Question

     Handoff report

-Mr.S Was admitted 2 days ago with congested heart failure;

-he had a restless night with some dyspnea and a dry nonproductive cough most of the night;

-crackles are heard in both lungs, he has 3+ pitting edema in both legs and sacrum;

-his 6.00 AM vital signs are T 97.9 F, P 110 and irregular, R 34, BP 150/100, pulse ox 94% with

Oxygen @ 3L/min/NC.

-his IV site looks slightly puffy, but there is a good blood return;

-he denies pain but just started to complain of nausea; his serum K+ this morning is 3.0 mEq; it might be low because he is retaining fluid;

-his physician always comes in early so I posted the results in front of the patient’s chart.

Now that you have listened to the handoff report, take a moment to review important client

background. Have a look at the patient care kardex and medication record.

    

Patient Care Kardex

• DX: CHF
• Age: 72
• VS: q4h
• Diet: 2 g Na+
• ↑ HOB
• I & O
• Bed rest with BRP
• Weigh daily
• O2 at 3 L/min/nasal cannula
• LBM (2 days ago)
• IV: D5/0.45 NS c– 20 mEq KCl q12h
• L hand # 20 g

LAB:

• Digoxin level
• K+, Na+, BUN, creatinine, AST

Medication History

• Digoxin 0.25 mg po qAM     0900
• Furosemide 40 mg IVP BID 0900 - 1700
• K-Dur 10 mEq po BID          0900 - 1700
• Captopril 6.25 mg po TID     0900 - 1700 - 2200
• Colace 100 mg po qAM        0900

PRN

• NTG SL 0.4 mg tab i q5min x3 doses prn chest pain

9:00 AM: The physician has not come in to see Mr. S. Mr. S is alert but experiencing increasing

shortness of breath, cough, and nausea and complaining of blurred vision. His pulse oximetry

result is 88%. P 116 and irregular, R 34 and short and shallow, BP 152/100. Skin cool, color with

slight cyanosis. Aside from the K+ of 3.0 mEq, Mr. S’s Na+ is 135+ mEq, and his digoxin level is

2.4 ng/mL. You call the physician and learn that he is in surgery and will call you back within

30 minutes.

At 0930 the physician calls you back. Using the ISBAR sheet, write how you will

communicate with the physician over the phone.

I	Identify	Self – name , position, location Patient – name, age, gender
S	Situation	Explain what has happened to trigger this phone call conversation
B	Background	Admission date, diagnosis, relevant history, investigations, what has been done so far
A	Assessment	Give a summary of the patient’s condition or situation. Explain what you think the problem is (if you can)
R	Request / Recommendation	State your request or recommendation

• Based on the current status of the patient which nursing interventions require immediate
• following up?

Answer 1

The emergency department complaining of shortness of breath , a dry nonproduction cough, hypoxia and general malaise lasting for srveral months , ISBAR is created to improve safety in the transfer of critical information. It originates from ISBAR the most frequently used mnemonic in health and other high risk environments .

A brief summative overview of the disease process and the central concept in heart failure as fundamental to the conceptualization of clinical care needs for a patient with heart failure was presented.

The specific objectives for the manuscript were to conduct a literature review on the clinical nursing care for patient with such ailments . Cough may be productive or nonproductiven, depending on the organism.

Dyspnea is frequently present in pneumonia , raging from mild exertional shortness of breath to severe dyspnea at rest. Nursing interventions are the actual treatments and actions that are performed to help the patient to reach the goals. Nurse uses his her knowledge , experience and critical thinking skills to decide which intervention will help the patient the most.

After the implementation of the caring interventions, the nurse conducts the evaluation of the impacts of the caring interventions on the patient .

Based on current situation the nurse should follow the physician , what the physician recommend then provide a proper medication , so that the patient could feel a better relief . During such conditions if blurred vision occurs nurse should follow medical history and exam can often give a good explanation . By opening the lung passages and offering relief of breath . These drugs in medication history typically given by inhalation . Mrs S will feel better and will help her to relax during night with out coughing that make her restless and impatient during night hours.