Common Test Week 8 Revision Model Answer PDF

## CT Revision - Results ### Attempt 1 of Unlimited - Written 02 December 2024 4:10 PM - 02 December 2024 4:17PM - Your CT revision answers have been submitted successfully. - To study and log in your first attempt before Week 8 tutorial. ### Attempt Score: 2 / 140 ### Overall Grade (Last Attemp...

## CT Revision - Results ### Attempt 1 of Unlimited - Written 02 December 2024 4:10 PM - 02 December 2024 4:17PM - Your CT revision answers have been submitted successfully. - To study and log in your first attempt before Week 8 tutorial. ### Attempt Score: 2 / 140 ### Overall Grade (Last Attempt): 2 / 140 ## Question 1 (Mandatory) ### Scenario 1 (Question 1-9) - Ismail, a 59-year-old, presented to the emergency department (ED) complaining of acute shortness of breath, wheezing and cough. - For the past three days, his inhalers have been ineffective, and he has a productive cough of thick yellowish sputum. - His symptoms began 3 days ago and progressively worsened. ### Assessment On Arrival (OA) - **Neurological:** Alert and orientated, but in distress with difficulty breathing. - **Respiratory:** Wheezes throughout all lung fields, with use of accessory muscles to breathe. Sputum is mucoid and purulent. ### His parameters were as follows: | Parameter | Value | | --------------------------- | ------------------------------ | | Heart Rate | 125 beats per minute (bpm) | | Blood Pressure | 130/72 mmHg | | Respiratory Rate | 28 breaths per minute | | SpO2 | 90% on room air | | Temperature | 38.4 °C | ### Doctor's Order: - Oxygen at 28%, 4 litres per minute (LPM) via venturi mask - Nebulisation of salbutamol: ipratropium: sodium chloride 2:2:1 every 4 hourly/PRN - PO prednisolone 40 mg OM - PO paracetamol 1 g 6 hourly/PRN - IV ampicillin / sulbactam (Unasyn) 1.5g q6h - The doctor diagnosed Ismail with acute exacerbation of asthma and pneumonia. ### a. Describe four (4) prioritized nursing interventions based on "Ineffective breathing pattern related to retained mucous secretions." Provide a rationale for each nursing intervention. (Mark 8) | Nursing Intervention (any 4, 1 mark each) | Rationale (any 4, 1 mark each) | | ----------------------------------------------------- | --------------------------------------------------------------------------------------------- | | 1. Monitor vital signs including heart rate (HR), blood pressure (BP), respiratory rate (RR), and SpO2 hourly/as ordered. | Establish baseline data and monitor for disease progress. Increased BP, RR, and HR occur during the initial hypoxia and hypercapnia. | | Assess the respiratory rate, depth, and rhythm hourly/as ordered. | Changes in the respiratory rate and rhythm may indicate an early sign of impending respiratory distress | | 2. Assess breath sounds and adventitious sounds such as wheezes and stridor. | To monitor for complications of pneumonia or bronchospasm | | 3. Place patient in a Fowler's or high-Fowler's position. | To promote maximum lung expansion and breathing. | | 4. Administer O2 at 28%, 4 litres per minute (LPM) via venturi mask since SPO2 90% | Reduce hypoxia and improve tissue perfusion. | | 5. Administer Nebulisation of salbutamol: ipratropium: sodium chloride2:2:1 every 4 hourly/PRN as ordered | To stimulate Beta 2 receptors, resulting in bronchial smooth muscle relaxation and bronchodilation. To block cholinergic receptors, resulting in bronchial smooth muscle relaxation and bronchodilation. | ### b. Describe four (4) prioritized nursing interventions based on "ineffective airway clearance related to increased production of secretions and retained secretions". Provide a rationale for each nursing intervention. (Mark 8) | Nursing Intervention (first 4 are marked) | Rationale (first 4 are marked) | | ----------------------------------------------------- | ----------------------------------------------------------------------------------------------------------------------------------------------------- | | 1. Monitor vital signs including heart rate (HR), blood pressure (BP), respiratory rate (RR), and SpO2 hourly/as ordered. | Establish baseline data and monitor for disease progress. A drop in oxygen saturation levels, increase RR may indicate worsening air way obstruction. Changes in the respiratory rate and rhythm may indicate an early sign of impending respiratory distress | | 2. Assess breath sounds and adventitious sounds such as wheezes and stridor. | To monitor for complications of