Question

• George is a 75 year-old patient with urosepsis being treated in the Intensive care unit (ICU). The nurse assesses George and finds that he has blood in his urine and stool, and is oozing blood from his central line site and his gums.

• 1. What does the nurse suspect maybe occurring with George?
  2. What medications should the nurse avoid administering to George?
  3. The nurse is monitoring George’s vital signs every 15 minutes. What other monitoring is essential to include along with the vital signs?
  4. What medication does the nurse anticipate infusing?

• Fred, a 43 year-old construction worker, has a history of hypertension. He smokes two packs of cigarettes a day, is nervous about the possibility of being unemployed, and has difficulty coping with stress. His current concern is calf pain during minimal exercise, which decrease with rest.

  1. What does the nurse is the hallmark symptom of peripheral arterial occlusion disease?
  2. The patient is having ankle-brachial index (ABI) determined. The right posterior tibial reading is 75 mm Hg, and the brachial systolic pressure is 150mm Hg. What would the ABI be for this patient?
  3. The nurse is educating Fred about managing his condition. What methids can the nurse suggest to increase arterial blood supply?
  4. What is the best method for the nurse to assess Fred’s peripheral pulses to obtain consistent results with other health care practitioners?

• Georgia, a 30 year-old woman, is diagnosed as having secondary hypertension when serial blood pressure recordings 170/100 mm Hg. Her hypertension is the result of renal dysfunction.

  1. How will Georgia’s kidney help maintain her hypertensive state?
  2. The nurse informs Georgia that she should see her ophthalmologist. Why is it important that Georgia adhere to follow up with an ophthalmologist?
  3. Georgia is prescribed with Furosemide (Lasix) 20mg once every day. What does the nurse understand about the action of Lasix?
  4. What health education can the nurse suggest to Georgia to reduce complications and improve disease outcomes?

Answer 1

• George is a 75 year-old patient with urosepsis being treated in the Intensive care unit (ICU). The nurse assesses George and finds that he has blood in his urine and stool, and is oozing blood from his central line site and his gums.

What does the nurse suspect maybe occurring with George?

Answer:

The nurse suspects that  the phenomenon of DIC disseminated intravascular coagulation may be occurring with George due to Urosepsis.The alteration of the normal clotting process is induced by sepsis leading to phenomenon of microvascular thrombosis and hemorrhage .As a result the patient has multiple visible capillary bleeding as in the case of George.

Since the clinical findings of bleeding manifestations in George in the background of uro sepsis relate to that of disseminated intravascular coagulation, hence the nurse should suspect this diagnosis

What medications should the nurse avoid administering to George?

Answer:

As George is having bleeding manifestations, the nurse should avoid administering anticoagulant drugs,large dose heparin  and intramuscular injections to George.Any anti-platelet drugs and drugs causing bleeding as side effects should be avoided.

The nurse is monitoring George’s vital signs every 15 minutes. What other monitoring is essential to include along with the vital signs?

Answer:

In addition to monitoring the vital signsof George every 15 minutes, it is important for the nurse to monitor George for his blood pressure ,urine output,increase/decrease in bleeding,CNS status,Patient consciousness,pupillary reaction and palor, acral cyanosis and digital ischemia which can occur as a complication of DIC

.Laboratory monitoring of the patient's hemoglobin, complete blood count, bleeding time, clotting time, platelet count and d-dimer and fibrin degradation products are required for the correct diagnosis and for initiation of the corrective measures

What medication does the nurse anticipate infusing?

Answer: Since there is occurrence of anaemia due to bleeding, low platelet count and low clotting factors in George due to DIC, the nurse anticipates administration of packed red blood cells, platelet concentrates, fresh frozen plasma, clotting factors to the patient in order to control the bleeding manifestations.

The nurse also anticipates infusion of higher antibiotics/ broad spectrum antibiotics to control the infection /urosepsis in the patient which is the underlying cause for the DIC and iv fluids to maintain blood pressure,urine output and patient hydration. Additionally low molecular weight heparin antithrombin, tranexamic acid may be given as per the hospital protocol for DIC management.

• Fred, a 43 year-old construction worker, has a history of hypertension. He smokes two packs of cigarettes a day, is nervous about the possibility of being unemployed, and has difficulty coping with stress. His current concern is calf pain during minimal exercise, which decrease with rest.
  1. What does the nurse is the hallmark symptom of peripheral arterial occlusion disease?

answer:Intermittent claudication is the Hallmark of peripheral arterial occlusion disease.

Intermittent claudication also called as vascular claudication is defined as the pain which occurs in the calf muscles when the patient is walking or exerting causing the patient to limp( claudio means to limp). This is the commonly reported symptom by the patients of the peripheral vascular disease and hence this is a hallmark symptom of peripheral vascular disease. The pain occurs due to the narrowing of the arterial lumen and vascular insufficiency to the calf muscles on exercise due to the build up of lactic acid metabolites It gets relieved on rest.

