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Critical Care Paper

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“Critical Care Paper”
Critical Care Nursing

Background Information
L.G. is a 75 year old man that presented to Fairfax ED with complaints of SOB and lower extremity edema. L.G. is married with two adult children. He lives with his wife in a colonial style home in Great Falls, Virginia. L.G. hobbies include playing golf with his friends at his Country Club, playing bridge, and gardening with his wife on the weekends.
L.G is a retired Navy Captain with 40 years of active duty service. During his years as an active duty sailor he worked as the “Air Boss”. The “Air Boss” is in charge of every plane and sailor involved on the flight deck of an aircraft carrier. His job was very stressful and he admitted to not sustaining the best diet and was a long time smoker. However, L.G. denies use of smokeless tobacco.
L.G. has a family history of heart disease. His father suffered a heart attack when he was a child. He does not know the age of his father when he had the heart attack. L.G. also states he has a family history of atherosclerosis. L.G. denies any other significant family medical history. L.G. denies illicit drug use and also denies alcohol use. L.G. denies any allergies to any medications, foods, or environmental factors.
Past Medical History
L.G. has a past medical history of hypertension, congestive heart failure, renal artery stenosis, atherosclerosis of the coronary artery, myocardial infarction x 4, Type 2 DM, permanent atrial fibrillation, hyperlipidemia, and anemia. L.G. states that his medical care is primarily performed at Walter Reed Medical Facility in Bethesda, Maryland. Therefore, the patient does not have a record of any of his previous medical procedures.

Past Surgical History
L.G. has a past surgical history of a Coronary artery bypass graft x 2 performed in 1990. Re-do of CABG in 2007 with aortic root replacement for aneurysm. L.G. states that all of these procedures were performed at Walter Reed Medical Facility in Bethesda, Maryland.
Current Medical Admission Data
As previously mentioned, L.G. presented to the Fairfax ED with complaints of SOB and lower extremity edema. L.G. was admitted to the Telemetry North unit for further assessment and evaluation. The patients admitting diagnosis is CHF exacerbation. Vital Signs | | BP | 142/64 | Pulse | 62 | Temp | 96.4 F | Resp | 18 | SpO2 | 96% | | |
Assessment
Overall appearance: elderly male, well-nourished and dressed appropriately, awake and alert.
Respiratory: Clear to auscultation in RUL, RLL, LUL, LLL, breathing regular and unlabored, no signs of acute respiratory distress.
Cardiovascular: Normal rate, regular rhythm, S1, S2 murmur heard throughout, pacemaker left chest.
RATIONALE: Murmurs reflect valvular stenosis.
Abdomen: Soft, nontender, nondistended, no masses, and audible bowel sounds.
Urinary: Voids amber colored urine in a bedside urinal
Neurological: Alert, oriented, normal speech and rate, sensory functions intact
Musculoskeletal: Full range of motion in all extremities
Extremities: Left femoral and bilateral dorsalis pedis and posterior tibial pulses audible by Doppler
RATIONALE: Decreased cardiac output reflects the diminished pulses.
Integumentary: Normal for ethnicity

Laboratory Results | 07/25/14 | 07/26/14 | 07/27/14 | 07/28/14 | WBC | | 6.97 | 6.90 | 7.55 | RBC | | 3.61* | 3.88* | 3.83* | HGB | | 9.3* | 10.0* | 9.8* | HCT | | 30.6* | 32.6* | 32.3* | PLT | | 148 | 148 | 159 | NA | | 135* | 138 | 138 | K | | 4.1 | 4.5 | 4.8 | CL | | 102 | 105 | 109* | CO2 | | 23 | 24 | 22 | BUN | | 62.0* | 52.0* | 42.0* | CREAT | | 2.3* | 1.8* | 1.6* | GLU | | 142 | 100 | 93 | CA | | 8.9 | 9.1 | 8.9 | BILIT | 0.6 | | | | ALKPHOS | 75 | | | | AST | 23 | | | | ALT | 6.7 | | | | PROT | 6.7 | | | | ALB | 3.3* | | | | PT | 19.5* | | | | INR | 1.7* | | | | PTT | 36 | | | |

“*” denotes abnormal laboratory result
RATIONALES FOR ABNORMAL LABS
RBC: Decreased due to anemia
HGB: Decreased due to anemia
HCT: Decreased due to anemia
NA: Decreased due to diuresis – loop diuretics
CL: Decreased due to CHF
BUN: Elevated due to renal insufficiency and diuretics
CREAT: Elevated due to renal insufficiency and diuretics
GLU: Elevated due to Type II DM
ALB: Elevated due to renal insufficiency
PT: Decreased due to anticoagulants
INR: Decreased due to anticoagulants (Hogan, Dentlinger, & Ramdin, 2014)