pneumonia or bronchospasm | | 3. Place the patient in a Fowler's or high-Fowler's position. | To promote maximum lung expansion and expectoration of secretions. | | 4. Administer nebulisation Salbutamol: Ipratropium Bromide: Sodium Chloride 2:2:1 every 4 hourly/PRN as ordered | To stimulate Beta 2 receptors, resulting in bronchial smooth muscle relaxation and bronchodilation. To block cholinergic receptors, resulting in bronchial smooth muscle relaxation and bronchodilation. | | 6. Administer PO Prednisolone 40 mg OM as ordered | To inhibit migration of leukocytes and phagocytes and decrease inflammatory mediators leading to decrease airway mucus secretions and oedema. | | 7. Administer IV ampicillin / sulbactam (Unasyn) 1.5g q6h as ordered | Drug binds to penicillin binding proteins and inhibits cell wall synthesis. | ## Question 2 (Mandatory) ### Scenario 1 (Question 1-9) - Ismail, a 59-year-old, presented to the emergency department (ED) complaining of acute shortness of breath, wheezing and cough. - For the past three days, his inhalers have been ineffective, and he has a productive cough of thick yellowish sputum. - His symptoms began 3 days ago and had progressively worsened. ### Assessment On Arrival (OA) - **Neurological:** Alert and orientated, but in distress with difficulty breathing. - **Respiratory:** Wheezes throughout all lung fields, with use of accessory muscles to breathe. Sputum is mucoid and purulent. ### His parameters were as follows: | Parameter | Value | | --------------------------- | ------------------------------ | | Heart Rate | 125 beats per minute (bpm) | | Blood Pressure | 130/72 mmHg | | Respiratory Rate | 28 breaths per minute | | SpO2 | 90% on room air | | Temperature | 38.4 °C | ### Doctor's Order: - Oxygen at 28%, 4 litres per minute (LPM) via venturi mask - Nebulisation of salbutamol: ipratropium: sodium chloride 2:2:1 every 4 hourly/PRN - PO prednisolone 40 mg OM - PO paracetamol 1 g 6 hourly/PRN - IV ampicillin / sulbactam (Unasyn) 1.5g q6h - The doctor diagnosed Ismail with acute exacerbation of asthma and pneumonia. - State four (4) pharmacotherapy goals in the treatment of Ismail with acute exacerbation of asthma and pneumonia. For each goal, name the associated medication(s) that was prescribed. | Pharmacotherapy Goals (4) | Medications (4) | | --------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------ | | Relieve the symptoms by causing bronchodilation | Nebulisation of salbutamol: ipratropium bromide: sodium chloride 2:2:1 every 4 hourly/PRN | | Prevent the recurrence of attacks by suppressing inflammatory response in the airway | PO prednisolone 40 mg OM | | To eradicate the infection, reduce morbidity, and prevent complications | IV ampicillin / sulbactam (Unasyn) 1.5g q6h | | To relieve symptoms of fever | PO paracetamol 1g 6 hourly/PRN | ## Question 3 (Mandatory) ### Scenario 1 (Question 1-9) ### Doctor's Order: - Oxygen at 28%, 4 litres per minute (LPM) via venturi mask - Nebulisation of salbutamol: ipratropium: sodium chloride 2:2:1 every 4 hourly/PRN - PO prednisolone 40 mg OM - PO paracetamol 1 g 6 hourly/PRN - IV ampicillin / sulbactam (Unasyn) 1.5g q6h - Match the medications with the correct mechanism of action. | Mechanism of Action | Medication | | --------------------------------------------------------------------- | --------------------------------------------------------------------------------------------------------- | | To stimulate Beta 2 receptors, resulting in bronchial smooth muscle relaxation and bronchodilation. | 1. salbutamol | | To inhibit migration of leukocytes and phagocytes and decrease inflammatory mediators leading to decrease airway mucus secretions and oedema. | 4. ampicillin / sulbactam (Unasyn) | | Drug binds to penicillin binding proteins and inhibits cell wall synthesis. | 3. prednisolone | | To block cholinergic receptors, resulting in bronchial smooth muscle relaxation and bronchodilation. | 2. ipratropium | ## Question 4 (Mandatory) ### Scenario 1 (Question 1-9) - State the pharmacological classes of the two medications in IV Ampicillin / Sulbactam (Unasyn) (2 marks). - Explain the purpose of giving combination-type antibiotics, like IV Unasyn to Ismail (2 marks)? - Unasyn contains two medications, Ampicillin's pharmacological class is penicillin, Sulbactam's pharmacological class is beta-lactamase inhibitor. - Sulbactam protects the penicillin molecule from destruction by the beta-lactamase and extends its spectrum of