Question

SB is a 74 year old man who presents to your family medicine office with his wife complaining of shortness of breath and fever. They just moved to the area and had been planning to come to your office next week to establish care as new patients. He is confused about what to use when, so you are not sure which medications he actually takes. No known allergies

Past Medical/Surgical History

o   Heart failure following myocardial infarction at age 68 years

o   COPD (on 2 L home oxygen)

o   Hypertension

o   Appendectomy

JS Past Record Review  (brought by wife)

–      Echocardiogram with EF of 25%

–      Spirometry with FEV1 35% predicted that does not change significantly after inhaled bronchodilator

Records Review

Unable to determine when last pneumoccal vaccine was given

–      Patient and wife don’t recall “a pneumonia shot”

–      Does know he got his “flu shot” last month at a grocery store

JS current symptoms include the following:

–      Unable to speak in full sentences for the past several hours per wife

–      Cough productive but unknown color of sputum

–      Audible wheezing since last night per wife

–      Mild chest tightness

–      Dyspnea

•       His wife has noted no change in his alertness or mental status

•       When you inquire, the wife states that JS usually has a cough, worse in the morning, productive of gray sputum, gets short of breath if he walks more then 10 feet, and has episodes of wheezing if he gets sick (e.g. with an upper respiratory infection).

•       He usually is able to help around the house with light work and fixing things.  

•       Physical examination

–      Vital Signs: BP 128/74; P 68, reg; RR 32; Ht 5ft 6 in; Wt 122 lbs; T 101.5 °F oral

–      Unable to speak in full sentences, audible wheezing, alert and oriented

–      Pertinent positives:

•       General:  audible wheezing, no accessory muscle use

•       Nails: tar stains, clubbing

•       Chest: increased anteroposterior (AP) diameter; diffuse wheezing to auscultation

•       Heart: regular, no murmurs

•       Study results

–      Pulse oximetry 86%

–      Chest x-ray shows hyperinflation and right lower lobe pneumonia

–      You continue his heart failure medications as per his home regimen

•       No need to discontinue the cardioselective beta-blocker

What is the patients admitting diagnosis and chief complaint?

What are two priority nursing diagnosis for this patient?

What is the patient at risk for/ potential complication? and an intervention to prevent it from happening?

Answer 1

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 Congestive heart failure.

2. The two priority nursing diagnosis for Mr.SB would be :

a . Ineffective Breathing Pattern related to decreased lung expansion secondary to congestive heart failure.

b. Activity intolerance related to imbalance between oxygen supply and demand secondary to congestive heart failure.

3. Potential complication :

SB is at risk of developing -

Impaired Renal function- Since the cardiac output and ejection fraction is decreased, there is a risk of renal impairment.

Arrythmias : Since the contractility of heart is affected, arrhythmias like atrial fibrillation, ventricular fibrillation may set in.

Myocardial infarction : Due to decreased blood supply to the heart , 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 support mode used in CHF.
• If there is fluid retention and edema, diuretics is drug of choice.

These are done to prevent complications of CHF.

Thank you.