Bonnie RogersStonecrest Medical Center

JS, 79 years oldCaucasian female

Primary languageEnglish

Resident of SmyrnaTN

Married with one son and two grandchildren

Retired accountant

Religion: Christian

Full Code Status

Weight: 252 lbs

Height 5ft. 1 in.

BMI 45.1 (obese)

Admission on 04/07/10 Presentation: Extreme Progressive

Weakness Admitting Diagnosis: Congestive Heart

Failure, Weakness Risk Factors:

◦ Diabetes Mellitus ◦ Hypertension◦ Obesity◦ Hyperlipidemia◦ CAD

Coronary Artery Disease with Cardiac Bypass x4 vessel on 11/16/09

Severe Pulmonary Hypertension Atrial Fibrillation with tachybrady syndrome with dual chamber pacemaker 12/01/09

Chronic Kidney Disease Iron Deficiency Anemia Osteoporosis Hypothyroidism Allergic to Shellfish containing substances and penecillins

Portable Chest x-ray on 4/7/10 Reason: weakness Findings: cardiomegaly. Obscuration of the left hemidiaphram likely related to the large heart. The right lung is clear. Vasculature appears normal

Congestive Heart Failure Right Side

Caused from left-sided heart failure. As pressure in the pulmonary circulation rises, the

resistance to right ventricular emptying increases. The right ventricle is poorly prepared to compensate for this increased afterload and will dilate and fail. When this happens, pressure will rise in the systemic venous circulation.

Clinical Manifestations: edema, jugular vein distention, fatigue

Normal Range Reason

RBC’s 3.22 (L) 4.2-5.4 M/UL Anemia

HGB 7.6 (L) 12-16 gm/dl Anemia

HCT 23.9 (L) 35-47 % Anemia

MCV 74.1 (L) 80-100fl Anemia

MCH 23.6 (L) 25.4-34.6 pg/cell

Anemia

Normal Range Reason

PT 37.9 11-13.5 seconds

Pt prior to hospitalization on Coumadin

BUN 28 mg/dl (H) 10-20 mg/dl Chronic Renal Failure

Creatine 2.6 mg/dl (H) 0.5-1.2mg/dl Chronic Renal Failure

Medication Class Dose, Route, and Frequency

Rationale for Use

Sodium Bicarbonate

Alkalinizer 650mg, PO, TID Chronic Renal Disease causes metabolic acidosis

Sertraline(Zoloft)

Antidepressant 50mg Patient depressed

Levothyroxine(Levothroid)

Thyroid Horomone

0.125,mg, PO, Daily

Hypothyroidism

Omeprazole (Prilosec)

Proton Pump Inhibitor

20mg, PO, Daily GERD

Medication Class Dose, Route, and Frequency

Rationale for Use

Ciprofloxacin(Cipro)

Fluoroquinolone Antibiotic

500mg, PO, Q12

Urinary Tract Infection

Carvedilol(Coreg)

Beta Blocker 12.5mg, PO, BID

Hypertension

Potassium Chloride

Electrolyte replenisher

20 meq K+ 3.2 (norm)

Medication Class Dose, Route, and Frequency

Rationale for use

Acetazolamide(Diamox)

Diuretic 250mg, IVP, Q48hrs

CHF, CRF, edema

Iron Sucrose(Venofer)

Hematinic 500mg, IV, Daily

Iron deficiency anemia

Lasix/Diuril Drip Loop Diuretic/Thiazide duiretic

500mg/500mg, IV, Continuois @ 10mg/hr

CHF, CRF, edema

Ranges from two days 4/8/10 and 4/10/10◦BP: 94/38-112/43◦HR: 48-139 (tachybrady syndrome)◦RR: 13-23 bpm◦SpO2: 94-100%◦Temp: 96.6-97.6 F

PERRLA Glasses No drainage from eyes, ears, or nose Complete dentures Oral care performed every 2 hrs using

toothbrush and toothpaste with moderate assistance

Lip moisturizer applied after mouth care and meals

Patient Oriented to person, place, time, and situation

Confused at times Drowsy all day Arouses easily and follows commands

Cardiac Monitoring: Atrial paced with occasional SB and ST

Normal S1 and S2 auscultated◦No audible murmurs

Cap refill <3 seconds, nail beds pink Radial pulses 3+, regular rate and rhythm Dorsalis pedis pulse: Bilateral 1+ weak Edema 2+ present in ankles and lower

legs bilaterally

Fine crackles auscultated at RLL Diminished breath sounds in RUL, LUL, LLL anteriorly and posteriorly

Dyspnea on exertion O2 per NC at 2L

Bowel sounds present in all four quadrants

No palpable masses, no tenderness noted

Abdomen soft, non-distended Passing flatus

Foley Catheter in place, urethral area dry with no complications, tubing secured to thigh

Urine clear and yellow Intake and output qhr Average urine output after 2 shifts approximately 150ml/hr order to call if <100ml/hr

