Question

Sally Jones, 75-year old Hispanic female, is brought to the ER by her daughter with complaints of 3lb weight gain in a day, increase SOB (shortness of breath), swelling in her bilaterally lower extremities, and elevated BP. Her daughter stated she was coughing up a pink frothy sputum. She has a history of Heart Failure, CAD, MI 2 years ago, diabetes Type II, gout, HTN, Alzheimer’s Dementia, and COPD.

She is 5’6” and weighs 210lbs.

Sally is awake, alert, and oriented x2. VS: T. 38.7, HR: 96 and irregular, RR 28, and use of accessory muscles to breathe, BP 166/90.

Pulse ox 87% on room air. Crackles heard in BLL (bilateral lower lobes), +bowel sounds in all 4 quadrants, + pedal pulses, +2 bilateral pitting edema in bilateral lower extremities. Family states she has been incontinent of small amounts of urine. LBM (last bowel movement) was 3 days ago. She normally moves her bowels every day.

She was ordered a CXR that showed small bilateral pleural effusions.

Her last Echocardiogram showed an Ejection Fraction of 30%

Social History:

Sally is married to her husband of 55 years and has 6 children. She worked as a bank teller for 30 years until she began showing signs of forgetfulness. She was the primary caregiver to her husband who had a stroke and requires moderate assistance with care.   After her diagnosis with Alzheimer’s Dementia 5 years ago she and her husband moved in with their youngest daughter and her 3 children (ages 8, 10, 12). Sally’s daughter works as a waitress. Her shifts change daily. While she is at work and the kids are in school, Sally’s mother and father are home. A neighbor checks in on them a couple of times/week.

Her current home medications include:

Losartan 25mg po daily                               Metoprolol 50mgp po BID

Furosemide 40mg po daily                          Allopurinol 300mg po daily

Metformin 1000mg po BID                         Potassium Chloride 40 mEq po daily

Aricept 10mg po daily                                  Namenda 10mg po daily

Salmeterol and fluticasone 1 puff BID      Miralax one packet every other day

Colace 100mg po daily                                 ASA 81mg po daily

Novolog sliding scale insulin

Current orders include: Digoxin 0.125mg daily Losartan 25mg po daily Metoprolol 50mg po BID Furosemide 40mg IV daily Allopurinol 300mg daily Potassium Chloride 40MEq po daily Aricept 10mg po daily Namenda 10mg po daily at bedtime Salmeterol and fluticasone 1 puff BID Colace 100mg po daily Novolog sliding scale insulin Azithromycin 500mg IV q 24hrs

Current labs: RBC: 2.54                               Na:    141 WBC: 12.3                             K+:    2.9 Hgb: 11.6                                Cl:    103                    Hct:   37.4                               Mg:     1.8                     Platelets: 315,000                 Ca:      9.8 BUN:   25 Cr:       1.1 BNP:   8500

1.      What risk factors does Sally have for Heart Failure?

2.      What are the classifications of Heart Failure according to the New York Heart Association? Explain each classification.

3.      What is a normal Ejection Fraction? Define Ejection Fraction.

4.      Comparing Sally’s home meds to current meds ordered. Is there anything you would question?

5.      What is a pleural effusion?

When completing the evening assessment, the nurse notes Sally lying in a low-Fowler’s position having difficulty breathing?  

6.      What should the nurse do?

After the interventions in #6 are performed, the nurse notes Sally is still short of breath with a respiratory rate of 32, using accessory muscles to breathe, and crackles bilaterally throughout her lung fields. Sally’s pulse ox is 90% on 2L. The nurse notifies the hospitalist who orders 80mg IV Furosemide x 1 dose

7.      Can IV Furosemide be given IV push?

8.      If so, does it need to be diluted? How many minutes should the IV Furosemide be pushed over?

9.      What are the nursing implications for administering IV Furosemide? (What do you need to monitor?)

10.  According to the drug guide, what are the most frequent adverse reactions/side effects of Furosemide?

11.  Sally is ordered a Low Fat, 2gm Sodium Diet. Create a one-day meal plan (breakfast, lunch and dinner for Sally)

12.  Sally will be discharged back home with her daughter. Are there any services that could be provided for Sally and her family?

Answer 1

• 1, coronory artery disease
• Highh blood pressure
• Heart attack
• Diabetic medications

American heart assocciation classified the heart failure in to difrent methods,Accoring to the patient symptoms it is divided in to 4 classess, and Acoording to the Objective assessment it is divided in to A,C,D.

The volumetric fraction of blood ejected from the left ventricle with each contraction of the heart.The normal ejection fraction is 50-70%

The pleural effusion is the build up to fluid between the viseral pluura and the parietal plura of the chest and the lung,