2.The patient is having ankle-brachial index (ABI) determined. The right posterior tibial reading is 75 mm Hg, and the brachial systolic pressure is 150mm Hg. What would the ABI be for this patient?

answer:

The ankle brachial pressure index is the ratio of the systolic blood pressure of the ankle vessels that is the tibial vessels to the systolic blood pressure of the arm vessels that is the brachial artery. The right posterior tibial reading is 75 mm Hg, and the brachial systolic pressure is 150mm Hg for this patient

ankle-brachial index (ABI) =ankle systolic blood pressure /brachial systolic blood pressure

ankle-brachial index (ABI) for this patient=75mmHg/150mmHg

ankle-brachial index (ABI) for this patient=0.5

The ankle-brachial index (ABI) normal values are considered as values >0.9.The ankle-brachial index (ABI)be for this patient is 0.5 which indicates moderate arterial disease and moderate ischemia.(0.5-0.8 moderate arterial disease)

3.The nurse is educating Fred about managing his condition. What methids can the nurse suggest to increase arterial blood supply?

answer:

The methods the nurse can suggest to increase arterial blood supply are

a]To keep the legs below the level of the heart while sitting and resting in order to improve the blood supply,

b]keep legs feet warm wear socks/hose for support and to decrease edema and slippers for protection of the feet,

c]Passive exercises and active exercise such as walking or riding a bicycle for 30 to 60 minutes daily gradually increasing duration as tolerated in order to improve the action of the calf muscle pump and improve blood supply

d] avoid prolonged standing to prevent venous stasis and use support hose for the lower Limbs as venous stasis further decreases the blood supply.

e}educate the patient to walk with support hose on and perform toe exercises In order to decrease the the venous stasis improve the circulation, buildup collateral circulation and strengthen the calf muscles

f] Apart from these instructions Lifestyle modifications such as weight  management ,control of blood pressure, stoppage of smoking,dietary modifications , use of blood thinners like Aspirin and clopidogrel as per physicians' advice are the other measures which can improve the blood supply for the lower limbs.

4.What is the best method for the nurse to assess Fred’s peripheral pulses to obtain consistent results with other health care practitioners?

answer:

The best method for the nurse to assess the patients pulses is to thoroughly palpate and perform a careful clinical examination of all the patients pulses and compare the pulses of the lower limb with the pulses of the opposite limb and the upper limb and note them down.

There should be no constricting device like cast ,stocking bandage or BP cuff on the patient's limbs and patient should be rested.She should be careful to avoid palpating her own pulses as patients pulses. The use of ultrasound doppler to document the patients pulses is another way for the nurse  to get results for peripheral pulses palpation consistent with the other health care professionals

1. Georgia, a 30 year-old woman, is diagnosed as having secondary hypertension when serial blood pressure recordings 170/100 mm Hg. Her hypertension is the result of renal dysfunction.

How will Georgia’s kidney help maintain her hypertensive state?

answer:

The decrease in the blood supply to the Kidneys with ischemic kidneys or damaged kidneys act by retaining the salt and water from the urine causing volume overload and aggravating the hypertension.

The Kidneys play an important role in maintaining the blood pressure of the body .They do this by retaining/ absorbing the sodium and the water that is excreted in the urine and work through the renin angiotensin aldosterone system in order to maintain the fluid electrolyte hemostasis and blood pressure. Kidney disease impairs the maintenance of the blood pressure control. Impairment in the blood pressure control and increase blood pressure further decreases the blood flow to the damaged kidneys and decreases the kidney function even further aggravating the hypertension.

Thus by preventing proper excretion of sodium and water by activating renin angitoensin cascade,Georgia’s dysfunctional kidneys maintain her hypertensive state.

2.The nurse informs Georgia that she should see her ophthalmologist. Why is it important that Georgia adhere to follow up with an ophthalmologist?

answer:

Hypertension can predispose the patient to hypertensive retinopathy and vision loss.Hypertensive retinopathy occurs on account of arteriosclerotic of changes in the retinal vessels. There may be episodes of bleeding into the retina and hence the patient must be regularly examined by an ophthalmologist and a fundoscopy performed at a regular intervals to assess for hemorrhage into the retina. Older patients with glaucoma experience aggravation of their symptoms and require regular intraocular pressure monitoring along with antihypertensive medications for the glaucoma control

It is for this reason that ophthalmologist examination and follow up is important for the patient

Georgia is prescribed with Furosemide (Lasix) 20mg once every day. What does the nurse understand about the action of Lasix?

answer The facts the nurse understand about the action of Lasix is that lasix is a loop diuretic and works by inhibiting the absorption of sodium and water in the distal tubules of the nephron thereby promoting their excretion decreasing the circulating blood volume and decreasing hypertension.it can cause hypokalemia and patient should be monitored for same.High potassium foods are advised to patient's taking lasix.

What health education can the nurse suggest to Georgia to reduce complications and improve disease outcomes?

answer:

The nursing education to be given to a patient of hypertension to reduce complications are

a] weight management

b] Lifestyle modification like stopping smoking daily exercise

c]low salt ,low fat diet

d]monitoring the blood pressure at home if possible and maintaining normal blood pressure ranges by regular intake of medicines

e]limiting alcohol intake,stop smoking.

f]regular checkups with the physician ophthalmologist to prevent complications