[reidesert]

Critical Thinking Case Study and Study Questions Alterations in Function: Cardiovascular (1st page of our packet)
You are caring for a 72 year old female client with congestive heart failure. The client is alert and oriented, BP is 170/80, HR 110, RR 32, Temp 98.6, O2 sat 89% # RA, crackles heard bilaterally at bases, jugular neck vein distention noted with HOB elevated 30%, 3+pedal edema, urine output 90ml over past 4 hours, saline lock to right arm, no redness or swelling.

• Identify all abnormal assessment findings and discuss possible causes for those findings.

• BP 170/80 (normal range for systolic 90-140 and diastolic 60-90): the systolic blood pressure is elevated. Hypertension or abnormally high blood pressure increases the amount of work the left ventricle has to do to pump blood out into the circulatory system. Over time, this greater workload causes left ventricular hypertrophy and can damage and weaken the heart. This can lead to heart failure.
• HR 110 (normal range for HR is 60-100 bmp: the HR is slightly elevated. The heart muscle is too weak to contract fully. Reduced volume of blood leaves ventricles during systolic ejection. A heart rhythm that is too fast (or slow) and is sustained over time can cause the heart to weaken, which can cause heart failure.
• RR 32 (normal range 12-20): tachypnea r/t respiratory distress d/t increased effort of breathing d/t circulatory overload. Compensatory Mechanisms: Heart failure results when heart is unable to increase workload to handle excess blood volume: Left-sided heart failure- pulmonary edema
• Temperature 98.6 (normal 98.6 F or 37.0 C): temperature is normal
• Oxygen saturation 89%@ RA (normal range 95-100%): This indicates moderate hypoxemia.
• Crackles heard bilaterally at bases are an adventitious lung sounds that may be r/t congestion in the pulmonary circulation; d/t the inability of the left heart accommodate the blood entering it from pulmonary circulation. Left-sided heart failure- pulmonary edema
• Distended Jugular Neck Veins r/t water and salt retention d/t the blood not being adequately pumped from the systemic circulation into the pulmonary circulation. The heart is unable to handle systemic venous return and blood gets “backed up” which results in systemic venous congestion w/ signs and symptoms of fluid volume excess that leads to circulatory overload. Right-sided heart failure-peripheral edema.
• 3+ Pedal Edema is r/t fluid overload d/t the heart’s inability to handle systemic

venous return and results in systemic venous congestion. This results in systemic
edema.

• Urine output @ 90 cc over 4 h (normal urine output = 30 ml/ h which over 4 hours 30 ml X 4 h = 120 ml): her urine output indicates inadequate output. This may be d/t fluid retention d/t fluid volume excess and fluid building up into the interstitial space

2. What assessment findings are consistent with Right Ventricular Failure- (Congestion occurs when blood is not pumped adequately from the systemic circulation into the pulmonary circulation resulting in systemic edema, blood gets backed into the systemic circulation).
A. Peripheral Edema 3+ pedal edema.
B. Jugular Vein distention
3. Which assessment findings are consistent with Left Ventricular Failure- (reduced compliance that alters diastolic pressures that leads to an inadequately filled heart d/t left ventricular hypertrophy. This means decreased cardiac output to the systemic circulation and pulmonary congestion d/t the inability of the left ventricular to accommodate the blood entering it from the pulmonary circulation.)
A. Pulmonary Congestion: Bilateral lobar crackles
C. Tachycardia: HR 110
D. Tachypnea: RR 32
E. 90 ml urine output in 4 h- oliguria-(decreased urine production) during the day.
4. What is the client’s primary nursing diagnosis?
* ABC’s is always a priority in any client*
Ineffective Breathing Pattern r/t pulmonary congestion AEB bilateral lobar crackles, Tachypnea, and oxygen saturation of 89%
5. Identify possible independent nursing interventions: (1st thing I would do is put patient on oxygen, recheck oxygen saturation and call doctor for order) although this is a dependent intervention)
1. Elevate HOB to High Fowler’s position.
2. Monitor VS, lung sounds, heart sounds, peripheral pulses, edema, jugular vein distention, intake & output, urine output, creatinine and BUN, potassium level (in anticipation of administering diuretics), get a weight baseline if it has not been done (to have something to compare to when doing daily weights).
3. Evaluate for and reduce anxiety by encouraging patient to deep breath and reducing stimuli in room (turning off lights, noise etc...)
4. Frequent turning/positioning and hygiene care because of edematous skin/tissue. Do not elevate feet because it increases blood flow to the heart too quickly and increases workload of the heart.

[Angie O'Plasty, RN]

You answered that question like I would have. It's really refreshing to see such complete answers with rationales.

I think the only thing I might add is, in the section where you'd check labs, if it's available, you'd want to look at the BNP, as that's the Gold Standard for CHF. If one wasn't done, the doc will probably treat the patient with Lasix based on the other s/s you report.

