Question

Perform Head To Toe assessment

Admission Date June 10, 2020

Name: S.B.

MR# 80590278364

D.O.B 01/20/1960

Allergies: codeine, shellfish

Diet: Low sodium, Renal Diet

Diagnosis: CHF

Anxious, well groomed 60-year-old male is a retiree and was admitted to the hospital via stretcher accompanied by his daughter. He is 100kg at a height of 180cm so his calculated body mass index (BMI) was 30.9 indicating that he was overweight. When admitted, patient was complained of shortness of breath for 2 weeks and was worsening on the day of admission. Besides, he also experienced orthopnea, fatigue, paroxysmal nocturnal dyspnea and 2 plus pitting leg edema up to his thigh. Mr. SB was admitted to the hospital for to the same problem last year.

Mr. SB had known case of heart failure since 3 years ago and he had also diagnosed with hypertension for 5 years. Before admitted to the hospital, patient was taking fursosemide 40mg, aspirin 150mg, metoprolol 50mg, amlodipine 10mg, and simvastatin 40mg for his hypertension and heart failure. Patient does have allergies to medication and he does not take any traditional medicines at home. His family history revealed that his father had died of ischemic heart disease 4 years ago while his brother has hypertension. As for his social history, he smokes 2-3 cigarettes a day for 35 years and the calculated smoking pack years was 5 pack years. Besides, Mr. SB also drinks occasionally.

On examination, Mr. SB was found to be alert and conscious but he was having pedal edema 2plus pitting up to his knee. Besides, the patient was noted with bibasilar crackles with no rhonchi. His body temperature was 97.9. However, his blood pressure was found to be elevated upon admission with a record of 159/100 mmHg with an irregular pulse rate at 85beats/min. His echocardiogram showed that he had left ventricle hypertrophy while chest X-ray was conducted and revealed that the patient had cardiomegaly.

Lab investigations such as full blood count, liver function test, urea and electrolyte test and cardiac enzyme were done upon admission. His creatinine concentration was found to be 143µmol/L. Therefore, the calculated creatinine clearance was 68.8ml/min. Besides, there was also trace blood found in the urine and foul smelling and the echocardiography showed that the patient has sinus tachycardia. In addition, ECG test was performed on day 1 and the result indicated that there was a T-wave inversion. The patient’s INR was 1.04 which was lower than normal while APTT was found to be slightly higher (59.4 seconds). Mr. SB’s random blood glucose was found to be 68mg/dl during his hospitalization.

Mr. SB was diagnosed with congestive cardiac failure (CCF) with fluid overload. The patient also suffered from hypertension. The management plan included intraveneous furosemide 40mg twice

daily, aspirin 150mg once daily, simvastatin 40mg once at night and ramipril 2.5mg once a day, Augmentin 250mg BID PO and Digoxin 0.125mg PO daily. Besides, patient was asked to restrict his fluid intake to 500ml per day and oxygen therapy was given to patient at high flow using nasal cannula 2L/min. O2 saturation level 98% when patient experiencing shortness of breath.

As for his clinical progression, today Echocardiogram showed that he had cardiomegaly. CT scan of chest with iodine ordered to be done at 8pm tonight. Lab results showed, Bun 25, CR2.0, WBC 6000, Hemoglobin/Hematocrit15/36, potassium 4.0.

Assessment Day 1: Pt Awake, alert and oriented x3, well groomed. PERRLA. Head round, scalp intact and nontender. Mucous membranes moist and pink. Trachea midline. No swelling or goiter noted. Gag reflex intact. No difficulty swallowing. Carotid pulse palpable x2. No bruit noted.

Rales to bilateral lung base noted. Dyspnea on exertion. O2 sat at 95% via 2.5L of N/C. Pt in orthopneic position. Apical pulse rate 85bpm. Irregular. Bowel sounds in all four quadrant active and present. Abdomen soft and non tender and round. Last BM 2 days ago. Foley catheter patent, draining cloudy yellow urine. Redness to sacral area noted. No palpable lymph nodes noted.

During Assessment patient C/o Pain in bilateral legs 6/10, new onset. States, “my legs ache so much”, “it just started hurting 5mins ago.” Difficulty standing and walking. Gait unsteady. Bilateral lower extremities weak. Bilateral hand grasp strong. CMS <3secs. Legs pale in color. 3 plus pitting edema to bilateral legs noted. Pedal pulse weak bilaterally. Skin warm and dry. Ecchymosis to bilateral legs noted. Pt able to move all extremeties. Temperature 97.9, Apical Pulse 88, R24. Intake 700ml, output 500ml.

