Chapter 30: Coordinating Care for Patients With Cardiac Disorders
MAKING CONNECTIONS TO CLINICAL JUDGMENT
Clinical Judgment Case Study Analysis of Heart Failure
What clinical findings of heart failure does Mr. Thompson have? Suggested Answer: Physical findings of shortness of breath, orthopnea, fatigue, tachypnea, crackles in lungs, jugular vein distension, pitting edema, delayed capillary refill, cool extremities. Diagnostic test findings of LV hypertrophy, ejection fraction of 30%, and elevated creatinine and BNP. How do the physical findings relate to the pathophysiology of heart failure? Suggested Answer: The heart muscle is weak and does not pump enough blood forward through the vascular system. The lack of forward blood flow causes pressure to build up in the heart chambers and blood vessels. From the left side of the heart, fluid backs up into the pulmonary vasculature and leaks from the blood vessels causing the alveoli in the lungs to fill with fluid which prevents adequate gas exchange. This manifests as crackles, shortness of breath, orthopnea, tachypnea, and fatigue. From the right side of the heart, fluid backs up into the venous system causing jugular vein distension, peripheral edema. Delayed capillary refill, cool extremities, and fatigue are also caused by the lack of blood flow being delivered to tissues. What are the highest priority findings that need to be addressed? Why? Suggested Answer: Tachypnea, orthopnea, shortness of breath, and crackles in the lungs should be addressed first. Respiratory failure can occur as a result of heart failure. Tissue oxygenation is critical to organ function. What interventions would best address Mr. Thompson’s respiratory needs? Suggested Answer: Supplemental oxygenation to keep oxygen saturations greater than 93%. Non-invasive respiratory support such as nasal cannula, facemasks, and CPAP or BiPAP should be used first. Endotracheal intubation with mechanical ventilation may be needed if these methods are ineffective. The HOB should be elevated. An IV diuretic such as Lasix will improve pulmonary edema. Morphine may also be used to dilate vessels, relieve vascular pressure, and increase comfort. Reduce environmental stimuli to decrease oxygen demands. Continuous cardiac and oxygen saturation are needed. What are the nursing intervention priorities? Suggested Answer: Nursing priorities include careful and frequent monitoring of vital signs, respiratory status, urine output, pertinent laboratory values, and neurological status. Administration of medications as ordered is imperative along with patient teaching about medications and self-management.
Recognizing Cues
Analyzing Cues
Prioritizing Hypotheses
Generating Solutions
Taking Actions
What are the findings related to fluid balance that would indicate an effective response?
Evaluating Outcomes
Suggested Answer: Increased urine output, urine becoming more dilute, decreased weights, decreased BP, clearing of crackles, less dependence on supplemental oxygen.
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