CHF Nursing Situation – What would you expect skin condition/lower extremities to be like – Solution

CHF Nursing Situation – What would you expect skin condition/lower extremities to be like

Patient is a 82 year old male who presented to the ED at 5am for shortness of breath worsening over the past day, PMH includes CHF, HTN, hyperlipidemia, CAD s/p cardiac stents in 2014, DM, osteoarthrtis, BPH, depression, CKD st 3.

Admitted for CHF exacerbation, pneumonia, acute on chronic renal disease

You receive him on the floor at 11:30 am, he appears to be alert and oriented, but lethargic, states he hasn’t taken any home meds yet today, has not eaten yet either.  Lives at ALF, uses walker

In the ED, he received IV furosemide 40mg, 650mg Tylenol, 500mg IV levofloxacin and an albuterol/ipratropium nebulizer treatment

Selected labs, diagnostics, and orders

WBC

18.2

Hgb

10.4

K (potassium)

3.1

creatinine

4.1

blood glucose

308

BNP

8023

Urine – blood

large

Urine – leukocytes

+3

Urine – culture

pending

COVID 19 PCR – negative

chest x-ray

bilateral infiltrates, pleural effusions

sputum sample to be collected

normal sinus rhythm on tele monitor

vital signs

170/64, P55, R23, O2 90% room air, temp 100.4, ht 178cm, wt 90kg

Diet: cardiac, 1800 ADA, 1 liter free water restriction

Activity: as tolerated

Strict I&O

home medications – have all been profiled to  MAR

Hospital meds

metoprolol

25mg

BID

albuterol/ipratropium

Q6hrs

amlodipine

5mg

QAM

furosemide IV

40mg

once 6pm

lisinopril

20mg

QAM

levafloxacin IV

500mg

Q24hrs

atorvastatin

40mg

QPM

tylenol

650mg

Q6hrs  PRN

tamsulosin

0.4mg

QPM

IV potassium  10 meq

x3

clopidogrel

75mg

QAM

aspirin

81mg

QAM

escitalopram

10mg

QAM

metformin

1000mg

BID

tramadol

50mg

Q8hrs PRN

gabapentin

200mg

BID

temazepam

7.5mg

QHS PRN

Consults pending – cardiology, ID, nephrology

Personal history

former smoker, quit 35 years ago

does not drink alcohol

did not get flu shot this year

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Discussion 

What would you expect breath sounds may be like (document this in EHR)?

What would you expect skin condition/lower extremities to be like (document this in EHR)?

What interventions would you perform (safety, patient care, medication, etc)

What else are you concerned about when assessing?

Think about questions to ask the patient so you have a better report to give to consulting providers if they call

What does each medication do?  Would you hold any?

Additional assessment to document in EHR:

GI – bowel sounds in all quadrants, soft non-tender

GU – noted this in urinal

Cardiac S1S2, pulses ok in all ext, normal cap refill

HEENT – seems a bit hard of hearing, head without wounds, eyes, nose, oral mucosa ok. Has dentures (upper and lower)

Resp – seems to cough a lot after drinking water/taking pills

Pain – no issues

IV – left forearm 20g, flushes well, no leaks

Possessions – has glasses, iPhone, bottle of home tramadol

Retired engineer, married, lives at ALF with spouse

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Related FAQs

1. What is the nursing priority for heart failure?

Nursing Priorities
Improve myocardial contractility/systemic perfusion. Reduce fluid volume overload. Prevent complications. Provide information about disease/prognosis, therapy needs, and prevention of recurrences.

2. What are priority assessments for CHF?

Assessment of CHF:

• Vital Signs. Baseline vital signs are important here as well as for our other assessments, including an apical pulse; history is also important.
• Cardiovascular. Assess heart rhythm, and strength of the heartbeat. …
• Respiratory. Assess lung sounds for congestion, rales.
• General Medical.

3. What is nursing diagnosis for CHF?

Nursing Diagnosis: Decreased Cardiac Output related to increased preload and afterload and impaired contractility as evidenced by irregular heartbeat, heart rate of 128, dyspnea upon exertion, and fatigue. Desired outcome: The patient will be able to maintain adequate cardiac output.

4. What are interventions for CHF?

Immediate interventions
Obtaining a room air pulse oximetry, administering supplemental oxygen as needed, obtaining IV access to offload the fluid overload, obtaining baseline lab work, and administering diuretics. These things should all be done immediately for a CHF patient, says Swailes.

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