Question

Case Study 1:

Maria Cortez is a 32-year-old client who had surgery on her left knee 2 months ago. She is obese and has had difficulty ambulating since the surgery. She also has a history of pulmonary embolus (PE). She has been taking a low molecular weight heparin, enoxaparin, since the surgery because of her history of PE and risk for the development of deep vein thrombosis (DVT).

1. Ms. Cortez calls the medical clinic and asks to speak to the nurse. She states that she has just learned that she is pregnant and is concerned that the enoxaparin will harm the baby. How should the nurse respond?
2. Ms. Cortez has a successful delivery of a baby girl. Ten months later, she is hospitalized for additional surgery on her knee. Her recovery is complicated by the development of a DVT, and she is started on warfarin. Discuss the teaching that the nurse should provide Ms. Cortez before discharging her on warfarin.

Case Study 2:

A client is being treated for a deep vein thrombosis in the left lower leg.

1. The client is being treated with heparin. Discuss potential assessments for this client.
2. The client is started on warfarin along with the heparin infusion. The client asks, “Why am I on two anticoagulants?” Discuss your possible responses and client teaching.

Case Study 3:

Heparin-induced thrombocytopenia (HIT) is a life-threatening complication of heparin administration.

1. Describe the occurrence of HIT in clients and how it is detected.
2. What are the risk factors for this disorder?
3. What are the potential interventions to control the outcome of HIT?

Case Study 4:

Andrew Oliver is a 45-year-old man who works as a mental health counselor. He presents to a small community emergency department with an acute anterior ST elevation myocardial infarction. Within 20 minutes of arrival, he receives alteplase by continuous intravenous (IV) infusion over 3 hours. He also simultaneously receives an IV bolus of heparin and is started on a heparin drip. You are the nurse assigned to his care.

1. To regulate the amount of heparin Mr. Oliver receives, his aPTT is measured. What is the therapeutic value for aPTT?
2. Oliver’s prescriber adds warfarin to his treatment regimen. The order is for Warfarin 5 mg PO daily and for evaluation of baseline Pt and INR. The nurse administers the warfarin and order the blood work for the next morning. What therapeutic INR value indicates that the warfarin dosage is appropriate?

Case study 5:

A 57-year-old man with a history of hypertension and unstable angina is admitted to the emergency room with severe, crushing chest pain. He was working in the yard when he began to have pain in his left arm with diaphoresis and nausea. He took three sublingual nitroglycerin tablets before asking his wife to call EMS.

1. Why is nitroglycerin indicated for the relief of chest pain caused by myocardial ischemia?
2. What instructions should be given to patients prescribed sublingual nitroglycerin?
3. The following medications are ordered. What is the purpose of these drugs, and what assessment should the nurse perform related to the administration of these drugs?

• Aspirin 81 mg chewable tablets, give 4 tablets STAT
• Intravenous morphine sulfate 2 to 4 mg every 10 minutes as needed to control pain
• Atenolol 5 mg IV
• Nitroglycerin IV drip at 10 mcg/minute

The patient undergoes a successful placement of a stent in the right coronary artery. The patient has aspirin 324 mg orally every day and metoprolol 100 mg orally twice a day prescribed.

The following medications are ordered. What is the purpose of each of these drugs and patient teaching required?

• Nifedipine 20 mg PO twice a day
• Clopidogrel 75 mg PO daily

Case Study 6:

Richard Gerald, a 72-year-old man, has a history of hypertension and coronary artery disease. He stopped smoking and began a regular exercise program after having a non-ST-segment elevation myocardial infarction 2 months ago. He was discharged on nitroglycerin- in a sublingual form and as transdermal patch (1 inch) every 4 hours while awake (off at night) – and on atenolol 50 mg orally daily.

1. Why dose Richard have to remove the nitroglycerin transdermal patch at night time?

Mr. Gerald returns to the clinic for a follow-up. His blood pressure is 130/86 mm Hg. And his heart rate is 86 beats per minute. He reports that he has been pain free since discharge. He is taking his atenolol as prescribed but reports that he is using the nitroglycerin patch four times a day around the clock because it is easier for his schedule. Given his vital signs, his provider increased the atenolol to 100 mg daily.

1. Gerald asks the nurse why he needs to take atenolol at all, when he has no pain, and why the dose has been increased. How should the nurse respond? What patient teaching needs to be reinforced?

While reviewing his medication instructions with Mr. Gerald, the nurse learns that he has a history of erectile dysfunction and has some sildenafil.

1. Which was prescribed for him before his MI. what actions should the nurse take?

Answer 1

CASE STUDY 1 ANSWER; *The nurse respond to the patient like this"don't worry about it. Enoxaparin is safe for your baby. It is a low molecular weight heparin, doesn't cross the placenta" TEACHINGS OF PATIENT ABOUT WARFARIN: Precautions should be take - *Avoid strain during Toileting *Blow the nose gently *The using of tooth brush and tooth pick carefully. *Reduce the risk for bleeding or wound formation by anything. *Foods ;should avoid vitamin k rich foods, grape fruit juice, green tea and alcohol. DRUGS should avoided with WARFARIN- Aspirin contained medication,Laxative, Antacid, Allergy medication, Antifungal medication. Need medical EMERGENCY- GUM BLEEDING, NASAL BLEEDING, INTERNAL BLEEDING or HEMORRHAGE from any parts of the body, BROWN or DARK COLOURED URINE, DARK COLOURED STOOL, COFFEE COLOURED VOMITING, EXCESSIVE MENSTRUAL BLEEDING, BLUE COLOURED SKIN, RED SPOTS PRESENT ON SKIN, VOMITING or DIARRHOEA, FEVER(above 100.4°F is the sign of infection can change INR VALUE), * educate the patient about avoid discontinuation of WARFARIN it can cause PULMONARY EMBOLISM and DEEP VEIN THROMBOSIS.