DRNP 6566 Week 2 Assignment – Branching Exercise: Cardiac Case 1 Instructions
For this Assignment, you will review the interactive media piece/branching exercise provided in the Learning Resources. As you examine the patient case, consider how you might assess and treat patients with the symptoms and conditions presented.
To prepare:
- Review the interactive media under Required Media: Branching exercise. This is provided in the Learning Resources.
- Review the information provided in the case (patient presentation, vital signs, pmh, home meds, results of labs and diagnostics. With this information, critically think about what is happening with the patient.
- Use your critical thinking skills and current guidelines to develop orders. Include additional labs/diagnostics, what needs repeated and followed up on. Medications that need to be ordered or changed.
The Assignment:
- Using the required admission orders template found under the Learning Resources: Required Reading.
- Develop a set of orders as the admitting provider.
- Be sure to address each aspect of the order template
- Write the orders as you would in the patient’s chart. Be specific. Do not leave room for the nurse to interpret your orders.
- Do not assume anything has already been done/order. Use the information given. Example: If the case does not mention fluids were given, the patient did not receive fluids. You may have to start from scratch as if you are working in the ER. And you must provide orders if the patient needs to be admitted.
- Make sure the order is complete and applicable to the patient.
- Make sure you provide rationales for your labs and diagnostics and anything else you feel the need to explain. This should be done at the end of the order set – not included with the order.
- Please do not write per protocol. We do not know what your protocol is and you need to demonstrate what is the appropriate standard of care for this patient.
- A minimum of three current (within the last 5 years), evidenced based references are required.
By Day 7 of Week 2
Submit your completed Assignment by Day 7 of Week 2 in Module 2.
Scenario #1 63 year old female
BACKGROUND
- 63-year-old female presents to the Emergency Department complaining of dizziness and shortness of breath.
VITAL SIGNS
- PMH: HTN, Diabetes, TIA
- Home Meds: Lisinopril, Metformin
- Allergies: Penicillin
- HR: 180, O2 Sat 94%, BP: 107/78, RR: 21
- The patient is a full code
DRNP 6566 Week 2 Assignment – Branching Exercise: Cardiac Case 1 Example
Admission Orders Template
(Scenario 1, 63-year-old female)
BACKGROUND
63-year-old female presents to the Emergency Department complaining of dizziness and shortness of breath.
VITAL SIGNS
PMH: HTN, Diabetes, TIA
Home Meds: Lisinopril, Metformin
Allergies: Penicillin
HR: 180, O2 Sat 94%, BP: 107/78, RR: 21
The patient is a full code
Primary Diagnosis: Atrial Fibrillation with Rapid Ventricular Response
Status/Condition Stable
Code Status: Full code
Allergies: No known drug allergies to food or drugs
Admit to Unit: Cardiac unit
Activity Level: to remain on bed rest until heart rate is adequately regulated and stabilized.
Diet: cardiac diet
IV Fluids: restricted before electrolyte results
- Critical Drips none
Respiratory: administer oxygen via nasal cannula at 2 L/min if SpO₂ < 92%.
Medications:
- Administer Diltiazem as a 15-20 mg intravenous bolus over 2 minutes, followed by a continuous infusion of 5-15 mg per hour if the heart rate exceeds 110 beats per minute and the patient exhibits symptoms.
- Once the heart rate is stabilized, initiate Metoprolol at a dosage of 25 mg orally twice daily, unless contraindications arise or the patient experiences hypotension or bradycardia (Burum et al., 2023).
- For anticoagulation, prescribe Apixaban at 5 mg orally twice daily, adjust the dosage based on the renal function to mitigate stroke risk (Healey et al., 2024), and provide Acetaminophen 650 mg orally every 6 hours as needed for pain relief. Additionally, Magnesium sulfate should be administered at 2 g intravenously over 1 hour if serum magnesium levels fall below 1.8 mg/dL (Bhatti et al., 2020).
Nursing Orders:
- continuous cardiac monitoring to identify arrhythmias, and evaluate heart rate management.
- Assess vital signs at 15-minute intervals until the patient is stable, followed by monitoring every 1 hour.
- Strict measurement of fluid intake and output to ensure proper fluid balance.
- Weight patient daily.
- Notify the provider of any new onset of arrhythmias or patient becomes hemodynamically unstable.
Follow-Up Lab Tests:
- Conduct a transthoracic echocardiogram to assess cardiac structure and functionality.
- Obtain a chest X-ray to evaluate for pulmonary congestion or other underlying conditions.
- Conduct a Basic Metabolic Panel (BMP), Complete Blood Count (CBC), and Coagulation Profile upon admission, followed by assessments every six hours until the patient’s condition stabilizes.
- Measure electrolytes, including potassium (K+), magnesium (Mg2+), and calcium (Ca2+), immediately, with subsequent tests every six hours if any abnormalities are detected.
- Obtain troponin levels on admission and repeat the test six hours later if the initial results indicate elevation; additionally, perform thyroid function tests (TSH and Free T4) to evaluate any potential thyroid-related contributions to arrhythmia.
Consults:
- Consultation in cardiology is required for the assessment and treatment of newly diagnosed atrial fibrillation accompanied by rapid ventricular response (RVR).
- A pharmacy consultation is necessary to confirm the adequacy of anticoagulation therapy and validate dosing concerning renal function.
Patient Education and Health Promotion (address age-appropriate patient education. if applicable):
- Inform the patient about atrial fibrillation, covering its symptoms, potential triggers, and the critical nature of adhering to prescribed medications.
- The patient ‘s CHA2DS2-VASc score is 5+, which places her at high risk for thromboembolic strokes. The patient is educated on the significance of anticoagulation therapy in minimizing stroke risk, along with the necessity of regular INR monitoring when prescribed warfarin.
- Offer recommendations for lifestyle changes, such as limiting caffeine and alcohol consumption, effectively managing stress, and identifying symptoms that necessitate immediate medical intervention.
Discharge Planning and Required Follow-Up Care:
- The patient may be discharged when the heart rate is stable at less than 100 beats per minute while on oral medications and the patient exhibits no symptoms.
- Schedule a follow-up appointment with cardiology within two weeks post-discharge for additional assessment and management.
- Provide the patient with comprehensive discharge instructions, emphasizing the importance of medication adherence, awareness of potential side effects, and guidelines for seeking emergency care. Ensure that the patient receives prescriptions for all required medications prior to discharge.
References
Bhatti, H., Mohmand, B., Ojha, N., Carvounis, C. P., & Carhart, R. L. (2020). The role of magnesium in the management of atrial fibrillation with rapid ventricular rate. Journal of Atrial Fibrillation, 13(4), 2389. https://doi.org/10.4022/jafib.2389
Burum, A., Carino, J., McBeth, M., Samuel, N., & Hintze, T. D. (2023). A systematic review of weight-based metoprolol for acute atrial fibrillation with rapid ventricular rate. Emergency Medicine International, 2023, 3138064. https://doi.org/10.1155/2023/3138064
Healey, J. S., Lopes, R. D., Granger, C. B., Alings, M., Rivard, L., McIntyre, W. F., Atar, D., Birnie, D. H., Boriani, G., Camm, A. J., Conen, D., Erath, J. W., Gold, M. R., Hohnloser, S. H., Ip, J., Kautzner, J., Kutyifa, V., Linde, C., Mabo, P., … Connolly, S. J. (2024). Apixaban for stroke prevention in subclinical atrial fibrillation. The New England Journal of Medicine, 390(2), 107–117. https://doi.org/10.1056/nejmoa2310234