Nursing Situation CHF
CHF nursing situation
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
Urine – blood
Urine – leukocytes
Urine – culture
COVID 19 PCR – negative
bilateral infiltrates, pleural effusions
sputum sample to be collected
normal sinus rhythm on tele monitor
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
home medications – have all been profiled to MAR
IV potassium 10 meq
Consults pending – cardiology, ID, nephrology
former smoker, quit 35 years ago
does not drink alcohol
did not get flu shot this year
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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