Bonnie Rogers
Stonecrest Medical Center
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JS, 79 years old
Caucasian female
Primary language
English
Resident of Smyrna
TN
Married with one son
and two grandchildren
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Retired accountant
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Religion: Christian
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Full Code Status
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Weight: 252 lbs
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Height 5ft. 1 in.
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BMI 45.1 (obese)
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Admission on 04/07/10
Presentation: Extreme Progressive Weakness
Admitting Diagnosis: Congestive Heart
Failure, Weakness
Risk Factors:
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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
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Chronic Kidney Disease
 Iron Deficiency Anemia
 Osteoporosis
 Hypothyroidism
 Allergic to Shellfish containing
substances and penecillins
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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
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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/Thiazid
e duiretic
500mg/500mg,
IV, Continuois @
10mg/hr
CHF, CRF,
edema
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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
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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
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Patient Oriented to person, place, time, and
situation
Confused at times
Drowsy all day
Arouses easily and follows commands
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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
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Bowel sounds present in all four
quadrants
 No palpable masses, no tenderness
noted
 Abdomen soft, non-distended
 Passing flatus
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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
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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
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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
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Left AC
◦ Saline Lock
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Left Hand
◦ 20 gauge
◦ Lasix/diuril drip @ 10mg/hr
◦ Both sites: patent line, dressing dry and intact, no
complications
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Patient depressed and emotional, crying
occasionally
Patient voices concerns of putting a burden
on family members
Family at bedside during visiting hours
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Primary Nurse (RN)
Attending Physician
Cardilogist
Nephrologist
Physical therapist
Occupational Therapist
Student Collegues
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Decreased Cardiac Output r/t decreased
pumping ability AEB:
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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
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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
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Goals Met:
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Urine output of aproximately100ml/hr
Respirations stayed between 10-25bpm
No audile abnormal heart sounds
No presence of arrhythmias
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Goals Not Met:
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◦ Peripheral pulses still +1 by end of shifts
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Imaired gas exchange r/t inadequate cardiac
function secondary to heart failure AEB
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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
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Balancing oxygenation and activity
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Initial bedrest
Progress ADLs as tolerated
Oxygen at 2L
Head of bead 30-60 degree
Auscultate lung sounds q2hrs
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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
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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
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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
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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
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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
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Goals Not Met:
◦ Edema was still +2 by end of clinical shift
◦ Crackles still auscultated in RLL
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Objectives: examine whether patients with CHF
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The Group Studied: Patients with a diagnosis of
were receiving the optimum treatment for heart
failure and propose recommendations for CHF
management that would be useful to all kinds of
healthcare facilities.
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.
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Findings:
◦ All patients had at least one risk factor
◦ 71% had hypertension.
◦ A significant percentage (22%) had renal insufficiency.
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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.
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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.