Liza Marie L.

Nayre BSN-4

SDL Day 1 – Heart failure

Mr. J, a 69-year old male, presents to the Emergency Department (ED) after visiting
his physician complaining of general fatigue for 4 days, shortness of breath, and
abdominal discomfort. Mr. J’s medical history includes hypertension and coronary artery
disease. He had a previous 90% LAD blockage and 50% RCA blockage with stent
placements in both.

What initial nursing assessments need to be performed for Mr. J?

 We are going to initially place the patient into a high-fowler’s position to help the
patient overcome breathing problems. Administer oxygen to relieve shortness of
breath. Monitor vital signs, assess for capillary refill test and auscultate heart and
lung sounds. Raised side rails up for the safety of the patient.

What diagnostic tests do you anticipate being ordered by the provider?

 Chest x-ray to evaluate the lungs, heart and chest wall and may be used to help
diagnose shortness of breath and chest pain. Echocardiogram checks how your
heart's chambers and valves are pumping blood through your
heart. Electrocardiogram to record electrical signals. Brain Natriuretic Peptide to
measure the level of protein. Cardiac enzyme test to determine whether the patient
is having or already had a heart attack.

Upon further assessment, the patient has crackles bilaterally and tachycardia. A chest X-
ray shows cardiomegaly and bilateral pulmonary edema. An ECG revealed atrial
fibrillation. His vital signs were as follows:

 BP 150/72 mmHg
 Urine Yellow and Cloudy
 HR 102-123 bpm and irregular
 BUN 17 mg/dL
 RR 24-32 bpm
 Cr 1.2 mg/dL
 Temp 37.3°C
 Hemoglobin 11.8 g/dL
 Hematocrit 36.2%
 LDH 705 U/L
 Ht 175 cm
 Wt 79 kg
 BNP 843 pg/mL

Mr. J was admitted to the cardiac telemetry unit.

Mr. J states that this weight is approximately 3 kg more than it was 3 days ago.

What is the significance of Mr. J’s weight gain?

 It’s very common for people with heart failure to experience rapid changes in their
weight. If your heart failure is causing fluid accumulation, you will gain
weight. Heart failure means that the heart isn't working as well as it should. One
effect of this can be extra fluid in your body. This can cause rapid weight gain and
can cause swelling in the ankles, feet or legs, or sometimes around the stomach.
Fluid can also build up in the lungs, which can cause breathlessness.

What medications do you anticipate the provider orders for Mr. J? Why?
 Beta blockers, vasodilators, antihyperlipidemic and diuretics

About three hours after admission to the telemetry unit, Mr. J’s skin becomes cool and
clammy. His respirations are labored and he is complaining of abdominal pain. Upon
physical examination, Mr. J is diaphoretic and gasping for air, with jugular venous
distension, bilateral crackles, and an expiratory wheeze. His SpO2 is 88% on room air
and it was noted that his urine output had been approximately 20 mL/hr since
admission. His BP is 190/100 mmHg, HR 130 bpm and irregular, RR 43 bpm.

What nursing interventions should you perform right away for Mr. J?
 We are going to place the patient into a high-fowler’s position to help the patient
overcome breathing problems. Measure her oxygen saturation and administer
oxygen. Monitor vital signs and administer blood pressure medication as prescribed
by the physician. Raised side rails up, assess level of pain 0 to no pain at all, provide
a calm environment and notify the health care provider.

Describe what is happening to Mr. J physiologically.

 The patient's heart is unable to pump enough blood and oxygen to the brain,
kidneys, and other essential organs, resulting in pulmonary edema, which causes
 shortness of breath. His heart, on the other hand, is attempting to compensate for
the low cardiac output caused by the increased heart rate and blood pressure. His
kidneys are not perfusing properly, resulting in a reduction in urine output.

What medications should be given to decrease Mr. J’s preload? Improve his
contractility? Decrease his afterload?
 Medications that decreases preload are vasodilators such as nitrates and beta
blockers such as bisoprolol, carvedilol and metropolol.

Mr. J was transferred to the CCU for hemodynamic monitoring and aggressive therapy.
His Central Venous Pressure (CVP) was found to be 19 mmHg, Cardiac Output was 4.5
L/min, and Cardiac Index was 2.3 L/min /m2. He has been placed in high-fowler’s
position, and his SpO2 is now 96% on 4L nasal cannula. Mr. J received Furosemide 80 mg
IV and Digoxin 0.5 mg IV.

What is the expected outcome of administration of Furosemide? Digoxin?

 Furosemide works by blocking the absorption of sodium, chloride, and water from
the filtered fluid in the kidney tubules, causing a profound increase in the output of
urine (diuresis). Digoxin increases the strength and efficiency of heart contractions,
and is useful in the treatment of heart failure and control the rate and rhythm of
the heart.