Select case of your choice below and answer questions; click on
underlined cases with mouse:
1. Chemotherapy: Hodgkin's
Disease
2. Chest
Trauma: Pulmonary Contusion, Flail
Chest, ARDS
3. Neuro
Trauma: Increased Intracranial
Pressure
I. CASE STUDY--CHEMOTHERAPY:
Four months ago, Mr. J.F. , age 45, was diagnosed with Hodgkin's
Disease, Stage IIIB, after a visit to his doctor and referral to an
oncologist with complaints of weight loss, fever, night sweats, and
progressive shortness of breath. A CT scan showed mediastinal and
peritoneal lymph node involvement. Physical exam was significant for
splenomegaly and enlarged inguinal nodes. A lymph node biopsy showed
Reed-Sternberg cells. A staging laparotomy was done along with a
splenectomy. After sufficient healing had taken place, radiation
treatment was carried out over several weeks. Now, Mr. J.F. is back
for his course of chemotherapy. LFTs and CBC are WNL, as are PT and
PTT. Mr. J.F. is 6' tall and 160 lbs.
The following schedule of chemo drugs will be given together as a
"cycle". The cycle is administered for the first 2 weeks followed by
a resting or recovery period of 2 weeks:
*MOPP
M = Mechlorethamine(nitrogen mustard) 6mg
IV/m2 on days 1 and 8
O = Oncovin(vincristine) 2.0mg IV/m2 on
days 1 and 8
P = Procarbazine(Matulane) 100mg po/m2
continuously days 1 through 14
P = Prednisone 40mg po/m2 continuously days
1 through 14(only during cycles 1 and 4)
After the recovery period, the ABVD regimen
will be administered (on one day) followed by a 2-week recovery
period:
*ABVD
A = Adriamycin(doxorubicin) 25mg
IV/m2
B = Bleomycin(Blenoxane) 10units
IV/m2
V = Vinblastine(Velban) 6mg
IV/m2
D = Dacarbazine (DTIC) 375mg
IV/m2
Before each round, Mr. J.F. will be premedicated with Zofran
100mg. IV, Benadryl 50mg. IV and Dexamethasone, 4mg IV. All
medications will be given through a PICC line which was previously
inserted for this purpose.
Questions:
1. What is the rationale for ordering the baseline lab
work?
2. Why are chemo drugs given in combinations and in
"cycles"?
3. How is the dosage determined? The route?
4. What is the reason for the premedication?
5. What are the major toxic effects of the chemo drugs and
why?
6. Discuss the nursing care of the patient receiving
chemotherapy relating to neutropenic precautions and bleeding
precautions.
7. Other nursing care considerations?
2. Case Study--Chest
Trauma: Pulmonary Contusion, Flail Chest,
Pneumothorax, Cardiac Tamponade, ARDS
Mike Arnold, a 19 y.o. male, is brought into the ER following a
MVC(Motor Vehicle Crash) in which he, the driver, sustained blunt
trauma to the anterior trunk from striking the steering wheel and
dashboard. The patient is alert, short of breath, and c/o acute chest
pain, especially on the right. He is on a backboard with cervical
spine restraint, and has O2 @ 3l/min. via N/C and one peripheral I.V.
line with Ringer's running at 125cc/hr. As he is being taken to
Trauma Room 1, the paramedics report that his latest baseline
assessment shows: GCS=15, B/P 90/60, P=130 regular, R=30, shallow
with paradoxical breathing and hemoptysis present, O2 sats of 93, and
no other apparent injuries except for the chest trauma and possible
abdominal trauma. The police found an empty six pack in the car.
Blood is drawn for ABGs, CBC, Chem 21, Type and cross for 4 units,
and a Medical Blood Alcohol level. After initial assessment, the ER
team prepares to insert a chest tube on the right and perform a
peritoneal tap. Cross table C-spine and chest films are ordered.
Abdominal series is ordered with pending CT of abdomen without
contrast depending on the results of the abdominal series. All of a
suddent, the patient yells, "I have to throw up. . . ."
What should this initial ER assessment include, and what
interventions will be immediately necessary?
What would you expect the blood gases to show?
What are paradoxical respirations and what would you suspect as
the cause in this case? What about the etiology of
hemoptysis?
What assessments would lead up to the decision to place a chest
tube?
