Case Study
Heart Failure
Patient Profile
M.G. is a 77 year old woman who saw
her health care provider for dyspnea. She is now being admitted to the hospital
for acute heart failure. She was diagnosed once before with heart failure 6
years ago. She is currently taking the following medications:
Furosemide
40mg po daily
Potassium chloride
20meq po daily
Enalapril
10mg po BID
Subjective data
Was
taking furosemide at home but ran out two days ago and has not been able to
refill her prescription
Complains
of difficulty breathing; had to sleep in the chair last night
Has
some swelling in her feet that is worse than usual
Objective Data
Physical examination
· Temp 98.4 F, pulse 92 irreg., resp. 24
labored, blood pressure 144/86, oxygen saturation 89% on Room air
· Ht. 55, wt. 170 lbs.
· Alert and oriented to person, place, and time
· Fine crackles bilateral lower lobes
· Shortness of breath with minimal exertion
· S1 and S2 without murmur or extra heart sounds
· Capillary refill sluggish in
lower
extremities, normal in upper extremities
· 2+ pitting edema bilateral lower extremities
Interprofessional Care
Admission orders include:
·
Oxygen 2L/ nasal cannula
·
Furosemide 40mg intravenous BID
·
Enalapril 10mg po BID
·
ECG now
·
Vital signs with SPO2 q 4 hrs
·
2 gm sodium diet
·
Strict I&O
·
Daily weight
Answer
the following questions thoroughly and cite resources appropriately in APA 7th
edition format. It should be in an essay
form.
Describe a plan for implementing these orders.
Based on M.G.s clinical manifestations, what type of heart failure do
you suspect? Support your answer
What assessment data will you use to determine the effectiveness of
the providers orders?
What is the rationale for the oxygen, IV furosemide, and enalapril?
What are the priority nursing diagnoses for this patient? (list at
least 3)
What other orders might you anticipate for this patient?
Think about plans for discharge, what are your primary concerns for
this patient?
Any other information you need or would like about this patient?