Mr. Aloha Das is a 68–year–old gentleman presenting to the emergency department at 0400hrs with worsening shortness of breath. Onset 2 days ago and progressively worsening. He also developed wheeze and right sided pleuritic chest pain this morning. Vomited x1, ongoing nausea. Has history of non–compliance with medication and adherence to fluid restriction. Past History Hypertension, Inferior Myocardial Infarction in 2020, Heart Failure, non–ischemic Cardiomyopathy, Permanent Pacemaker inserted 2021, DM Type II, GORD, Osteoarthritis.
Current medications: Furosemide 40mg OD, Captopril 6.25 mg TiD, Digoxin 0.125 mg BD, Metformin 500mg
TiD, Nexium 40 mg BD. On 1.2 L fluid restriction; Echocardiogram results in 2021– systolic dysfunction, mild mitral valve regurgitation, dilated left atrium and ejection fraction (EF) 33%.
Nursing Assessment
A. Clear, speaking in short sentences
B. RR 28 bpm, SpO2 90% RA, bilateral crackles, diffuse wheeze anteriorly and posteriorly
C. HR 120 bpm, peripherally cold, centrally warm, BP 186/108 mmHg, capillary refill<3 sec
D. GCS 15 (E4V5M6) PEARL
E. Patient looks distressed, diaphoretic, right JVP distension++, bilateral pedal pitting edema 2+
F. No IV fluids in progress
G. BGL 14.0mmol/L Plan
• Continuous cardiac monitoring
• 12 lead ECG
• Blood pathology order
• Troponin I High Sensitivity
• Chest X–Ray
• Insert IVC right hand
• Furosemide 40mg IV Stat
• Echocardiogram
Results of Investigations:
Chest x– ray: Left ventricular hypertrophy, interstitial edema noted by Kerley B lines in the
costophrenic angle.
ECG:
Blood Results:
Electrolyte, urea and creatinine:
Result Reference Range
Sodium 137 mmol/L 135–147 mmol/L
Potassium 3.9 mmol/L 3.5–5.2 mmol/L
Chloride 105 mmol/L 95–107 mmol/L
Urea nitrogen
(BUN)
14.0 mmol/L 3.0–8.0 mmol/L
Creatinine 147 μmol/L 64 –104 μmol/L
Coagulation profile:
Result Reference
range
Partial thromboplastin time
(PTT)
35 sec 30–45 sec
Prothrombin time (PT) 12 sec 10–12 sec
Cardiac enzymes:
Result Reference range
High sensitivity Troponin T 25 ng/L 0–14 ng/L
Arterial blood gas analysis
Result Reference Range
pH 7.30 7.35–7.45
PaO2 75 mmHg 80–100 mmHg
PaCO2 37 mmHg 35–45 mmHg
HCO3– 19 mmol/L 22–26 mmol/L
SpO2 94% >95%
BE –9 mmol/L –2 – +2mmol/L
Lactate 4mmol/L 0.5–1.6mmol/L
Impression: Exacerbation of Congestive Cardiac Failure and fluid volume overload
Question 1
In order to prioritise your nursing actions, you are expected to have a sound understanding of
the pathogenesis and pathophysiology.
Explain the pathogenesis and pathophysiology causing the clinical manifestations with which
Mr Das presents.
Question 2
Choose One high priority nursing intervention that you will perform for Mr Das
– Briefly explain why you chose this nursing intervention
– Explain how the nursing intervention will alleviate the clinical features of Mr Das using physiological linking
– Describe briefly the impact of not performing the intervention
Question 3
Mr Das has been prescribed Furosemide 40mg IV Stat and Glyceryl Trinitrate IV Infusion 10
mcg/min starting rate.
For both medications explain
– The mechanism of action
– Why your patient is receiving this medication in relation to his symptoms and diagnosis?
– What are the nursing considerations for this medication?
– What clinical response you expect?
– What continuing clinical observations will you need to undertake
