Chapter 26

Answers to Case Study Questions

Patient profile J.G.

1. Quantifying smoking habits in pack years is done by multiplying the number of packs smoked per day by the number of years
smoked. In this case, Mr. J.G. smoked an average of 3 packs per
year for 15 years. The risks of lung cancer rise in direct proportion
to the number of years smoked. Smoking is the most important risk
factor for COPD and lung cancer.
2. Observe for the following: unexplained restlessness or irritability,
lethargy, rapid respiration, use of accessory muscles of breathing,
and rapid heart rate. When interacting, also observe J.G.s capacity to answer oral questions, whether he stops to catch his breath
while talking. The data collected from the observation serves as a
guide to nursing problem identification and prioritizing nursing
intervention.
3. An elderly person is expected to have a less forceful cough and
fewer and less functional cilia. Thus, he will use more energy when
coughing. These pathophysiologic changes may help explain easy
fatigability, weakness, and shortness of breath. When assessing,
evaluate the quality of the cough. For example, a loose-sounding
cough indicates the presence of secretions. Ask the patient to
describe the pattern of coughing.
4. (1) Establishing rapport is a basic nursing function for nurse
patient interaction. J.G. should be given respct and courtesies.
Safety, comfort, and privacy during assessment should be provided
for. (2) The expected findings from the general survey include the
following: easy fatigability, orthopnea, tachypnea, tachycardia, the
presence of sputum when coughing, and general weakness; head
and neck: pursed lip breathing; thorax and lungs: barrel chested,
hyperresonant lungs upon percussion, the use of accessory muscles
upon breathing (intercostal retractions, the use of neck muscles in
breathing), and wheezes.
5. For objective physical examination: observe: respiratory rate and
quality, pattern of breathing; inspect: neck for the position of trachea, chest wall shape, symmetry and movement; skin and nails for
integrity and color; palpate: chest and back for masses, symmetry
of the chest, tenderness; auscultate: breath (lung) sounds. Making
a check-list of assessment parameters provides an easy framework
for the nurse on assessment that can be developed further over
time.

6. The physician would probably order a complete blood count

(CBC), arterial blood gas (ABG), chest X-ray, and pulmonary
function tests (PFTs). CBC will help to determine whether there
is an increase in RBCs, which is a compensatory mechanism for
persistently low-oxygen saturation; ABG will help to measure the
amount of oxygen and carbon dioxide in the blood and assess
oxygenation status. Along with other parameters, ABG helps the
health care providers in determining the adaptability of the body
with low-oxygen saturation; chest X-ray will help to visualize if the
normal lung markings are still present and determine the extent of
damage the disease caused to the lungs; and pulmonary function
tests (PFTs) are used to determine the severity of the lung disease.
When answering this question, you should be able to get most of
these.
7. In emphysema, the walls of the alveoli gradually get destroyed. The
alveolar surface area in direct contact with the pulmonary capillaries continually decreases, causing an increase in dead space and
impaired diffusion, which may lead to hypoxemia. To compensate
for the increased airway resistance, the patient purses his lips to
prevent airway collapse as he slowly exhales. This describes the
puffing part. Patients with emphysema usually have flushed skin,
hence the term pink puffers.
8. The 6-minute walk test (6MWT) is an exercise test. It is used in
diagnosis, in determining exercise capacity, and also for disability evaluation. This is a common procedure prescribed as part of
pulmonary rehabilitation. The six-minute walk test (6MWT) measures the distance an individual is able to walk over a total of six
minutes on a hard, flat surface. The goal is for the individual to
walk as far as possible in six minutes. The individual is allowed to
self-pace and rest as needed as he traverses back and forth along a
marked walkway.

Chapter 27
Answers to Case Study Questions
Patient profile C.J.

1. The nose functions to protect the lower airways by warming and

humidifying the air and filtering small particles before air enters
the lungs. The tonsils are located in the oropharynx. Air moves
through the nose and then through the oropharynx to the laryngopharynx to the trachea.
2. Continuous high fever can be regarded harmful, but it is also an
important host defense mechanism. Steps are taken to lower the
body temperature to relieve the anxiety of the patient. Sponge
baths are advised, as this procedure helps to increase the evaporative loss and lower the body temperature. But it has been recommended to combine sponge bath with the use of antipyretic drugs.
3. A throat swab for culture and sensitivity may also be indicated for
confirmatory diagnosis of patients with suspected streptococcal
throat infection. It is the gold standard in diagnosing streptococcal throat infection.
4. The tonsils may enlarge sufficiently to threaten the patency of the
airway. The inflamed tonsils may cause partial airway obstruction.
Complete airway obstruction is a medical treatment.
5. Signs and symptoms of obstruction in the patency of the airway
include the following: stridor, the use of accessory muscles, suprasternal and intercostal retractions, wheezing, restlessness, tachycardia, and even cyanosis.

