level is 4.5. What is your diagnosis now? 

Decision Point Three

Septic Shock Guidance to Student

Correct!

SIRS (systemic inflammatory response syndrome) requires the presence of two of the four factors:

  • Temperature less than 36.0 C or greater than 38.0 C
  • Heart rate greater than 90 BPM
  • Respiratory rate > 24 breaths per minute or PaCO2 < 32
  • WBC less than 4,000 or greater than 12,000; or Bandemia>10%