Unfolding Case Study

Unfolding Case Study

Meet Mr. Beat Z. Funny

Mr. Beat Z. Funny, 62, retired drummer, arrives on telemetry for evaluation of fatigue. He jokes, “I’ve always kept the beat.” No acute distress.
Vitals: BP 128/76, HR 78 regular, RR 16, SpO₂ 98% RA
Labs: WNL
Hx/Med: HTN on lisinopril; OSA (mild); overweight

Word Cloud

What additional baseline assessments are priority for a new telemetry admit?

Mr. Funny reports “a drum solo in my chest.”

Multiple Choice

What is the rhythm?

• Aflutter

• Vtach

• Afib

• Vfib

Open Ended

What key features helped you identify AFib?

Multiple Choice

What are the first actions for Mr. Funny's new onset AFib?

• Apply 6-step rhythm read, obtain 12-lead ECG, notify provider.

• Shock immediately.

• Give IV antiarrhythmic without an order.

• Monitor and document vital signs.

While ambulating to the bathroom, HR climbs to 160–180.

Multiple Choice

What is the current rhythm?

• Afib

• Vfib

• ST

• VTach

Open Ended

What key features helped you identify AFib with RVR?

Multiple Choice

Based on these findings, is he stable or unstable?

• yes

• no

• maybe

Word Cloud

What other data assessments do you need to determine stability?

Multiple Choice

Mr. Funny’s current vitals: BP 98/64 (MAP 75), SpO₂ 94% RA, alert and oriented, denies chest pain. How would you classify his stability?

• Unstable — requires immediate synchronized cardioversion

• . Stable — can attempt pharmacologic therapy and anticoagulation first

• Stable — no intervention needed

• Unstable — requires CPR

Multiple Choice

The provider orders an IV bolus and infusion of diltiazem for rate control. What will you monitor most closely in the next 15–30 minutes?

• Urine output

• Heart rate and blood pressure

• Daily weight

• INR level

Multiple Choice

Despite diltiazem infusion, the patient’s HR remains elevated at 150–160. The provider considers additional therapy. Which medication may be added for rhythm control?

• Amiodarone

• Digoxin

• Furosemide

• Atropine

Multiple Choice

The provider orders IV unfractionated heparin using a weight-based protocol. Why is anticoagulation essential in this situation?

• To prevent GI bleeding

• To prevent dehydration

• To increase blood pressure

• To reduce the risk of thromboembolism and stroke

Multiple Choice

Which nursing actions are prioritized now?

• Start diltiazem per order, begin heparin protocol, continuous monitoring, reassess stability.

• Schedule cardioversion immediately without trying meds.

• Wait and see if it improves on its own.

Heparin Weight-Based Protocol

Pre-infusion checklist

Starting Orders
Concentration
Bolus vs non-bolus

1. calculate the bolus amount

2. calculate the infusion rate

3. Immediate next steps

Multiple Choice

When do you need to obtain a new aPTT or Xa?

• 6 hours

• 12 hours

1. What change is implemented?

2. What is the rate for the pump?

3. Next action(s)?

​6-hr aPTT returns 42 sec

Multiple Choice

What is the bolus in units for a patient weighing 92 kg according to the Heparin Weight-Based Protocol?

• 7,360 units

• 1,656 units

• 33.1 mL/hr

• 18 units/kg/hr

Multiple Choice

Which is most likely prescribed today for stroke prevention long term after discharge?

• Apixaban (DOAC)

• Warfarin

• C. Aspirin alone

Open Ended

List three bedside bleeding assessments you will perform each shift on a heparinized patient.

Multiple Choice

According to the aPTT Titration Table, what action should be taken if the aPTT is 74 seconds?

• Hold 1 hr

• Increase by 2 u/kg/hr

• No change

• Decrease by 3 u/kg/hr

Multiple Choice

Which statement shows correct DOAC teaching?

• I’ll take apixaban same time daily and report any unusual bleeding.

• If I miss a dose, I’ll double the next one.

• I don’t need to tell my dentist I’m on this.

Multiple Choice

What is the best next step after the patient's heart rate improved?

• Stop all anticoagulation since HR improved.

• Continue heparin per protocol, monitor labs, prepare patient/education for scheduled cardioversion.

• Discharge now that he feels better.

Open Ended

Why did you get IV heparin in the hospital but go home on apixaban?

Multiple Choice

What is the reversal agent for dabigatran?

• Vitamin K

• Idarucizumab

• Andexanet alfa

• PCC/FFP

Multiple Choice

What is the therapeutic INR range for AF on warfarin?

• 1.5–2.0

• 2.0–3.0

• 3.0–4.0

• 4.0–5.0

Poll

How confident do you feel about this topic now?

• Very confident
• Somewhat confident
• Not confident