**Complete clinical packet using the information above including SBAR and nursing notes, careplan using the nursing process

Answer 1

Care plan for Mr SB can be done as follows

Monitor heart rhythmGet a 12 lead ECG

• Patients with CHF will have a low voltage ECG, after peripheral edema is resolved the ECG gains voltage again and becomes more of a normal looking ECG.
• Patients may also have Atrial Fibrillation – a condition in which the atria quiver instead of contracting – this can lead to the development of heart failure.
• May also see signs of current or previous ischemia or infarction.

• Restrict sodium intake

Water follows salt! The patient has too much fluid on board and needs to get rid of it, restricting the sodium helps with this.

This means educating the patient on dietary changes that need to happen and be adhered to.

• 300-600 mg of salt per serving.
• Avoid processed foods or lunch meats
• Do not add salt to meals

Caution with salt substitute in renal insufficiency – it is made with potassium chloride and can raise the patient’s K+!

• Monitor BNPNormal range: <100 pg/mL

Brain natriuretic peptide (BNP): is a hormone made by the heart. When the heart is stressed or working hard to pump blood, it releases BNP.

• Assess respiratory function:
  • Listen to breath sounds
  • Monitor O2 saturation
  • Apply O2 as needed

Fluid can back up into the lungs and cause shortness of breath, especially upon exertion. Be careful about laying these patients flat as you can put them in respiratory distress.

Place the patient on O2 as needed to help them keep their O2 levels adequate – usually above 92% or as ordered by the provider.

• Administer diuretics:
  • Furosemide (Lasix)
  • Bumetanide (Bumex)
  • Hydrochlorothiazide (Microzide)
  • Spironolactone (Aldactone)

We need to get all this fluid out of the patient… The best way to do this is administer diuretics.

The FIRST thing you do BEFORE you administer a diuretic is have a pee plan. Do not under any circumstances administer a diuretic without a bathroom plan. And a word to the wise, have a backup plan. Meaning if you have an independent patient with functioning arms and a strong call light finger, I still would set up a bedside commode just.in.case. I walk them to the bathroom or assist them in any way needed, but it is possible that they do not know how urgent their situation is and you can clean up pee, but you can’t clean up that patients dignity.

Diuretics work on different parts of the nephrons. The goal of diuretics is to help the kidneys rid the body of salt (notice I didn’t say sodium (Na+)?) and fluids. It is important to note for every Na+ molecule there is a compound of one water (H20) that follows it. Psssst: potassium is a salt, too…

There are three kinds of diuretics: Loop, Thiazide, and potassium sparing.

• Loop: works on the loop of henle and excretes Na+, K+, and Ca-. Water follows. (Yikes! Watch your patient’s electrolytes!)
• Thiazide: Works on the distal convoluted tubule and blocks the Na+/Cl- symporter (which reabsorbs…you guessed it Na+ and Cl-). This symporter is responsible for about 5% of Na+ reabsorption. So monitor your patient’s sodium and chloride. Oh, and your K+…Why? Because K+, Cl- and Na+ have direct relationships!
• Potassium-Sparing: Works on the Na+/K+ pumps in the collecting ducts of the kidney by blocking the effects of aldosterone at that site. Aldosterone has the collecting ducts reabsorbing Na+ and thus water, and for every Na+ absorbed, one molecule of K+ is excreted. So this diuretic does the opposite of that, saves a K+ and excretes a Na+ and H20.

Most commonly used diuretics in congestive heart failure are loop and sometimes thiazides are used with loop diuretics:

• Furosemide: Loop
• Bumetanide: Loop
• Hydrochlorothiazide: Thiazide

• Strict intake and output (I&O’s)

These patients should only have around 8 cups of fluid or just slightly under 2 liters of fluid per day. This can change per patient and per doctor recommendation, so make sure to get a goal from the physician.

Strict I&O means measuring every drop that goes in or out of that patient.

• Teach patient to drink one cup at a time and to report how many they’ve had
• Put a hat in the toilet if the patient has bathroom privileges
• Be familiar with common beverage options and their volumes (juice, milk, coffee cup, etc.)

• Monitor swelling/edema

Edema is caused by volume overload due to congestion within the system. Worsening edema can indicate worsening heart failure.

Edema is measured by pressing over a bony prominence, usually the top of the foot or the tibia and is charted by a number and whether the skin bounces back or stays pitted (called pitting edema).

• Non-pitting – doesn’t stay pitted
• +1: mild indent, 2mm
• +2: Moderate indent, 4mm
• +3: Deep indent, 6mm
• +4: Very deep indent, 8mm

• Daily Weights

Daily weights should be done at the same time of the day, same clothes (or none), same scale. A weight gain of 1 kg is equivalent to 1 L of fluid – notify HCP for gain of 2 lbs in a day or 5 lbs in a week.