NURSING PROGRAM
MMC/MS. HOUGHLAND
CLINICAL PREPARATION
STUDENT NAME:______DATE:______
PATHOPHYSIOLOGY/ETIOLOGY
Congestive Heart Failure (CHF): occurs when the heart has lost its ability to effectively pump blood. Many conditions can cause congestive heart failure, these include: faulty valves, an enlarged heart (cardiomegaly), hypertension or myocardial infarction just to name a few. CHF can then be divided into two types: right sided or left sided. With right sided failure: you will see peripheral edema, liver congestion, ascites, and weight gain. With left sided failure: you will see, hypoxia, shortness of breath, rales upon auscultation and weight gain. It is possible to have both right sided and left sided heart failure
Chronic Illnesses:
Hypertension: blood pressure that is elevated, (normal 120/80, evaluated = 140/90), due to increased vascular resistance: causes include fluid overload, hormones, arterial vascular disease
Myocardial infarction: where heart muscle is irreversibility damaged due to the lack of blood supply. The lack of blood supply can be caused by a blood clot, fat emboli, arterial spasms, atherosclerosis or the use of illegal drugs.
Other history: smoker, cardiac stent x2, angioplasty x2, social drinker
Patient was admitted 1.17.08
Day of care 1.18.08
PATIENT SIGNS AND SYMPTOMS (Include Subjective and Objective Data)
Patient: fatigue, 2+ pedal edema, weight gain of 15 pounds with 5 days, unable to wear shoes, was progressively getting short of breath in the past week. Was placed on oxygen nc in the ED when it was found that his pulse ox was 89% on room air.
Book: pitting edema, rales, S3,JVD, SOB, weight gain, enlarged liver, ascites, hypertension, poor ejection fraction from a echocardiogram, chest pain, increased heart rate (tachycardia), decreased blood pressure (end stage), tachypnea, cyanosis, orthopnea, paroxysmal nocturnal excertional dyspnea or confusion.
DIAGNOSTIC TESTS:
(Include implications of abnormal lab/radiology tests, signs and symptoms to observe for, teaching of patient/family regarding abnormal labs/tests).
Echocardiogram: 25% ejection fraction, with moderate tricuspid valve and pulmonary valve regurgitation. (with regurgitiation: it doesn’t allow the blood to flow as well as it should therefore causing the blood to back up into the pulmonary system) Tell the patient that the test usually takes 20mins to do, a gel will be placed on his chest and the tech will take a hand held device to place over his heart to look at the structure of the heart
Blood Tests: CBC: wnl (monitors red blood cells, white blood cells and plt, needed for clotting, oxygen carrying capability, infection control) (H/H could be low because of the hemodilution)
: BMP: creatinine: elevated(3.1) (used to eval kidney function)
Na: sodium: low 110 (electrolytes need to muscle movement) with fluid overload: could be from hemodilution
K+ potassium normal 4.1(electrolytes need to muscle movement): important for muscle contraction and diuretic administration
CPK: 213: normal: muscles will release CPK into the blood stream when damage is inflicted. With the normal level it could mean that there was no damage to the heart.
BNP: 1500: elevated: when it is elevated it represents the stretching of the myocardium which is consistent with heart failure (symptoms include: edema, rales, sob, weight gain, fatique)
Teaching: teach the patient to hold still and the reasons why the tests are needed (explain more)
Chest x-ray: enlarged heart, infiltrates bilateral bases (used to see structures of the patient’s body): infiltrates would be the fluid build up: enlarged heart could be due to overusage therefore the heart will not function as well. Will need to help that patient sit up and able to hold their breath
TREATMENTS (book and patient)
Acute: diuretics: Lasix: used to rid excess fluid
Inotrope: dopamine IV: helps increase myocardial contractility, with increased contractility it will help with perfusion and therefore will related to an increased urine output (which is needed for a patient in CHF)
Daily routine: diet control: decreased weight: less stress on heart, with less stress on the heart: there will be an decarese in oxygen demand. A enlarged heart is not as capable as one that is not to “pump” blood throughout the body
Lower salt intake: with reduce retained fluid. With retained fluid, it increases the workload on the heart
Exercise: helps with weight control and health of heart. Losing weight decreases workload on heart
Diuretics: used to rid excess fluid. With retained fluid, it increases the workload on the heart
Digoxin: helps with slowing down the heart so it can contract more productively therefore increased cardiac output.
Ace inhibitor: lowers afterload, helps with ventricular dysfunction
MEDICATIONS:
( DOSE,INCLUDE PURPOSE FOR SPECIFIC TO THIS PATIENT, SIDE EFFECTS, SPECIAL INSTRUCTIONS)
Digoxin 0.25 mg po once a day: helps with heart to slow down and pump more effectively which would help a patient with CHF because it will help push forward the blood and not back up into the lungs or extremities. Sid
Side effects: nausea, bradycardia, dizziness, needs to monitor potassium level (low K level can potentate digoixn toxicity), do not skip a dose, do not double dose
Patient needs to be taught how to take an apical pulse and not to take a dose if one’s heart rate drops below 60 bpm
Lasix 20 mg one a day: diuretic: use to rid excess fluid. If the excess fluid is taken off, it will decrease the work load on the heart
Side effects: nausea, leg cramps, frequent urination, hypokalemia
Patient needs to be taught: take early in the day, do not skip a dose
May need to take supplemental potassium, because it could increase the chance of digoxin toxicity
COMPLICATIONS
Fatigue
Respiratory failure
Intubation
DVT: due to immobility
Discomfort: due to liver congestion, ascites
Hypoxia
Liver failure
Myocardial infarction
Death
NURSING DX#1
Excessive Fluid volume R/T hearts inability to pump blood effectively as evidence by patients 15 pound weight gain and 2 pulse pitting edema
______NURSING DX#2
Impaired gas exchange r/t alveolar capillary membrane changes due to the fluid shift into the intersitital space/alveoli as evidence by 89% sat on room air, coarse rales bilaterally during auscultation and patient complain of sob
______
Prioritized Needs List
1) Provide more oxygen to the patient (nasal cannula or mask)
2) Reduce work load by removing the fluid or medications
3) Assessment of patient’s understanding of disease: to help prevent
4) Increase activity tolerance
5) Will need to monitor weight and output
6) Monitor that the patient does not become dehydrated also
Plan of Care
During the care of the patient, he did not tolerate any sort of activity, his sentences were only 2 to 3 words long inbetween each breath. His lungs had coarse rales. The order on the chart was to give 40 mg of IV lasix and the nurse after looking at the patient stated that he probably needs more lasix. The patient’s sats were only 91% on 6 liters.
We increase his oxygen to a 50% venti mask and his sats increased to 95%. He also only had 200ml of urine output within the last 8 hours. The nurse got an order of 60mg of Lasix IV stat.
I monitored the patient every 15 minutes for his blood pressure, heart rate and resp rate. His urine output was 600 ml in 1 hour.
His heart rate, resp rate and blood pressure decreased in one hour. He stated he felt like he could breath better after 1 hour.
I didn’t not think of getting a set of ABG’s or a CXR (the nurse did) but it I think I would think of it the next time.
Rev date 8/27/08 EH
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