6. The goals for nursing and collaborative management are infection control, symptomatic relief, and the prevention of secondary
infection.
7. Some nursing measures for self-care include the following.
Encourage C.J. to increase fluid intake. Advise him on diet and
nutrition to have cool, bland liquids, and gelatin for diet, to avoid
irritating the throat. Warm saline gargle is recommended to alleviate throat discomfort. Having adequate rest can help to speed
up recovery and prevent relapse. Provide C.J. with information so
that he makes an informed decision about his health. Is taking the
examination more important that regaining his health back first?
8. The trachea bifurcates into the right and left mainstream bronchi
at a point known as the carina. Its location on physical assessment
corresponds to the level of the manubriosternal junction, also
called the angle of Louis. The carina is highly sensitive, and irritaing it during suctioning causes vigorous coughing.

Chapter 28
Answers to Case Study Questions
Patient profile S.A.

1. The defense mechanisms include filtration of air, warming, and

humidification of inspired air, epiglottis closure over the trachea,
cough reflex, mucociliary escalator system, secretions of immunoglobulin A, and alveolar macrophages.
2. Possible risk factors include the following: advancing age, air pollution, exposure to people with the infection, smoking, upper
respiratory tract infection, malnutrition, the presence of chronic
illness, and immobility.
3. The following signs and symptoms support the findings: fever,
lethargy, tachypnea, nasal flaring, asymmetric chest movements,
the use of accessory muscles of breathing, decreased breath sounds
on the right lung fields, rusty and purulent sputum, and abnormal
arterial blood gas.
4. Penumonia results when the lung defense mechanisms become
incompetent or are overwhelmed by the infectious agents, when
the cough mechanism is decreasing (in cases of elderly changes),
or when the patients aspirate oropharyngeal contents into the
lungs. Endotracheal intubation interferes with the normal cough
reflex, and the mucociliary escalator mechanism, bypasses the
upper airways, in which filtration and humidification normally
take place.
5. The physician would probably order the following tests: arterial
blood gas (ABG), complete blood count (CBC), sputum for culture and sensitivity (CS), and chest X-ray.
6. The overall goals for a patient with pneumonia include the following: clear breath sounds, normal breathing pattern, no signs on
hypoxia, normal chest X-ray, no complications related to pneumonia. The need for health education for better self-care at home
is also important as it will help S.A. allay her anxieties and gain
knowledge about the disease.

7. Nursing interventions should focus on improving gas exchange

and helping the airway clear secretions. This should be done
by increasing oral fluid intake to liquefy bronchial secretions;
encouraging the patient to perform deep breathing exercise to aid
in adequate ventilation and increase efficiency of respiratory muscles; and performing nebulization to loosen thick secretions and
improve ventilation, postural drainage to mobilize secretions, and
chest physiotherapy postnebulization to loosen thick secretions
that are difficult to cough up. In addition, the patient should be
instructed on the proper coughing technique to effectively expectorate bronchial secretions.
8. The focus of the patients health promotion education encompasses the following: practice of good health habits in the community to prevent infection, such as frequent hand washing, eating
a balanced diet, adequate rest, and exercise. Health-promoting
actions such as the following should be emphasized: covering the
mouth during coughing and sneezing and avoidance of cigarette
smoke. Seeking medical care early enough in the illness should be
advised. It is important to make S.A. aware of the different community and barangay resources that are available to her.

Chapter 29
Answers to Case Study Questions
Patient profile L.E.

