Mr. Jones, a 69-year old male, presents to the Emergency Department (ED) after visiting his primary physician complaining of general fatigue for 4 days, shortness of breath, and abdominal discomfort. Mr. Jones’s medical history includes hypertension and coronary artery disease. He had a previous 90% LAD blockage and 50% RCA blockage with stent placements in both.
Critical Thinking Check
Bloom's Taxonomy: Application
What initial nursing assessments need to be performed for Mr. Jones?
Upon further assessment, the patient has crackles bilaterally and tachycardia. A chest X-ray shows cardiomegaly and bilateral pulmonary edema. An ECG revealed atrial fibrillation. His vital signs were as follows:
BP 150/72 mmHgUrineYellow and Cloudy
HR102-123 bpm and irregularBUN17 mg/dL
RR24-32 bpmCr1.2 mg/dL
Temp37.3°CH/H11.8 g/dL / 36.2%
Ht 175 cmLDH705 U/L
Wt79 kg **BNP843 pg/mL
Mr. Jones was admitted to the cardiac telemetry unit.
Mr. Jones states that this weight is approximately 3 kg more than it was 3 days ago.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What is the signficance of Mr. Jones' weight gain?
Diuretics – he is volume overloaded and it is affected his lungs. Diuretics can help relieve fluid retention by promoting excretion of water from the kidneys.
Beta-Blockers – his blood pressure is high and his heart rate is fast. The beta-blocker can help slow this down and relieve some of the workload of his heart
About three hours after admission to the telemetry unit, Mr. Jones’s skin becomes cool and clammy. His respirations are labored and he is complaining of abdominal pain. Upon physical examination, Mr. Jones is diaphoretic and gasping for air, with jugular venous distension, bilateral crackles, and an expiratory wheeze. His SpO2 is 88% on room air and it was noted that his urine output had been approximately 20 mL/hr since admission. His BP is 190/100 mmHg, HR 130 bpm and irregular, RR 43 bpm.
Critical Thinking Check
Bloom's Taxonomy: Application
What nursing interventions should you perform right away for Mr. Jones?
Because his heart cannot pump blood efficiently to the body, the blood is backing up into the lungs. This causes pulmonary edema. His pulmonary edema is so severe that he is struggling to breathe and struggling to oxygenate appropriately.
His heart is trying to work extra hard to compensate for the low cardiac output, that’s why his blood pressure and heart rate are so elevated. This is perpetuated by the RAAS.
We also see that his kidneys are not being perfused as his urine output has decreased
Critical Thinking Check
Bloom's Taxonomy: Analysis
What medications should be given to decrease Mr. Jones’s preload? Improve his contractility? Decrease his afterload?
Mr. Jones was transferred to the CCU for hemodynamic monitoring and aggressive therapy. His Central Venous Pressure (CVP) was found to be 19 mmHg, Cardiac Output was 4.5 L/min, Cardiac Index was 2.3 L/min/m2. He has been placed in high-fowler’s position, and his SpO2 is now 96% on 4L nasal cannula. Mr. Jones received Furosemide 80 mg IV and Digoxin 0.5 mg IV.
Critical Thinking Check
Bloom's Taxonomy: Comprehension
What is the expected outcome of administration of Furosemide? Digoxin?
This nursing case study course is designed to help nursing students build critical thinking. Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process. To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs. If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding. In the end, that is what nursing case studies are all about – growing in your clinical judgement.
Miriam Wahrman, MSN/Ed, RNC-MNN 
Chance Reaves, MSN-Ed, RN 