Question

Unit 5C Discussion

You will have multiple components to the discussion that will need to be answered. You may answer these items in a list with the number by them in the initial discussion. First post is due by Wednesday and requires two credible references. You must reply to two of your peers and the final post is due by Sunday. You must participate on a minimum of two different days when posting. Your replies should be based on differences in your answers from another person’s. It is alright to disagree with a peer as long as the post is respectful. There is more than one right answer to many of the questions.

*Initial post is due by Wednesday, April 8th and the final post (the two replies to two different students) is due by Monday, April 13.

There are two stories to read and answer questions on in this week's discussion assignment.

Case #1: Use the following story to complete the questions below:

Jessica is a 50-year-old married woman with a genetic autoimmune deficiency; she has had recurrent infective endocarditis. The most recent episodes were a Staphylococcus aureus infection of the mitral valve 16 months ago and a Streptococcus viridans infection of the aortic valve 1 month ago. During the recent hospitalization, an echocardiogram showed moderate aortic stenosis, moderate aortic insufficiency, chronic valvular vegetations, and moderate left atrial enlargement. Two years ago, Jessica received an 18-month course of total parenteral nutrition (TPN) for malnutrition caused by idiopathic, relentless nausea and vomiting (N/V). She has had coronary artery disease for several years and 2 years ago had an acute anterior wall myocardial infarction (MI). In addition, she has a history of chronic joint pain.

Now, after having been home for only a week, Jessica has been readmitted to your floor with infective endocarditis (IE), N/V, and renal failure. Since yesterday, she has been vomiting and retching constantly. She also has had chills, fever, fatigue, joint pain, and headache. As you go through the admission process with her, you note that she wears glasses and has dentures. Intravenous (IV) access is obtained with a double-lumen peripherally inserted central catheter (PICC) line. Other orders and your assessment are shown in the box.

Admission Orders

STAT blood cultures (aerobic and anaerobic) × 2, 30 minutes apart
STAT CMP & CBC
Begin TPN at 85 mL/hr
Piperacillin sodium/tazobactam sodium (Zosyn) 2.25 g q6h
Vancomycin (Vancocin), renal dosing per pharmacy, IVPB q12h
Furosemide (Lasix) 80 mg PO daily
Amlodipine (Norvasc) 5 mg PO daily
Potassium chloride (K-Dur) 40 mEq PO daily
Metoprolol (Lopressor) 25 mg PO bid
Ondansetron 4 mg IV every 6 hours PRN
Transesophageal echocardiogram ASAP

Admission Assessment

Blood pressure	152/48 (supine) and 100/40 (sitting)
Pulse rate	116 beats/min
Respiratory rate	22 breaths/min
Temperature	100.2°F (37.9°C)

Oriented × 3 to person, place and time, but drowsy.
Grade III/VI murmur.
Lungs clear bilaterally.
Abdomen soft with slight left upper quadrant tenderness.
Multiple petechiae on skin of arms, legs, and chest; splinter hemorrhages under the fingernails, hematuria noted in voided urine.

Laboratory Test Results

Na	138 mEq/L (138 mmol/L)
K	3.9 mEq/L (3.9 mmol/L)
Cl	103 mEq/L (103 mmol/L)
BUN	85 mg/dL (30.3 mmol/L)
Creatinine	3.9 mg/dL (345 mcmol/L)
Glucose	165 mg/dL (9.2 mmol/L)
WBC	6700/mm3 (6.7 x 109/L)
Hct	27%
Hgb	9.0 g/dL (90 g/L)

1. What is the specific pathophysiology of Jessica’s infective endocarditis?
2. What assessment data above supports this diagnosis?
3. How are you going to specifically monitor the following anatomy for and how? (i.e. monitor coronary arteries for signs of angina, MI, heart failure, and cardiac dysrhythmias through EKG, BNP, pulse, blood pressure, respiratory rate, cardiac enzymes, and patient’s description of chest pain.)

a. Cerebral:

b. Extremities:

c. Spleen:

d. Kidneys:

e. Bowels:

Case #2: Use the following story to complete the questions below:

Ruth is an 85-year-old woman who lives with her husband, who is 87. Two nights before her admission to your cardiac unit, she awoke with heavy substernal pressure accompanied by epigastric distress. The pain was reduced somewhat when she rolled onto her side but did not completely subside for about 6 hours. The next night, she experienced the same chest pressure. The following morning, Ruth’s husband took her to the physician, and she was subsequently hospitalized to rule out myocardial infarction (MI). Lab specimens were drawn in the emergency department. She was given 325 mg chewable, non–enteric-coated aspirin, and an IV line was started. She was placed on oxygen (O₂) at 2 L via nasal cannula.

