Professor Parkblackard Case Scenario For Concept Map 8 Cw 48

Professor Parkblackard Case Scenario For Concept Map 8 Cw 481l

Professor Park/Blackard Case scenario for Concept Map # 8 C.W 481L Advance Medical-Surgical. A 70-year-old man, C.W., was brought to the emergency department with a history of diarrhea for two days, including dark red stool the previous night. Upon arrival, his vital signs indicated hypotension and tachycardia, with a blood pressure of approximately 70 systolic and a pulse rate of 110. Physical assessment revealed pale skin, disorientation, weakness, and symptoms consistent with hypovolemia and possible hypoperfusion. Laboratory results showed significant abnormalities such as elevated potassium (6.9 mEq/L), elevated BUN (90 mg/dL), elevated creatinine (2.1 mg/dL), anemia (Hgb 8.4 g/dL), and evidence of infection or inflammation indicated by an elevated WBC count (16,000/mm3). His ECG showed sinus tachycardia, and additional diagnostics revealed bilateral pulmonary edema, low cardiac output, and prior cardiomyopathy with an ejection fraction of 13% and recent echo showing 35%.

The patient has an extensive medical history including idiopathic dilated cardiomyopathy, hypertension, atrial fibrillation, peptic ulcer disease, and previous episodes of hypokalemia and hypovolemia. Current medications include enalapril, warfarin, digoxin, potassium chloride, diclofenac, and tolmedin, which may influence his current condition. On admission, he was administered aggressive fluid resuscitation with lactated Ringer’s solution, and a Swan-Ganz catheter along with an arterial line were placed for hemodynamic monitoring. Vital signs reflected ongoing instability, with blood pressure of 98/52, pulse 118, a respiratory rate of 26, and persistent disorientation and confusion.

Advanced interventions included inotropic support with Levophed (norepinephrine), mechanical ventilation for respiratory failure, and broad-spectrum antibiotics (Zosyn). His labs indicated multiple organ dysfunction, including renal impairment (creatinine 2.1, BUN 90), metabolic acidosis (arterial pH 7.27, HCO3 19.8), and evidence of infection (elevated procalcitonin 1.5). The patient's clinical course included significant fluid shifts, ongoing bleeding evidenced by blood-tinged NG suction, skin breakdown with edema, and signs of heart failure exacerbation.

The social history indicates that C.W. lives at home with his wife, practices Judaism, and owns a business that has been impacted by his illness. He has a supportive family but expresses a desire for independence and reluctance to seek help. His clinical management involves optimal medical therapy, close monitoring of hemodynamics, electrolyte balance, infection control, and planning for ongoing rehabilitation and discharge considerations addressing his home support system and spiritual needs.

Paper For Above instruction

Introduction

The case of C.W. exemplifies the complexity of managing elderly patients with multimorbidity presenting with acute decompensations rooted in pre-existing chronic conditions such as cardiomyopathy, hypertension, and peptic ulcer disease. Rapid assessment, stabilization, and comprehensive planning are essential to improving outcomes in such critically ill patients. This paper discusses the pathophysiology, medical management, psychosocial considerations, and discharge planning pertinent to C.W.'s case, grounded in current nursing and medical standards.

History of Present Illness (HPI) and Pathophysiology of Admitting Diagnosis

C.W.'s presentation of dark red diarrhea suggests gastrointestinal bleeding, likely from a peptic ulcer, as evidenced by his history. The ongoing diarrhea for two days indicates fluid and electrolyte losses, which precipitated hypovolemic shock. His hypotension and tachycardia reflect compensatory responses to hypovolemia and decreased cardiac output. The significant anemia (Hgb 8.4) and elevated BUN/Cr ratio are indicative of volume depletion and possible gastrointestinal bleeding (Miller et al., 2018). His pre-existing cardiomyopathy with low ejection fraction (13%) impairs his ability to tolerate hypovolemia, worsening his clinical condition (Mann et al., 2019). Additionally, hypokalemia and effects of medications such as diuretics, NSAIDs (diclofenac), and ACE inhibitors influence his electrolyte and renal status (Kumar et al., 2020).

Medical, Surgical, and Social History

• Medical History: Idiopathic dilated cardiomyopathy, hypertension, atrial fibrillation (formerly controlled), peptic ulcer disease, hypokalemia, heart failure.
• Surgical History: Past cardiac catheterization, endoscopy for ulcer cauterization.
• Social History: Resides with wife at home, practices Judaism, owns a business disrupted due to illness, maintains a strong family support system, desires independence.

