Age/Sex 60years ,male.Admitted 05/23/2015.
Attending Doctor: Dr. DON’T HATE.
Location : MedTelemetry .RM 4023
CODE STATUS : Full code.
Allergy : NKDA.
Diagnosis : Left sided CHF.
CHF is the failure of the heart to pump blood effectively to meet metabolic demands.Because of that failure, there is excessive amount of fluid in the heart, lungs and tissues.
The left sided failure the blood will back up into the lungs causing pulmonary edema manifestations.When the right side of the heart fails blood backs up into the venous and portal system manifestations.Signs/Symptoms of CHF are dyspnea, orthopnea,weight gain,Pulmonary edema,distended neck veins, crackles.
Treatment: 02 2 Liter NC,digoxin, dopamine, diuretics (lasix )
Digoxin 0.125mg po daily .
Lasix 20mg IV BID.
Nurses responsibilities:
Place patient in high Fowler’s position.
Assess vital signs Q4hours.
Lung sounds.
Monitor Intake and output.
Check peripheral pulses.
Provide good skin care.
The nurse formulates a plan of care for a patient with left sided CHF.An appropriate nursing diagnosis would be an alteration in gas exchange secondary to increased in Capillary hydrostatic pressure.
Questions:
Why is patient placed on low sodium diet?.
What is the rationale for potassium supplements?.
Patient is on lasix. Why?.
The nurse is preparing to begin a dopamine infusion on a client. Before beginning the infusion the nurse should assess for the Patency of IV.
CASE SCENARIO 21ST B.
A 68years old man is admitted to the hospital for the treatment of left sided CHF.While the nurse is assessing the patient, she should identify that dyspnea is an early sign of left sided heart failure. Identify the key word “early ” and left sided. As a way to differentiate left versus right sided CHF.Think of cars on a highway. If a car cannot get onto a highway because of traffic congestion, it remains on the entrance ramp. If blood can’t get into the heart due to congestion, it remains where it is .Blood attempting to get into the right side of the heart remains in the vessel of systemic circulation.
Dyspnea because the lungs vital capacity is reduced when air is displaced by fluid.Left sided failure signs and symptoms are dyspnea, orthopnea,crackles, tachycardia, diaphoresis, confusion.
But the Right Sided Heart signs and symptoms weight gain,edema,distended neck vein,increased CVP.
A 45years old man is admitted for the treatment of heart disease ( CHF).The doctor orders an IVF of 0.9NS at 125ml/hour and the CVP readings Q4hours. 16hours after admission the CVP readings is 3cmH20.What is the evaluation of patient’s fluid status if made by the nurse is accurate?.
Answer:
The patient need more fluid because the normal level is 3 – 8cm, and patient fluid status indicates hypovolemia.
C.CASE SCENARIO.MI.
A 65years old woman is admitted to the hospital with a diagnosis of Myocardial infarction. Morphine sulfate is ordered by the doctor for the relief of pain. In addition to providing pain relief, the nurse knows that morphine sulfate will provide what effect?.
Answer:
Decreased blood return to the right side of the heart;decreased peripheral resistance. Decreased preload and after load pressure. Morphine sulfate is the drug of choice for an MI because it reduces the preload and after load pressure, also provides relief for anxiety. Demerol is used if patient is if patient is allergic to morphine or sensitive to respiratory depression.
The nurse plans care for of a patient diagnosed with an acute myocardial infarction. An appropriate nursing diagnosis would be. A potential for alteration in cardiac output secondary to what?.
Answer:
Ventricular dysrhythmia . Tgv his reduce the efficiency of the heart, which is common after myocardial infarction.
A 23 years old female comes to the Emergency room with a possible Pneumothorax. Based on the nurse’s knowledge about the respiratory patterns of a patient with a Pneumothorax. The nurse should assess the patient for the development of?.
Answer:
Tachypnea.
The nurse cares for a 48years old man who sustained a Pneumothorax in an automobile accident. The patient has a chest tube attached to three chamber water seal drainage system ( Pleur evac) connected to suction. When assessing the functioning of the chest tube the nurse should be most concerned if?.
Answer:
There is continous bubbling during both inspiration and expiration in the water seal chamber.
Pleur- evac has three chamber water seal drainage system.
First Chamber collect drainage.
Second Chamber act as waterseal.
Should fluctuate (tidal) with respiration. If it stops fluctuating the lungs has re- expanded or tubes are obstructed.
Continuous bubbling is an indication of Airleak.
Third Chamber is the Suction control. Alters the amount of suction delivered to pleural Space. And should bubble gently and continuously.
A 44years old man returns to his room following a Cardiac Catheterization. Which assessment if made by the nurse would justify calling the doctor?.
Answer:
Absence of a pulse distal to the catheter insertion site.
A 50years old man is admitted to the hospital for evaluation of cardiac disease. He is scheduled to have cardiac Catheterization. Three hours before the procedure. He said to the nurse, “I don’t want this procedure to be done on me”.Which of the following responses by the nurse will be the best.
Answer:
Offer to discuss with him,his concern with the procedure.
Nurses You Move Me 