Which laboratory tests might be ordered to investigate W.R.'s ...

[DelorasTo]

Which laboratory tests might be ordered to investigate W.R.'s condition? If the order is appropriate, place an A in the space provided. If inappropriate, mark with an I. Provide rationales for your decisions.
 
  1. Complete blood count (CBC)
  2. Electroencephalogra m (EEG) in the morning
  3. Basal metabolic panel (BMP)
  4. Prothrombin time (PT) and partial thromboplastin time (PTT)
  5. Bilirubin
  6. Urinalysis (UA)
  7. STAT 12-lead electrocardiogram (ECG) and repeat in the morning
  8. Type and crossmatch for 2 units of packed red blood cells (PRBCs)
  9. Chest x-ray on admission and in the morning

Question 2

The time is 1900. You are working in a small, rural hospital. It has been snowing heavily all day, and the medical helicopters at the large regional medical center, 4 hours away by car (in good weather), have been grounded by the weather until morning.
 
  The roads are barely passable. W.R., a 48-year-old plumber
  with a 36pack-year smoking history, is admitted to your floor with a diagnosis of rule out myocardial
  infarction (R/O MI). He has significant male-pattern obesity (beer belly, large waist circumference) and a
  barrel chest and reports a dietary history of high-fat food. His wife brought him to the emergency department
  after he complained of unrelieved indigestion. His admission vital signs (VS) were blood pressure
  (BP) 202/124 mm Hg, pulse (P) 106 beats/min, respirations 18 breaths/min, and oral temperature 98.2
  F (36.8  C). W.R. was put on oxygen (O2) by nasal cannula (NC) titrated to maintain Spo2 over 92 and
  started on an IV nitroglycerin (NTG) infusion. He was given aspirin 325 mg to chew and swallow and was
  admitted to Dr. A.'s service. There are plans to transfer him by helicopter to the regional medical center
  for a cardiac catheterization in the morning when the weather clears. Meanwhile, you have to deal with
  limited laboratory and pharmacy resources. The minute W.R. comes through the door of your unit, he
  announces he's just fine in a loud and angry voice and demands a cigarette. He also says he has no time
  to fool around with hospitals.
 
  What is the first priority in his care?
 
  Are these VS reasonable for a man of his age? If not, which one(s) concern(s) you? Explain
  why or why not.
 
  Identify five priority problems associated with the care of a patient such as W.R.

[owenfalvey]

Answer to Question 1

Answers: 1. A; 2. I; 3. A; 4. A; 5. I; 6. A; 7. A; 8. I; 9. A
The CBC, BMP, PT and PTT, and UA are appropriate admitting laboratory tests for all patients with
BP disorders. The STAT 12-lead ECG is appropriate for this patient because his heart is involved. The
chest x-ray will provide information about pulmonary and cardiac status. The EEG, bilirubin, and type
and crossmatch are not appropriate for this patient.

Answer to Question 2

The first priority is his safety. That means maintaining cardiac tissue perfusion and, if he has had an
MI, keeping him alive and limiting cardiac damage.

His blood pressure (BP is dangerously high, and his pulse (P is rapid for a 48-year-old man who is at
rest. Both of these can contribute to myocardial ischemia.

BP control: Monitor for efficacy of medication and side effects.
Myocardial ischemia: This results from (1) increased oxygen demand because of increased cardiac
output (high BP and P); (2) probable decreased oxygen availability related to coronary artery
disease (CAD) and/or chronic obstructive pulmonary disease (COPD); and (3) possible decreased
diffusion of gases across the alveolar-capillary membrane. The last two issues are directly related
to his smoking history as well as a possibly obstructed coronary artery.
Cigarette smoking: He is going to want to smoke. Smoking negatively affects the heart because of
the increased stress on the lungs and the vasoconstriction that restricts oxygenation. You need
to caution him about not smoking during his stay in the hospital, and ask his wife to take his
cigarettes and lighter or matches home with her.
Teaching needs: Teach him to report any chest pain or discomfort or difficult breathing.
Pain control: Pain will increase his anxiety and the heart rate, which increases the workload of the
heart and myocardial tissue perfusion.
Cardiac dysrhythmias: These increase the possibility of sudden death.
Constipation: His high-fat, low-fiber dietary preferences and decreased activity during
hospitalization increase his risk for constipation; the pattern of breath-holding during a bowel
movement is termed the Valsalva maneuver. In cardiac patients who are constipated, it can
precipitate an MI or sudden death.
Hostility: His anger is probably masking fear of death and fear of loss of control, which can contribute
to more stress on his heart and would be dangerous at this time. Consider an antianxiety agent at
this time.
Denial: His denial is a coping mechanism related to his fear. Although denial sometimes serves a
positive purpose, in this situation it is contributing to behaviors that increase W.R.'s risk for cardiac
damage.

[DelorasTo]

Gracias!

[Mochi]

Excellent