Question

One year ago, Arthur Jackson, 67 years old, had a large anterior

wall MI and underwent subsequent coronary artery bypass surgery.

On discharge, he was started on a regimen of enalapril (Vasotec),

digoxin, furosemide (Lasix), warfarin (Coumadin), and a potassium

chloride supplement. He is now in the cardiac unit complaining

of severe shortness of breath, hemoptysis, and poor appetite for

1 week. He is diagnosed with acute heart failure.

ASSESSMENT

Mr. Jackson refuses to settle in bed, preferring to sit in the bedside recliner in high-Fowler’s position. He states, “Lately, this is the only way I can breathe.” Mr. Jackson states that he has not been able to work in his garden without getting short of breath. He complains of his shoes and belt being too tight. When Mr. Jackson’s nurse, Ms. Takashi, RN, obtains his nursing history, Mr. Jackson insists that he takes his medications regularly. He states that he normally works in his garden or light exercise. In his diet history, Mr. Jackson admits a fondness for bacon and Chinese food and sheepishly admits to snacking between meals “even though I need to lose weight.”Mr. Jackson’s vital signs are BP 95/72 mmHg, HR 124 bpm and irregular, R 28/min and labored, and T 97.5°F (36.5°C). The cardiac monitor shows atrial fibrillation. An S3 s noted on auscultation; the cardiac impulse is left of the midclavicular

line. He has crackles and diminished breath sounds in the bases of both lungs. Significant jugular venous distention, 3+pitting edema of feet and ankles, and abdominal distention are noted. Liver size is within normal limits by percussion. Skin cool and diaphoretic. Chest x-ray shows cardio-megaly and pulmonary infiltrates.

Questions:

1. Provide 3 nursing diagnosis for Mr. Jackson
2. Provide 3 Expected Outcomes of nursing care
3. The crackles on the exam indicate left or right side heart failure?
4. The pitting edema is indicative of left or right side heart failure?
5. Atrial fibrillation puts Mr. Jackson at risk for what other pathologies to occur? And Why? (name 2)
6. What about Mr. Jackson’s diet can further his cardiovascular disease and why?

Answer 1

1. Nursing diagnosis for Mr Jackson :

I) Altered respiratory pattern related to fluid collection in the lungs.

II) Fluid volume excess related to edema in the abdomen and lower extremities.

III) Imbalanced nutrition less than body requirement related to poor appetite.

2. Expected outcome of nursing care:

I) Breathing pattern has to be improved .

II) Excess fluid volume has to be reduced.

III) Normal nutritional pattern has to be maintained .

3. Crackles on the exam indicate left heart failure. Due to left heart failure, fluid gets accumulated in the lungs and produces crackles.

4. The pitting edema is indicative of right heart failure. Due to right heart failure, fluid gets accumulated in the body especially in the lower extremities and gets pitting edema.