High-Acuity Nursing, 7th Edition Solution Manual

DECISION-MAKING CASE SUMMARIES HIGH ACUITY NURSING #2: COGNITIVE DYSFUNCTION CASE NAME OVERVIEW MAJOR CASE DECISIONS Grace Potter Grace Potter is a 74-year-old woman who was admitted four days ago to the Medical ICU in acute respiratory failure with severe pneumococcus pneumonia. A conservative initial treatment plan was initiated. Ms. Potter was orally intubated and mechanically ventilated 12 hours post admission when her respiratory status deteriorated. She responded well to antibiotic therapy and was extubated 36 hours post admission. On day 4 post admission, Ms. Potter began to show signs of neurological changes. 1. Identifying and responding to abnormal test results, vital signs, or symptoms 2. Selecting appropriate diagnostic tests 3. Interpreting test results 4. Identifying risk factors for cognitive dysfunction 5. Responding to patient and family questions 6. Setting patient management goals 7. Selecting interventions for the plan of care Estimated Case Length: Difficulty Level: High Learning Objectives: • • • • • • • Assess the patient for the presence of a cognitive dysfunction. Demonstrate knowledge of the clinical significance of abnormal laboratory values. Identify risk factors for development of delirium cognitive dysfunction. Demonstrate an understanding of the confusional cognitive disorders. Select management goals for the patient with a confusional cognitive disorder. Demonstrate understanding of evidence-based management of a confusional cognitive disorder. Determine evidence-based actions to prevent reoccurrence of cognitive dysfunction. Questions Correct Answers 1. It is now 1930 and you Take her vital signs. are performing your initial shift bedside assessment Check her oxygenation status. on Ms. Potter. You assess her Glasgow Coma Scale Perform an abbreviated neurologic assessment. score as 13 (E=4, M=5, V=4). While she momentarily looks directly at you when you speak, she does not focus on you for any length of time and does not appear to be attending to what you are asking her. She seems agitated, frequently moving around in bed. Based on these findings, what initial actions should you take? Select all that apply. 2. Ms. Potter’s 1800 ABG results are now available and you review them to verify her oxygenation status. The results are as follows: • • • • • Make note of the results and continue with your patient care. pH of 7.44 PaCO2 of 33 mmHg PaO2 of 92 mmHg HCO3 of 22 mEq/L, and SaO2 of 96% Her most current vital signs include BP of 134/74, HR of 92, and RR of 22. How should you respond to these new ABG values? 3. You discuss your concerns regarding Ms. Potter’s changing level of consciousness with the Perform a Letters Attention Test. Obtain a RASS score. intensivist, who agrees Perform a Command test. that further investigation is warranted. You review her Perform a Yes/No Question test. EHR and prepare to Review Ms. Potter’s EHR to check for mental status perform the CAM-ICU. changes. Which tests and scores will you include to complete the CAM-ICU? (Select all that apply) 4. You have completed the CAM-ICU on Ms. Potter and review the worksheet results, which include: She meets the CAM-ICU criteria for delirium. • 3 errors when attempting to correctly identify the letter A • RASS score of +1. • Lifted 3 fingers on right hand none on left when commanded to do so. • Answered 2 of 4 yes/no questions correctly. • Her baseline GCS was 15 and is now 13. Based on these data, which conclusion can you draw? 5. You are reviewing Ms. Age of 74 years Potter’s EHR to check for Her recent severe pneumococcal pneumonia. possible risk factors that could have precipitated her delirium. Which of the ICU patient status following of Ms. Potter’s Recent mechanical ventilation support EHR data place her at risk for an acute confusional cognitive disorder? Select all that apply. 6. You are aware that certain drugs have been associated with development of delirium. For this reason, you are reviewing Ms. Potter’s prescribed medications. alprazolam (Xanax) ranitidine (Zantac) acetaminophen (Tylenol) Which of her medications have been associated with increased risk for delirium? Select all that apply. 7. You are talking with Ms. “Delirium is an acute onset problem, meaning that the Potter’s daughter, symptoms develop quickly.” Rebecca, about her mother’s altered cognitive “People with dementia develop symptoms slowly over status and the CAM-ICU months to years.” results. During your conversation she states, “People with delirium usually alternate between being “I’m really confused about hypoactive and hyperactive.” the difference between delirium and dementia. We hear a lot about dementia, but I’ve never really learned about delirium. Can you explain them to me?” Which statements accurately reflect dementia and delirium. Select all that apply. 8. You are currently Identification of underlying cause reporting on Ms. Potter’s mental status changes during interdisciplinary rounds. The contents of your verbal report should include patient data that help achieve what essential management goal specific to Ms. Potter’s changed cognitive status? 9. You and the ICU interdisciplinary team have developed an evidence-based delirium management plan for Ms. Potter, and new orders are being written. Which of the following deliriumfocused interventions should you include in your plan of care? Select all that apply. Reorient to room environment, staff, and activities as needed and provide orientation cues. Maintain quiet, calm environment, reducing stimuli and unnecessary noise. Promote adequate sleep and rest, maintaining normal day and night light variations. Encourage family visitation throughout day. Administer haloperidol (Haldol) as ordered for severe agitation. 10. You have A new onset catheter-related UTI may be contributing to Ms. Potter’s onset of delirium. implemented the latest orders written for Ms. Potter and are now reviewing the latest lab results and new orders. What tentative conclusions can you draw regarding these latest data? 11. Ms. Potter is resting Maintain intake and output balance. quietly and you are doing Initiate a progressive ambulation regimen. some preliminary consideration of how her Assure that the patient’s glasses are on during the plan of care should be revised to prevent future daytime. occurrences of delirium once this current episode has been resolved. In addition to her current delirium-related interventions, what additional interventions do you recommend? Select all that apply.