activity. ## Question 5 (Mandatory) ### Scenario 1 (Question 1-9) - In the administration of the following order: Nebulisation of salbutamol: ipratropium: sodium chloride 2:2:1 every 4 hourly/PRN, the correct dosage to be given is 2mL of salbutamol, 2 mL of ipratropium and 1 mL of sodium chloride. ## Question 6 (Mandatory) ### Scenario 1 (Question 1-9) - 2 years later, Ismail presents to the doctor for evaluation and follow-up of his asthma. - He has had 4 admissions over the last 2 years for acute exacerbation of asthma and is functionally limited with breathlessness, RR 35 breath/min, Oxygen saturation of 89% on 2L/min and wheezing with subcostal retraction OA. - He has been having a chronic cough with thick secretions that refused to go away. - Yesterday, he felt more congested and cough more than usual yielding yellowish greenish sputum with fever and chills. - His doctor informs Ismail that he has developed asthma-COPD Overlap Syndrome (ACOS) and should be admitted as for his breathlessness and " low oxygen levels". - Identify two (2) pieces of evidence from Ismail's clinical presentation to support the nursing diagnosis of "ineffective airway clearance". 1. He has been having a chronic cough with thick secretions that refused to go away. 2. Yesterday he felt more congested and cough more than usual yielding yellowish greenish sputum. ## Question 7 (Mandatory) ### Scenario 1 (Question 1-9) - Briefly explain why Ismail was prescribed with only low flow oxygen of 2litres/min via nasal cannula. - Ismail was given low flow oxygen as he has Chronic Obstructive Pulmonary Disease (COPD). - In COPD, the hypercapnia drive is blunted and the trigger to the respiratory drive, is the low levels of oxygen in their blood. - If high concentration of oxygen is given, the stimulus to breathe is reduced, causing hypoventilation and allowing carbon dioxide to accumulate further. ## Question 8 (Mandatory) ### Scenario 1 (Question 1-9) - Ismail was discharged home with the following medication - Inh glycopyrronium /formoterol/betamethasone (Trimbow) 100/6/12.5 mcg MDI 2 puffs BD ### a) State the pharmacological class of the following medications (3 marks). | Medication | Pharmacological Class | | --------------------- | ------------------------------------------------------------------------------------------------------------ | | Glycopyrronium | Anticholinergic Or Muscarinic antagonist | | Formoterol | Beta-2 adrenergic agonist | | Beclomethasone | Corticosteroid | ### b) Identify 2 health education to minimize the adverse effects of each of the following medications. Provide a rationale for each health education. #### Glycopyrronium (Muscarinic Antagonist / Anticholinergic) - 4 marks - **Health Education (HE):** Advise patient to rinse mouth with water after inhalation. - **Rationale (R):** To prevent dry mouth and throat which is an adverse effect of the drug. - **HE:** Teach Patient to report to the doctor if their heart rate is elevated or experience palpitation. - **R:** Drug can cause the adverse effect of tachycardia. - **HE:** Advise patient to report any problems with voiding urine. - **R:** Drugs can cause urinary retention. #### Formoterol (Beta-2 adrenergic agonist) - 4 marks - **HE:** Advise patient to rinse mouth with water after inhalation - **R:** To prevent dry mouth and throat which is an adverse effect of the drug. - **HE:** Teach Patient to report to the doctor if their heart rate is elevated or experience palpitation. - **R:** Drug can cause the adverse effect of tachycardia. #### Beclomethasone (Corticosteroids) - 4 marks - **HE:** Advise patient to rinse mouth with water immediately after inhalation and maintain good oral hygiene. - **R:** To minimize side effects of oral candidiasis. - **HE:** Advise patient to monitor and report signs and symptoms of infection such as increased body temperature, mouth ulcers, sore throat or flu-like symptoms. - **R:** Corticosteroids may increase susceptibility to infection. - **HE:** Inform patient not to stop drug abruptly and to discuss any changes in therapy with doctor. - **R:** Dosage of corticosteroids needs to be tapered down gradually before discontinuation. OR Abrupt discontinuation may trigger adrenal insufficiency and shock. ## Question 9 (Mandatory) ### Scenario 1 (Question 1-9) Identify four (4) health education for Ismail to prevent further exacerbations. Provide a rationale for each answer. | Health Education (1, any 4) | Rationale (1, any 