35 Cardiac Problems
A 73-year-old woman is admitted to the telemetry unit with right-sided heart failure, type 2 diabetes mellitus, hypertension, and COPD. When the patient arrives to the unit, you observe that her color is pale, she is becoming increasingly dyspneic, and she reports a new onset of chest discomfort. The patient's husband is very concerned as he feels his wife is slightly disoriented. Her oxygen saturation levels are 88% on oxygen 2L per nasal cannula 3. The patient's health care provider prescribes an initial dose of furosemide (Lasix) 40 mg IVP. What assessments will you perform to determine if the drug was effective?
Assess for improvement of lung sounds, increased urinary output, and relief of dyspnea.
A 73-year-old woman is admitted to the telemetry unit with right-sided heart failure, type 2 diabetes mellitus, hypertension, and COPD. When the patient arrives to the unit, you observe that her color is pale, she is becoming increasingly dyspneic, and she reports a new onset of chest discomfort. The patient's husband is very concerned as he feels his wife is slightly disoriented. Her oxygen saturation levels are 88% on oxygen 2L per nasal cannula. 4. The patient's husband remains very anxious and requests to stay at her bedside. What will you tell the patient's husband about her condition at this time? Should the patient's husband be present during her emergency treatment? Why or why not?
Provide as much information to the husband as possible. Explain the process of heart failure and indicate the steps that are being done to help his wife improve. Allowing the husband to stay is agency specific and should be based on the patient's needs.
A 73-year-old woman is admitted to the telemetry unit with right-sided heart failure, type 2 diabetes mellitus, hypertension, and COPD. When the patient arrives to the unit, you observe that her color is pale, she is becoming increasingly dyspneic, and she reports a new onset of chest discomfort. The patient's husband is very concerned as he feels his wife is slightly disoriented. Her oxygen saturation levels are 88% on oxygen 2L per nasal cannula. 2. What evidence-based actions will you plan to implement at this time based on your assessment? What is the source of the evidence?
Provide the necessary amount of supplemental oxygen within a range prescribed by the health care provider to maintain oxygen saturation at 90% or greater. If the patient has dyspnea, place in a high-Fowler's position with pillows under each arm to maximize chest expansion and improve gas exchange. Repositioning and performing coughing and deep-breathing exercises every 2 hours helps to improve gas exchange and prevents atelectasis. The decreased oxygen level is likely contributing to the confusion.
A 73-year-old woman is admitted to the telemetry unit with right-sided heart failure, type 2 diabetes mellitus, hypertension, and COPD. When the patient arrives to the unit, you observe that her color is pale, she is becoming increasingly dyspneic, and she reports a new onset of chest discomfort. The patient's husband is very concerned as he feels his wife is slightly disoriented. Her oxygen saturation levels are 88% on oxygen 2L per nasal cannula. 1. Using clinical judgment, what should you assess first?
The priority assessment is gas exchange. While the patient has known right-sided heart failure, she is showing signs of respiratory distress which could indicate progression to left-sided heart failure and/or pulmonary edema. Assess lung sounds and heart rhythm. Document the precise location of the crackles because the level of the fluid progresses from the bases to higher levels in the lungs as the condition worsens. Monitor oxygenation as the decreased oxygenation is likely contributing to the confusion. Blood sugar should also be assessed following priority assessment.
1. An 84-year-old client with heart failure presents to the emergency department with confusion, blurry vision, and an upset stomach. Which assessment data is most concerning to the nurse? a. Digoxin (Lanoxin) therapy daily. b. Daily metoprolol (Lopressor). c. Furosemide (Lasix) twice daily. d. Currently taking an antacid for upset stomach
ANS: A Confusion, blurry vision, and upset stomach are symptoms of Digoxin toxicity, which is common in older adults and requires immediate treatment. The other answers are important assessment data but do not indicate immediate connection to the client's presentation.
1. A client is diagnosed with right-sided heart failure. Which assessment findings will the nurse expect the client to have? (Select all that apply.) a. Peripheral edema b. Crackles in both lungs c. Increased abdominal girth d. Ascites e. Tachypnea
ANS: A, C, D, E Peripheral edema, increased abdominal girth, ascites, and tachypnea are all symptoms associated with right-sided heart failure due to the back up into the peripheral system. Crackles in the lungs are associated with left-sided heart failure. Cognitive Level: Application Client Needs Category: Safe Effective Care Environment: Management of Care Nursing Process Step: Assessment
1. A client who recently had a heart valve replacement is preparing for discharge. What statement by the client indicates that the nurse will need to do additional health teaching? a. "I need to brush my teeth at least twice daily and rinse with water." b. "I will eat foods that are low in vitamin K, such as potatoes and iceberg lettuce." c. "I need to take a full course of antibiotics prior to my colonoscopy." d. "I will take my blood pressure every day and call if it is too high or low."
ANS: C Antibiotics are only required prior to dental procedures. Good oral hygiene is the best prevention for endocarditis. The statement in option A is correct and shows the patient understands the need for oral hygiene. The patient with a mechanical valve will be on warfarin (Coumadin); thus, foods high in Vitamin K should be avoided. This statement is in option B is correct and shows the patient understands foods that are LOW in Vitamin K. This statement in option D is also correct and shows that the patient understands the importance of regular BP assessment as well as when to call the provider based on the assessment.
1. A client with chronic heart failure presents to the ED with a new onset of atrial fibrillation. Which of the following medications would the nurse question? a. Lasix (furosemide) b. Toprol XL (metoprolol succinate) c. Cardizem (diltiazem) d. Corlanor (ivabradine)
ANS: D Ivabradine is contraindicated in the presence of atrial fibrillation and should be stopped. Cognitive Level: Analysis Client Needs Category: Physiological Integrity-Pharmacological and Parenteral Therapies Nursing Process Step: Assessment
A 73-year-old woman is admitted to the telemetry unit with right-sided heart failure, type 2 diabetes mellitus, hypertension, and COPD. When the patient arrives to the unit, you observe that her color is pale, she is becoming increasingly dyspneic, and she reports a new onset of chest discomfort. The patient's husband is very concerned as he feels his wife is slightly disoriented. Her oxygen saturation levels are 88% on oxygen 2L per nasal cannula. 5. After two doses of Lasix, the patient's condition improves. What data will you document in the electronic medical record (EMR)?
Document assessment information, including specific location of crackles as well as the changes in lung sound and breathing following Lasix administration. Urinary output should also be documented as well as teaching measures provided to patient and husband.
