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Fundamentals of Nursing

Chapter 19

Fundamentals of NursingChapter 19

Chapter 19

Unfolding Case Study

1.
The nurse should first recognize the patient is exhibiting signs of respiratory distress, including a low oxygen saturation level on room air, tachypnea, worsening shortness of breath, dyspnea, and crackles in the lungs. The nurse should also recognize the patient is experiencing tachycardia, hypertension, 6/10 pain, bilateral lower extremity edema, and fatigue.
2.
Many of the patient’s symptoms recognized in the previous question (e.g., crackles, tachypnea) are consistent with the patient’s past medical history of heart failure. Additionally, the patient’s blood pressure is elevated, which is consistent with her history of hypertension. The patient is also reporting 6/10 joint pain, which is likely related to her history of osteoarthritis.
3.
The patient is likely experiencing a mix of both types. The patient is exhibiting crackles in the lungs, dyspnea, and tachypnea, which are consistent with left-sided heart failure. The patient is also experiencing bilateral lower extremity edema, which is more prevalent in cases of right-sided heart failure. Because this patient has a history of heart failure, it is possible that it originally started on the left but then began to affect the right side of the heart over time.
4.
The provider has ordered that the patient be admitted to the telemetry unit. This is likely because the patient is exhibiting symptoms that are indicative of heart failure exacerbation, which will require close cardiac monitoring. The rationale for the 12-lead ECG is to monitor the electrical activity of the heart to make sure the patient is not experiencing any abnormal underlying cardiac dysrhythmias. The oxygen has been ordered because the patient’s oxygen saturation is low (88 percent on room air). This indicates that the patient is not receiving an adequate amount of oxygen to perfuse the lungs and other tissues of the body, which can be improved with application of supplemental oxygen. The IV furosemide is ordered because it appears the patient is in a fluid overload state, related to her heart failure, as evidenced by the crackles in the lungs and bilateral lower extremity edema.
5.
The nurse needs to keep a close watch on the patient's electrolyte levels due to the administration of an IV diuretic. Diuretics, especially when administered intravenously, can deplete electrolytes in the circulatory system, which can quickly become life-threatening if not replaced. The nurse should also closely monitor the patient’s output, as the IV diuretic will cause the patient to urinate more frequently. She has not yet used the bathroom, so that will be something to monitor closely.
6.
The patient’s blood pressure, respiratory rate, oxygen saturation, and heart rate have all slightly improved, indicating that the interventions were effective. The patient is still reporting 6/10 joint pain, so this aspect of her condition is not showing signs of improvement. Now that the patient’s vital signs are stabilizing, it is important for the nurse to address and treat the pain.
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