Study case
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Admission diagnosis
Admitted with abdominal pain, she was taking accidentally 2 pills of metoprolol instead of 1. Suffering from atrial fibrillation with rapid ventricular rate and heart rate of 140 bpm, having hypotension.
Primary complaints
Had atrial fibrillation with rapid ventricular rate and heart rate in 140s having hypotension.
Current diagnosis and pathophysiology
Atrial Fibrillation with RVR
Clinical manifestation (Book)
Having a fast heart rate with abnormal beats and arrhythmia. Heartbeats too slow and sometimes too quick (Brunner, 2010). Mostly common in patients having cardiovascular disorders (Arara & Karani, 2018).
Clinical manifestation (Patient)
Admitted with rapid heart rate, abdominal pain, and hypotension.
Past medical history
This patient was diagnosed with persistent Atrial Fibrillation, CAD, HTN, and COPD requiring home O2, Hypothyroidism, and Chronic systolic CHF. Previously diagnosed with GI bleeding. Rheumatoid arthritis and osteoarthritis were also present in her medical history. Carcinoma in situ of duodenum was also present in previous medical history. The patient had her splenectomy in January 2000, neck surgery was performed on June 2000, and Lumbar herniated disc repair in July 2000 and in September 2003. Bladder surgery in 1986 and thyroidectomy in 1969. Colonoscopy was performed in 2017 and upper endoscopy in May 2017. In 2017, IVC filter was also accomplished. History of insertion of pacemaker and atrio-ventricular node ablution.
Family history
Father had an MI, Mother had a brain aneurysm, and brother had lung cancer
Assessment
Long-standing persistent atrial fibrillation with RVR, reported chronic systolic CHF, CAD, HTH, H/O IVC filter implant and chronic renal insufficiency.
Nursing Plan
Will utilize IV digoxin load 0.125mg IV every 8 hours for 2 doses. Continue PO digoxin 0.125 mg PO daily, continue Metoprolol tartrate 25 mg QID. A single chamber pacemaker implant has been discussed with the patient. She will give it an option. Keep NPO after midnight for possible procedures on 10/4/2019. Continuation of telemetry monitoring and will follow. Contraindicated d/t prior GI bleed.
Chief complaints with nursing implications
Abdominal pain and suffering from atrial fibrillation with rapid ventricular rate and heart rate 140s having hypotension
Signs and symptoms with nursing implications
Alert, oriented, BP 119/68, pulse 135, temperature 90.3 F, respiration 16, Weight 75.6 kg, admit weight 65 kg, height 66 in. Alert, active no acute distress, fatigue and exercise intolerance. Normal, non-focal, normal strength sensation, clear to auscultation, no wheezing. On home O2 chronically. Irregular tachycardia, normal BS; patient reports slightly tender, abdominal pain but no vomiting.
Primary medical health
Diagnosis with nursing implications
Atrial Fibrillation with RVR. Management with reducing the blood clots and control RVR
Duration with nursing implications
Continue using Metoprolol tartrate 25 mg.
Treatment with nursing implications
For the management of high blood pressure to help prevent stroke
Data from other areas
Social. Non-smoker, daily cigarette quit day: 11/25/1970. Alcohol use: previously, recreational, drug history, lived alone.
Psychological health is normal
Cultural factors are associated, such as lifestyle is sedentary and nutrition is inadequate
Economic factors are observed normal
Medication
Drugs
Dose
Mechanism of action
Considerations
Side effects
Teaching information
Rationale
Asmanex
200 mcg/actuation inhaler
Inhalation
For the prevention of asthma, wheezing, and difficulty in breathing
Hoarseness, throats and mouth sores.
Serious allergic reactions are rare, helps preventing asthma and difficulty in breathing
Serious allergic reactions are rare, helps preventing asthma and difficulty in breathing
Atorvastatin calcium
40 mg
Oral
For the prevention of cardiac-related problems
Diarrhea, gas, heartburn and joint pain
Blood thinner, slowing the capability of blood vessels to narrowing
Used as a blood thinner, prevent clotting of blood and would help in lowering blood cholesterol level
Digoxin Stat
125 mcg
Oral
For atrial fibrillation
Dizziness, anxiety, nausea, and enlargement of breasts
Specifically used for the treatment of heart-related problems
Used for preventing cardiovascular disorders.