After the chest tube is inserted, 200cc of blood drains from the
chest into the autotransfusion/chest drainage system. The chest x-ray
that was taken indicates a pulmonary contusion, fractures of the ribs
1 thru 4 on the right hemithorax, and a proper placement of a chest
tube and jugular central line. C-spine films are negative. The
patient has been medicated for pain with I.V. MS, 3mg, and reports a
decrease in pain from "8" to "5" within minutes.
Fifteen minutes following this report, the patient's LOC
deteriorates to obtunded with withdrawal to pain, B/P 85/70, P=105,
irregular, R=14 and slowing. Cardiac monitor shows sinus tachycardia
with PVCs, and O2 sats are now 89. CV exam reveals muffled heart
sounds, JVD, and faint peripheral pulses. Skin is cool and moist.
Urinary output decreased to 25cc. in last hour. The girlfriend
arrives and becomes hysterical in the patient's cubicle when she sees
him.
What may be happening to the patient at this point?
What is the expected treatment?
What nursing interventions are necessary?
After these emergency interventions, Mike stabilizes enough to be
taken up to the O.R. for exploratory surgery to control the bleeding
and repair injured structures. Postoperatively, he is taken to ICU
intubated on a Mechanical Ventilator with the following settings:
FiO2= 100%, Vt(Tidal Volume)=800, Respiratory Rate=10 and
Mode=SIMV(Synchronized Intermittent Mandatory Ventilation). After an
hour, despite 100% O2, Mike's ABGs are: ph=7.32, pCO2=55, HCO3=17 and
pO2=50; O2 sats=88. Monitor shows sinus tachycardia with occasional
PVCs. A stat chest x-ray reveals patchy infiltrates. The PAWP is 18.
B/P is 90/50 and being maintained with a Dopamine drip. The high
pressure ventilator alarm continues to trigger despite the fact that
Mike's airway is kept cleared of secretions with p.r.n. suctioning
and despite the fact that he is sedated.
What does this total picture suggest?
What is causing the high pressure alarm to trigger despite a
clear airway in a sedated patient?
What treatment would be initiated at this point?
What is PEEP and give the rationale for its use?
What are the complications of Mechanical Ventilation?
What are nursing care priorities for a patient with an
endotracheal(ET) tube on a ventilator?
Calculate the following: Order: Dopamine 10mcg/kg/min to maintain
B/P above 90 systolic(Mike is 176 lbs.)
Supply: 400 mg Dopamine in 250cc D-5-W. Set pump at:
_____cc./hr.
After 10 days, Mike is improving slowly, and has received
multiple infusions of TPN, lipids, antibiotics, and blood products.
However, he cannot be weaned off the ventilator at this time, so a
decision is made to do a tracheotomy for airway management until the
weaning process can be completed. He is alert at this time and
appears anxious.
How would you explain why he needs the tracheotomy
procedure?
What other teaching would you initiate at this time?
How would you give him emotional support?
3.
Case Study--Neuro Trauma and Increased Intracranial
Pressure:
Situation: Two days ago, Mr. John Maitland,
age 23, was involved in an MVC(Motor Vehicle Crash) and incurred
injuries resulting in closed head trauma; a right pneumothorax, and
blunt abdominal trauma. He currently has a GCS(Glasgow Coma Scale) of
7 (eye opening=1; verbal=1; motor=5), and "dolls eyes" are present.
You are assigned to take care of him today in the ICU. John is lying
in bed with eyes closed when you come into his cubicle. Her has a
intraventricular catheter in place connected by pressure tubing to an
ICP monitoring system, an arterial line, a Swan-Ganz pulmonary artery
catheter, an N/G tube currently draining coffee ground material and a
foley catheter. He is on a hypothermia blanket and is orally
intubated on a ventilator. He also has a right chest tube in place to
water seal drainage and set at -20cm suction. A peritoneal tap was
done in the ER to determine if exploratory surgery was necessary; it
was negative. His medications include:
Pepcid 20mg I.V.
b.i.d.
Lasix 40mg I.V.P.
b.i.d.
Claforan 1 Gm. I.V.
q8h.
Gentamycin 400mg. I.V.
q8h.
Maalox 30cc. thru N/G q4h.--clamp
tube for 30 min. afterwards
Thorazine 25mg. I.M. q3h. prn for
shivering
Codeine gr. i I.M. q4h. prn for
pain
Versed 0.2mg./kg. I.V.P. q2h. prn
for agitation
Mannitol 1.5 Gm./kg. of a 25%
solution over 30 min. for sustained ICP q4h. prn
Dopamine 10mcg/kg/min, titrate to
keep CPP above 60mmHg.