1. L.E. is an elderly patient with a history of hypertension. Elderly

patients have more complicated health issues than younger
patients with asthma. L.E.s need for the nurses bedside presence and support is expressed by the patient holding on tightly
to the nurses hand.
2. Asthma is a chronic inflammatory disease of the airways that
causes airway hyper-responsiveness, mucosal edema, and
mucus production. The inflammation leads to swelling of the
membranes that line the airways, reducing the air diameter.
Bronchial smooth muscles that encircle the airways contract,
causing further narrowing, leading to airway obstruction that
causes inspiratory stridor, difficulty of breathing, distress,
retractions upon breathing, and decreased breath sounds on the
upper lung fields. Inflammation also causes increased mucus
production that results in the presence of rhonchi upon auscultation. As a result, there is a ventilation/perfusion mismatch
that leads to decreased oxygen saturation. Thus, the cells are
inadequately oxygenated to compensate the heart pumps faster
(tachycardia) and the lungs breathe in air faster (tachypnea).
Due to increased cardiac workload, the blood pressure rises as
well. Eventually, cardiac cells become hypoxic, due to decreased
oxygenation and increased workload, which may result in chest
discomfort.
3. The priority nursing diagnoses are impaired gas exchange
related to ventilation/perfusion mismatch; ineffective airway
clearance related to increased airway resistance/airway obstruction, and anxiety related to difficulty in breathing and feelings
of helplessness. The nurse considered allaying L.E.s anxieties by
staying with her and providing information about her current
condition and treatment plan.
4. The following explanation was provided. The peak flow meter
is a device that measures how well air moves in and out of the
lungs. Peak flow meters are used to check asthma, the way that
blood pressure cuffs are used to check blood pressure. During
an asthma episode, the airways of the lungs usually begin to
narrow slowly. The peak flow meter may tell you if there is narrowing in the airways before the patient experiences asthma
symptoms. Then, explain how to use the peak flow meter.
5. There are combination medications that have both bronchodilator and expectorant functions that are sold over-the-counter
(OTC). They can come in the form of cough syrups. These medications should be used with caution as they may cause stimula-

tion of the cardiovascular system and may produce effects as

heart palpitations, tremors, and insomnia. Warn the patient
about the dangers associated with non-prescription combination drugs. These drugs are especially dangerous to patients
with underlying cardiac problems because elevated blood pressure and tachycardia often occur.
6. The overall goals include the attainment of asthma control as
evidenced by the following: minimal symptoms during the
day and night, acceptable activtity levels (including exercise
and other physical activity), maintenance of greater than 80%
of personal best peak expiratory flow rate, few or no adverse
effects of therapy, no recurrent exacerbations of asthma, and
adequate knowledge to participate in and carry out management.
7. In planning nursing interventions, the nurse should consider
that the patient is elderly, with a history of hypertension, who
also uses OTC drugs to control her asthma symptoms. Further,
the chest discomfort will be examined. Priority nursing interventions should include making sure that the airway is patent by
positioning the patient correctly, using oxygen therapy, managing secretions, and ensuring that the patients fear and anxiety
are addressed. Being with the patient or presence at the bedside
can provide reassurance early in the stage of acute attack. As
prescribed, administration of fast-acting bronchodilators and
anti-inflammatory drugs can be part of the collaborative function. The nurse perform continuously and closely monitor L.E.s
cardiorespiratory status.
8. Given the home situation of L.E. in a barangay community, the
following discharge plan and patient education instructions
may be provided. Identify and avoid possible asthma triggers,
such as personal triggers (cigarette smoke, animal dander from
pets, and house dust mites) and irritants (air pollutants, like
exhaust fumes, indoor air pollution, and aerosol sprays). The
use of special dust covers on mattresses and pillows, washing
bed clothes in hot water, with the use of detergent and bleach
may help control triggers. Avoid public places. Adequate nutritional intake must be emphasized. Healthy lifestyle guides on
adequate physical activity are important. Adequate instruction
to identify asthma attack, use of peak flow meter, and correct
instructions on the use of medications are necessary. L.E. and
her daughter may also benefit from keeping a diary of daily
activities.

Chapter 30
Answers to Case Study Questions
Patient profile J.C.

1. The following concepts are important in understanding the role

of the hematologic system: (a) blood as a transport mechanism,
transporting oxygen, nutrients, hormones, and waste products
around the body; (b) role of blood in regulation of fluid, electrolyte, and acidbase balance, and (c) bloods protective role
and its ability to clot and combat invasion of pathogens and
other foreign substances. An understanding of these concepts
enhances the nurses ability to link signs and symptoms with
pathophysiology, and pathophysiology with treatments and
interventions.
2. Iron is obtained from food and dietary supplements and is present in all RBCs as heme in hemoglobin. The heme in hemoglobin accounts for two-thirds of the bodys iron. The other
one-third is stored as ferritin and hemosiderin in the bone marrow, spleen, liver, and macrophages. When the stored iron is not
replaced, hemoglobin production is reduced.
3. The four components that contribute to normal hemostasis: (a)
vascular response, (b) platelet plug formation, (c) plasma clotting factors, and (d) lysis of clot.
4. Objective assessment may include measurement of weight,
palpation for swelling in the armpits, neck, or groin, and
inspection for skin petechiae, or bleeding of the gums. For the
interview questions, you should focus on dietary history such
as intake of meat, eggs, leafy green vegetables, dried fruits, and
legumes. Local eating patterns and common sources of dietary
iron should also be assessed.