Pathophysiology of Medical History

1. Idiopathic Dilated Cardiomyopathy: Characterized by dilation of ventricular chambers leading to systolic dysfunction, reduced ejection fraction, and heart failure symptoms (Taylor et al., 2020).
2. Hypertension: Chronic hypertension causes increased afterload, hypertrophy, and subsequent myocardial stress contributing to cardiomyopathy progression (Kumar & Gupta, 2019).
3. Peptic Ulcer Disease: Mucosal erosion exposing blood vessels can lead to gastrointestinal bleeding, precipitating hypovolemia and anemia (Lau et al., 2021).

Medical Management and Orders

Management focuses on stabilizing hemodynamics, correcting electrolyte imbalances, controlling infection, and preventing further bleeding:

• Fluid resuscitation with isotonic solutions like lactated Ringer’s.
• Electrolyte correction, especially potassium repletion to correct hyperkalemia or hypokalemia risks. His potassium is critically high at 6.9 mEq/L, requiring cautious correction (Kumar et al., 2020).
• Vasopressor support with Levophed to maintain MAP > 65 mm Hg.
• Antibiotics (Zosyn) to address possible infection.
• Blood products if indicated by ongoing bleeding or anemia.
• Medication adjustments: holding NSAIDs and ACE inhibitors temporarily; monitoring digoxin levels due to renal impairment.
• Advanced monitoring with Swan-Ganz catheter and arterial line for accurate hemodynamic assessment.

Pharmacological Considerations

Numerous medications have to be carefully titrated:

• Enalapril: An ACE inhibitor to decrease afterload; this needs adjustment considering renal function and blood pressure (Mann et al., 2019).
• Warfarin: To prevent thromboembolism; requires close INR monitoring due to bleeding risk.
• Digoxin: Heart failure management; renal impairment raises toxicity risk, necessitating careful serum level monitoring.
• Potassium chloride: Electrolyte repletion, cautious to avoid hyperkalemia, especially with renal impairment.
• NSAIDs (Diclofenac): To control pain but can impair renal function and exacerbate hypertension; temporarily discontinued.

Psychosocial and Cultural Considerations

C.W.'s religious practices and desire for independence significantly impact care planning. Respecting his religious beliefs involves facilitating access to synagogue services as tolerated and considering spiritual supports. Financial strain due to his inability to manage his business is a source of stress, necessitating social work involvement for financial and community support. Maintaining patient dignity and autonomy is critical, especially given his age and personal preferences (Kim & Lee, 2022).

Diagnostic Testing and Laboratory Results

Patient Education and Discharge Planning

Education focuses on medication adherence, recognizing signs of gastrointestinal bleeding, managing heart failure symptoms, and lifestyle modifications. Given his dependence on others and financial constraints, social services, home health, and spiritual support are essential. Emphasizing the importance of follow-up in cardiology and gastroenterology clinics helps prevent readmission. Post-discharge, his care will involve medication adjustments, dietary counseling, and monitoring renal and cardiac function.

Conclusion

The case of C.W. illustrates the integration of physiological, pharmacological, psychosocial, and cultural considerations in managing complex patients with multiple comorbidities. Critical thinking, ongoing assessment, and patient-centered care are essential to optimize outcomes. Addressing his medical needs while respecting his cultural and personal preferences ensures a holistic approach to recovery and long-term health maintenance.

References

• Miller, K. L., et al. (2018). Gastrointestinal bleeding in the elderly: diagnosis and management. Journal of Clinical Gastroenterology, 52(4), 321-329.
• Mann, D. L., et al. (2019). Heart failure: physiology, diagnosis, and management. Circulation, 139(24), e1035-e1056.
• Kumar, P., & Gupta, S. (2019). Hypertension and associated cardiac remodeling. Heart Failure Clinics, 15(3), 329-338.
• Lau, J. Y., et al. (2021). Peptic ulcer disease and gastrointestinal bleeding management. Gastroenterology Clinics, 50(3), 505-517.
• Kumar, S., et al. (2020). Electrolyte disturbances in acute illness. American Journal of Kidney Diseases, 75(2), 291-297.
• Kim, H., & Lee, S. (2022). Spiritual care and cultural sensitivity in nursing practice. Journal of Holistic Nursing, 40(1), 48-57.
• Taylor, R. S., et al. (2020). Pathophysiology of dilated cardiomyopathy. Nature Reviews Cardiology, 17(3), 157-172.
• Harvard Health Publishing. (2021). Understanding laboratory tests: procalcitonin and BNP. Harvard Medical School.
• Lau, W. C., et al. (2021). Gastrointestinal bleeding and peptic ulcer management strategies. World Journal of Gastroenterology, 27(34), 5741-5754.
• Jones, N., & Williams, T. (2020). Caring for older adults with multiple chronic conditions: a review of best practices. Journal of Gerontological Nursing, 46(10), 11-19.