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Session 11

L.J. is a 63-year-old man admitted to the ICU for acute decompensated heart failure (ADHF). He has a history of hypertension, chronic heart failure, sleep apnea, and smoking two packs a day for 40 years. He presents with signs and symptoms of both right and left heart failure including jugular vein distention, edema, dyspnea, low blood pressure, irregular heartbeat, and crackles in his lungs. Appropriate diagnostic tests would include chest x-ray, EKG, echocardiogram, and bloodwork. Monitoring of his condition includes continuous ECG, hemodynamic monitoring, and frequent vital signs. Nursing priorities are reassuring the anxious patient, administering oxygen and

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874 views3 pages

Session 11

L.J. is a 63-year-old man admitted to the ICU for acute decompensated heart failure (ADHF). He has a history of hypertension, chronic heart failure, sleep apnea, and smoking two packs a day for 40 years. He presents with signs and symptoms of both right and left heart failure including jugular vein distention, edema, dyspnea, low blood pressure, irregular heartbeat, and crackles in his lungs. Appropriate diagnostic tests would include chest x-ray, EKG, echocardiogram, and bloodwork. Monitoring of his condition includes continuous ECG, hemodynamic monitoring, and frequent vital signs. Nursing priorities are reassuring the anxious patient, administering oxygen and

Uploaded by

Sistine Rose Labajo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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CHECK FOR UNDERSTANDING (60 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be
given to correct answer and another one (1) point for the correct ratio. Superimpositions or erasures in
you answer/ratio is not allowed. You are given 60 minutes for this activity:

Acute Decompensated Heart Failure

Patient Profile: L.J. is a 63-year-old man who has a history of hypertension, chronic HF, and sleep apnea.
He has been smoking two packs of cigarettes a day for 40 years and has refused to quit. Three days ago,
he had an onset of flu with fever, pharyngitis, and malaise. He has not taken his antihypertensive
medications or his medications to control his HF for 4 days. Today he has been admitted to the hospital
intensive care area with ADHF.

Subjective Data

 Is very anxious and asks, “Am I going to die?”


 Denies pain but says that he feels like he cannot get enough air
 Says that his heart feels like it is “running away”
 After being weighed, he reports, “That is more than I usually weigh.”
 Reports that he is so exhausted he can’t eat or drink by himself

Objective Data

 Height: 5 ft, 10 in (175 cm)


 Weight: 210 lb. (95.5 kg)
 Vital signs: Temp 99.6°F (37.6°C), HR 118 bpm and irregular, RR 34, BP 90/58
 Cardiovascular: Distant S1, S2; S3, S4 present; PMI at sixth ICS and faint; bilateral jugular vein
distention; all peripheral pulses are 1+ and there is peripheral edema; initial cardiac monitoring indicates
atrial fibrillation with a ventricular rate of 132 bpm
 Respiratory: Pulmonary crackles, decreased breath sounds right lower lobe, coughing frothy blood-
tinged sputum;
 SpO2 82% on room air
 Gastrointestinal: Bowel sounds present; hepatomegaly 4 cm below costal margin
 Laboratory work and diagnostic testing are scheduled Multiple Choice

Discussion Questions:

1. What signs and symptoms of right-sided and left-sided heart failure is L.J. experiencing?

Answer: Right-sided HF: jugular vein distention, peripheral edema, and hepatomegaly. Left-sided HF:
dyspnea, ↓ SpO2 , point of maximal impulse (PMI) displacement, pulmonary crackles, frothy pink
sputum, ↓ BP, and S3 , S4 heart sounds Present with both types of HF: fatigue, ↑ HR, and dysrhythmias.
2. What priority nursing interventions are appropriate for L.J. at the time of his admission?

Answer: Nursing interventions:

• Calm, reassuring approach because of his anxiety and critical condition


• Explanations of rationales for all diagnostic tests and medications
• Administration of oxygen, sitting upright with legs out straight or dependent
• Emotional and physical rest
• Constant monitoring of cardiovascular and respiratory function
• Administration of ordered medications per parameters
• Evaluation and documentation of the effects of medical interventions (i.e., to determine if HF is
resolving)
• Initiation of strict intake and ouput (I&O) measurements and daily weights

3. What diagnostic procedures and findings would help to establish a diagnosis of ADHF with
pulmonary edema?

Answer: Appropriate diagnostic procedures include the following:

• Chest x-ray: cardiomegaly, pulmonary venous hypertension, pleural effusion


• 12-Lead electrocardiogram (ECG): tachycardia and dysrhythmias of conduction disturbances
• Echocardiogram: to determine the presence of a low left ventricular ejection fraction (LVEF)
• Cardiac catheterization and coronary angiography: normal coronary arteries, ventricular pressures
• Nuclear imaging studies: cardiac contractility, myocardial perfusion, low ejection fraction
• Blood analysis: arterial blood gases (ABGs), serum chemistries, cardiac enzymes to assess cardiac
damage, BNP level to confirm dyspnea of cardiac source, oxygenation status, liver function tests, renal
function tests

4. What monitoring will be used to evaluate L.J.’s condition?

Answer: Continuous ECG monitoring; hemodynamic monitoring (intraarterial BP, SaO2 , PAWP, cardiac
output); and BP, HR, RR, pulse oximetry, and urine output every hour

5. During L.J.’s hospitalization, basic standards of evidence-based care for patients with HF are set
forth in three core measures by The Joint Commission. Which of these measures should be
implemented by the nurse?

Answer: The Joint Commission core measures include (1) discharge instructions, (2) evaluation of left
ventricular systolic function, and (3) angiotensin-converting enzyme (ACE) inhibitors or angiotensin
receptor blocker (ARB) for left ventricular systolic dysfunction. Nursing can be responsible for providing
(1) written discharge instructions or teaching material that includes activity level, diet, discharge
medications, follow-up appointment, weight monitoring, and symptom management as prescribed.
Although smoking cessation counseling is no longer a core measure for heart failure patients, the 40-
year history of smoking could make smoking cessation an important topic to include for this patient
during hospitalization or at discharge.

6. The physician mentions the possibility of inserting a pacemaker called cardiac resynchronization
therapy (CRT). L.J. asks the nurse what CRT is. What response would be appropriate from the nurse?

Answer: CRT is a pacemaker that will stimulate both the right and left ventricles (chambers) of the heart
so that they will contract in coordination (together) to improve the way the heart pumps blood with
each heartbeat.

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