Ringers Solution 1000cc. I.V. at
rate of 100cc/hr.
TPN per MST
protocol
Other orders for John are:
Ventilator settings should be
adjusted to maintain pCO2 between 30-35; keep O2 sats >95; suction
prn
Hypothermia Blanket to maintain
body temperature between 96-97 degrees
Fahrenheit
Neuro checks, vital signs, PAWP
readings and ICP readings q1h.
Urine output q2h. with specific
gravity q2h.
Fluid intake to maintain blood
osmolarity at 310mOsm--follow protocols for fluid
resuscitation/restriction
Seizure
Precautions
----------------------------------------------------------------------------------------------------------------
Questions:
1. What are the priorities of care for
this patient during your shift today?
2. What is the rationale for the
osmolarity level of the serum? What drugs are be used to aid the
process?
3. Describe positions that are best for
this patient to reduce ICP and positions and activities to avoid for
a patient with increased ICP.
4. Explain the rationale for the
hypothermia order.
5. Explain the rationale for the
ventilator and O2 sat parameters. What would his blood gases look
like?
6. What drugs are ordered for this
patient that specifically reduce or control ICP? Give the action and
rationale for each.
7. Give the rationale for the other drugs
ordered.
8. In general, what category of drugs
should be avoided with increased ICP and why?
When routinely suctioning John through
his ET tube, you see "A" or plateau waves on the ICP monitor.
9. What would you do in this situation?
Be prepared to give a rationale for your answer:
a. Stop suctioning
immediately
b. Give Mannitol as
ordered
c. Lower his head
d. Note the period of suctioning on the
graphic readout from the ICP monitor
10. If John becomes markedly restless and
begins thrashing about, what assessments would you make and what
nursing interventions would be appropriate at this
point?
As you do John's neuro check, he no
longer responds to painful stimulus by withdrawing from the stimulus,
but, instead, responds with a decorticate posture.
11. What area of his GCS would change,
and what is now his total score?
12. What nursing assessments and
interventions would be necessary now?
13. List other changes in John's signs
(other than his ICP pressure readout) that would occur with
increasing ICP.
John's level of consciousness continues
to deteriorate and everytime you move him for care, he goes into
decebrate posturing.
14. You report this to his neurosurgeon
who may order what medical intervention at this point?
At 10:00 a.m., John's right pupil
becomes dilated and fixed; this is a sudden change from fifteen
minutes before. Doll's eyes are now absent.
15. What is the significance of these
events, and what medical and nursing interventions are
needed?
Sites for more case studies
dealing with trauma:
Case Study
#4: Spinal Cord Injury
Zack Wright, age 20, was brought into the
ER after being pulled out of a local pond and resuscitated. He had
unknowingly dived into shallow water and sustained a cervical spine
injury with no movement or sensation below the level of the
clavicles. At the scene, his GCS was 10, and he was intubated using
the jaw thrust maneuver as he was having difficulty breathing and
given 100% O2 via ambu bag. In route to the hospital, he was
transported on a backboard with a cervical collar. He has no signs of
other injuries. He is alert, appears very anxious, and is grimacing.
PERRLA. The skin below the level of injury is very cool to touch.
There is no spontaneous movement of his extremities. Vital signs are
as follows: B/P=90/60, P=45, R=27 per ambu bag. An I.V. of Ringer's
is running at 100cc/hr. via an antecubital site.
1. What assessments would be made in the ER and compared to the
field assessments?
A--intubate, check blood gases and O2 sats, suction as needed;
insert N/G tube to suction
B--give 100% O2 via ventilator; assess symmetry of chest
movement and placement of ET tube
C--Place electrodes to monitor patient's cardiac status and
start another line--preferably central-- to give fluids according to
protocol for fluid resuscitation and to maintain B/P and urine output
at ordered parameters; check vital signs frequently and treat for
spinal shock; insert Foley
D--rule out head injury--continue to check GCS; check level of
sensory and motor functioning and compare to paramedics report(cord
edema can extend upward and worsen deficits)
E--expose to check for other injuries, but-----
F--keep patient warm since the level below his injury is cool
with lack of sweating(poikilothermia) due to temporary dysruption of
Autonomic Nervous System
G--Monitor vital signs & treat for pain which can occur at
level of injury
H--continue to do frequent head to toe assessments for any
deterioration and report to physician
I--inspect posterior surfaces by logrolling patient
Assessment as to whether the patient needs to go to surgery
immediately--is there hemorrhage or CSF blockage at the site of
injury or worsening neuro deficits with paralysis and sensory loss
above the clavicles?
