NURS 1300 CASE STUDIES and Lab Work Jackie Morgan MBA, MSN, CCRN, CNS-BC HEALTH HISTORY/GENERAL

SURVEY/ASSESSMENT TECHNIQUES Please complete the following case and questions as you wait to test out on vital signs Week 2: It is the beginning of your shift as a nurse and a new patient has just arrived on the unit and is in need of a complete health history, general survey, and a head to toe assessment. Prior to entering the patients room, you review the faxed report you received from the Emergency Department. The report reads as follows: Jane Patient, 60 Admitting diagnosis: UTI rule out urosepsis Admitting MD: Dr. Yourein Allergies: Sulfa History of diabetes and hypertension Patient complaining of burning upon urination, chills, though I had the swine flu T: 38.7C Pulse: 104 RR 28, BP 98/68 Urinalysis: + for bacteria, trace of blood, cloudy turbidity 1. What was this patients reason for seeking care? 2. What are the patients symptoms? What are the patients signs? What is the difference between the two? 3. Name five components of Past Health History 4. What are the purposes of the review of systems, and describe the components that would pertain to this patient. 5. What should the patient be asked about her Sulfa allergy? 6. What would be an example of an open ended question to ask about the reason for seeking care? 7. What are the four techniques utilized for all body systems during the head to toe assessment? 8. What type of sounds are heard best with the diaphragm of the stethoscope? The bell? 9. Describe the meaning (normal location, etc) of the following percussion notes: a. resonant b. hyperresonant c. tympany d. dull

VITAL SIGNS Please complete the following case and questions as you wait to test out on vital signs Week 2: Mr N is a 28 year old male with a history of diverticulosis and he is admitted for gastrointestinal bleeding. His vital signs are: 36.5C, 100, 24, BP 108/64 while lying in bed. When palpating his pulse it speeds up with inspiration and slows with expiration. The patients heart rate increases to 120 and is thready upon standing. His blood pressure when standing is 84/54. 1. What is the patients pulse pressure when the patient is supine? Standing? 2. How would you document the amplitude of this patients palpable pulses? 3. What is the term for the respiratory variation on the patients pulse? 4. What is the terminology for the pulse/BP change the patient is experiencing upon standing? What is the significance of this finding in the case of this patient? Additional Questions: 1. What instrument can be used to obtain a blood pressure if it cannot be auscultated? 2. If you do not have a cuff that fits the upper arm, where are two sites to utilize as an alternate? 3. If the forearm is used to determine the blood pressure, which artery is used to align the blood pressure cuff? 4. If the radial pulse is less that the apical pulse, how is this documented? 5. IF a Doppler is used to determine blood pressure and the first sound is heard at 90, how is this blood pressure documented in the medical record? 6. If the pulse rate palpated increases and decreases with the respiratory pattern, what is this called? 7. A pulse rate of 50 is known as: 8. The patient has the perception that they are short of breath, this is known as? 9. What is the normal amplitude of a pulse charted as? 10. What is the respiratory pattern that waxes and wanes and has regular periods of apnea?

GLUCOMETERS, HEIGHT, WEIGHT, PULSE OX Please complete the following case and questions while you are waiting to test out Week 3: MM is a 38 year old female with a lifelong history of diabetes for which she was noncompliant with treatment. As a result she has severe peripheral vascular disease and renal failure. She has dialysis on M-W-F. She is very short of breath even after dialysis and admits to having a moist, productive cough. The nurse at the clinic suspects pneumonia. 1. Why is measurement of height and weight important for this patient/ 2. Describe the typical guidelines for obtaining a weight then think of this case: a. When would weights be taken for this and why b. What trends would be important to follow for this patient 3. Describe the meaning of obtaining: a. higher reading than possible on the meter b. Lower reading than possible on the meter 4. Based on this patients history, what issues do you see in obtaining a pulse ox reading 5. If the patient does have pneumonia, what do you expect to see in the pulse ox reading 6. What are the limitations of pulse oximetry? Additional Questions: 1. What is BMI? 2. What is the impact of high BMI? 3. When is the best time to get a patient weight? 4. What prep is needed prior to getting a height and weight? 5. What is the cause of a decrease in height with age? 6. Discuss the link between height, weight, and development. 7. What readings are shown on most pulse ox machines 8. What is a normal pulse ox reading for a healthy non-smoking adult? 9. What can be considered a normal pulse ox for a patient with severe chronic lung disease? 10. At what locations on the body can a pulse ox probe be applied?