Activity limited by range of motion and generalized weakness

Turning and repositioning schedule set for q2hrs

Up to chair with extensive assistance from OT and PT for approximately 20 minutes

Henrich II Fall Risk Score 7: High Risk with fall precautions maintained

Skin color normal for ethnicity Skin warm and dry to touch Absence of tissue breakdown Braden Skin Integrity Risk Score: 15 (mild

risk, skin bundle precautions maintained) Repositioning schedule q2hrs Bed linens with minimal layers and free of

wrinkles

Left AC◦ Saline Lock

Left Hand◦ 20 gauge ◦ Lasix/diuril drip @ 10mg/hr

◦ Both sites: patent line, dressing dry and intact, no complications

Patient depressed and emotional, crying occasionally

Patient voices concerns of putting a burden on family members

Family at bedside during visiting hours

Primary Nurse (RN) Attending Physician Cardilogist Nephrologist Physical therapist Occupational Therapist Student Collegues

Decreased Cardiac Output r/t decreased pumping ability AEB:◦ need for pacemaker (previous arrhythmias)◦ Decreased urine output ◦ Diminished peripheral pulses◦ DOE◦ JVD

Urine output of >100ml/hr Respirations of 10-25bpm Peripheral pulse +2 regular No audile abnormal heart sounds No presence of arrhythmias

Monitor urine intake and output qhr Titrate lasix/diuril drip according to I&O Administer Diamox q48hrs Auscultate heart and lung sounds q 2hrs Monitor BP and HR qhr HOB elevated 30-45 degrees

Goals Met: Urine output of aproximately100ml/hr Respirations stayed between 10-25bpm No audile abnormal heart sounds No presence of arrhythmias

Goals Not Met:◦ Peripheral pulses still +1 by end of shifts

Imaired gas exchange r/t inadequate cardiac function secondary to heart failure AEB ◦ Occasional confused mental status◦ DOE◦ Generalized weakness◦ Need assistance with ADL’s◦ Need for O2 per NC

RR 10-25 SpO2 >95% Alert and Oriented x3 HR will not increase by more than 20 during activity

RR will not increase by more than 5 during activity

Balancing oxygenation and activity◦ Initial bedrest◦ Progress ADLs as tolerated◦ Oxygen at 2L◦ Head of bead 30-60 degree◦ Auscultate lung sounds q2hrs

Goals Met: RR remained within 10-25 bpm SpO2 was >95% Pt alert and oriented x3 HR did not increase by more than 20

during activity RR did not increase by more than 5 during

activity

Fluid Volume Excess r/t impaired excretion of Na and H2O secondary to renal insufficency AED:◦ +2 pitting edema bilaterally on lower legs and

ankles◦ Jugular Vein Distention◦ Crackles auscultated in RLL◦ Decreased urinary output

Maintain urine output within 500 ml of intake

Reduce +2 pitting edema to +1 by end of shifts

Lose 2 lbs of fluid by end of shift Lungs clear bilaterally

WEIGH daily Maintain a strict intake and output qhr and

report less than 30ml/hr Restricit fluid and sodium as ordered Monitor creatinine and BUN

Goals Met: ◦ urine output within 500 ml of intake◦Lose 2 lbs of fluid by end of shift. Pt lost

over 6lbs of fluid being 3000ml Goals Not Met:

◦Edema was still +2 by end of clinical shift◦Crackles still auscultated in RLL

Objectives: examine whether patients with CHF were receiving the optimum treatment for heart failure and propose recommendations for CHF management that would be useful to all kinds of healthcare facilities.

The Group Studied: Patients with a diagnosis of Congestive Heart Failure and an ejection fraction less than 40%. A retrospective review of 300 clinic records of patients with CHF dating from January 1, 2003 to July 31, 2004 was performed.

Findings: ◦ All patients had at least one risk factor ◦ 71% had hypertension. ◦ A significant percentage (22%) had renal insufficiency.

Recommendations:◦ Teach patients about risk factors such as hypertension,

smoking, diabetes, and obesity◦ Nurses need to educate regarding early intervention and

better management of hypertension to limit its development.

◦ Teach It’s not ALL about you’re heart! CHF can affect many organs. Teach pts to weigh daily, avoid nephrotoxic drugs, and pay attention to how much they void.

In relation to JS◦ Patient and family were taught about minimizing

risk factors for CHF including referral to cardiac rehabilitation center, nutritional support, and diabetic management.

◦ JS was taught about the importance of her chronic renal insufficiency and how it affects her heart. Pt taught to monitor weight daily (notifying MD if >2lbs in one day) and paying attention to voiding patterns.

Ancheta, I. (2006). A retrospective pilot study: management of patients with heart failure.Dimensions of Critical Care Nursing, 25(5), 228-233. Retrieved from CINAHL with Full Text database.

Huether, S.E. & McCance, K.L. (2008). Understanding Pathophysiology (4th ed) St. Louis: Mosby, Inc.

Skidmore, L (2009). Mosby’s Drug Guide for Nurses. St Louis: Mosby, Inc.