DIAGNOSTIC STUDIES
Renal Ultrasound with Doppler:
FINDINGS:
Right kidney is atrophic, echogenic and demonstrates cortical thinning. Right kidney measures 6.8 cm in length. The left kidney is normal in size and demonstrated normal cortical thickness and echogenicity. The left kidney measures 13.0 cm in length. There is no hydronephrosis. No perinephric collection is seen.
IMPRESSION:
1. Elevated velocities in the origin and proximal left renal artery, suggestive of renal artery stenosis. Follow-up MRA or CTA is recommended. 2. Echogenic atrophic right kidney.
MEDICATIONS
Aspirin chewable tablet 81mg
RATIONALE:
Dextrose (Glucose) 40 % oral gel
RATIONALE: PRN for episodes of hypoglycemia
Dextrose 50 % bolus 25 ml
RATIONALE: PRN for episodes of hypoglycemia
Ferrous Sulfate EC tablet (Iron) 324mg
RATIONALE: Given for low RBC’s to combat anemia
Glucagon (rDNA) (Glucagen) Injection
RATIONALE: PRN for hypoglycemia if the pt cannot tolerate po and does not have IV access.
Insulin aspart (NovoLOG) injection 1-3 units
RATIONALE: PRN for hyperglycemia
Insulin aspart (NovoLOG) injection 1-5 units
RATIONALE: PRN for hyperglycemia
Isosorbide dinitrate (Isordil) tablet 40 mg
RATIONALE: PRN for angina
Metoprolol XL (Toprol-XL) 24 hr tablet
RATIONALE: Given for hypertension
Pantoprazole (Protonix) EC tablet 40 mg
RATIONALE: Given to treat high levels of stomach acid
Ranolazine (Ranexa) 12 hr tablet 1,000 mg
RATIONALE: Given to treat chronic chest pain
Tamsulosin (Flomax) capsule 0.4 mg
RATIONALE: Given to treat problems with urination caused by BPH
Apixaban (Eliquis) tablet 5 mg
RATIONALE: Given to treat thromboembolic events
Nursing Diagnoses/Interventions/Outcomes 1. Nursing Dx: Excessive fluid volume r/t decreased cardiac output and water retention AEB edema on lower extremities secondary to CHF (Carpenito, 2012)
INTERVENTIONS:
a. Assess breath sounds q2hrs for the presence of crackles. b. Monitor I&O’s. c. Weight patient daily noting any losses/gains.
NURSING OUTCOME: Pt will be free from s/s or complications from fluid overload. 2. Nursing Dx: Potential for Ineffective tissue perfusion r/t decreased cardiac output (Carpenito, 2012).
INTERVENTIONS:
a. Provide oxygen and monitor oxygen saturation via pulse oximetry. b. Assess mental status and level of consciousness. c. Monitor oxygen saturation and ABG’s.
NURSING OUTCOME: The patient will have demonstrated behaviors to improve circulation. 3. Nursing Dx: Potential for decreased cardiac output AEB generalized weakness (Carpenito, 2012).
INTERVENTIONS:
a. Assess for abnormal heart and lung sounds. b. Monitor results of lab and diagnostic results. c. Monitor blood pressure and pulse.
NURSING OUTCOME: After providing nursing interventions the patient will participate in activities that reduce the workload of the heart.

COLLABORATIVE MANAGEMENT
The patient is receiving care from Cardiology and Nephrology. The Cardiologist is the primary regarding the patient’s diagnosis of Congestive Heart Failure. The Nephrologist is also closely following the care of the patient due to his decreasing kidney function. The patient has an extensive history with coronary issues. The patient’s condition has deteriorated to the point that one of his kidneys is not functioning and the other is starting to show signs of impairment. The Cardiologist and Nephrologist must collaborate on the patients care to ensure no further damage is caused to either the heart or the kidneys.
THERAPEUDIC MODALITIES
The patient may benefit from guided imagery if he is suffering from anxiety while inpatient. The rationale is to divert the patient’s attention from his anxiety and to help him relax in an environment of his choosing. The main priorities are to ensure that my patient is not in pain, has adequate tissue perfusion, and that his vital signs are stable.

NURSING ROLE REFLECTION
The communication between the patient’s care team and the patient is instrumental in the effective treatment of the patient. The care team must have an open line of communication to assess the patient’s needs as they can change very quickly. This patient is considered a walking time bomb. He has an array of medical issues that exacerbate his primary diagnosis. The patient’s CHF has been controlled with medications that have had a counter effect on his body. His kidneys were already damaged due to his decreased cardiac output. His kidneys have taken another hit by the medications he has been taking to keep his CHF at bay.
My communication with the patient was pretty limited as he was going to be discharged the same day. He was referred back to his primary Cardiologist and Nephrologist at Walter Reed Medical Facility in Bethesda, Maryland. The key to continuity of care with this patient is to forward a copy of the care received to the primary care provider.
The patient confided that he knew the care he was receiving was very good. However, he did not seem to trust the providers in the facility. He said that he would feel more comfortable with seeing his own doctor because they have been friends for years. What I take away from that conversation is it is very important to build a rapport with your patient so that you can provide the best care possible. Prior to completing my physical assessment, I had a nice conversation with the patient. Once he told me he was a retied Navy Captain, I let him know that I was a former Hospital Corpsman and he seemed more relaxed.
The barriers that I see in this patients care is that he is not primarily followed by any physician that is associated with the hospital. There is not a quick reference to his past procedures or surgical history. All the information obtained must be provided by the patient. As previously stated the patient has an extensive medical history and I’m sure some information was negated due to his extensive medical history.
My plan is to use therapeutic communication to gain the trust of my patients. I want to ensure that my patients receive the best care possible and that is not possible without the trust of the patient. If my patient is treated by another facility I would ensure that my patient filled out a request for medical records and procedures to ensure that a proper medical and surgery history was obtained.

References
Carpenito, L. J. (2012). Handbook of Nursing Diagnosis. New York: Lipincott Williams & Wilkins.
Hogan, M., Dentlinger, N., & Ramdin, V. (2014). Medical-Surgical Nursing Pearson Reviews and Rationales. In M. Hogan, N. Dentlinger, & V. Ramdin, Medical-Surgical Nursing Pearson Reviews and Rationales 3rd Edition. Upper Saddle: Pearson Education Inc.

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