4) | | --------------------------------------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------------------------- | | Teach Ismail about medication compliance and check that Ismail has good inhaler technique (glycopyrronium /formoterol/betamethasone | For symptomatic management and to decrease inflammation of the bronchioles. | | (Trimbow) 100/6/12.5 mcg MDI ) and takes prednisolone as prescribed. | **Rationale:** To reduce the risk of respiratory infections and seek early treatment if any. | | To decrease respiratory infections by: frequent hand washing, going for yearly flu vaccinations, taking the pneumococcal vaccination | **Rationale:** To decrease water retention, which affects the ability to breathe. To limit the production of carbon dioxide from metabolism of carbohydrates. To improve the function of the digestive system and blood sugar management. To maintain strong respiratory muscles. | | To refer to a dietician to plan a low salt, low carbohydrate, high fiber and high protein diet | **Rationale:** To refer Ismail to a pulmonary rehabilitation program. To improve the quality of life and daily functioning. | | To teach Ismail to perform pursed lip, deep breathing and huff cough | **Rationale:** To reduce the work of breathing, prevent air trappings and to cough out mucus effectively without tiring. | | Attend the scheduled follow up care | **Rationale:** Close follow up by physicians reduces the risk of Asthma chronic obstructive pulmonary disease (COPD) exacerbation requiring hospitalization. | ## Question 10 (Mandatory) ### Scenario 2 (Question 10-15) - Lee-hom, 58-year-old, is admitted to the emergency department complaining of chest pain lasting 20-30 minutes occurring at rest. - He described the pain as starting from his left shoulder and radiating to his jaw. - The pain first started approximately 1 hour ago after he ate breakfast and was unrelieved by taking S/L GTN tablet x 3. - He has been experiencing intermittent chest pain over the past 3-4 weeks with minimal exertion. - He appears to use his accessory muscles for breathing and is sitting in the upright position and with his head leaning forward. ### Past Medical History - Hypertension x 10 yrs - Hyperlipidaemia x 2 years - Myocardial infarction X 1 year ago with 1 stent insitu ### Family History - Father died from a heart attack at age 65 and mother is alive at age 88 with HTN and type 2 DM. ### Social History - Smoker of 20 years but quit when he received his PCI 3 years ago; drinks beer usually on weekends; no time to exercise ### Nursing Assessment - **Neurological:** alert, but tired out due to the chest pain - **Respiratory:** RR 22 breaths/min, SPO2 89% on room air, bilateral crepitation heard upon auscultation. - **Cardiovascular:** HR 95 bpm, BP 145/80 mmhg, Temperature 37.3 °C - **Others:** Weight 90 kg, Height 170cm. Serum cholesterol 270mg/dL (normal range < 200mg/dL). - Identify three (3) possible issues Lee-Hom could be suffering from, using the clinical information provided in the case scenario. Provide one (1) evidence to support each issue listed. 1. **Unstable Angina** - Chest Pain at rest, Chest pain lasting 20-30 minutes occurring at rest. He described the pain as starting from his left shoulder and radiating to his jaw. The pain first started approximately 1 hour ago after he ate breakfast and was unrelieved by S/L GTN × 3. He has been experiencing intermittent chest pain over the past 3-4 weeks with minimal exertion. 2. **Obesity** - BMI 31.1, Weight 90kg Height 170 cm. 3. **High Cholesterol** - Serum cholesterol 270 mg/dl (normal range < 200 mg/dL). ## Question 11 (Mandatory) ### Scenario 2 (Question 10-15) - Identify five (5) characteristics of the ECG depicted above and interpret the ECG | Parameter | Value | | ------------ | --------------------------- | | Rate | 80 beats per minute | | Rhythm | Regular | | P Wave | Present and Normal | | QRS Complex | Present and < 0.12 secs | | Interpretation | Sinus Rhythm with ST Depression. Consider rate ( < 60 b/min, 60-100b/min or > 100 b/min) and ST (with ST depression or ST elevation), Check T wave - is there any inversion? If it is present, add with T wave inversion to the interpretation) | ## Question 12 (Mandatory) ### Scenario 2 (Question 10-15) - The cardiac enzymes are as presented below. | Parameters | Result | Normal Value | | ---------- | ------ | ------------- | | CK | 168 | 30-170 IU/L | | CKMB | 4.5 | 0-4.9 ng/ml | | Troponin I | 0.01 | <0.03 ng/ml | - Identify Lee-hom's