Heparin
5000 unit
Oral
Anticoagulant
Bleeding, itching, bluish skin
Used to treat stroke and related conditions
Blood coagulant, treat angina illness and heart-related other disorders
Levothyroxine sodium
75 mcg
Oral
Thyroid deficiency treatment
Heat sensitivity, headache, hyperactivity, and increased appetite
Prescribed for thyroid deficiency
Treating thyroid-related issues specifically thyroid deficiency
Linaclotide
145 mcg
Oral
For bowel treatment
Stomach pain, dehydration, vomiting
Severe constipation
Irritable bowel conditions, constipation, and chronic bowel conditions
Metoprolol tartrate
25 mg
Oral
Chest pain and high blood pressure
Depression, anxiety, memory issues, and diarrhea
Suggested for chest pain
It lowers chest pain, treating high blood pressure condition
Montelukast Sodium
10 mg
Oral
Asthma and difficult breathing
Fever, diarrhea, chest pain, vomiting
It is prescribed for patients with asthma
It is prescribed for patients with asthma and difficulty breathing.
Prednisone
5 mg
Oral
COPD and rheumatoid diseases
Troubled sleep, loss of appetite
Lowers COPD symptoms and suggested for rheumatoid arthritis
Lowers COPD symptoms and suggested for rheumatoid arthritis
Umeclidinium
Inhalation
Nasal
COPD
Stomach pain, cough, stuffy nose, and chest pain
Treated emphysema, COPD and other chronic conditions of the lung
Treated emphysema, COPD and other chronic conditions of bronchitis
Acetaminophen
650 mg
Oral
Pain and fever
Pain, cough, loss of appetite and itching
Prescribed for treating pain and high fever
Prescribed for treating pain and high fever.
Bisacodyl
10 mg
Oral
Laxative, ease in passing stool
Pain, dehydration
Treatment of constipation
Treating constipation
Fluticasone
2 sprays
Oral
Steroids
Sneezing, backache, vomiting
Anti-inflammatory
Anti-inflammatory
Magnesium Hydroxide
2400 Mg/30 ml
Oral
Laxative
Rectal bleeding, severe nausea, slow heartbeat
To treat constipation
Prescribed as laxative
Magnesium Oxide
400 mg
Oral
Muscles and bone health
Itching, unusual fatigue
Recommended for muscles
For muscles
Magnesium Sulfate
1 g
Oral
To prevent seizures
Heart disturbance, confusion, weakness
To stop seizures
To prevent seizures
Nitroglycerin
0.4 mg
Oral
To prevent chest pain
Headache nausea, lightheadedness
For chest pain
To prevent chest pain
Ondansetron HCL
2mg/2ml
Oral
To prevent nausea, vomiting
Headache, fatigue, and constipation
For the prevention of nausea and vomiting
To prevent nausea and vomiting
Laboratory and others
Category
Admission results
High/Low
Most recent
High/low
Rationale for abnormal results
Sodium
138
Normal
136
Normal
Potassium
3.8
Normal
3.8
High
Renal problems including nephritis
Glucose
114
High
Diabetes
CL
102
Normal
101
Normal
CO2
31
Normal
29
Normal
ANGAP
5
Normal
6
Normal
BUN
28
High
27
High
Kidney failure
Creatinine
0.9
Normal
0.9
Normal
WBC
12.4
Normal
13.9
Normal
RBC
4.01
Normal
4.34
Normal
HGB
12.4
Normal
13.4
Normal
HCT
38.8
Normal
41.4
Normal
MCV
96.8
Normal
95.4
Normal
MCH
30.9
Normal
30.9
Normal
MCHC
32.0
Normal
32.4
Normal
PLT
331
Normal
340
Normal
RDW
17.0
High
17
Normal
MPV
10.9
Normal
10.3
Normal
MG
2.1
Normal
2.3
Normal
INR
1.1
Normal
Ptt
27.9
Normal
GFR
56.25
Normal
Current physical assessment
Head to toe assessment
Nursing implications
Current vitals
Alert, oriented, BP 119/68, pulse 135, temperature 90.3 F, respiration 16
Weight 75.6 kg, admit weight 65 kg, height 66 in.
It emphases actual or possible problems related to disorders of skin, height, and weight. It also relates to nutrition and liquid. This configuration is dysfunctional because she is not consuming a balanced diet.
General appearance
Alert, active no acute distress, fatigue and exercise intolerance
It also helps in the identification of actual or possible problems related to disorders of hair, skin, and membranes. It also relates to nutrition and liquid and sleep cycle.
neurological
Normal, non-focal, normal strength sensation
This filed refers to the identification of senses and alertness of the patient. She is quite active.
Respiratory
Clear to auscultation, no wheezing. On home O2 chronically.
This implies difficulty in breathing. Also helpful in the identification of COPD related disorders.
Cardiac
Irregularly irregular, tachycardia
Relates the condition with cardiovascular disorders. It emphasizes that the patient has an irregular heartbeat.
GI
Normal BS, patient reports slightly tender, abdominal pain but no vomiting
Refers to the nutrition and elimination areas of patients. Patient has been admitted because of abdominal pain
Extremities
No cyanosis, no edema
Performs normal
Neck
No JVD
It seems normal at the time of admission and has soreness in the throat.
