Question

Case Study Mr. Grinch is a 68 year old male who presented to the Emergency Department (ED) with severe shortness of breath (SOB), fatigue, and recent weight gain of 5 kg. It is two days after Thanksgiving and Mr. Grinch has been eating salted ham and a large amount of leftovers for every meal. He is having trouble speaking, but reports he has been having difficulty sleeping and states, “I feel like I’m drowning. I’ve tried using multiple pillows to get rid of this feeling, but the only way for me not to feel so SOB is if I sleep sitting up”. This is Mr. Grinch’s second admission this year for a similar complaint. He has a history of heart failure, Ischemic heart diseases [with his last echo showing an EF 25%], hyperlipidemia, Coronary Artery Disease (CAD) [CABG 2 vessel 2 years prior], hypertension (HTN), and Type II diabetes. The patient’s son, who is also his main caregiver and lives nearby, has accompanied him to the ED and reports that Mr. Grinch is not adherent to either diet nor medication regimens. He also reports that Mr. Grinch likes to eat fast food or frozen dinners for most of his meals a week. He refuses to exercises and generally lives a sedentary lifestyle. Home meds include Lisinopril 5mg, Metoprolol 25mg, Spironolactone 25mg, Atorvastatin 10mg Daily. Assessment in the ED revealed: vitals BP: 198/103, HR 131, RR 22, T 98.4, O2 of 84% on Room Air so the patient is placed on 10L Non rebreather which increases O2 to 94%. The patient is alert, oriented x4, anxious, PERRLA, with facial symmetry and reflexes intact. The EKG shows sinus tachycardia and no new ischemic changes. Cardiac assessment revealed s3, bilateral pitting pedal edema 2+, and 2+ pulses in all extremities. Auscultation of the lungs revealed bibasilar pulmonary rales. There is also use of accessory muscles, nasal flaring, and severe SOB. The abdomen was distended/non tender with positive hepatojugular reflux. All other assessment findings were normal. In addition to the EKG, a chest x-ray was performed and showed cardiomegaly, vascular engorgement, and mild interstitial edema. Labs: Na 128 mEq/L, K 5.2 mEq/L, BUN 82 g/dL, Crt 1.8 mg/dL, trop I 0.1 ng/mL , BNP 1300 pg/mL, Glu 140 g/dL. Mr. Grinch receives oxygen by non rebreather mask, is placed on fluid restriction and strict I&O. Therefore, it’s imperative that an indwelling foley catheter is inserted. Orders are made for Furosemide 40 mg IV and Nitroprusside 0.3mcg/kg/min IV. Upon reassessment in 30 mins, Mr. Grinch reports a decrease in SOB and has put out 500 mls of urine. Lung auscultation shows improved, but still present rales. Vitals are now BP 150/96, HR 89, RR18, T 98.5, and O2 of 97% on 10L non rebreather. Mr. Grinch is stable and is now being transferred to a telemetry floor for further monitoring. When setting patient goals for Mr. Grinch, the nurse decides the priorities for the patient will be to improve ventilation, maintain hemodynamic stability, and be able to verbalize understanding of his condition and associated treatments prior to discharge. Case management will be consulted as the patient lives alone and may require home health care upon discharge.Neuro: What objective findings upon arrival to the ED could suggest an altered LOC? How would we best identify Mr. Grinch’s LOC on exam? Pulm: What potential respiratory process is occurring given Mr. Grinch’s clinical presentation? FEN: How can we best define the fluid volume status of Mr. Grinch? Nursing Diagnosis What nursing diagnosis would be most appropriate? (give one priority).

Answer 1

1. Objective findings of altered LOC:

Orientation, verbal response and PERRLA should be assessed. As Mr.Grinch had not slept well since two days his sleep and mental ability could have been altered. Continuous GCS monitor will be helpful to find out early symptoms of altered LOC.

2. PULM:

As per his clinical presentation, he has orthopnea and Hus health history also relates that he could suffer with Pulmonary edema. Pulmonary edema is a major complication of heart failure.

3. FEN:

Fluid is retented in Hus body as evidenced by weight gain, shortness of breath and orthopnea. Strict I/O should be maintained.

Nursing diagnosis:

Impaired gas exchange related to pulmonary edema(fluid retention in the lungs) as evidenced by rale sound.