SKIN, HAIR, NAILS Please complete the following case and questions while you are waiting to test out Week 4: A patient is in a long term acute care hospital after suffering a stroke. The patient also has a history of diabetes. She is incontinent of liquid stool. The float nurse arrives on the unit. During her assessment she notes a blister to the right hip that is still intact. There is an area on her right hip that is read but changes to the color of the collagen underneath when palpated. Her groin and buttocks is red, bleeding, wet, and shiny from the loose stools. 1. 2. 3. 4. 5. How would you describe her groin and buttocks in your nursing notes? How would you describe the blister? How would you define the area on her right hip? What are the risk factors for skin issues in this patient? What other assessments (body system) tests need to be considered?

Additional questions: 1. If a patient has persistent hyperemia to a pressure area, what stage is the pressure ulcer? 2. Name two strategies for pressure ulcer prevention? 3. Should a Stage I pressure ulcer be vigorously rubbed? 4. Is reactive hyperemia a pressure ulcer? 5. What is the term for a sutured wound that opens up? 6. A wound that opens and underlying contents protrude is known as? 7. What is the term used to describe edges of a surgical wound that is healing appropriately? 8. What are two changes to a mole that may indicate a cancerous lesion? 9. What gives hair its color? 10. What is the cause of clubbing?

TWELVE LEAD EKG Please complete the following case and questions while waiting to test out Week 5: A patient whom passed out at work is brought to the ED. He is a 58 year old male whom is obese and a pack a day smoker. He fell outside in the cold while working on a crane in the snow. He has an irregular pulse on assessment and is complaining of chest pain. He is cold and shivering despite wearing a turtleneck, and several layers of clothes. He has thick dark hair on his chest and extremities. 1. What cardiac diagnostic test will be done? 2. Why would this test be done? 3. What patient characteristics does this patient have that would make getting a 12 lead EKG difficult? 4. What preparation for the 12 lead would this patient need? 5. What disease states can be diagnosed with a 12 lead EKG? Additional questions: 1. What is the term for a wavy baseline on the EKG? 2. What normal function of the body can interfere with the baseline of an EKG? 3. What can happen if there are a lot of electrical and other devices in the pockets of the gown or near the patient during a 12 lead EKG? 4. What do you do with lead placement if the patient has a pacemaker? 5. What directions do you give the patient prior to a 12 lead EKG? 6. Can you delegate the task of obtaining an EKG, and to whom? 7. What is the normal conduction pathway in the heart? 8. What does the P wave represent? 9. What does the QRS represent? 10. What does the T wave represent?

CARDIAC Please complete the following case and questions while you are waiting to test out on Week 6 Mr. D is a 48 year old male with a history of hypertension, Cardiomyopathy/LV hypertrophy, and end stage heart failure with subsequent atrial fibrillation (an irregular rhythm) whom is in the hospital and awaiting an overdrive pacer/defibrillator to be placed. 1. Due to the patients arrhythmia, what possible palpable pulse variation may exist between the apical and radial pulse sites? 2. For how long should his pulse be counted due to these issues? 3. Due to his LV hypertrophy, where do you expect his apical pulse (PMI) to be palpable? 4. What is a possible finding over the chest wall during general chest palpation? 5. What extra heart sound may be present at the end of diastole due to a stiff ventricle wall? Describe the technique for assessing its presence. 6. If the patient suddenly goes into fluid overload: What extra heart sound heard early in diastole will be audible? What affect would fluid overload have on jugular venous pressure? 7. If unable to distinguish the jugular vein during inspection, which abdominal palpation technique may be useful in its identification and how is this technique performed? 8. What respiratory pattern is common in patients with end stage heart failure Additional Questions: 1. What valves are responsible for S1? 2. What valves are responsible for S2? 3. What is the meaning of a displaced apical pulse? 4. What is the meaning of S3? 5. What is the meaning of S4? 6. What part of the stethoscope should be used to identify extra heart sounds? 7. What is a bruit, what does it signify? 8. What is a thrill? 9. Which side of the heart is reflected by the jugular vein? 10. What is the significance of an elevated jugular venous pressure?

