Question

Over the last week Abigail's heart failure has worsened and she has developed pneumonia. While you are assessing the patient you now hear bilateral crackles, note 1+ pitting edema. She has dyspnea with any exertion, and is having difficulty eating. Her VS are: BP 178/100, HR 100 and irregular, RR 26 and labored and with a pulse ox of 90% on 3L of oxygen. The US of her leg was negative for DVT, but she continues to complain of pain in the right hip and lower leg with movement. The physician has now ordered the following medications. Lasix increased to 40 mg po BID Potassium increased to 20 meq po BID Increased her Lisinopril to 10 mg daily Lopressor 25 po mg daily. Nitroglycerine 0.4 mg/hour patch Unasyn 3 Gram IVPB every 6 hours Other orders are as follows Daily weight Low sodium soft diet What does the nurse need to look for with each of the above medications? When should the Lasix be given? What lab work would need to be checked? What special assessments need to be implemented? What is the priority nursing diagnosis and why? What would be the outcome and why? What nursing interventions will now need to be implemented? What are the rationales for each? How would you evaluate the nursing interventions? Abigail does not understand why she cannot have salt on her tray, explain to her why it is important to decrease her salt intake.

Answer 1

Following are the answers:

1. With all the medicines, the nurse needs to look for 10 rights of medication

2. Lasix should be given immediately as well as after 12 hours to remove excess fluid from the body  

3. Lab work should include sodium as Lasix being a diuretic removes too much sodium and can lead to hyponatremia and also the patient needs to be kept on a low sodium diet. Potassium also needs to be checked due to its administration

4.Priority nursing diagnosis is :

Ineffective airway clearance related to pneumonia secondary to worsened heart failure