Scenario #3 K.B. is a 65-year-old man

Scenario #3 K.B. is a 65-year-old man admitted to the hospital after a 5-day episode of “the flu” with complaints of dyspnea on exertion, palpitations, chest pain, insomnia, and fatigue. K.B. was diagnosed with Graves’ disease 6 months ago and placed on methimazole (Tapazole) 15 mg/day. His other past medical history includes heart failure and hypertension requiring antihypertensive medications; however, he states that he has not been taking these medications on a regular basis. Vital signs (VS) are: 150/90, 124 irregular, 20, 100.2° F (37.9 ° C). Admission assessment findings are: height 5 ft, 8 in; weight 132 lb; appears anxious and restless; loud heart sounds; 1+ pitting edema noted in bilateral lower extremities; diminished breath sounds with fine crackles in the posterior bases. K.B. begins to cry when he tells you he recently lost his wife; you notice someone has punched several more holes in his belt so he could tighten it. Chart View: Laboratory Test Results Hemoglobin (Hgb) 11.8 g/dL Hematocrit (Hct) 36% Erythrocyte sedimentation rate (ESR) 48 mm/hr Sodium 141 mmol/L Potassium 4.7 mmol/L Chloride 101 mmol/L Blood urea nitrogen (BUN) 33 mg/dL Creatinine 1.9 mg/dL Free thyroxine (T4) 14.0 ng/dL Triiodothyronine (T3) 230 ng/dL 1. Which of K.B.’s assessment findings represent manifestations of hypermetabolism? 2. Interpret K.B.’s laboratory results. 3. You go to assess K.B. What additional data do you need to obtain because he has Graves’ disease? Chart View Physician’s Orders Propranolol (Inderal) 20 mg PO q6h Dexamethasone (Decadron) 10 mg IV q6h Verapamil (Calan SR) 120 mg/day PO Furosemide (Lasix) 80 mg IV push now, then 40 mg/day IVP Diet as tolerated STAT ECG and echocardiogram Up ad lib IV of D5W at 125 mL/hr Daily weights with intake and output (I&O) 4. The physician writes these admission orders. Which will you , and why? 5. Describe four priority problems related to K.B.’s nursing care. CASE STUDY PROGRESS Later on your shift, you note that K.B. is extremely restless and disoriented to person, place, and time. VS are 174/82, 180 and irregular, 32 and labored, 104 ° F (40 ° C). His electrocardiogram (ECG) shows atrial fibrillation. 6. What is likely happening with K.B.? State your rationale. 7. What will you do first? 8. You need to call the physician regarding K.B.’s status. Using SBAR, what will you report to the physician? CASE STUDY PROGRESS The physician evaluates K.B. and determines he is in thyroid crisis. The physician’s orders are shown in the chart. Chart View Physician’s Orders Oxygen at 2 L per nasal cannula STAT arterial blood gases, brain natriuretic peptide (BNP), and cardiac enzymes Digoxin (Lanoxin) 0.25 mg IV push now, then 0.125 mg IVP q8h Ã…~ 2 doses Diltiazem (Cardizem) bolus dose of 0.25 mg/kg IV; after 15 minutes, give a second dose of 0.35 mg/kg IV for heart rate greater than 140 Increase methimazole (Tapazole) to 15 mg PO q6h Lugol’s solution 10 drops PO tid: start 1 hour after first methimazole dose Hydrocortisone (HydroCort) 50 mg IVP q6h Absolute bed rest Acetaminophen (Tylenol) 650 mg PO q6h prn for temp over 100 ° F (37.8 ° C) 9. Describe how you would care for K.B. in the next hour. 10. The label on the vial of diltiazem (Cardizem) states that there are 5 mg/mL. How many total milliliters will you administer for the first dose? How many for the second (if needed)? 11. Describe how to safely administer Lugol’s solution. 12. What is your primary nursing goal at this time? 13. Describe six interventions you will perform over the next few hours for K.B. based on this priority. 14. Why was K.B. at risk for developing thyroid storm? 15. Identify three outcomes that you expect for K.B. as a result of your interventions. CASE STUDY PROGRESS After several hours of treatment, K.B.’s condition stabilizes. The physician discusses two treatment options with K.B. and his family: radioactive iodine (RAI) therapy, also known as I-131, and subtotal thyroidectomy. 16. K.B. is fearful of radiation treatment and asks you for your opinion. How would you respond? 17. K.B. decides to receive RAI. During pretreatment instructions, the family asks whether he will be radioactive and what precautions they should take. Outline important guidelines for instructing K.B. and his family regarding home precautions. 18. In the midst of all this, you remain concerned over K.B.’s bereavement after the loss of his wife. How would you address this issue? 19. K.B. does have some exophthalmos and is experiencing periodic photophobia and dry eyes. What should you include in teaching him how to manage these problems? Select all that apply. a. Wear sunglasses at all times when outside. b. Report any changes in vision to the physician. c. Use artificial tears to provide moisture as needed. d. Tape the eyes closed at night with nonallergenic tape. e. Apply warm compresses to the eyes if they are irritated. 20. Which statement indicates K.B. understands the discharge instructions? a. “I will take this medication on a full stomach.” b. “If I get a sore throat, ice chips should help me feel better.” c. “I should see an improvement in my symptoms by tomorrow.” d. “I will follow the precautions for 2 weeks to keep my family safe.” CASE STUDY OUTCOME Six months later, K.B.’s heart rate, blood pressure, and thyroid hormone levels are within normal limits. He has gained 14 pounds and has started walking in the mornings without any dyspnea. He says he has started to do woodworking and has been doing some volunteer work at the senior center. SCIENCE HEALTH SCIENCE NURSING NURSING MISC

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