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Grand Rounds

Grand Rounds. Bonnie Rogers Stonecrest Medical Center. Patient Demographics. Retired accountant Religion: Christian Full Code Status Weight: 252 lbs Height 5ft. 1 in. BMI 45.1 (obese). JS, 79 years old Caucasian female Primary language English Resident of Smyrna TN

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Grand Rounds

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  1. Grand Rounds Bonnie Rogers Stonecrest Medical Center

  2. Patient Demographics • Retired accountant • Religion: Christian • Full Code Status • Weight: 252 lbs • Height 5ft. 1 in. • BMI 45.1 (obese) • JS, 79 years old Caucasian female • Primary language English • Resident of Smyrna TN • Married with one son and two grandchildren

  3. Events Leading to Hospitalization • Admission on 04/07/10 • Presentation: Extreme Progressive Weakness • Admitting Diagnosis: Congestive Heart Failure, Weakness • Risk Factors: • Diabetes Mellitus • Hypertension • Obesity • Hyperlipidemia • CAD

  4. Past History • Coronary Artery Disease with Cardiac Bypass x4 vessel on 11/16/09 • Severe Pulmonary Hypertension • Atrial Fibrillation with tachybrady syndrome with dual chamber pacemaker 12/01/09

  5. Past History con’t • Chronic Kidney Disease • Iron Deficiency Anemia • Osteoporosis • Hypothyroidism • Allergic to Shellfish containing substances and penecillins

  6. Diagnostics • Portable Chest x-ray on 4/7/10 • Reason: weakness • Findings: cardiomegaly. Obscuration of the left hemidiaphram likely related to the large heart. The right lung is clear. Vasculature appears normal

  7. Medical Diagnosis Congestive Heart Failure Right Side • Caused from left-sided heart failure. • As pressure in the pulmonary circulation rises, the resistance to right ventricular emptying increases. The right ventricle is poorly prepared to compensate for this increased afterload and will dilate and fail. When this happens, pressure will rise in the systemic venous circulation. • Clinical Manifestations: edema, jugular vein distention, fatigue

  8. Laboratory Data

  9. Laboratory Date

  10. Pharmacological Interventions

  11. Pharmacological Interventions

  12. Pharmacological Interventions

  13. Physical Assessment

  14. Vital Signs • Ranges from two days 4/8/10 and 4/10/10 • BP: 94/38-112/43 • HR: 48-139 (tachybrady syndrome) • RR: 13-23 bpm • SpO2: 94-100% • Temp: 96.6-97.6 F

  15. EENT • PERRLA • Glasses • No drainage from eyes, ears, or nose • Complete dentures • Oral care performed every 2 hrs using toothbrush and toothpaste with moderate assistance • Lip moisturizer applied after mouth care and meals

  16. Neurological • Patient Oriented to person, place, time, and situation • Confused at times • Drowsy all day • Arouses easily and follows commands

  17. Cardiovascular • Cardiac Monitoring: Atrial paced with occasional SB and ST • Normal S1 and S2 auscultated • No audible murmurs • Cap refill <3 seconds, nail beds pink • Radial pulses 3+, regular rate and rhythm • Dorsalis pedis pulse: Bilateral 1+ weak • Edema 2+ present in ankles and lower legs bilaterally

  18. Respiratory • Fine crackles auscultated at RLL • Diminished breath sounds in RUL, LUL, LLL anteriorly and posteriorly • Dyspnea on exertion • O2 per NC at 2L

  19. Gastrointestinal • Bowel sounds present in all four quadrants • No palpable masses, no tenderness noted • Abdomen soft, non-distended • Passing flatus

  20. Genitoururinary • Foley Catheter in place, urethral area dry with no complications, tubing secured to thigh • Urine clear and yellow • Intake and output qhr • Average urine output after 2 shifts approximately 150ml/hr order to call if <100ml/hr

  21. Musculoskeletal • Activity limited by range of motion and generalized weakness • Turning and repositioning schedule set for q2hrs • Up to chair with extensive assistance from OT and PT for approximately 20 minutes • Henrich II Fall Risk Score 7: High Risk with fall precautions maintained

  22. Integumentary • Skin color normal for ethnicity • Skin warm and dry to touch • Absence of tissue breakdown • Braden Skin Integrity Risk Score: 15 (mild risk, skin bundle precautions maintained) • Repositioning schedule q2hrs • Bed linens with minimal layers and free of wrinkles

  23. Integumentarycon’t • Left AC • Saline Lock • Left Hand • 20 gauge • Lasix/diuril drip @ 10mg/hr • Both sites: patent line, dressing dry and intact, no complications

  24. Psychosocial • Patient depressed and emotional, crying occasionally • Patient voices concerns of putting a burden on family members • Family at bedside during visiting hours