5. The activityexercise pattern is closely associated with functional ability. Questions to assess this pattern include: feeling
of tiredness, weakness, complaints of heavy extremities, body
malaise, dyspnea, and palpitations. Fatigue is a prominent
symptom in many hematologic disorders.
6. J.C. may report that she has feelings of increased heart beats and
fluttering of pounding of the chest. Rapid heartbeat means the
heart rate is above 100 beats/min. Palpitations may be felt as a
compensatory mechanism of anemia, in an attempt by the heart
to increase cardiac output.
7. Hemoglobin normal values: male = 13.217.3 g/dl (132173
g/L); female = 11.716.0 g/dl (117160 g/L). J.C.s values are
abnormally low, confirming the diagnosis of anemia, and
explaining the patients signs and symptoms.
8. The following indicators are important to assess: knowledge of
concepts in hematology, related functional health patterns of
assessment, common related diagnostic tests, and normal values, and skills in physical examination procedures and assisting
with common diagnostic procedures. Atttitude competencies
relate to the demonstration of good rapport, respect during
examination procedures, privacy when needed, and presence
when anxiety situation arises.

Chapter 31
Answers to Case Study Questions
Iron-deficiency anemia

1. MDGs are a set of social objectives that need to be responded to

by 2015 as part of the countrys global commitment to attain better
health outcomes.
2. Department of Health (National Objectives for Health 20112016)
data on the prevalence of iron-deficiency anemia among different
demographic groups 19982008) are as follows:
Age group

6 to 1 year

1998

56.6

2003

66.2

2008

55.7

1 5 years old

29.6

29.6

20.8

612 years old

35.6

37.4

19.8

Pregnant women

50.7

43.9

42.5

Lactating women

45.7

42.2

31.4

Source: Department of Health, National Objectives for Health,

20112016, p. 80

3. Anemia is not a specific disease, it is a manifestation of a pathologic process. It is a deficiency in the number of erythrocytes or
red blood cells (RBCs), the quantity of hemoglobin, and/or the
volume of packed RBCs (hematocrit). It is a prevalent condition with many causes such as blood loss, impaired production
of erythrocytes, or increased destruction of erythrocytes. RBCs
transport oxygen, thus erythrocyte disorders can lead to tissue
hypoxia.
4. Subjective data included the following: dietary history, general
dietary patterns, intake of vegetables and fruits. Objective data
are elicited from the general survey, like easy fatigability, lethargy,
apathy; assessment of the integumentary to include paleness of the
skin and mucous membrane, poor skin turgor, presence of petechiae, nose or gingival bleeding, dryness of the hair; rapid respiratory rate, increased heart rate, low blood pressure; oocasional
headache, anxiety; and diagnostic tests showing decreased hemoglobin levels.

5. Signs and symptoms of anemia in older persons may go unnoticed, because of the changes in aging and the presence of other
health problems, and that nutritional type of anemia (folate and
iron) is reported as common in older persons. Therefore, food
assessment is important.
6. The nursing interventions that were recommended include:
collaborating with the nutritionist/dietician on the type of
nutrients needed to meet nutritional requirements, diet teaching
with emphasis on iron-rich food, maintaining a food diary, and
providing medications that are prescribed.
7. Data for 1998 and 2003 showed that intake of vegetables slightly
decreased, and the intake of fruits decreased drastically.
8. Community-based information and education campaigns should
include information on how to improve consumption of vegetables and fruits. Health information should include the following
information:
Nutrients Needed for Erythrocytes
Role in erythropoiesis

Food source

Cobalamin (vitamin B12)

RBC maturation

Red meat, liver, eggs,

enriched grains

Folic acid RBC

maturation

Green leafy vegetables,

liver, meat, fish, legumes,
whole grains

Iron hemoglobin
synthesis

Liver and muscle meat,

eggs, dried fruits,
legumes, dark green
leafy vegetables, cereals,
potatoes

Ascorbic acid (vitamin C)

conversion of folic acid
to its active forms aids in
iron absorption

Citrus fruits, green leafy

vegetables, cantaloupes

Chapter 32
Answers to Case Study Questions
Patient profile C.R.