probable diagnosis from the 2 investigative results presented. Provide a rationale for each investigation findings. - Lee-Hom is diagnosed with Unstable Angina as his ECG showed presence of ST depression which depicts myocardial ischemia. The alternate diagnosis of Non ST elevation myocardial infarction is excluded as Troponin I results is negative signifying no myocardial damage at this stage. ## Question 13 (Mandatory) ### Scenario 2 (Question 10-15) - Lee-hom, 58-year-old, is admitted to the emergency department complaining of chest pain lasting 20-30 minutes occurring at rest. - He described the pain as starting from his left shoulder and radiating to his jaw. - The pain first started approximately 1 hour ago after he ate breakfast and was unrelieved by taking S/L GTN tablet x 3. - He has been experiencing intermittent chest pain over the past 3-4 weeks with minimal exertion. - He appears to use his accessory muscles for breathing and is sitting in the upright position and with his head leaning forward. ### Past Medical History - Hypertension x 10 yrs - Hyperlipidaemia x 2 years - Myocardial infarction X 1 year ago with 1 stent insitu - Identify the indication and pharmacologic class of the medications ordered by the doctor. | Medication | Pharmacologic Class (6 m) | Indication (6 m) | | --------------------- | -------------------------------------- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | PO aspirin 325 mg stat | a. Nonsteroidal anti-inflammatory drug | b. Unstable Angina (**consider the diagnosis**) | | PO clopidogrel 300 mg stat | c. Platelet Aggregation Inhibitor | d. Unstable Angina Or For Percutaneous coronary Intervention (**consider the diagnosis**) | | PO carvedilol 25 mg BD | e. Beta blocker | f. Hypertension Or Unstable Angina (**consider the indication**) | | IV nitroglycerin 10-40 mcg/min | g. Nitrates | h. Chest pain | | IV morphine 4 mg stat, if pain persist | i. Opiates | j. Chest pain unrelieved by nitroglycerin | | PO atorvastatin 80 mg ON | k. HMG-CoA reductase inhibitor | I. Hyperlipidaemia | ## Question 14 (Mandatory) ### Scenario 2 (Question 11-16) - Lee-hom, 58-year-old, is admitted to the emergency department complaining of chest pain lasting 20-30 minutes occurring at rest. - He described the pain as starting from his left shoulder and radiating to his jaw. - The pain first started approximately 1 hour ago after he ate breakfast and was unrelieved by taking S/L GTN tablet x 3. - He has been experiencing intermittent chest pain over the past 3-4 weeks with minimal exertion. - He appears to use his accessory muscles for breathing and is sitting in the upright position and with his head leaning forward. ### Past Medical History - Hypertension x 10 yrs - Hyperlipidaemia x 2 years - Myocardial infarction X 1 year ago with 1 stent insitu ### Medications - PO soluble aspirin 325 mg stat - PO clopidogrel 600mg stat - PO carvedilol 25 mg BD - IV nitroglycerin 10-40 mcg/min - IV morphine 4 mg stat, if pain persist - Identify one (1) adverse effects for the combination of medications ordered. - Propose two (2) nursing consideration that would minimise the risk of the adverse effect while Lee-hom is on these medications. Provide a rationale for your answer. | Medication | Adverse Effect (1 m) | Nursing Consideration and Rationale (4 m) | | --------------------- | ------------------- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | PO soluble aspirin 325 mg stat | Bleeding | Any 2 NC and 2 Rationale | | PO clopidogrel 600 mg stat | | 1. Monitor for signs and symptoms of abnormal bleeding such as increased bruising, hematoma, petechiae (tiny spots of bleeding under the skin or in the mucous membranes), hematuria (blood in urine). **Rationale:** Bleeding is an adverse effect of antiplatelet medication. Immediate medical attention is needed to stop the bleeding and prevent further complication. | | | | 2. Monitor full blood count regularly. **Rationale:** This is to identify decreased red blood cells, hemoglobin and platelet count caused by the medication. | | | | 3. Clarify with doctor if there are plans for patient to go for any surgeries or invasive procedures. **Rationale:** Antiplatelet medication must be discontinued prior to invasive surgery. This prevents complications like excessive bleeding during and after surgery. | | PO carvedilol 25 mg BD | Hypotension | Any 2 NC and 2 example | | IV nitroglycerin 10-40 mcg/min | Orthostatic hypotension | 1. Monitor patient vital sign