A Complete Patient Assessment Susan Eisen RN Ramapo College of New Jersey

A 63 y/o African American female presents to the emergency room

complaining of shortness of breath worsening over the past week. Patient states

she becomes severely short of breath while preforming everyday activities and

has noticed that her legs have been “getting bigger”. Patient had been sleeping

with 3-4 pillows a night for comfort and occasionally sleeping in a recliner.

Patient states this evening she got up to use the restroom and had a sudden onset

of severe shortness of breath. Felt as though she wasn’t moving any air. Patient

called 911. The paramedics on scene established IV access and medicated patient

with 40 of furosemide and Nitroglycerin sublingual 0.4 mg times 3 doses. Patient

was placed on CPAP and brought to the ER.

Upon arrival CPAP was continued, a nitroglycerin infusion was started at

20mcg/min. Additional IV access was established and labs were obtained. Stat

EKG and Chest Xray were completed. Additional dose of furosemide 80mg was

administered IV push and patient was provided with an indwelling foley catheter

which is draining clear yellow urine.

Past Medical History is significant for Hypertension, Diabetes, Congestive

Heart failure, and Atrial Fibrillation with two unsuccessful cardioversions.

Medications: Patient currently taking Furosemide, Lisinopril, Digoxin,

Metformin, and Glyburide. Patient unable to recall dosages.

Past Surgical History is significant for cesarian sections x 3 and ORIF of

left hip 8 years ago.

Social History: Patient is a 1 pack per day smoker x 40 years. Consumes

alcohol on a social basis. Denies using any illicit drugs. Patient is a retired

secretary. Patient lives in the community and attends church regularly. Patient

also participates in a weekly bridge game. Patient lives off of social security in a

senior citizen complex. Patient’s family also resides in the same state and come

to visit often.

Family History: Father died by suicide at age 48. Mother died at 82 of

pneumonia. Two sisters both who suffer from Hypertension. Patient had Six

children alive and well

Physical Exam as follows: height 5’5”, weight 310lbs.

Vitals: Blood pressure 224/118, Heart rate of 121 irregular, Respiratory Rate 30

labored, O2 saturation on room air is 88%, on CPAP 97%. Patient is afebrile at

98.3 Head is normocephalic, eyes, ears, nose and mouth are within normal limits.

Neck is + for JVD. Lungs have scattered rhonchi throughout the lung fields,

diminished at the bases, crackle about halfway up. Patient has frothy productive

cough. Abdomen is obese, soft and non tender. Bowel sounds are present in all

four quadrants. Genitalia is intact with no obvious deficits. Bilateral lower

extremities show 4+ pitting edema extending to the knees. Pulses intact.

Neurologically patient is awake and oriented times 4 with no motor or sensory

deficits.

EKG shows atrial fibrillation with a ventricular rate of 121.

Chest Xray shows cardiomegaly with diffuse pulmonary infiltrates consistent

with pulmonary edema.

Laboratory Results as follows: WBC 7.2, HGB 9.4, HCT 28.1, platelets 233.

Glucose was 278, BUN 22 Creatine 2.1 Sodium 130 Potassium 3.2 Bicarbonate

ABG on room air was pH 7.30, PaO2 55, PaCO2 28. Creatine Kinase 197

Troponin 0.11 and BNP of 3398.

Patient was subsequently admitted to Telemetry for Congestive Heart Failure.

There are multiple priorities when caring for patients with congestive

heart failure. It is imperative to treat the current symptoms while maintaining

their current state of functioning. Frequent hospitalizations from poor

medication management or follow up will lead to increased hospitalizations and

decreased levels of functioning. Assessment tools such as the Katz index of

Independence in Activities of Daily Living is key in assessing function during

hospitalization to improve deficits upon discharge.

Another assessment tool to be used with the diagnosis of congestive heart

failure is Urinary Incontinence Assessment in Older Adults: Part 1 Transient

Urinary Incontinence. The use of diuretics in the prevention of heart failure

episodes can lead to problems with incontinence. Daily bladder charting can

identify deficits and allow for adjustments in medications to prevent further

incontinence.

Oxygenation: Elimination Nutrition
Admit 5/1/10 CHF Nocturia preferences
Increased fatigue I&O bmp results
Sob 3-4 days stress incontinence daily weights
O2 3l nc Diaper 2g na diet
Smoker
Hypertensive
Moderate resp distress
Crackles CHF
Elevate hob
Sleep 3 pillows 1. Decreased Cardiac Output
Vs q4 hours 2. Fluid Volume Excess Saftey/Skin
Continuous pulse ox 3. Activity Intolerance wounds
Cxr results 4. Impaired Gas Exchange skin reddened
Lasix 5. Self Care Deficit reads
Nitroglycerin glasses
Lab results Uses walker Hearing Aids
Neurological Activity/Concern
Alert oriented x 3 multiple admission
Fluent Historian medication management no sensory/ motor deficits little home support

Comfort\Sexuality Widower past 15 years Denies complaints

Love\Belonging/ Culture
Retired
Church goer Activity
Family to visit weekly Assist with ADL’s
Weekly bridge group Activity as tolerated
Knitting Wheelchair for transportation

Priority 1: Decreased Cardiac Output related to inability to pump blood forward secondary to fluid volume overload.

