Question

Case Study: Fluid and Electrolyte Imbalances- Chapter 39

Mr. Abdul is a 76-year-old male who has been admitted to the hospital with a diagnosis of congestive heart failure (CHF). He complains of being tired all the time and barely having enough energy to sit up sometimes. “I think I've put on some weight. My waistband and shoes seem to be tighter and more uncomfortable to wear.” He has a history of coronary artery disease. He has smoked one pack of cigarettes per day for 56 years. He has no known drug allergies (NKDA) and has full code status.

Mr. Abdul's vital signs on admission are T 36.5° C (97.7° F), P 118 regular and bounding, R 32 and labored, BP 160/100, with a pulse oximetry reading of 90% on room air. He denies pain and is alert and oriented to person, place, time, and event. He can move all extremities easily but requires assistance with activities of daily living (ADLs) such as bathing and dressing, He becomes short of breath on exertion. He has fine crackles throughout all lung fields and has a moist, nonproductive cough. Bowel sounds are active in all four quadrants. The last bowel movement, a formed brown stool, was yesterday. His skin is warm, dry, and slightly pale. He has +3 pitting edema in both ankles and +1 bilateral dorsalis pedis and posterior tibial pulses. Admission laboratory test results are as follows:

• Electrolytes: sodium 142 mEq/L; potassium 3.3 mEq/L; chloride 100 mEq/L; bicarbonate 29 mEq/L; blood urea nitrogen 18 mg/dL; creatinine 0.8 mg/dL; glucose 140 mg/dL

Complete blood count: hemoglobin 15 g/dL; hematocrit 45%; white blood cells 8000 mm3; platelets 300,000 mm3

• Arterial blood gases: pH 7.34; PCO2 56 mm Hg; bicarbonate 32 mEq/L; PO2 80 mm Hg; O2 saturation 90%.

Medications are as follows:

• Digoxin 0.125 mg PO q A.M.

• Furosemide 80 mg IV now, then Lasix 40 mg PO q A.M. beginning tomorrow

Treatment orders are as

• O2 2 L/min per nasal cannula

• Vital signs q 4 hr. with pulse oximetry

• Daily weight

• Strict intake and output

• Diet: no added salt

• Activity: bed rest

• Saline lock

7. Identify two nursing diagnoses appropriate for Mr. Abdul. Include related factors and objective and subjective data (written as evidenced by)

8 Identify three priority interventions for Mr. Abdul and provide the rationales.

9. Name the medications that are prescribe medications that are prescribed for Mr. Abdul.

a. For each medication, discuss the action, two common side effects and nursing interventions for each side effect

10. The physician orders furosemide 80 mg intravenously (IV) for Mr. Abdul. An important nursing intervention is monitoring the IV access site every shift to assess for complication. Describe the complications of intravenous therapy as well as the symptom and the nursing consideration.

Answer 1

7.

1. Nursing diagnosis:- Fluid imbalance

Subjective data:- Tightening of wasteband and shoes

Objective data:- Pitting edema +3 on ankles

Nursing diagnoses:- Fluid imbalance related to congestive heart failure as evidenced by edema.

2. Nursing diagnosis:- impaired self activity

Subjective data:- verbalizing as he can't take bath by self

Objective data:- Taking assistance for activities of daily living (ADL)

Nursing diagnosis:- impaired self care activity related to edema and SOB as evidenced by taking assistance for bathing and dressing.