  25. Collaboraton • Primary Nurse (RN) • Attending Physician • Cardilogist • Nephrologist • Physical therapist • Occupational Therapist • Student Collegues

  26. Primary Nursing Diagnosis • Decreased Cardiac Output r/t decreased pumping ability AEB: • need for pacemaker (previous arrhythmias) • Decreased urine output • Diminished peripheral pulses • DOE • JVD

  27. Primary Nursing Diagnosis: Goals • Urine output of >100ml/hr • Respirations of 10-25bpm • Peripheral pulse +2 regular • No audile abnormal heart sounds • No presence of arrhythmias

  28. Primary Nursing Diagnosis: Interventions • Monitor urine intake and output qhr • Titrate lasix/diuril drip according to I&O • Administer Diamox q48hrs • Auscultate heart and lung sounds q 2hrs • Monitor BP and HR qhr • HOB elevated 30-45 degrees

  29. Primary Nursing Diagnosis: Outcomes • Goals Met: • Urine output of aproximately100ml/hr • Respirations stayed between 10-25bpm • No audile abnormal heart sounds • No presence of arrhythmias • Goals Not Met: • Peripheral pulses still +1 by end of shifts

  30. Secondary Nursing Diagnosis • Imaired gas exchange r/t inadequate cardiac function secondary to heart failure AEB • Occasional confused mental status • DOE • Generalized weakness • Need assistance with ADL’s • Need for O2 per NC

  31. Secondary Nursing Diagnosis: Goals • RR 10-25 • SpO2 >95% • Alert and Oriented x3 • HR will not increase by more than 20 during activity • RR will not increase by more than 5 during activity

  32. Secondary Nursing Diagnosis: Interventions • Balancing oxygenation and activity • Initial bedrest • Progress ADLs as tolerated • Oxygen at 2L • Head of bead 30-60 degree • Auscultate lung sounds q2hrs

  33. Secondary Nursing Diagnosis: Outcomes • Goals Met: • RR remained within 10-25 bpm • SpO2 was >95% • Pt alert and oriented x3 • HR did not increase by more than 20 during activity • RR did not increase by more than 5 during activity

  34. Tertiary Nursing Diagnosis • Fluid Volume Excess r/t impaired excretion of Na and H2O secondary to renal insufficency AED: • +2 pitting edema bilaterally on lower legs and ankles • Jugular Vein Distention • Crackles auscultated in RLL • Decreased urinary output

  35. Tertiary Nursing Diagnosis: Goals • Maintain urine output within 500 ml of intake • Reduce +2 pitting edema to +1 by end of shifts • Lose 2 lbs of fluid by end of shift • Lungs clear bilaterally

  36. Tertiary Nursing Diagnosis: Interventions • WEIGH daily • Maintain a strict intake and output qhr and report less than 30ml/hr • Restricit fluid and sodium as ordered • Monitor creatinine and BUN

  37. Tertiary Nursing Diagnosis: Outcomes • Goals Met: • urine output within 500 ml of intake • Lose 2 lbs of fluid by end of shift. Pt lost over 6lbs of fluid being 3000ml • Goals Not Met: • Edema was still +2 by end of clinical shift • Crackles still auscultated in RLL

  38. Related ResearchManagement of Patients With Heart Failure • Objectives: examine whether patients with CHF were receiving the optimum treatment for heart failure and propose recommendations for CHF management that would be useful to all kinds of healthcare facilities. • The Group Studied: Patients with a diagnosis of Congestive Heart Failure and an ejection fraction less than 40%. A retrospective review of 300 clinic records of patients with CHF dating from January 1, 2003 to July 31, 2004 was performed.

  39. Related Research • Findings: • All patients had at least one risk factor • 71% had hypertension. • A significant percentage (22%) had renal insufficiency. • Recommendations: • Teach patients about risk factors such as hypertension, smoking, diabetes, and obesity • Nurses need to educate regarding early intervention and better management of hypertension to limit its development. • Teach It’s not ALL about you’re heart! CHF can affect many organs. Teach pts to weigh daily, avoid nephrotoxic drugs, and pay attention to how much they void.

  40. Related Research con’t • In relation to JS • Patient and family were taught about minimizing risk factors for CHF including referral to cardiac rehabilitation center, nutritional support, and diabetic management. • JS was taught about the importance of her chronic renal insufficiency and how it affects her heart. Pt taught to monitor weight daily (notifying MD if >2lbs in one day) and paying attention to voiding patterns.

  41. References Ancheta, I. (2006). A retrospective pilot study: management of patients with heart failure.Dimensions of Critical Care Nursing, 25(5), 228-233. Retrieved from CINAHL with Full Text database. Huether, S.E. & McCance, K.L. (2008). Understanding Pathophysiology (4th ed) St. Louis: Mosby, Inc. Skidmore, L (2009). Mosby’s Drug Guide for Nurses. St Louis: Mosby, Inc.

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