2. What state do the vital signs indicate?
Spinal shock--hypotension, bradycardia and altered
respirations--fast or slow depending on level of injury;
Treat symptomatic bradycardia with Atropine as ordered
3. How does a spinal cord injury affect the autonomic nervous
system?
Lack of temperature control and sweating below level of injury,
no peristalsis, no bladder, bowel or sexual function, positional
hypotension, no reflexes; some of these functions will return when
spinal shock is over, but in an exaggerated or erratic
manner.
4. What drugs would the patient be given in the ER and for what
reasons?
High doses of Solu Medrol I.V. within 6-8hrs. after injury to
reduce spinal cord edema and lessen level of nerve dysfunction; pt.
would also be given pain control, possibly anxiolytics, Atropine for
bradycardia, vasopressors for low B/P, Pepcid or similar drug for
prevention of stress ulcer.
5. What other treatments/interventions are necessary at this
point?
Labs? Xrays?
CBC, U/A, clotting profile, Blood chemistry, chest film,
C-spine films to assess fracture- dislocation of vertebrae and if
stable or unstable
Treatments?
Pt. would be placed in cervical traction with Gardner well
tongs and weights on a special turning frame or Roto Rest Bed to
immobilize him and prevent movement of injured spine; the bed would
constantly rotate to prevent complications of immobility like
pneumonia, pressure sores, DVT, etc. Later, a Halo device would be
placed on the patient when he goes to rehab. so he is able to get out
of bed to a wheelchair--Pin care would be done daily with cervical
traction
SCD or Ted hose would be placed on the patient to prevent DVT;
Lovenox would be started
Surgery may be done later if traction does not reduce fracture
satisfactorily; patients with thoracic or lumbar vertebral fractures
may need open reduction and spinal fusion at a later date to
stabilize spinal column; they would be put in a body brace following
this type of surgery.
Interventions?
TPN would be started for nutrition to meet his increased
metabolic needs; P.T. for bracing and range of motion; chaplain to
attend to spiritual needs
6. Zack's family arrives and asks if he is paralyzed. What do
you say?
You would say that the extent of his motor loss cannot be fully
determined at this time until the acute phase is over and spinal
shock is over; give them emotional support without destroying hope or
giving false reassurances.
7. What are other emotional and psychosocial concerns related
to this type of injury?
Grieving for multiple losses: loss of freedom and mobility,
sexual dysfunction, loss of other bodily functions like bladder and
bowel control, loss of independence, often, loss of relationships or
potential relationships(significant others often leave the injured
person, or he becomes unattractive to potential mates). Pts. may
become depressed and suicidal when faced with all these losses, and,
since many may have drug or alcohol dependence, must be watched
carefully.
8. How long will he be in the Intensive Care Unit?
Until spinal shock is resolved and any breathing or pulmonary
issues are stabilized
After two weeks in ICU, Zack is transferred to a rehab unit. A
trach was done as he needs help clearing his secretions, although he
has diaphragmatic, spontaneous breathing at this point. The trach
also protects the airway as he is on continuous tube feedings via
Entreflex tube at 60cc./hr. He has some movement in his upper arms
and feeling to the nipple line. He is in a Halo device, but his blood
pressure drops significantly when his head is raised. New orders
read:
1. Wean off trach--use Passy-Muir valve with instructions by
speech therapist
These valves help patients relearn swallowing without
aspiration; they can speak with the cuff of the trach tube deflated
for if the trach tube is fenestrated.
2. Regular soft diet when tolerated
A diet high in protein, carbohydrates and fat calories is
essential to prevent negative nitrogen balance, regain strength and
bolster the immune system. Supplements will be given as necessary
orally or by tube.
3. Intermittant Catheterization for residual every 4 hours;
increase to every 6 hours as residuals decrease to <100cc
It is possible for a quad such as Zack who has return of
autonomic reflexes that empty the bladder after spinal shock is over,
to gain control over the pattern of urination through stimulation and
intermittent catheterization. After the foley is discontinued, he
will be catheterized for residual on a schedule such as every 4 hrs.