such as blood pressure regularly. **Rationale:** To detect hypotension and postural hypotension as these are the adverse effects. To inform doctor for early interventions such as to reduce the dose of the medications. | | IV morphine 4 mg stat, if pain persist | | 2. To help patient to change position slowly when rising. **Rationale:** To prevent the risk of fall due to dizziness and orthostatic hypotension caused by the medication. | ## Question 15 (Mandatory) ### Scenario 2 (Question 10-15) - Lee-hom was planned for discharge with below medications: - PO soluble aspirin 100 mg om - PO clopidogrel 75 mg pm - PO carvedilol 25 mg BD - S/L glyceryl trinitrate 0.5mg PRN - Identify three (3) piece of health education advice to prevent re-admission upon Lee-hom discharge. 1. Teach patient to recognize the signs and symptoms of severe chest pain, unrelieved by rest and sublingual glyceryl trinitrate 2. To take medications as prescribed by doctor: PO soluble aspirin 100 mg om, PO clopidogrel 75 mg om, PO carvedilol 25 mg BD, S/L glyceryl trinitrate 0.5mg PRN. 3. Refer patient to a dietician and advise him to adhere to a diet: Low in fat and cholesterol diet, Low in salt and high in calcium. 4. To attend a Cardiac Rehabilitation program ## Question 16 (Mandatory) ### Scenario 3 (Question 16-21) - Danny, with a past medical history of atrial fibrillation and hypertension, was found to be progressively breathless and needed to "sit upright to be less breathless". His neck veins were prominent and distended to the mandible when seated upright. He felt extremely 'tired" and diminished peripheral pulses felt over his extremities. - The doctor diagnosed Danny with congestive cardiac failure. - Identify two (2) important nursing diagnosis (ND) the nurse will put up for Danny. - Provide two (2) evidence (E) from Danny's clinical presentation to support each nursing diagnosis identified. - Note: Your answers should be presented in a table format or answers labelled in this manner. However only first two points will be marked. | Nursing Diagnosis (1 /each) | Evidence (1, any 4) | | -------------------------------------- | -------------------------------------------------------------------------------------------------------------------------- | | ND: Excess fluid volume | E: Danny was found to be progressively breathless. E: Needed to "sit upright to be less breathless". E: His neck veins were prominent and distended to the mandible when seated upright. Only first 2 points are marked | | ND: Decreased cardiac output | E: Fatigue. E: Diminished peripheral pulses at extremities. | ## Question 17 (Mandatory) ### Scenario 3 (Question 16-21) ### Doctor's Order - IN Oxygen 30% 9L/min via venti mask - IV Nitroglycerin 10-20 mcg/min - IV Bumetanide 2mg BD - Identify four (4) immediate nursing interventions based on the two (2) nursing diagnosis identified at admission. Provide a rationale for each intervention. | ND: Excess fluid volume | NI: Nursing Intervention (1, any 4) 4m | R: Rationale (1, any 4) 4m | | -------------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------ | -------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | | Monitor vital signs including heart rate (HR), blood pressure (BP), respiratory rate (RR), and SpO2 hourly | Establish baseline data and monitor for disease progression. High BP and hypoxia may indicate fluid overload | | | Assess the respiratory status and auscultate breath sounds every 4 hourly | The presence of adventitious sounds (rhonchi) and respiratory symptoms (dyspnoea, paroxysmal nocturnal dyspnoea, orthopnoea) reflects pulmonary congestion. | | | Monitor intake output strictly | To monitor fluid status and guide diuretic therapy | | | Weigh Chang Wook daily and compare to his previous weights | Weight is an indicator of fluid balance and an increase indicates fluid volume excess. | | | Maintain fluid restriction of 1.2L /day and sodium restrictions as ordered. | This is to reduce total body water and prevent fluid accumulation. | | | Administer IV Bumetanide 2mg BD | Bumetanide inhibits sodium and chloride reabsorption in the ascending loop of Henle, proximal and distal tubule resulting in excretion of sodium, chloride, potassium and water. | | ND: Decreased cardiac output | Monitor vital signs including heart rate (HR), blood pressure (BP), respiratory rate (RR), and SpO2 hourly. | Establish baseline data and monitor for disease progress. Hypotension, tachycardia and hypoxia may indicate a