You obtain the following information from your history and physical examination: Ruth has no history of smoking or alcohol use, and she has been in good general health, with the exception of osteoarthritis of her hands and knees and some osteoarthritis of the spine. Her only medications are simvastatin (Zocor), ibuprofen as needed for bone and joint pain, and “herbs.” Her admission vital signs (VS) are blood pressure 132/84, pulse 88, respirations 18 breaths/min, and oral temperature 99 ° F (37.2 ° C). Her weight is 114 pounds (51.7 kg) and height is 5 ft, 4 in. (163 cm). Moderate edema of both ankles is present; capillary refill is brisk, and peripheral pulses are 1+. You hear a soft systolic murmur. She denies any discomfort at present. You place her on telemetry, which shows the rhythm in the following figure.

Cardiac Rhythm Strip

Laboratory Results

Cardiac troponin T is less than 0.01 ng/mL (0.01 mcg/L) (at admission) and same result 4 hours after admission

Serial CPK tests are 30 units/L at admission, 32 units/L 4 hours after admission

d-Dimer test result less than 250 ng/mL (250 mcg/L)

Vital Signs

BP 140/92, P 110; R 20

1. What cardiac rhythm is Ruth in?

2. What is the purpose of administering an aspirin tablet?

3. What are 4 specific focused assessments that should be done on Ruth and why?

4. Identify which of the following conditions you believe Ruth has from the list below. Give a brief explanation of each as to why you believe she has this or does not have this.

a. Pulmonary Emboli:

b. Angina:

c. Myocardial Infarction:

Answer 1

CASE 1.

1. Pathophysiology of infective endocarditis

Endothelial damage

                                                  Followed by

Platelet - fibrin deposition and formation of a lesion known as a non bacterial thrombotic endocarditis

                                                     leads to

Bacteremia then allows bacterial colonization

                                                     leads to

colonization allows formation of vegetation as microorganisms adhere to the non bacterial thrombotic endocarditis lesions

                                                 leads to

infective endocarditis with structural abnormality in a valve

The bacteria that is entering in to the blood stream infect the heart. It infects the body through microorganisms in the mouth, spread through areas such as blood stream and attach to the damaged portion of the heart. A staphylococcus infection followed by a streptococcus infection especially from the viridan group followed by a gram negative staphylococcal infection contributes the condition

In the case of Mrs. Jessica she had a history of staphylococcus aureus infection of the mitral valve 16 months ago and a streptococcus viridans attack on the aortic valve1 month ago.

2. Assessment details

• Patient health history esp past medical history
• Findings of echocardiogram
• Symptoms such as chills, fever, fatigue, joint pain, headache
• vital signs - BP variations, tachycardia, fever
• Murmur sound
• Lab values - elevated creatinine level,

3. a. Cerebral : BP variations, neurological status reveals drowsiness

b. extremities : PICC line, pulse rate, multiple petechiae on skin of arms, legs, splint hemorrhages under the finger nails

c. Spleen : Abdomen soft with slight left upper quadrant tenderness, hb level

d. Kidneys : h/ o renal failure Blood analysis - sodium, pottasium, cl, BUN, hct, , Urinalysis, hematuria in voided urine

e. Bowel : Abdominal examination, C/ ovomiting and retching

CASE STUDY 2

2. aspirin reduces blood clotting, which can help blood flow through a narrowed artery that causes heart attack

3. lab test such as LDL, triglyceride and HDL - elevated level of LDL and triglyceride may results in chest pain

Assessment of factors contributing to chest pain, - position, activity, food habits, stress

Cardiac markers to rule out MI

4. Angina - Because the patient is having night time chest pain, nothing significant with troponin finding and releives after administering aspirin She might have been suffering with nocturnal angina