1. The aorta is the origin of the two major coronary arteries. Blood
flow to the myocardium occurs during diastole (when the myocardium relaxes). The two major coronaries are the right coronary
artery and the left main coronary artery.
2. The slow HR (30/min) was identified as the most immediate concern. The possible reason for the slow HR (bradycardia) may arise
from the conduction system of the heart. The pacemaker of the
heart is the sinoatrial (SA) node. Each impulse generated from the
SA node travels through the atria, the atrioventricular (AV) node
down the bundle of His to depolarize the Purkinje fibers in the
ventricles. The normal HR ranges about 60100/min.
3. The CO refers to the amount of blood pumped by each ventricle of
the heart in one minute. It is calculated by multiplying the stroke
volume (SV) with the heart rate (HR). Thus, CO= SV HR. Stroke
volume is the amount of blood ejected from the ventricle with
each heart beat. C.F.s reported HR is 30 beats/min. His slow HR
is not adequate to support good CO, and thus, less circulation to
the brain may contribute to the dizziness and fainting spells.
4. The stimulation of the parasympathetic system, which is mediated
by the vagus nerve, causes the decrease inHR. This is due to the
SA node rate, and so the conduction down the conduction system
slows down.

5. Two patterns will be assessed for C.R.s functional capacity: healthperception self-management pattern and activityexercise pattern.
6. The objective data for physical examination should include the
following: patients general appearance; vital signs (blood pressure, HR, respiratory rate, body temperature, and chest pain, if
any); data on the peripheral vascular system by doing inspection,
palpation, and auscultation; and assessment of the pulses.
7. The electrocardiogram can help identify conduction abnormalities. Deviations from the normal sinus rhythm will potentially
indicate the focus for nursing problems. Cardiac monitoring is a
required nursing competency in the care of patients with oxygenation problems.
8. The information will include the following: exercise or stress testing, which is a method to evaluate the cardiovascular response to
physical stress, such as work, or prolonged walking. The test helps
to assess cardiovascular disease and define limits for exercise programs.

Chapter 33
Answers to Case Study Questions
Patient profile A.L.

1. Hypertension prevention measures include: maintaining a healthy

weight; reducing salt and sodium intake; increasing the level of
physical exercise; moderate alcohol consumption; monitoring
blood pressure periodically to know whether it is increasing; and
taking medication to control BP, when prescribed by physician.
2. The following are sources of information about hypertension
prevalence in the Philippines: the Department of Health, the Food
and Nutrition Research Institute (FNRI) of the Department of
Science and Technology, and specialty organizations, such as the
Philippine Society of Hypertension and Philippine Heart Association.
3. The known risk factors for the development of hypertension
include increasing age, alcohol consumption, cigarette smoking,
diabetes mellitus, elevated serum lipids, excess dietary sodium,
gender, family history, obesity, sedentary lifestyle, and socioeconomic status.
4. Awareness of risk factors will help the nurse to plan patient and
family education on the prevention and control of hypertension. In the case of A.L., the following factors contributed to risk:
increasing age, alcohol consumption, elevated serum lipids, excess
dietary salt, obesity, and socioeconomic status. In this case, it is
also significant to note that the family livelihood involves the
preparation of salted fish.

5. The family approach to patient and family education is the appropriate paradigm for helping A.L. and his family members. The
education on the prevention and control of hypertension works
well for all members of the family.
6. Hypertensive emergency, a type of hypertensive crisis, is a situation that develops over hours to days in which the patients BP
is severely elevated (often above 220/140 mmHg). It can cause
severe complications, and thus the patients should be monitored
regularly. The rate of increase in BP is more important than the
absolute value in determining the need for emergency treatment.
Hypertensive crisis occurs most commonly in patients with a history of hypertension who have failed to comply with their prescribed medication.
7. It is important for the nurse to consider the age-related factors that
will affect the blood pressure in elderly persons. Blood pressure
should be determined carefully to avoid the occurrence of auscultatory gaps.
8. When treating hypertensive crisis, such as IV administration of
drugs, the mean arterial blood pressure (MAP) is often used to
guide and evaluate therapy. The MAP is calculated as follows:
MAP = (SBP + 2DBP)/3.

Chapter 34
Answers to Case Study Questions
Patient profile E.D.

