Harding: Lewis’s Medical-Surgical Nursing, 11th Edition   NGN Case Study   Title: Dysrhythmia and

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Harding: Lewis’s Medical-Surgical Nursing, 11th Edition

 

NGN Case Study

 

Title: Dysrhythmia and Pacemaker (Ch. 35)

Scenario: A 38-year-old female is admitted to the emergency department after “feeling palpitations and almost fainting.” She states that this started a few hours ago and got progressively worse as she tried to get ready for work. The ECG reveals nonconducted P waves without progressive PR intervals. On conducted beats, the PR interval is constant, with a ratio of 3:1 (three P waves to one conducted QRS interval). The ventricular rate ranges from 50 to 60. The PR interval is slightly prolonged; the QRS complex is greater than 0.12 seconds. Blood pressure is 108/54 mm hg, temperature 97.8°F (36.6°C), respirations 18 breaths/minute. Currently she is not feeling faint but reports feeling occasional palpitations. She reports that she has felt extremely tired for the past few days. The patient states that she has a family history of heart disease and that her mother had a heart attack at age 35. She denies having any chest pain or tightness. The patient states that she has smoked 1 pack of cigarettes a day for years but stopped smoking a month ago. Her skin is warm and dry, and capillary refill is brisk.

 

1. NGN Item Type: Highlighting/Enhanced Hot Spot

Highlight or place a check mark next to the assessment findings that require follow-up by the nurse.

 

 

Cognitive Skill: Recognize Cues

 

2. NGN Item Type: Cloze

Choose the most likely options for the information missing from the statement, below, by selecting from the list of options provided.

The nurse recognizes that, based on the assessment data and patient’s history, the patient is currently at risk for complications, including __________, _________, and __________.

Options

Heart failure

Complete heart block

Tachycardia

Myocardial ischemia

Decreased cardiac output

First-degree heart block

Hypotension

Infection

 

Cognitive Skill: Analyze Cues

 

 

Scenario: Four hours after her arrival to the emergency department, the patient remains in second-degree type II heart block and her vital signs are stable. She is transferred to a telemetry unit to prepare for insertion of a permanent pacemaker later in the day. When she gets out of bed to use the restroom, she felt faint and had to sit on the floor. The nurse finds her sitting on the floor beside the commode; the patient is awake but somewhat confused. The patient is assisted back to bed. The nurse notes that the ECG monitor shows that the patient’s heart rate is at 40 beats/minute and she is now in third degree heart block. The Rapid Response team is called, and preparations are made for the immediate application of a transcutaneous pacemaker (TCP).

 

1. NGN Item Type: Extended Multiple Response

Based on the patient’s current treatment plan, the patient’s priority needs will be to prevent which of the following? Select all that apply.

_____ 1. Angina

_____ 2. Pneumothorax

_____ 3. Hypertension

_____ 4. Dislodged pacing electrodes 

_____ 5. Pacemaker failure to pace

_____ 6. Infection of the incision site

_____ 7. Injury from falling due to syncope

_____ 8. Hypotension

 

 

 

 

Cognitive Skill: Prioritize Hypotheses

 

2. NGN Item Type: Extended Drag and Drop

Use an X (or drag and drop) to indicate which actions listed in the left column would be included in the plan of care for this patient.

Nursing Actions Relevant Nursing Actions
Prepare to administer atropine.  
Prepare to administer epinephrine.  
Reassure the patient that the TCP is temporary.  
Place both TCP pads on the chest over the heart.  
Provide analgesia as needed after the TCP is placed.  
Monitor vital signs and ECG.  

 

Cognitive Skill: Generate Solutions

 

Scenario: That afternoon, the patient is sent to the operating room and receives a dual-chamber rate-responsive pacemaker implanted via the left upper chest. The rate is set at 70 beats/minute. Postoperatively, she is sent back to the telemetry unit. Vital signs: Blood pressure 122/84 mm Hg, pulse 70 beats/minute, respirations 18 breaths/minute, and temperature 98.4°F (36.9°C). The ECG shows paced rhythm, rate 70 beats/minute. The incision is covered with a light dressing. The patient comments that she feels better with less fatigue. That evening, after dinner, the nurse reviews education about pacemakers with the patient and her spouse.

 

1. NGN Item Type: Matrix

Use an X for nursing actions listed below that are Indicated (necessary), Contraindicated (could be harmful), or Nonessential (not necessary). Only one selection can be made for each nursing action.

Nursing Action Indicated Contraindicated Nonessential
Encourage the patient to exercise the operative side after the pacemaker is inserted.      
Check the patient’s ECG every 4 hours.      
Instruct the patient to keep follow-up appointments for pacemaker checks.      
Wash the incision site with soap and water twice a day.      
Teach the patient to avoid the use of microwave ovens.      
Instruct the patient to check her pulse and notify the HCP if the heart rate drops below 70 beats/minute.      
Teach the patient to report any redness, drainage or swelling of the incision site.      

 

 

Cognitive Skill: Take Action

 

2. NGN Item Type: Extended Multiple Response

The nurse evaluates the effectiveness of actions. Which of the following findings indicate effectiveness? Select all that apply.

_____ 1. Blood pressure 122/84

_____ 2. ECG shows paced rhythm, rate 70 beats/min.

_____ 3. Patient states she will limit use of her left arm and shoulder.

_____ 4. The incision dressing has serosanguinous drainage visible.

_____ 5. The patient states she will change the pacemaker battery every 6 months.

_____ 6. The ECG shows occasional pacer spikes that are not followed by a QRS complex (failure to capture).

_____ 7. The patient states that she will remind HCPs about her pacemaker before undergoing an MRI test.

 

 

Cognitive Skill: Evaluate Outcomes

SCIENCE
HEALTH SCIENCE
NURSING
NURS 201

 

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