Then, after his residual decreases, his cath routine will be advanced
to every six hours, every eight hours, and so on. Before each cath,
the patient is taught to "crede" or put pressure over the pubic bone
or to stroke the thigh to get the bladder to empty spontaneously; the
cath for residual is then carried out to completely empty the
bladder. The patient's fluid intake must be considered in scheduling
the intermittant cath routine, and it will be taught to the patient
to do himself if he is able or to his caretakers with a clean
technique once he goes home.
Patients with lower injuries in the lumbar area(paraplegics)
will have no return of reflexes and their bladders will be
flaccid(neurogenic bladder). They will have to have a suprapubic
catheter or urinary diversion procedure such as an ileal conduit
done. Foleys are not used long term in these patients since they are
a major source of UTI and sepsis.
4. Start on Bowel Program three times per week
As with the bladder retraining program, it is possible in
patients with return of autonomic reflexes to retrain the bowel to
empty in response to digital stimulation and a Dulcolax suppository
on a set schedule, usually q.o.d. or three times per week; caretakers
must be taught to carry out this procedure since the quad cannot do
this for himself. Patients have stated that this is the most
embarrassing and difficult routine for them to accept from either
their family caretakers or hired caretakers.
Again, patients with no return of these reflexes will have a
flaccid bowel and will have to have enemas to evacuate the bowel.
These are paraplegics, however, who can usually manage this routine
themselves.
5. Reclining wheelchair with gradual adjustments to a sitting
position as tolerated
Since the autonomic nervous system cannot react smoothly or
rapidly to raise B/P in response to the upright position, quads must
be acclimated to the upright position gradually through use of a
reclining wheelchair. Their heads are gradually raised to a higher
level over days or weeks so that their B/P will gradually adjust.
Sometimes, vasopressors p.o. must be added to medication schedule to
support B/P.
6. Continue ted hose and fit for abdominal binder when up in
w/c
They also wear abdominal binders and compression stockings to
aid in venous return on position change.
7. P.T. and O.T.
P.T. for strengthening, use of special wheelchairs, fitting for
special w/c cushions to prevent pressure sores, teaching patients to
do "weight shifts" to get pressure off their hips and buttocks
periodically; O.T. for relearning as much as possible about ADLs,
fitting special braces for upper extremities or suggesting home
adaptations for independence. Rehab is a team approach with all
disciplines involved in getting the patient to the highest level of
functioning possible both independently and by training
caretakers.
8. Percocet 1-2 tabs every six hours for pain prn
Many patients can become dependent on drugs, so they should be
weaned as fast as possible to a nonnarcotic analgesic that is
effective in controlling their pain. If patients have parasthesias
that are painful, drugs such as Elavil or Neurontin that relieve
painful neuropathies can be prescribed.
9. Lioresal (baclofen)10 mg p.o. tid
This is a skeletal muscle relaxant that lessens painful muscle
spasms that interfere with daily functioning. Quads have spastic
muscles that are prone to spasms; Paraplegics with flaccid muscle
tone do not experience spasms.
10. Bactrim DS one tablet bid
Many patients are on prophylactic doses of urinary tract
antiseptic drugs to prevent U.T.I.s which are common and can lead to
renal dysfunction. Yearly, the patient should have a creatinine
clearance test to evaluate renal function.
11. Ativan 1 mg q6h prn for anxiety
Again, a short term course is necessary, but counseling must be
used when needed to lessen patient's dependence on this class of
drugs. An antidepressant drug will be needed for clinical
depression.
12. Vocational Rehab evaluation
Job retraining is necessary to get the patient back to being
and perceiving himself as a productive member of society.
Zack seems to be progressing on the rehab unit; after a week
he is on a routine of P.T. and O.T. bid, intermittant cath q6 hrs.,
bowel program q.o.d. on M-W-F. His head is now at 45 degrees with
stable blood pressure and he is tolerating a soft diet with in
between meal supplements. Pain is not a big problem. His affect is
passive and he is cooperative, but quiet. His family are very
overprotective at this point. One afternoon he calls you and states
he has a terrible headache, looks flushed and is complaining of nasal
stuffiness. His skin below the level of injury is cold with marked
goose bumps.
1. What is happening to Zack and what assessments and
interventions are necessary?
