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
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.