1. In the case of E.D., the nonmodifiable risk factors to be considered

include the following: age, gender, and being postmenopausal;
family history since diabetes is also present. For the modifiable
risk factors, look into the elevation of serum lipid levels, blood
pressure elevation, diabetes, obesity, physical inactivity, and
degree of stress.
2. The two leading causes of death in the Philippines are diseases of
the heart and cerebrovascular diseases.
3. The nurse should ask about the history of GI bleeding. This information will alert her of the contraindication of GI bleeding.
4. An important memory aid for pain assessment is PQRST. P
stands for precipitating factors, Q for quality of pain, R for radiation of pain, S for severity of chest pain, and T for timing of chest
pain.
5. Myocardial infarction is a disease process where areas of myocardial cells in the heart are destroyed permanently. It is usually
caused by decreased blood flow in a coronary artery because of
atherosclerosis or occlusion by thrombus or embolus. In the case
of E.D., coronary branches supplying the anterior portion of the
heart are blocked. As the cells are deprived of oxygen, ischemia
develops, cellular injury occurs, and over time, the lack of oxygen
results in infarction, or the death of cells. The chest pain experienced by patients experiencing MI is caused by the build-up
of lactic acid, which is a by-product of anaerobic metabolism
by myocardial cells. Dyspnea and shortness of breath are atypical symptoms usually seen in female patients with MI. Therefore,
accurate and prompt diagnosis is important in treating this lifethreatening condition.
6. Initial management for E.D. include the following:

a. Emergency care for chest pain.

b. Establish an IV route for the access of emergency IV therapy.

c. Provide oxygen by nasal cannula at a rate of 24 L/minute.

d. Cardiac monitoring for dysrhythmias, pulse oximetry, and continuous vital signs assessment for changes in condition.

e. Provide comfortable positioning, initial bed rest, and implement limitation of activity.

f. Allay E.D.s anxiety by constant presence at the bedside and
explaining procedures to be done.
7. The goal for collaborative management of myocardial infarction
is to salvage as much myocardial muscle as possible. Nurses need
to provide emotional care. The nurses role is to understand what
the patient is currently experiencing, to assist the patient in coping
with the illness. Patients like E.D. may have experienced denial,
and manifest behavior such as ignoring the signs and symptoms
related to heart disease as well as anxiety and fear, such as fears
of undertaking physical activity or fear of long-term disability.
The nurse becomes an important support system while in the
hospital and helps patients accept the event through constant
nursepatient interaction. The nurses role include engaging the
caregivers in the care, informing them of the patients progress,
and encouraging the patient and caregiver to interact as necessary during confinement. It is also beneficial for nurses to identify
additional support systems.
8. There are three phases of cardiac rehabilitation: Phase 1, hospital; Phase II, early recovery; and Phase III, late recovery. Phase I
occurs while the patient is still in the hospital. The nurse needs
to continuously assess the level of chest pain occurrence, anxiety,
dysrhythmias, and other possible complications. The findings
will serve as guide for decision-making especially with regards
to activities that can be provided. E.D., may be helped to initially
sit-up in bed or chair, perform range of motion exercises, and
self-care activities, such as washing her face, performing simple
grooming activities, and progressing to ambulation, once cleared
medically. During this time, the nurse interacts with E.D. on discharge planning.

Chapter 35
Answers to Case Study Questions
Patient profile P.C.

1. Heart failure is an abnormal clinical syndrome characterized by

impaired cardiac pumping and/or cardiac filling. It was formerly
called congestive heart failure. Heart failure is the preferred terminology since not all patients experience pulmonary congestion
and volume overload.
2. The following factors regulate cardiac output: (1) preload, (2)
afterload, (3) myocardial contractility, and (4) heart rate.
3. Left-side failure results from left ventricular dysfunction, which
prevents normal blood flow thus causing blood to flow back up in
the left atrium and into the pulmonary veins. Thus, the increasing pulmonary pressure causes fluid extravasation from the pulmonary capillary bed into the interstitium, and then the alveoli,
which manifests as pulmonary congestion, and edema. In the case
of P.C., there were findings of crackles on the lung bases.
4. Right-side heart failure causes back up of the blood into the right
atrium and venous circulation. Venous congestion in the systemic
circulation results in jugular venous distention, hepatomegaly,
splenomegaly, vascular congestion of the gastrointestinal tract,
and peripheral edema.
5. The following should be considered: history of uncontrolled
hypertension, increasing fatigue and decreasing capacity for
work, complaints of not being able to walk as before, and increasing need for assistance. The situation may cause emotional problems of anxiety relating to the inability to work for his livelihood.

Immediate referral for admission to a general hospital is the recommended action.

