SB is a 74 year old man who pr
SB is a 74 year old man who presents to your family medicineoffice with his wife complaining of shortness of breath and fever.They just moved to the area and had been planning to come to youroffice next week to establish care as new patients. He is confusedabout what to use when, so you are not sure which medications heactually takes. No known allergies
Past Medical/Surgical History
o Heart failure following myocardial infarctionat age 68 years
o COPD (on 2 L home oxygen)
o Hypertension
o Appendectomy
JS Past Record Review (brought bywife)
– Echocardiogram with EF of25%
– Spirometry with FEV1 35%predicted that does not change significantly after inhaledbronchodilator
Records Review
Unable to determine when last pneumoccal vaccine was given
– Patient and wife don’trecall “a pneumonia shot”
– Does know he got his “flushot” last month at a grocery store
JS current symptoms include the following:
– Unable to speak in fullsentences for the past several hours per wife
– Cough productive butunknown color of sputum
– Audible wheezing since lastnight per wife
– Mild chest tightness
– Dyspnea
• His wife has noted nochange in his alertness or mental status
• When you inquire, thewife states that JS usually has a cough, worse in the morning,productive of gray sputum, gets short of breath if he walks morethen 10 feet, and has episodes of wheezing if he gets sick (e.g.with an upper respiratory infection).
• He usually is able tohelp around the house with light work and fixingthings.
• Physicalexamination
– Vital Signs: BP 128/74; P68, reg; RR 32; Ht 5ft 6 in; Wt 122 lbs; T 101.5 °F oral
– Unable to speak in fullsentences, audible wheezing, alert and oriented
– Pertinent positives:
• General: audiblewheezing, no accessory muscle use
• Nails: tar stains,clubbing
• Chest: increasedanteroposterior (AP) diameter; diffuse wheezing to auscultation
• Heart: regular, nomurmurs
• Studyresults
– Pulse oximetry 86%
– Chest x-ray showshyperinflation and right lower lobe pneumonia
– You continue his heartfailure medications as per his home regimen
• No need todiscontinue the cardioselective beta-blocker
What is the patients admitting diagnosis and chiefcomplaint?
What are two priority nursing diagnosis for this patient?
What is the patient at risk for/ potential complication? and anintervention to prevent it from happening?
Answer:
1 . Diagnosis :
The patient’s admitting diagnosis would be — CHF (Congestive Heart Failure) .
The patient came with chief complaints of :
- Dyspnea.
- Productive cough more in the morning hours.
- Audible wheeze since last night.
- Not able to speak in full sentences since morning.
- Gets tired after walking very shorter distance.
These are the signs and symptoms of the person with Congestiveheart failure.
2. The two priority nursing diagnosis for Mr.SB would be :
a . Ineffective Breathing Pattern related to decreased lungexpansion secondary to congestive heart failure.
b. Activity intolerance related to imbalance between oxygensupply and demand secondary to congestive heart failure.
3. Potential complication :
SB is at risk of developing –
Impaired Renal function- Since the cardiac output and ejectionfraction is decreased, there is a risk of renal impairment.
Arrythmias : Since the contractility of heart is affected,arrhythmias like atrial fibrillation, ventricular fibrillation mayset in.
Myocardial infarction : Due to decreased blood supply to theheart , MI may result causing death.
Prevention :
- Refer Mr. SB to hospital with emergency services.
- Ensure oxygen supply so that SPO² levels are above 95.Continuous Positive Airway Pressure ( CPAP ) is usually the supportmode used in CHF.
- If there is fluid retention and edema, diuretics is drug ofchoice.
These are done to prevent complications of CHF.
Thank you.
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