Question

A patient was admitted in the medical ward with chief complaints of shortness of breath. Further assessment reveals the following findings:

• BP –140/90 mm Hg
• HR –111 bpm
• RR –24 cpm
• +2 bipedal edema
• Bibasilar crackles upon auscultation

The doctor initially ordered furosemide 20 mg ampule TIV every 8 hours and the following laboratory tests: Complete Blood Count (CBC), Serum Sodium, Serum Potassium, Blood Urea Nitrogen, Serum Creatinine, Total Protein, and Chest X-ray.

1. Write down three (3) priority nursing diagnoses for the patient and create a hypothetical FDAR.

Answer 1

Diffrential diagnosis include congestive cardiac failure . BP is increased and the fluid is accumulated behind . Sign of fluid accumulation is present which is crackels in lung ,bipedal edema and increased breathing rate.

Furosemide is given so that excessive fluid is lost in urination .

CCF may be due to MI, any stenosis in valve , or due to coarctation of aorta.

Respiratory causes such as pneumothorax is ruled out because crackel sound is present

Rule out Myicardial Infarction . Pain is present radiating over left arm . Ecg done to rule out MI. If MI is present then thrombolytic agent given immediately

Arrhythmia can be detected by ecg .