Zack is experiencing Autonomic Dysreflexia(A.D.)--a potentially
life threatening situation; his B/P must be taken and monitored
frequently, antihypertensives given as ordered to lower a B/P that is
frequently over 200 systolic, his head elevated and bladder checked
initially for distention(the most frequent cause of this
hyperreflexia). M.D. must be notified. If the bladder and bowel are
not the problem, the causes could range from severe muscle spasms to
pressure over a bony prominence to an ingrown toenail. The cause must
be found and relieved.
2. What other concerns need to be addressed?
Zack and his caretakers must be taught how to recognize and
deal with "A.D.", since this can occur for years after the
injury(patients with lesions above T-6).
Case Study
Prerenal Azotemia
Linda Hererra, a 45 year old businesswoman with a history of
peptic ulcer disease, presents to the Emergency Department with a 10
day history of intractable vomiting and abdominal pain. She has been
unable to keep solid foods down but has been drinking small amounts
of water at frequent intervals. She has become progressively weaker
and now complains of dizziness upon assuming an upright position. On
physical examination, Ms. Hererra appears acutely ill and pale.
Vital Signs(supine)
B/P 96/50, HR 110, Resp. 20, Temp
99F
Vital Signs(sitting)
B/P 72/38, HR 140
Physical examination is remarkable for tenting fo the skin,
sunken eyes, dry mucous membranes, flat jugular veins, absence of
axillary sweat, and epigastric tenderness. Pertinent laboratory data
includes:
Serum Electrolytes: Na= 134; K= 2.6; Cl= 70; CO2=41;
Gluc=80; Creat=4.5; BUN=112
ABGs: ph=7.55; PaCO2=50; PaO2=90; SaO2=95;
HCO3=40
Hematology Values: Hct=51; Hgb=17;
WBC=10,000
Urine Chemistries: Na=15; K=40; Cl=<10; Creat=200;
Urea=2000; Osmolarity=700
Urinalysis: Color= Dark Amber; ph= 5.0; specific
gravity=1.020; Ketones= +; Protein=neg.; Blood=neg.
Sediment: WBC= 0-1/HPF; RBC= 0-1/HPF; Casts= none;
Crystals= none
A central line is placed and reveals a central venous pressure
(CVP) of 2 cm. H2O. Volume replacement is initiated with normal
saline, and Ms. Hererra receives a total of 6 liters over 36 hours.
Six hours after initiation of IV therapy, the BUN and creatinine
levels begin to fall. Forty eight hours after admission her BUN is
12mg/dl and her creatinine is 1.0mg/dl.
Questions and Answers
1. Explain Ms. Hererra's physical findings.
2. Define prerenal azotemia and discuss its etiology and
pathogenesis.
3. What laboratory tests may be useful in diagnosing prerenal
azotemia?
4. Discuss the treatment of prerenal azotemia.
5. What nursing diagnoses apply in this case?
Chronic Renal Failure
James Brubaker is a 55 year old man who was diagnosed two years
ago with end-stage renal disease secondary to hypertension,
necessitating treatment and hemodialysis. He is dialyzed at an
outpatient clinic three times per week and is restricted to 1000 ml
of fluid/day. His medications include:
Basaljel 2 Tabs PO tid
Iberet Folate 500mg. PO qam
Os-Cal 250mg. 2 tabs PO tid with meals
Nifedipine 30mg. tid
During the past week, Mr. Brubaker had been feeling ill and was
not able to come for his dialysis appointments. In addition to his
noncompliance in meeting his scheduled dialysis appointments, Mr.
Brubaker omitted his medications on several occasions.
Today, Mr. Brubaker arrives in the Emergency Department extremely
dyspneic. Initial vital signs reflect the following:
B/P 210/120
HR 108
Resp. 36
Temp. 37.8 C
Weight 178 lbs.
He is immediately transferred to the Medical ICU. Upon arrival,
you assess Mr. Brubaker and find he is lethargic, slightly confused,
nauseated, and vomiting. He complains of chest pain, described as
moderate in intensity, diffusely located over the precordium and
worsened by deep inspiration. Neck vein distention is present. He has
rapid, shallow respirations at 36/minute. Auscultation of his lungs
reveals crackles scattered throughout the lower 2/3 of his lung
fields. A pericardial friction rub is auscultated in addition to an
S3 gallop. Pitting peripheral edema is noted bilaterally in the lower
extremities. The EKG monitor shows sinus tachycardia with occasional
PVCs. The outpatient dialysis clinic states Mr. Brubaker's dry
(ideal) weight is 160 lbs. Laboratory data reflect the
following:
