Upload
vernon-bates
View
224
Download
0
Tags:
Embed Size (px)
Citation preview
Bonnie RogersStonecrest Medical Center
JS, 79 years oldCaucasian female
Primary languageEnglish
Resident of SmyrnaTN
Married with one son and two grandchildren
Retired accountant
Religion: Christian
Full Code Status
Weight: 252 lbs
Height 5ft. 1 in.
BMI 45.1 (obese)
Admission on 04/07/10 Presentation: Extreme Progressive
Weakness Admitting Diagnosis: Congestive Heart
Failure, Weakness Risk Factors:
◦ Diabetes Mellitus ◦ Hypertension◦ Obesity◦ Hyperlipidemia◦ CAD
Coronary Artery Disease with Cardiac Bypass x4 vessel on 11/16/09
Severe Pulmonary Hypertension Atrial Fibrillation with tachybrady syndrome with dual chamber pacemaker 12/01/09
Chronic Kidney Disease Iron Deficiency Anemia Osteoporosis Hypothyroidism Allergic to Shellfish containing substances and penecillins
Portable Chest x-ray on 4/7/10 Reason: weakness Findings: cardiomegaly. Obscuration of the left hemidiaphram likely related to the large heart. The right lung is clear. Vasculature appears normal
Congestive Heart Failure Right Side
Caused from left-sided heart failure. As pressure in the pulmonary circulation rises, the
resistance to right ventricular emptying increases. The right ventricle is poorly prepared to compensate for this increased afterload and will dilate and fail. When this happens, pressure will rise in the systemic venous circulation.
Clinical Manifestations: edema, jugular vein distention, fatigue
Normal Range Reason
RBC’s 3.22 (L) 4.2-5.4 M/UL Anemia
HGB 7.6 (L) 12-16 gm/dl Anemia
HCT 23.9 (L) 35-47 % Anemia
MCV 74.1 (L) 80-100fl Anemia
MCH 23.6 (L) 25.4-34.6 pg/cell
Anemia
Normal Range Reason
PT 37.9 11-13.5 seconds
Pt prior to hospitalization on Coumadin
BUN 28 mg/dl (H) 10-20 mg/dl Chronic Renal Failure
Creatine 2.6 mg/dl (H) 0.5-1.2mg/dl Chronic Renal Failure
Medication Class Dose, Route, and Frequency
Rationale for Use
Sodium Bicarbonate
Alkalinizer 650mg, PO, TID Chronic Renal Disease causes metabolic acidosis
Sertraline(Zoloft)
Antidepressant 50mg Patient depressed
Levothyroxine(Levothroid)
Thyroid Horomone
0.125,mg, PO, Daily
Hypothyroidism
Omeprazole (Prilosec)
Proton Pump Inhibitor
20mg, PO, Daily GERD
Medication Class Dose, Route, and Frequency
Rationale for Use
Ciprofloxacin(Cipro)
Fluoroquinolone Antibiotic
500mg, PO, Q12
Urinary Tract Infection
Carvedilol(Coreg)
Beta Blocker 12.5mg, PO, BID
Hypertension
Potassium Chloride
Electrolyte replenisher
20 meq K+ 3.2 (norm)
Medication Class Dose, Route, and Frequency
Rationale for use
Acetazolamide(Diamox)
Diuretic 250mg, IVP, Q48hrs
CHF, CRF, edema
Iron Sucrose(Venofer)
Hematinic 500mg, IV, Daily
Iron deficiency anemia
Lasix/Diuril Drip Loop Diuretic/Thiazide duiretic
500mg/500mg, IV, Continuois @ 10mg/hr
CHF, CRF, edema
Ranges from two days 4/8/10 and 4/10/10◦BP: 94/38-112/43◦HR: 48-139 (tachybrady syndrome)◦RR: 13-23 bpm◦SpO2: 94-100%◦Temp: 96.6-97.6 F
PERRLA Glasses No drainage from eyes, ears, or nose Complete dentures Oral care performed every 2 hrs using
toothbrush and toothpaste with moderate assistance
Lip moisturizer applied after mouth care and meals
Patient Oriented to person, place, time, and situation
Confused at times Drowsy all day Arouses easily and follows commands
Cardiac Monitoring: Atrial paced with occasional SB and ST
Normal S1 and S2 auscultated◦No audible murmurs
Cap refill <3 seconds, nail beds pink Radial pulses 3+, regular rate and rhythm Dorsalis pedis pulse: Bilateral 1+ weak Edema 2+ present in ankles and lower
legs bilaterally
Fine crackles auscultated at RLL Diminished breath sounds in RUL, LUL, LLL anteriorly and posteriorly
Dyspnea on exertion O2 per NC at 2L
Bowel sounds present in all four quadrants
No palpable masses, no tenderness noted
Abdomen soft, non-distended Passing flatus
Foley Catheter in place, urethral area dry with no complications, tubing secured to thigh
Urine clear and yellow Intake and output qhr Average urine output after 2 shifts approximately 150ml/hr order to call if <100ml/hr
Activity limited by range of motion and generalized weakness
Turning and repositioning schedule set for q2hrs
Up to chair with extensive assistance from OT and PT for approximately 20 minutes
Henrich II Fall Risk Score 7: High Risk with fall precautions maintained
Skin color normal for ethnicity Skin warm and dry to touch Absence of tissue breakdown Braden Skin Integrity Risk Score: 15 (mild
risk, skin bundle precautions maintained) Repositioning schedule q2hrs Bed linens with minimal layers and free of
wrinkles
Left AC◦ Saline Lock
Left Hand◦ 20 gauge ◦ Lasix/diuril drip @ 10mg/hr
◦ Both sites: patent line, dressing dry and intact, no complications
Patient depressed and emotional, crying occasionally
Patient voices concerns of putting a burden on family members
Family at bedside during visiting hours
Primary Nurse (RN) Attending Physician Cardilogist Nephrologist Physical therapist Occupational Therapist Student Collegues
Decreased Cardiac Output r/t decreased pumping ability AEB:◦ need for pacemaker (previous arrhythmias)◦ Decreased urine output ◦ Diminished peripheral pulses◦ DOE◦ JVD
Urine output of >100ml/hr Respirations of 10-25bpm Peripheral pulse +2 regular No audile abnormal heart sounds No presence of arrhythmias
Monitor urine intake and output qhr Titrate lasix/diuril drip according to I&O Administer Diamox q48hrs Auscultate heart and lung sounds q 2hrs Monitor BP and HR qhr HOB elevated 30-45 degrees
Goals Met: Urine output of aproximately100ml/hr Respirations stayed between 10-25bpm No audile abnormal heart sounds No presence of arrhythmias
Goals Not Met:◦ Peripheral pulses still +1 by end of shifts
Imaired gas exchange r/t inadequate cardiac function secondary to heart failure AEB ◦ Occasional confused mental status◦ DOE◦ Generalized weakness◦ Need assistance with ADL’s◦ Need for O2 per NC
RR 10-25 SpO2 >95% Alert and Oriented x3 HR will not increase by more than 20 during activity
RR will not increase by more than 5 during activity
Balancing oxygenation and activity◦ Initial bedrest◦ Progress ADLs as tolerated◦ Oxygen at 2L◦ Head of bead 30-60 degree◦ Auscultate lung sounds q2hrs
Goals Met: RR remained within 10-25 bpm SpO2 was >95% Pt alert and oriented x3 HR did not increase by more than 20
during activity RR did not increase by more than 5 during
activity
Fluid Volume Excess r/t impaired excretion of Na and H2O secondary to renal insufficency AED:◦ +2 pitting edema bilaterally on lower legs and
ankles◦ Jugular Vein Distention◦ Crackles auscultated in RLL◦ Decreased urinary output
Maintain urine output within 500 ml of intake
Reduce +2 pitting edema to +1 by end of shifts
Lose 2 lbs of fluid by end of shift Lungs clear bilaterally
WEIGH daily Maintain a strict intake and output qhr and
report less than 30ml/hr Restricit fluid and sodium as ordered Monitor creatinine and BUN
Goals Met: ◦ urine output within 500 ml of intake◦Lose 2 lbs of fluid by end of shift. Pt lost
over 6lbs of fluid being 3000ml Goals Not Met:
◦Edema was still +2 by end of clinical shift◦Crackles still auscultated in RLL
Objectives: examine whether patients with CHF were receiving the optimum treatment for heart failure and propose recommendations for CHF management that would be useful to all kinds of healthcare facilities.
The Group Studied: Patients with a diagnosis of Congestive Heart Failure and an ejection fraction less than 40%. A retrospective review of 300 clinic records of patients with CHF dating from January 1, 2003 to July 31, 2004 was performed.
Findings: ◦ All patients had at least one risk factor ◦ 71% had hypertension. ◦ A significant percentage (22%) had renal insufficiency.
Recommendations:◦ Teach patients about risk factors such as hypertension,
smoking, diabetes, and obesity◦ Nurses need to educate regarding early intervention and
better management of hypertension to limit its development.
◦ Teach It’s not ALL about you’re heart! CHF can affect many organs. Teach pts to weigh daily, avoid nephrotoxic drugs, and pay attention to how much they void.
In relation to JS◦ Patient and family were taught about minimizing
risk factors for CHF including referral to cardiac rehabilitation center, nutritional support, and diabetic management.
◦ JS was taught about the importance of her chronic renal insufficiency and how it affects her heart. Pt taught to monitor weight daily (notifying MD if >2lbs in one day) and paying attention to voiding patterns.
Ancheta, I. (2006). A retrospective pilot study: management of patients with heart failure.Dimensions of Critical Care Nursing, 25(5), 228-233. Retrieved from CINAHL with Full Text database.
Huether, S.E. & McCance, K.L. (2008). Understanding Pathophysiology (4th ed) St. Louis: Mosby, Inc.
Skidmore, L (2009). Mosby’s Drug Guide for Nurses. St Louis: Mosby, Inc.