Case study 1: To be completed today

Case study 1: To be completed today 11/21 and returned by email by 8pm. We will discuss this case at our next clinical scheduled for Monday 11/28 at Fairview. You are a public health nurse working at a county immunization and tuberculosis (TB) clinic. B.A. is a 51-year-old woman who wishes to obtain a food handler’s license and is required to show proof of a negative Mantoux (purified protein derivative [PPD]) test result before being hired. She came to your clinic 2 days ago to undergo a PPD test for TB. She has returned to have you evaluate her reaction. What is TB, and what microorganism causes it? 2. What is the route of transmission for TB? The Centers for Disease Control and Prevention (CDC) recommends screening people at high risk for TB. List five populations at high risk for developing active disease. Describe the two methods of TB screening. How do you determine whether a Mantoux test result is positive or negative? Interpret B.A.’s skin test What additional information do you need to obtain from B.A.? You inform B.A. of the test result. She asks you what the result means. How will you respond? Case Study Progress B.A. is a natural-born American and has no risk factors for TB infection according to the CDC guidelines. She has a 6-year history of type II diabetes mellitus that is well controlled with metformin (Glucophage). She admits that her mother had TB when she was a child but says she herself has never tested positive before. She is angry at the proposition that she might have TB and says, “I feel just fine and I don’t think anything else is necessary.” What steps need to be done to determine whether B.A. has an active TB infection? Case Study Progress The physician orders a chest x-ray (CXR) examination and informs B.A. that the image is clear, showing no signs of active TB infection. He tells her that she has class 2 TB, or a latent TB infection (LTBI), and that he will report her condition to the local public health department. 10. What is a LTBI? What parameters determine whether treatment is initiated for LTBI? Is B.A. a candidate for LTBI treatment? State your rationale Outline the current CDC guidelines for the treatment of LTBI. Case Study Progress The physician orders B.A. to begin a 12-dose, once-weekly regimen of isoniazid (INH) and rifapentine (RPT) as directly observed therapy (DOT). How will you describe LTBI and DOT to B.A? The medications used to treat LTBI are associated with different side effects. Identify the test used to monitor each possible side effect listed as follows: _____ A. Peripheral neuropathy 1. Audiogram _____ B. Clinical hepatitis 2. CBC (complete blood count) _____ C. Fever and bleeding problems 3. Blood urea nitrogen (BUN), creatinine, and creatinine clearance _____ D. Nephrotoxicity or renal failure 4. AST (aspartate transaminase) and ALT (alanine transaminase) _____ E. Hyperuricemia 5. Physical examination and monofilament testing _____ F. Optic neuritis 6. Red-green discrimination and visual acuity _____ G. Hearing neuritis 7. Uric acid 16 What additional information does B.A. need to receive before leaving the clinic? Case Study Outcome B.A. is hired under the condition that she complies with LTBI therapy and will immediately report any signs and symptoms of active disease to the clinic. She reports weekly for her medications and finishes her 12 weeks of therapy without experiencing any significant effects. Case study 2: To be completed today 11/21 and returned by email to Jayme Taylor by 8pm. We will discuss this case at our last clinical scheduled for Monday 12/5 at Fairview. M.G., a “frequent flier” (frequent visitor to the hospital) is admitted to the emergency department (ED) with a diagnosis of heart failure (HF). She was discharged from the hospital 10 days ago and comes in today stating, “I just had to come to the hospital today because I can’t catch my breath and my legs are as big as tree trunks.” After further questioning, you learn that she is strictly following the fluid and salt restriction ordered during her last hospital admission. She reports gaining 1 to 2 pounds every day since her discharge. What 10 additional ROS/ PMH/ HPI (review of systems, past medical history, history of preent illness) questions do we want to ask MG? What systems are important to include in your initial physical examination? Explain the pathophysiology of left sided heart failure? Of right sided heart failure? What error in teaching most likely occurred when M.G. was discharged 10 days ago? During the admission interview, the nurse makes a list of the medications M.G. took at home. Medications Taken at Home Enalapril (Vasotec) 5 mg PO bid Pioglitazone (Actos) 45 mg PO every morning Furosemide (Lasix) 40 mg/day PO Potassium chloride 20 mEq/day PO 2. Which of these medications may have contributed to M.G.’s HF? Explain. 3. How do angiotensin-converting enzyme (ACE) inhibitors, such as enalapril (Vasotec), work to reduce HF? Select all that apply. ACE inhibitors: a. prevent the conversion of angiotensin I to angiotensin II. b. cause systemic vasodilation. c. promote the excretion of sodium and water in the renal tubules. d. reduce preload and afterload. e. increase cardiac contractility. f. block sympathetic nervous system stimulation to the heart. After reviewing M.G.’s medications, the physician writes the following medication orders. Medication Orders Enalapril (Vasotec) 5mg PO bid Carvedilol (Coreg) 3.125mg PO twice daily Glipizide (Glucotrol) 10mg PO every morning Furosemide (Lasix) 80mg intravenous push (IVP) now, then 40mg/day IVP Potassium chloride (K-Dur) 20mEq/day PO 4. What is the rationale for changing the route of the furosemide (Lasix)? 5. You administer furosemide (Lasix) 80mg IVP. Identify three parameters you would use to monitor the effectiveness of this medication. 6. What laboratory tests should be ordered for M.G. related to the order for furosemide (Lasix)? Select all that apply. a. Magnesium level b. Sodium level c. Complete blood count (CBC) d. Serum glucose level e. Potassium level f. Coagulation studies 7. What is the purpose of the beta blocker carvedilol? It is given to: a. increase the contractility of the heart. b. cause peripheral vasodilation. c. increase urine output. d. reduce cardiac stimulation from catecholamines 8. You assess M.G. for conditions that may be a contraindication to carvedilol. Which condition, if present, may cause serious problems if the patient takes this medication? a. Angina b. Asthma c. Glaucoma d. Hypertension One day later, M.G. has shown only slight improvement, and digoxin (Lanoxin) 125 mcg PO daily is added to her orders. 9. What is the action of the digoxin? Digoxin: a. causes systemic vasodilation. b. promotes the excretion of sodium and water in the renal tubules. c. increases cardiac contractility and cardiac output. d. blocks sympathetic nervous system stimulation to the heart. 10. Which findings from M.G.’s assessment would indicate an increased possibility of digoxin toxicity? Explain your answer. a. Serum potassium level of 2.2mEq/L b. Serum sodium level of 139mEq/L c. Apical heart rate of 64 beats/minute d. Digoxin level 1.6ng/mL 11. When preparing to give the digoxin, you notice that it is available in milligrams (mg) not micrograms (mcg). Convert 125 mcg to mg. 12. M.G.’s symptoms improve with intravenous diuretics and the digoxin. She is placed back on oral furosemide (Lasix) once her weight loss is deemed adequate for achievement of a euvolemic state. What will determine whether the oral dose will be adequate for discharge to be considered? 13. M.G. is ready for discharge. what key management concepts should be taught to prevent relapse and another admission? 4. After the teaching session, which statement by M.G. indicates a need for further education? a. “I will weigh myself daily and tell the doctor at my next visit if I am gaining weight.” B. “I will not add salt when I am cooking.” c. “I will try to take a short walk around the block with my husband three times a week.” d. “I will use a pill calendar box to remind me to take my medicine.” After 3 days, the STOP Heart Failure Nurse calls M.G. to ask about her progress. M.G. reports that her weight has not changed since she has been home. SCIENCE HEALTH SCIENCE NURSING NURS 420

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