VASCULAR SYSTEM Please complete the following case and questions while you are waiting to test out on Week 7: Mr. C is a 74 year old male with a history of COPD from fifty years of smoking. He has been admitted for syncope after he complained of feeling like the room was spinning. Upon assessment, his lower extremities are swollen, with edema that persists for 3 seconds; they are discolored to a purplish brown and the skin in crusted over most of the calf. His pedal pulses are also somewhat diminished but are still palpable. He is diagnosed with PVD and near syncope and placed on bedrest. 1. What nail finding is common in patients with COPD? How is it assessed? 2. What is the expected chest appearance upon inspection of a patient with COPD? 3. Based upon his diagnosis of syncope, what vascular assessment(s) should be made? 4. What pathologic ausculatory finding is associated with decreased arterial flow to the brain? 5. Based on his history, how would this patients capillary refill be affected? 6. How would his pedal pulses be graded? 7. Do his lower extremities exhibit arterial or venous insufficiency or both? Why? Describe the differences in assessment findings of the two. 8. Based upon his PVD diagnosis and the fact that he has been placed on bedrest, for what vascular complication is he at risk and what assessment techniques should take place? 9. Describe the technique of Homans sign as well as its clinical significance. Additional Questions: 1. What is lymph edema 2. Who is at risk for lymph edema? 3. What is the difference between thrombophlebitis and DVT? 4. What is the best way to identify possible DVT? 5. Name a prevention method for DVT 6. Describe the differences in findings of an arterial clot versus arterial insufficiency? 7. Contrast venous insufficiency from arterial insufficiency: 8. What is the grade of a normal pulse 9. What is the meaning of a +4 pulse 10. What instrument can be used to locate pulses that cannot be palpated?

LUNGS/THORAX Please complete the following case and questions while you are waiting to test out on Week 8: Mrs. K is an 80 year old female with a history of dementia and stroke that left her unable to swallow and somewhat weaker on her right side. She has a PED through which she receives tube feeding and her medications. She is admitted for right middle lobar pneumonia secondary to aspiration. She is coughing up thick tan sputum. Vital signs: T38.1C, 98, 32, 112/68. 1. Which possible adventitious sound(s) may be audible over the RML based on her diagnosis? 2. Will her condition affect chest expansion? How is this assessment technique performed? 3. Based on her vital signs, how can her respiratory rate be described? 4. Prior to expectorating sputum which adventitious sound is likely to be audible over the lower portion of the trachea? 5. How is diaphragmatic excursion assessed? 6. What vocal sound changes will be audible over the RML and how are these techniques performed? 7. What will be the effect of this RML pneumonia on tactile fremitus and why? Additional Questions: 1. Where are vesicular breath sounds normally located 2. Where are bronchovesicular breath sounds normally located? 3. Where are bronchial breath sounds normally located? 4. What anatomical structure in the lungs are affected by crackles? 5. What are the two types of rhonchi? 6. What is one cause of unequal chest expansion? 7. What organ affects diaphragmatic excursion on the right side? 8. What is one condition that will enhance vocal fremitus? 9. What is one condition that will decrease vocal fremitus? 10. What is one possibility for bronchophony?

ABDOMEN Please complete the following 2 cases and questions while you are waiting to test out on Week9: Mr. y is a 50 year old male with a history of cirrhosis of the liver whom is admitted with abdominal pain of unknown origin. He cannot pinpoint the exact quadrant where his pain is the worst nor can he identify in which quadrant it began. He is slumped over in the bed somewhat with both arms draped over his abdomen as if protecting it. 1. How would the nurse document his position? 2. What palpation technique can be utilized to help determine the location/quad of the abdominal issue? 3. Based upon his history, this patient may have an enlarged liver, known as __________ and would indicate a size of greater than _________which can be determined by _______. 4. Fluid build up in the abdomen due to cirrhosis is known as _____ and the two assessment techniques to determine its presence include _________ and _________. 5. What are the assessment techniques for appendicitis? How are they performed/ 6. If a kidney infection is suspected, what percussion technique should be performed? 7. What assessment technique should be done for suspected gallbladder inflammation? 8. What is true of vascular sounds in the abdomen? Additional Questions: 1. What is meant by referred pain? 2. What is the meaning of costovertebral angle tenderness? 3. Is the bladder palpable? 4. What is the other name for the Murphys test? 5. What is the percussion sound over feces in the colon? 6. What is the percussion note over air filled bowel? 7. What is the normal liver span? 8. If the spleen is able to be percussed and the patient has LUQ pain, what should NOT be done? 9. What are two tests for ascites? 10. Organs are also known as