decrease in cardiac output. | | | Administer IN Oxygen 30% 9L/min via venti mask | This is to increase oxygenation levels and alleviate signs of hypoxia. | | | Administer IV Nitroglycerin 10-20 mcg/min | The drug dilates main coronary arteries and increases oxygen delivery to the heart. It also dilates peripheral veins and arteries to reduce preload and afterload, thus reducing myocardial oxygen demand. | | | Encourage periods of rest and assist with activities of daily living as needed | To reduce cardiac workload and minimize myocardial oxygen consumption and fatigue. | ## Question 18 (Mandatory) ### Scenario 3 (Question 16-21) - Identify two (2) nursing consideration to minimise the adverse effects of IV bumetanide. Provide a rationale for each answer. | Drug: Bumetanide | NC1: Nursing Consideration (1, any 2) | Rationale: (1, any 2) | | ------------------------------------------------------------------------------------ | ----------------------------------------------------------------------------------------------------------------------------- | --------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | | 1. Monitor daily body weight, fluid intake and output. | To detect for adverse effects of dehydration, oliguria and anuria | | | 2. Monitor renal function regularly | Diuretics may cause dehydration and may lead to renal insufficiency | | | 3. Monitor regular blood test such as: serum electrolytes level, especially potassium, magnesium, and sodium. | Diuretics can cause the following adverse effects such as: Hypokalemia, Hypomagnesaemia, and hyponatremia. | | | 4. Monitor and report for signs and symptoms of ototoxicity such as (to give at least one example) hearing loss, ringing in the ears, tinnitus. | To seek early medical attention to prevent worsening of adverse effects | ## Question 19 (Mandatory) ### Scenario 3 (Question 16-21) - Danny's heart failure improved and he was planned for discharge. - He has a past medical history of atrial fibrillation and hypertension and was prescribed the following medications for home. - PO warfarin 3mg OM - PO bisoprolol 5mg OM - PO sacubitril / valsartan 49/51 mg 1 tab BD - PO bumetanide 1mg BD - PO spironolactone 25 mg OM - PO digoxin 0.0625 mcg OM - Explain three (3) health education advice that the nurse needs to conduct relating to heart failure, provide rationale for each piece of health education advice. - Note: Your answers should be presented in a table format or answers labelled in this manner. However only first three points will be marked. | Health Education (first 3 are marked) | Rationale (first 3 are marked) | | --------------------------------------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ | | 1.Teach patient to recognize signs and symptoms of: chest pain, palpitations, ankle, legs and stomach swelling, coughing especially at night, exertional dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea (Must give at least one example of the signs and symptoms) | These are signs of cardiac decompensation that requires early treatment. | | 2. Advise patient to weigh and document his weight daily and compare it to his previous weights. | Weight is an indicator of fluid balance, and an increase of weight (1kg/2 days) indicates fluid volume excess. | | 3.Maintain low sodium dietary approach to stop hypertension (DASH) diet restrictions | This is to reduce total body water and prevent fluid accumulation. | | 4.Fluid Restriction < 1.5L/day (as recommended by doctor) | * Medications given for heart failure aims to slow the progression, reduce manifestations and prevent cardiac complications *To include the MOA of each drug in your answer | | 5. To take medications strictly ordered. PO warfarin 3mg OM, PO bisoprolol 5mg OM, PO sacubitril / valsartan 49/51 mg 1 tab BD, PO bumetanide 1mg BD, PO spironolactone 25 mg OM, PO digoxin 0.0625 mcg OM | *To prevent influenza and pneumococcal pneumonia* **Rationale:** To stabilize, slow or even reverse the progression of heart failure. | ## Question 20 (Mandatory) ### Scenario 3 (Question 16-21) - Danny's heart failure improved and he was planned for discharge. - He has a past medical history of atrial fibrillation and hypertension and was prescribed the following medications for home. - PO warfarin 3mg OM - PO bisoprolol 5mg OM - PO sacubitril / valsartan 49/51 mg 1 tab BD - PO bumetanide 1mg BD - PO spironolactone 25 mg OM - PO digoxin 0.0625 mcg OM ### a) State two pharmacotherapy goals in the treatment of