6. Priority findings include: BP = 90/60 (low), apical HR = 109/min
(slightly tachycardic), with occasional skip beats; respiratory rate
= 28/ min, fast and shallow, cannot tolerate the supine position,
accessory muscles are used for breathing, pronounced crackles on
both lower lung fields; cool and clammy skin; and edema of the
hands and feet. The cues support impaired cardiac output.
7. Priority actions should focus on the alleviation or relief of symptoms, such as shortness of breath, feeling of fatigue, and anxiety.
The patient is positioned in the position of comfort, usually the
high Fowlers to help decrease venous return to the heart, and
supplemental oxygen therapy, as ordered. To decrease anxiety, the
nurse should apply the concept of constant presence at the bedside. The overall goals of care include the following: prevention of
complications, compliance to medical regimen and interventions,
increase in physical tolerance, and improvement in activities of
daily living.
8. Patient and family education on the detection and control of
hypertension may serve as a focal point in the community setting
toward prevention of heart failure.

Chapter 36
Answers to Case Study Questions
Patient profile FC.

1. The following cues were considered by the nurse as priority concerns: (1) history of loose stools and vomiting, since F.C., an aging
person, may have fluid and electrolyte problems, and this could
trigger development of dysrhythmias. There is a need to monitor
the electrolyte studies and correlate these with ECG findings, (2)
chest heaviness, increased dyspnea, and palpitations; and (3) ECG
findings of frequent multifocal premature ventricular contractions
(PVCs) and S-T segment elevations in L II, III, and aVF.
2. The nurse who works in a coronary care unit needs to be competent in telemetry monitoring to provide safe care. Telemetry
monitoring refers to the observation of the patients heart rate
and rhythm at a site distant from the patient. There are generally
two types of systems: (1) the centralized monitoring system
continuous observation of a group of patients ECG rhythms at a
central location, and (2) systems that are capable of detecting and
storing data, including sophisticated alarm systems for different
levels of detection of dysrhythmias, ischemia, or infarction.
3. The nurse should aim for accurate interpretation to help identify
F.C.s immediate problems. The approaches include: immediately
evaluating the consequences of the findings for the individual
patient, assessing the patients hemodynamic response to any
change in the rhythm, selecting appropriate therapeutic interventions, and at all times, monitoring the patient, F.C., not the
monitor.

4. F.C. is an older person who experiences symptoms and verbalized

signs that caused her to be anxious. She was fearful that she may
die soon. The nurse showed compassion and provided reassurance
to F.C. by explaining events, equipment, treatments, and the environment in a manner that was easily understood by the patient.
5. During myocardial injury, the typical pattern observed is S-T segment elevation, usually occurring with chest pain and suggestive
of worsening of the patients condition. In F.C.s case, these findings were reported. This may suggest worsening of the condition.
The goal is to restore oxygen to the myocardium and avoid infarction.
6. The instructions include the following: (1) monitor the pulse rateand inform the primary care provider if it drops below the predetermined heart rate, (the nurse teaches the patient and the carer
in the home how to check the pulse rate); (2) report any signs
of infection in the incision site; (3) avoid lifting the arm on the
pacemaker site above the shoulder until clearance has been given;
(4) avoid close proximity to high-output electric generators, or
large magnets, such as the MRI scanner (these devices can interfere with the function of the pacemaker); and (5) carry pacemaker
information card and a current list of medications, at all the times.

Chapter 37
Answers to Case Study Questions
Patient profile S.A.

1. S.A.s throat culture was positive. She also has a history of Group A streptococcal infection. Her previous diagnostic test results
showed increased levels of antistreptolysin O titer.
2. The structural deformities cause obstruction of blood flow and create a pressure difference between the left atrium and left ventricle during diastole. The left atrial pressure and volume increase. This event results in higher pulmonary vasculature pressure
and then hypertrophy of the pulmonary vessels. In chronic mitral stenosis, as in the case of S.A., pressure overload occurs in
the left atrium, the pulmonary bed, and the right ventricle.
3. Mitral regurgitation allows blood to flow backward, from the left ventricle to the left atrium, due to the incomplete valve closure
during systole. The left ventricle and the left atrium both work hard to preserve the cardiac output. In situations when there is
sudden increase in pressure and volume transmitted to the pulmonary bed, pulmonary edema and cardiogenic shock result.
4. The stenosed mitral valve is not able to open sufficiently during atrial asystole, preventing the filling of the left ventricle.
5.

Clinical Manifestations

Possible Pathophysiologic Reasoning

Exertional dyspnea

Due to reduced lung compliance

Fatigue and palpitations

Due to atrial fibrillation, irregular rhythm is produced, and with

increased HR, there is no adequate ventricular filling.

Heart sounds: accentuated heart sounds,

the presence of murmur

There is an increased level of pressure to push blood through

a stenosed mitral valve, and with mitral regurgitation, blood
backflows to the left atrium.