Musculoskeletal
Exercise intolerance
This implies to the skeletal muscle problem. Helping in the identification of exercise intolerance.
Psycho/social/pain
Normal mood, affect
Implies the psychological health of patient which displayed as normal at the time of admission.
Self-Medication
Home medication
Cont’d in hospital and rationale
Allopurinol 100 mg orally
Asmanex 200 mcg
Continue
Flonase 50 mcg
Furosemide 40 mg
Irbesartan 75 mg
Klor Con M10 meq
Levothyroxine 75 mg
Linzess 145 mcg
Lipitor 40 mg
Metolazone 2.5 mg
Metoprolol 25 mg
Continue
Nitroglycerin 0.4 mg
Ondansetron 4 mg
Prednisone 5 mg
Proventil HFA 90 mcg
Singulair 10 mg
Spiriva respimat 2.5 mcg
Spironolactone 25 mg
5 Actual and 5 at-risk diagnosis
Chronic abdominal pain
GI bleeding
Hypotension
Atrial fibrillation with RVR
Tachycardia
Stroke
Brain hemorrhage
MI
Chronic heart disease
Arrhythmia
National Patient Safety Goals
Nursing diagnosis
Expected outcome
Nursing interventions
Rationale
Evaluation
National patient safety goal
Hypotension
Sustained blood pressure level
Montelukast Sodium
For better breathing and reduction in chest tightening
Blood pressure maintenance and improved breathing
Better and improved breathing.
Self-medication
Avoid the use of non-prescribed medications
Discontinuation of self-medication
Reduction of overdose and medication administration with proper prescription
Better health
Decrease overdose side effects and quality care
Teaching assessment
Teaching need
Teaching instructions
Methodology
Healthy people 2020 initiative
Treatment plan
For the delivery of quality care
Quality care delivery along with special attention to the patient.
Patient-centered care
Upsurge the harmless and operative management of pain
Drug Plan
For the delivery and administering safe medicine
Overdose side effects. Instructions to patient for not using any harmful substance
Reduction of overdose
Decrease drug overdose deaths comprising of natural, semi-synthetic, and synthetic opioids, excluding heroin
Program EOPSLO
Context and environment
Examine the health system and apply health promotion and strategies
The techniques of straight and proper alignment will endorse deep inspiration, upsurges oxygenation and inhibits atelectasis. Organized breathing approaches also help relaxed respiration in individuals who are tachypnea. Lengthy expiration prevents air trapping
Knowledge and science
Employ critical thinking to assure evidence-based care
Health education and training regarding disease will help prevent complications, Systematized breathing approaches also help relaxed breathing in these individuals.
Personal and behavioral development
Demonstrate appropriate culturally sensitive, ethical and professional behaviors
These changes will help a constant lifestyle change and will contribute maximum towards a healthy lifestyle. Maximizes the outcome also decreases the anxiety level. (Nicholson & Yee, 2018).
Quality and safety
Prioritize interventions to prevent potential risk factors and actual errors
For better and efficient recovery, this is important for the patient to be treated with patient-centered methodology.
Relationship centered care
Utilize effective interpersonal communications skills between client and team members
Patient-centered care would help fast recovery and better health.
Teamwork
Value attributes and collaboration between client, family and health team members
Better health is achieved by coordinating well on time. Teamwork contribution counts a lot in delivering quality care.
Recommendations
Health education and training regarding disease will help prevent complications, Organized breathing approaches also help in relaxed breathing in these individuals. The techniques of straight and proper alignment will endorse deep inspiration, upsurges oxygenation and inhibits atelectasis (Brunner, 2010). Organized breathing approaches also help in relaxed respirations in individuals who have tachypnea. Lengthy expiration prevents air trapping. These changes will help a constant lifestyle change and will contribute maximum towards healthy lifestyle. Maximizing the outcome also decreases the anxiety level. For better and efficient recovery, this is important for patient to be treated with patient centered methodology. Patient centered care would help fast recovery and better health. Better health is achieved by coordinating well on time. Teamwork contribution counts a lot in delivering quality care.
References
Brunner, L. S. (2010). Brunner & Suddarth's textbook of medical-surgical nursing (Vol. 1). Lippincott Williams & Wilkins.
Arara, D., & Karani, Y. (2018). Atrial fibrillation with flutter episode in patient with mitral stenosis. Majalah Kedokteran Andalas, 41(3), 134-142.
Nicholson, P., & Yee, J. (2018). Severe Sepsis Manifesting as A-Fib with Rapid Ventricular Rate. Journal of Education and Teaching in Emergency Medicine, 3(1).
Bosch, N. A., Cimini, J., & Walkey, A. J. (2018). Atrial fibrillation in the ICU. Chest, 154(6), 1424-1434.