ANUS,RECTUM, PROSTATE Mr. Q is a 58 year old male with a history of coronary artery disease and hypertension. He is a former smoker. He is in the clinic for a physical exam. He reports having urgency but then difficulty maintaining a urine stream once initiated. His father had prostate cancer and survived. He has been doing research on the internet and fears he has prostate cancer. 1. Describe the technique for assessment/palpation of the prostate. 2. Compare and contrast the findings of BPH and carcinoma. 3. What patient teaching about prostate cancer should be done? 4. What can be said to alleviate this patients anxiety?

NEURO Please complete the following case and questions while you are waiting to test out on Week 10: Mr. R is a 22 year old male involved in a motorcycle crash. He was not wearing a helmet and sustained a closed head injury (Upper motor neuron). Prior to being placed on the ventilator he opened his eyes to pain only, did not follow commands or speak, and displayed abnormal flexion when stimulated with pain. His right pupil is 7 and nonreactive; his left is 5 and sluggish. 1. Based on the Glasgow Coma Scale, what would this patient score? 2. What is the term for the abnormal flexion this patient is displaying? Of what is it indicative? 3. Based on the findings related to this patients pupils, on which side of the brain did this patient sustain the injury? 4. The patient is displaying a positive Babinski, Snout, and Sucking reflex. What do these indicate? What technique is used to attempt to cause these reflexes? 5. The patient still has a corneal, cough, and gag reflex. To which cranial nerves do these signs belong and what meaning does this have? Bonus neuro: In general (not related to this case): What is the earliest sign of increased intracranial pressure and which cranial nerve does this involve? Additional Questions: 1. A patient whom is having trouble saying words to describe their feelings, needs is said to have: 2. A patient with receptive aphasia has an issue with what lobe of the brain? 3. The lobe of the brain responsible for coordination: 4. The first sign on increased intracranial pressure: 5. What does PERRLA stand for? 6. If the person is having a stroke on the right side of the brain, which pupil will dilate? 7. What is the term for the fact that the body is weaker on the opposite side of the location where the stroke has taken place? 8. What blood pressure change will also accompany an increase in intracranial pressure? 9.Problems swallowing is known as 10. The lobe of the brain responsible for judgment and personality?

MUSCULOSKELETAL Please complete the following case and questions while you are waiting to test out on Week11: Mrs. J is a 64 year old female whom is an administrative secretary in a law firm. She has a history of asthma that has been well controlled with a steroid inhaler for the past thirty years. She is active on the law firm bowling league. She presents to her primary care physician after having increased knee pain and swelling to her right leg. She believes she may have injured herself at bowling. She complains of morning stiffness, warmth and swelling to the right knee. Upon assessment, the nurse notices that the patient has hard, non-tender nodules at the site of the bend of the first digit of the fingers on her left hand. The patient explains that she just figured that they were due to all the typing she does and she admits to having stiffness and pain to those areas as well. 1. With what instrument will the range of motion of her right knee be tested? 2. For what chronic issue are the symptoms of her fingers? 3. What diagnostic studies can be performed on the right knee? 4. For what possible abnormality will the nurse palpate the knee? 5. What exams will be used to specifically assess for knee and surrounding joint space issues? 6. How are they performed? Additional Questions: 1. What are two tests that can be done to test for water on the knee? (bulge sign, ballotment) 2. What are two tests that can be done to test for Carpal Tunnel? (tinels sign, phalens sign) 3. What test is used to identify a rotator cuff tear? (drop arm test) 4. What is the term for the grating sound, and scratchy feeling of a joint during ROM? (crepitus) 5. What is the term used for range of motion completed on a patient by a practitioner? (passive) 6. What deformity is caused by a shortened muscle? (contracture) 7. What are some inspection signs of osteoarthritis? (Heberdens nodes, Bouchards nodes) 8. What is happening to the bones of a patient with osteoporosis? (resorption > deposition) 9. What is a prevention method for osteoporosis? (calcium intake, weight bearing activity) 10. What type of assessment is crucial for the elderly whom have had a musculoskeletal injury? (functional)