With this patient, I would first call the Respiratory Therapist and start O2 via nasal cannula. Hopefully that would work, but if not, the RT is there to handle the breathing while I call the doc. The doc will probably order a blood gas, a BNP, a chest X-ray, and Lasix.

You can see that even though the patient is now a/o X3 and breathing sorta OK, I'd never trust a CHF'er with the s/s you describe to stay that way. They can deteriorate pretty rapidly, and one of the last things you'll see is some confusion and then loss of consciousness. So you'd also want to keep monitoring LOC.

To sum, I think you did an excellent job on this.

[reidesert]

Thanks so much for your suggestions! I really appreciate that you took the time to read and comment. I forgot about the BNP and calling the RT is important too. Thank you!!
Rachel

[Daytonite]

In the list of abnormal assessment findings I would not include the normal temperature reading. The directions specifically asked only for abnormal findings.

The tachycardia is due to sympathetic stimulation.

I have to disagree that this patient is in respiratory distress. Tachypnea is not the same as dyspnea or shortness or breath. It is just rapid breathing. It is, however, a reason to check a pulse ox and do further assessment for other symptoms and monitor for chest pain, abnormal heart sounds, abnormal lung sounds, cough, JVD, or edema.

Below normal oxygen saturations are due to decreased percentage of hemoglobin saturated with oxygen. Normal is 95-100% and panic values are below 75%. Although 89% on room air is abnormal, this is not a value I would send me running for the oxygen.

The crackles in the lung are due to venous congestion in the lung. The congestion and pressure force fluid into the alveolar capillaries where it leaks into the alveoli resulting in pulmonary congestion.

The jugular veins become distended secondary to the venous congestion and pressure that backed up blood causes in the vena cava.

As blood and pressure continues to back up, the systemic circulation is affected eventually causing pressure in the capillaries to force excess fluid into the interstitial spaces which results in the pitting 3+ pedal edema.

Kidney output declines due to sympathetic response of the body to peripheral vascular resistance resulting in vasoconstriction in the kidneys causing restricted blood flow to the kidneys. This is partly tied in to hypertension and the release of renin. (pathophysiology of hypertension: http://allnurses.com/forums/2768677-post4.html)

4. What is the client’s primary nursing diagnosis?
* ABC’s is always a priority in any client*


Ineffective Breathing Pattern r/t pulmonary congestion AEB bilateral lobar crackles, Tachypnea, and oxygen saturation of 89%

I would not use that diagnosis. I do not feel there is anything in this scenario that fits the "A" for airway (there is nothing about a cough or sputum blocking the airway or bronchi) or "B" for breathing (other than tachypnea there is no mention of dyspnea or SOB) insofar as the ABC assessment is concerned. Tachypnea is just rapid breathing. Also, bilateral lobar crackles and oxygen saturation of 89% are not defining characteristics (evidence, symptoms) of inadequate ventilation as listed by NANDA for this diagnosis.

I would go with something to do with "C" for circulation and I'd be looking specifically at tissue perfusion. There are two tissues involved here: the lung and the heart. Which needs oxygen most or will die off faster? The heart. Therefore, I would diagnose Decreased Cardiac Output R/T altered preload and contractility AEB peripheral edema, jugular vein distension, and crackles in the bases of the lungs. The only other choice I make might be Impaired Gas Exchange R/T ventilation perfusion imbalance AEB oxygen saturation 89% on room air and tachycardia.

I don't feel supplemental O2 is probably something that is going to be an emergency measure here. However, treating the peripheral edema, JVD and lung congestion will be. The rapid breathing can be addressed in interventions for the lung congestion.

• • Palpate/auscultate peripheral pulses
  • Note color and temperature of the skin of the legs; note any difference between the legs
  • Assess for tenderness or cords; perform Homan's sign
  • Elevate the legs
  • Monitor intake and output; a foley catheter may be inserted so foley care may be necessary
  • Daily weight
  • Monitor leg circumference of both legs daily
  • Have patient change position frequently to avoid skin breakdown
  • Monitor both legs for skin breakdown
  • If patient will require a central venous or pulmonary catheter prepare patient and explain purpose for catheter
  • Explain underlying condition to patient
  • Discuss which foods and fluids patient should avoid
  • Talk with patient about planning for rest periods during daily activities
  • Note the presence of any cough or sputum production
  • Note the amount, color, odor and consistence of any sputum produced
  • Assess lung sounds
  • Assess symmetry of chest during breathing
  • Keep head of bed elevated to help ease breathing
  • Encourage fluid intake to help liquefy secretions
  • Encourage deep breathing and coughing

How are things at my old school? It's been a long time since I've seen a post from you. Are the instructors working you to death?