Interventions:
Monitor and record vital signs q4 hours auscultate heart and breath sounds regularly note and report manifestations of decreased cardiac output: changes in mentation, decreased urine output, cool clammy skin, diminished pulses, pale or cyanotic coloring, or dysrhythmias encourage patients to to rest, keeping the head of the bed elevated to decreased the work of breathing administer supplemental oxygen as needed administer prescription medications as prescribed.

Goals:

Patient vital signs with be maintained within normal limits
Lung will become clear
Patient will show decreased need for supplement oxygen
Patient will be able to verbalize need for rest

Priority #2: Fluid Volume Overload secondary to decreased circulatory status

Interventions:
Daily weights assess patient respiratory status including rate and effort notify physician of any for any signs of air hunger or patient expresses feeling of doom monitor intake and output assess for other manifestations of fluid volume excess including jugular vein distention, peripheral changes and cardia rhythm changes monitor BNP results place patient on fluid restriction and dietary restrictions

Goals:
Patients will show a decrease in weight daily
Patient will express need for fluid and dietary restrictions
Patient will show decrease in BNP results.

The use of BNP in acute care settings is vital in diagnosing congestive heart failure. (Q. Dao et al )

Priority #3: Activity intolerance related to weakness and fluid volume overload

Interventions:
Asses vital signs before and after activity teach patient to rest if signs of intolerance are noted. organize nursing care to allow for rest periods assist clients with self care activities encourage clients to participate in self care activities independently within limits provide written and verbal information about activity upon discharge plan and implement a progressive activity plan. Employ passive and active range of motion exercise as appropriate.

Goals:
Patients vitals signs will be maintained within normal limits patient will demonstrate rest throughout the day
Daily progress will be noted by patient

Nurses need to take the the time to talk with patients and understand their daily schedule. Knowing the basic conditioning facts that affect self care behaviors allow for a more tailored program leading to increased compliance. ( N. Artinian et al 2002)

Priority #4: Impaired Gas Exchange related to fluid volume excess

Interventions: maintain bed rest administer medications as prescribed by physician monitor and record respiratory rate, depth and effort monitor and record the client’s level of consciousness and mental status monitor ABG results and report abnormal findings maintain pulse oximetry
Assess need for oxygen and stress importance of compliance of oxygen use

Goals
Patient vital signs will remain within normal limits
Patient’s mental status will remain within normal limits
Patient will express need for oxygen and verbalize importance of compliance for oxygen use

Physical training significantly improves exercise capacity and improves overall gas exchange. (Kiilavouri et al 2006)

Priority #5: Risk for Self Care Deficit related to increased fatigue and weakness

Interventions: assess patient’s ability to bathe and dress self assist with activity of daily living as needed for personal care teach importance of rest during bathing and dressing encourage use of assistive devices if required for eating, personal hygiene and dressing. educate patients on how to maintain independence

Goals patients will have increased strength to bath and dress self patients will have assistance as needed for personal care patients will verbalize and demonstrate the importance of rest during bathing and dressing patients will show improved independence in preforming ADLs

Education and demonstrations of improved function of ADLs in patients prior to discharge show those same patients are more likely to maintain their independence and less likely to be admitted into long term care facilities. (Landefeld,C 1995)

Refrences:

Landefeld, C. Palmer,R., Kresevic, D., Fortinsky,R., Kowal,J. (May 1995) A Ramdominized Trial of Care in a Hospital Medical Unit Especially Designed to Improve the Functional Outcome of Acutely Ill Older Patients. New England Jorunal of Medicine, 332(20); 1338-1344.
Kiilavouri, K., Sovijarvi, A., Naveri, H., Ikonen, T., Leinonen, H. (October 2006) Effects of Physical Training on Exercise Capacity and Gas Exchange in Patients With Chronic Heart Failure. European Journal of Cardiovascular Prevention and Rehabilitation, 110(4); 985-991
Artinian, N., Magnan, M., Sloan, M., Lange,M. (2002) Self Care Behaviors Among Patients With Heart Failure. Heart and Lung: The Journal of Acute and Critical Care, 31(3); 161-172
Dao,Q., Krishnaswamy, P., Kazanegra, R., Harrison, A., Amirnovin, R., Lenert, L., Clopton, P., Alberto,J., Hlavin, P., Maisel, A. (October 2002) Utility of b-Type Nautriuretic Peptide in the Diagnosis of Congestive Heart Failure in an Urgent Care Setting. Journal of the American College of Cardiology, 17(2); 379-385