Chest pain

Decreased cardiac output and coronary perfusion.

6. The possible nursing diagnoses include the following:

Decreased cardiac output related to valve dysfunction ( in this case mitral stenosis), or possibly heart failure (if complications set in)

Activity intolerance related to pain, or dyspnea, or heart failure

Ineffective self-health management related to lack of knowledge concerning need for long-term care and possible complications
7. The type of surgery can either be valve repair or valve replacement. In valve repair, the following are possible options: mitral
commissurotomy (valvulotomy) and minimally invasive valvuloplasty, which involves mini-sternotomy and may involve
robotic surgical systems. In valve replacements, prosthetic valves are used. Valves can be mechanical (from artificial materials,
such as metal alloys) and biologic valves (from bovine, porcine, and human cadaver tissue).
8. Mechanical valves have been reported to last longer than biologic valves. However, they have increased risk of thromboembolism and require long-term anticoagulant therapy. During these procedures, the nurse applies perioperative principles of care.
9. The following outcomes of care should be included: ability to perform activities of daily living with minimum fatigue and pain,
adherence to treatment regimen, prevention of complications, and confidence in managing self. Discharge and home care
instructions should be planned for S.A..The nurse should aim to increase self-care capabilities, increasing S.A.s confidence in
her ability to carry out a normal life, especially as a mother.

Chapter 38
Answers to Case Study Questions
Patient profile M.S.

1. The three types of clients are the individual, the population group, and the community. In this case, M.S. is an individual client
because of the unique complaint of pain in his legs. The population group covers, for example, all patients in the community
with elevated blood pressure. If the nurses focus is the health needs of all the people in a specific community, then, the community is her client.
2. The small town where M.S. lives has a local health unit where population and community data are kept. The reports showed that
the town had an increased number of people who had elevated blood pressures and increased fasting blood sugar levels. From
these data, the nurse may plan to start a blood pressure screening program targeting assessment for chronic illness.
3. Assessments of the individual client and his family, the population groups of hypertensives and those with chronic illness, and
the community all need to be done.
4. The students made the following differentiation.
CHARACTERISTICS

PERIPHERAL ARTERY DISEASE

VENOUS DISEASE

Pain in the legs

Intermittent claudication or rest pain in foot; ulcer

may have pain

Dull ache or heaviness in calf or thigh;

ulcer often painful

Peripheral pulses

Decreased or absent

Present, but may be difficult to palpate,

with edema

Capillary refill

>3 sec.

< 3 sec.

Skin color

Dependent rubor, redness. With elevation- pallor

Brownish; varicose veins may be visible

Skin temperature

Cold

Warm

Edema

Not present, not

unless leg is always in dependent position

Lower leg edema

Ulceration, if any

Location: tips of toes, foot or lateral malleolus

Location: near medial malleolus

Margin: rounded, smooth

Margin: irregular shaped

Tissue: black eschar, or pale pink granulation

Tissue: yellow slough or dark red

Drainage: minimal

Drainage: moderate to large amount

5. Intermittent claudication is consistent with increasing pain with work or exercise and resolution with rest. The ischemic pain
is the result of the accumulation of the end products of metabolism, such as lactic acid. Once the patient stops the exercise, or
work, the metabolites are cleared and the pain subsides.
6. Rest pain occurs when there is insufficient blood flow to meet basic metabolic requirements of the distal tissues. Rest pain most
often occurs in the forefoot of toes and is aggravated when the limb is elevated and blood flow is impaired. M.S. claims that he
also experiences rest pain at night. Rest pain occurs at night because cardiac output tends to decrease during sleep, and the limbs
are at the level of the heart.
7. Peripheral vascular disease leads to several complications. Prolonged ischemia leads to atrophy of the skin and the underlying
muscles. The decrease in arterial flow may result in delayed healing and wound infection., and tissue necrosis, especially if the
patient is diabetic. Nonhealing arterial ulcers and gangrene are the most serious complications.
8. The nursing care plan for M.S. includes risk factor modification strategies to prevent ischemic stroke, myocardial infarction, and
CVD-related emergencies. The strategies include lifestyle changes on the part of the patient, his carer, and the patients friends.
Smoking cessation is important and all must be assured accessibility to health education and smoking cessation interventions.
The collaborative therapy should include the following: regular physical activity (structured walking activity for the intermittent
claudication), achievement of ideal body weight, control of hypertension and diabetes, nutrition therapy (increase fruits and
vegetables, whole grains, low saturated fat, low salt), and good foot care.