Question

Please print so I can read it clearly.

Client Profile:

L.J. is a 63-year-old man who has a history of hypertension, congestive heart failure and sleep apnea.  He has been smoking two packs of cigarettes a day for 40 years and has refused to quit.   He has not taken his antihypertensive medication or his medications to control his heart failure for 4 days.  He went to the emergency room and now is admitted into the hospital, admitting diagnosis: CHF.

Subjective Assessment Data:

• Is very anxious and asks if he is going to die because he is so short of breath
• Denies pain but say that he feels like he cannot get enough air
• Says he feels like his heart is “running away”
• After weighing himself he reports that he gained 11 pounds and his shoes and waistband are tight
• I don’t like wearing my CPAP at night

Objective Assessment Data:

• Height: 5 feet 10 inches
• Weight: 220lbs
• Vital signs:  T: 99.6, HR: 118bpm and irregular, RR: 34, BP: 142/60, Pulse Ox: 90% (Room air)
• CV: Distant S1, S2, bilateral jugular vein distention, all peripheral pulses were +1 and there was bilateral lower leg edema
• Resp: Pulmonary crackles, decreased breath sounds right lower lobe, coughing frothy blood tinged sputum, shortness of breath on any type of exertion
• GI:  Bowel sounds present, hepatomegaly 4cm below costal margin
• Laboratory work and diagnostic testing is scheduled

Discuss and answer the following questions

1. How should the nurse explain in layman’s terms the diagnosis of Congestive Heart Failure to L.J.?

2. What signs and symptoms of right-sided and left-left sided heart failure is L.J experiencing?

3. What type of monitoring can the RN implement independently in caring for L.J.?

Answer 1

How should the nurse explain in layman’s terms the diagnosis of Congestive Heart Failure to L.J.?

Ans

In this case, fluid builds up around your heart which affects the pumping power of your heart muscles.

You have four heart chambers. The upper half of your heart has two atria, and the lower half of your heart has two ventricles. The ventricles pump blood to your body’s organs and tissues, and the atria receive blood from your body as it circulates back from the rest of your body.

CHF develops when your ventricles can’t pump enough blood volume to the body. Eventually, blood and other fluids can back up inside your lungs, abdomen, liver, and lower body.

The main thing is that you need complete blood rest because any kind of body activity will worsen your condition.

What signs and symptoms of right-sided and left-left sided heart failure is L.J experiencing?

Ans

He is experiencing symptoms like weight gain, bilateral lower leg edema, pulmonary crackles, fatigue, shortness of breath.

What type of monitoring can the RN implement independently in caring for L.J.?

Ans

• Objective measurement of dyspnoea severity. It includes effort breathing, respiratory rate, oxygen saturation.
• Hemodynamic status. ( systolic and diastolic blood pressure monitoring)
• Heart rhythm. It includes heart rate and rhythm, 12-lead ECG
• Cardiac output. It includes Body temperature, peripheral perfusion, urine output, mental status
• Clinical examination for signs of congestion. Mainly, pulmonary rates, peripheral edema, jugular venous pressure.

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