Question

77 year-old female presents to ER with shortness of breath

• States she did not take her heart medications for last 48 hours- was not able to refill her prescriptions

• Complains of difficulty breathing; she had to “sleep in the chair” last night

• States she has some swelling in her feet that is worse than usual

Medical history: type 2 DM, CHF, MI 2015, osteopenia, osteoarthritis

Allergies: bananas, kiwi fruit, Cipro

Medication list

Lasix 40 mg PO BID (last dose 48 hours ago)

Milk of magnesia 30 ml PO daily (last dose this morning)

Celebrex PO 100 mg PO daily (last dose this morning)

Digoxin 0.125 mg PO daily (last dose 48 hours ago)

Metoprolol 25 mg PO BID (last dose 48 hours ago)

Metformin 500 mg PO BID (last dose 48 hours ago)

Calcium 600 + D PO TID (last dose this morning)

Physical Examination

Alert and oriented to person, place, and time

Fine crackles bilateral lower lobes

Shortness of breath with minimal exertion

VS= T 98.4, P 122, RR 32, BP 188/88

Oxygen saturation 89% on room air

S1 and S2 without murmur or extra heart sounds

RUQ tenderness with palpation

Ht: 5’5”; Wt: 184 lb

Capillary refill sluggish in lower extremities

2+ pitting edema bilateral lower extremities

Lab values

On arrival (ER)

WBC

8,400/mm3

RBC

3.5million/mm3

HGB

8.2g/dl

HCT

31%

PLT

156,000/mm3

Na

112 mEq/L

Cl-

85mEq/L

K+

3.3 mEq/L

BUN

24 mg/dl

CREAT

1.2 /dl

CO2

28 mEq/L

RBS

248 mg/dl

BNP

862 pg/ml

Clinical Decision-Making Questions

1. What are the priority actions of the nurse and why?

2. Which medications should be administered and why?

3. What is the underlying pathophysiology causing the patient’s symptoms?

4. How do the abnormal laboratory values correlate with the patient’s symptoms?

5. Which diagnostic tests will the nurse expect to see ordered for the patient?

6. Create an appropriate 5-minute care plan for this patient to address the immediate health needs (the evaluation/outcome section may be left blank). Be sure to utilize correctly two formatted nursing diagnoses.

7. What additional nursing diagnoses would be appropriate for this patient?

Answer 1

Priority nursing action

Administer oxygen, as the saturation has dropped to 89℅, also patient is breathless with increases respiratory rate.

Medications

Digoxin patient has not taken it for last 48 hrs, and it has positive isotropic and negative chronotropic action the reduce breathlessness, improve peripheral capillary refill.

Lasix As patient has swelling due to fluid accumulation.

Metoprolol​​​​​​ As patient blood pressure is very high

3) As patient is suffering from CHF

which leads to increase in sympathetic nervous system activity

Increase in angiotensin II activity

Which leads to renal vasoconstriction

leading to fluid accumulation, hyponatremia and peripheral edema

Also improper heart pumping lead left ventricular overload and back flow of the blood causing fine crackles, breathlessness, increased respiration and pulse rate.

Lab values

Hyponatremia due to decreased GFR and decreased water excretion

Brain natriuretic peptide is increased greatly due to heart failure

Random Blood sugar is also high as patient has not taken diabetic medication(Metformin) for last 48 hours

Tests

Nurse will expect an ECG to be performed for the patient.

Nursing diagnosis

1) Decreased cardiac output related to heart failure as manifested by dyspnea, and increased respiration.

Interventions

Administer cardiac glycoside(Digoxin)

Administer diuretic (Lasix)

Position patient in fowlers position for easy lung expansion

Restrict movement.

2) Excess fluid volume related to decreased GFR as manifested by pedal edema

Interventions

Administer diuretics

Restrict fluid intake

3) Activity intolerance related to Hypoventilation as manifested by dyspnea and tachypnea.

4) Impaired breathing pattern related hypoventilation as manifested by decreased oxygen saturation

5) Anxiety related to recovery

6) Impaired drug compliance as manifested by missing of drug doses and verbalisation.