NextGen UNFOLDING Reasoning
Atrial Fibrillation/Heart Failure (2/2)
Suggested Answer Guidelines
Bill Hill, 71 years old
Primary Concept
Perfusion Gas Exchange
Interrelated Concepts (In order of emphasis)
• Clinical judgment
• Patient education
• Communication
• Collaborati...
Primary Concept
Perfusion Gas
Exchange
Interrelated Concepts (In order of emphasis)
• Clinical judgment
• Patient education
• Communication
• Collaboration
NCLEX Client Need Categories Covered in Case NCSBN Clinical Covered in Case
Study Judgment Model Study
Safe and Effective Care Step 1: Recognize Cues ✓
Environment
• Management of Care ✓ Step 2: Analyze Cues ✓
• Safety and Infection Control Step 3: Prioritize Hypotheses ✓
Health Promotion and Maintenance ✓ Step 4: Generate Solutions ✓
Psychosocial Integrity ✓ Step 5: Take Action ✓
Physiological Integrity Step 6: Evaluate Outcomes ✓
• Basic Care and Comfort ✓
• Pharmacological and ✓
Parenteral Therapies
• Reduction of Risk Potential ✓
• Physiological Adaptation ✓
, lOMoARcPSD|6070128
Part I: Initial Nursing Assessment
Present Problem:
Bill Hill is a 71-year old male with a past medical history of benign prostatic hyperplasia (BPH), peripheral vascular
disease and myelodysplastic syndrome two months ago after a bone marrow biopsy. Six weeks ago Bill was admitted
because he had a syncopal episode. He was diagnosed with paroxysmal atrial fibrillation and acute anemia with a Hgb of
6.9 and received a transfusion of one unit of PRBCs.
Bill presents to the emergency department today with increasing weakness, fatigue, sinus congestion, fever, and chills
the past week. He was around grandchildren with colds two weeks ago. Bill woke up at 6 am today feeling short of breath,
harsh coughing with clear sputum. He had difficulty walking back to bed after getting up to the bathroom. His wife who is
a retired nurse noted that he was much more pale, took his vital signs, which were BP: 96/62, HR: 140 irreg, RR: 24. Bill
admits to losing 15 lb (6.8 kg) over the last 2-3 months.
Personal/Social History:
Mr. Hill is retired and lives at home with his wife in a rural area. His two adult children live out of state. He has been an
active, healthy male who enjoys gardening, hunting, and splits wood to heat his home in the winter. Since he has been
dealing with changes in his health he has not been able to participate in these activities as much. In the past, he has been
employed as a minister who has a strong Christian faith. He denies smoking, alcohol use, and illicit drug us
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential)
RELEVANT Data from Clinical Significance:
Present Problem:
Myelodysplastic syndrome diagnosed one This is a categorical diagnosis, and this patient needs another bone
month ago marrow biopsy to obtain a definitive diagnosis, per his oncologist, and
treatment plan. Until this happens, the underlying disease is not treated
and can contribute to this patient’s symptoms.
Diagnosed with paroxysmal atrial fibrillation This recent medical history is relevant to his current presentation. He
and acute anemia with a Hgb of 6.9 and may again be anemic and be in atrial fibrillation that may be
received a transfusion of one unit of PRBCs. contributing to his current cluster of complaints. Consider the causes:
anemia, low BP, dehydraton.
What started as a viral infection could progress to more severe lung
Bill presents to the emergency department
pathology or secondary infection. When examining patient listen to the
today with increasing weakness, fatigue, sinus
lungs for pneumonia, pleural effusion, allergy, infection? What physical
congestion, fever, and chills the past week.
findings align? Weakness can indicate an electrolyte imbalance,
dehydration, sepsis, and anemia.
He was around grandchildren with colds two This raises the concern of a primary infectious source of his
weeks ago. current problem.
Bill woke up at 6 am today feeling short of Indicates a problem with the respiratory or cardiac system. will
breath, harsh coughing with clear sputum. require a thorough assessment of the respiratory and cardiac systems
and additional lab and diagnostic work.
He had difficulty walking back to bed This degree of weakness is significant and a clinical RED FLAG that
after getting up to the bathroom. indicates the underlying severity of his current cluster of complaints.
His wife who is a retired nurse noted that he Being pale could be multifactorial and could include severe anemia
was much more pale and took his vital signs, and hypotension. His initial vital signs are concerning because his
which were BP: 96/62, HR: 140 irreg, RR:
blood pressure is too low, his heart rate is too high and his respiratory
24.
, lOMoARcPSD|6070128
rate is too high and causing shortness of breath. Knowing that he has a
history of paroxysmal atrial fibrillation, knowing that his heart rate is
this rapid and irregular is a clinical red flag for atrial fibrillation been
a contributor a cause to his current problem.
Bill admits to losing 15 lb (6.8 kg) over the
last 2-3 months. Weight loss is more than expected and another clinical RED FLAG that
requires further investigation by the nurse.
RELEVANT Data from Social History: Clinical Significance:
He has been an active, healthy male who New onset of disease and change in condition for patient and
enjoys gardening, hunting, and splits wood to wife.These psychosocial considerations will need to be integrated into
heat his home in the winter. the plan of care once he is admitted to the hospital.
Since he has been dealing changes in his Identify the psychosocial impact of this change in status upon
health he has not been able to participate in his overall emotional and mental well-being.
these activities as much.
In the past, he has been employed as a This defines the patient’s values and relates to the decisions made by
minister who has a strong Christian faith. this patient. Consider supporting the patient’s Christian perspective by
offering pastoral care.
You quickly review this patient’s past medical history and home
medications in the electronic health record:
What is the RELATIONSHIP of the past medical history and current medications? Why is your patient receiving these
medications? (Which medication treats which condition? Draw lines to connect)
Past Medical History: Home Medications:
Benign prostatic hypertrophy (BPH) Clopidogrel 75 mg PO daily
Peripheral vascular disease (PVD) Tamsulosin 0.4 mg PO
Myelodysplastic syndrome (MDS) daily Atenolol 50 mg PO
Paroxysmal atrial fibrillation daily
(PAF)
Benign prostatic hypertrophy
(BPH)>>>tamsulosin Peripheral vascular disease
(PVD)>>>clopidogrel Myelodysplastic syndrome
(MDS) no medications Paroxysmal atrial
fibrillation (PAF)>>>atenolol
Bill is transferred to a cart in the ED and quickly brought to a room. You
introduce yourself, and collect the following clinical data:
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment:
T: 99.6 F/37.6 C (oral) Provoking/Palliative:
P: 148 (irreg) Quality: Denies
R: 24 (reg) Region/Radiation:
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