Chief Complaint:

Ms. B is a 47-year-old morbidly obese female who was admitted to the hospital via the ED on 6/22/19 with a chief complaint of shortness of breath (SOB) and congestive heart failure (CHF).

Diagnosis:

Chronic diastolic heart failure and chronic respiratory failure

History of Present Illness:

Ms. B has had repeated admission for heart failure. She is now presenting with decompensated diastolic heart failure and acute hypoxic respiratory failure requiring BIPAP when her pulse ox desaturates to the 60-70s.  Ms. B has had SOB for 2 weeks which has gotten worse over the last two days associated with dyspnea, paroxysmal nocturnal dyspnea, and BLE swelling. In the ED, she was found to be hypoxic and required 6L of O

₂

by NC and an ICU consult was obtained. They recommended no need to admit to ICU at that time. She’s currently on a 2g NA diet and was placed on a 1,000 mL fluid restriction.

Past Medical History:

The patient’s past medical history includes:

1. Congestive heart failure
2. Diabetes mellitus
3. Hypertension
4. Systemic lupus erythematosus (SLE)
5. Mixed connective tissue disease (MCTD)
6. Interstitial lung disease (ILD)
7. Pulmonary hypertension
8. Obesity hypoventilation syndrome
9. Chronic coronary artery disease
10. Upper respiratory tract infection
11. Anemia
12. Acute kidney injury (AKI)
13. Chronic kidney disease stage III

Past Surgical History:

The patient’s past surgical history includes:

1.Cholecytectomy

2. Partial lung removal

Medications:

Acetaminophen (Tylenol)

650 mg Oral Q6H (mild pain)

Albuterol

2.5 mg Inhalation route Q4H as needed (wheezes, shortness of breath)

Aspirin

81 mg Oral Daily (prevent and manage heart disease and stroke)

Azithromycin

500 mg IV Q24H (antibiotic, to treat bacterial infections due to CAP)

Bumetanide

2 mg Oral BID (diuretic, to treat hypertension)

Carvedilol

25 mg Oral Q12H  (Beta blocker, to treat hypertension)

Ceftriaxone

1 g 100mL/hr IV Q24H (Antibiotic, to treat bacterial infections due to CAP)

Dextrose

10% bolus 125mL 937.5mL/hr  IV (as needed per glucommander – low blood glucose less than 70mg/dL)

Glucagon

1mg injection IM (as needed per glucommander – low blood glucose less than 70mg/dL)

Heparin

5,000 units SubQ Q12H (anticoagulant, to treat or prevent clots)

Hydroxychloroquine

200 mg Oral BID (to treat lupus)

Metolazone

5 mg Oral BID (diuretic, to treat hypertension )

Mycophenolate

1,000 mg Oral Q12H (to treat lupus)

Ondansetron

4mginjection IV Q6H PRN (for nausea and vomiting)

Allergies:

Ms. B is allergic to atenolol (causes facial swelling)

Smoking and Alcohol (and any other substance abuse):

Ms. B reports she has never smoked previously or used chewing tobacco, she also reports no alcohol or drug use.

Family/Social/Work History:

Ms. B has a family history of diabetes, heart disease, heart attack, and hypertension from her mother’s side. Her father is deceased. She used to work as a pharmacy tech and lives with her mother and sister. She is not married and has one son. She identifies herself as a Christian and her hobbies include drawing and listening to music.

Pathophysiology:

Diastolic heart failure occurs when the left ventricle is not properly filled with blood during the filling phase. Consequently, the heart has less blood to pump out to the body. This is caused by thickening of the ventricular walls, which leads to slower relaxation of the ventricle. The heart then increases pressure inside the ventricle to make up for the thickened walls. This manifests as fatigue and exertional dyspnea. Increased pressure inside the ventricle can lead to buildup of blood in the atrium and even into the lungs which can lead to fluid congestion and shortness of breath, edema, fatigue, weakness, and rapid irregular heart beats. The ejection fraction represents the amount of blood that is ejected from the heart after each contraction. A normal ejection fraction is more than 50%. Diastolic heart failure is defined as having symptoms of clinical heart failure with a normal left ventricular ejection fraction. Ms. B’s ejection fraction was recorded as 60-65%.

Side note:

Systolic heart failure is when the heart doesn’t contract properly (indicating a pumping problem). While diastolic heart failure is when the heart fails to relax or fill fully how it should (indicating a filling problem).

The function of the respiratory system is to facilitate the exchange of oxygen and carbon dioxide between the blood and the atmosphere. Gas exchange takes place in the alveoli of the lungs. Oxygen molecules in the alveoli cross the alveolar membrane and enter the bloodstream while carbon dioxide from the blood travels out into the alveoli. Respiratory failure occurs when there is no longer that exchange in the body between blood and air. This can be due to fluid filling the alveolar spaces, alveolar space collapse, pulmonary embolism, emphysema, and thickening of the alveolar membranes. Chronic respiratory failure can be divided into two types: hypercapnic respiratory failure and hypoxemic respiratory failure. Hypercapnic respiratory failure occurs when carbon dioxide is not exchanged out and accumulates in the blood (increased carbon dioxide in the blood). Hypoxemic respiratory failure occurs when there are low oxygen levels in the arterial blood.

Physical Assessment:

• 
  Vital signs
  
  BP 115/69, HR 76, Temp 96.9 °F (Oral), Resp 18, Ht 5′ 8″, Wt 154.2 kg (340 lb), SpO2 89%, BMI 51.70 kg/m²
• 
  Level of Consciousness:
  
  Awake, interactive, alert and oriented x4. Patient speaks freely and in full sentences.

HEENT:

Head is normocephalic, no gross motor or sensory deficits. Pupils are equal, round, reactive to light, and accommodate. Ears are intact; mucous membranes are moist and pink. No nasal discharge or other apparent abnormalities to the head, nose, or throat.

• 
  Respiratory:
  
  On continuous BIPAP, 60% O
  
  ₂
  
  , uses nonrebreather when not on BIPAP. Normal respiratory rate, no retractions or increased work of breathing. Symmetrical chest expansion. Clear to auscultation and percussion bilaterally. Crackles heard bilaterally in lung bases, but no wheezes, rhonchi or rales.
• 
  Cardiovascular:
  
  Normal S1 S2, normal sinus rhythm, no murmurs, gallops, or palpable thrills. No JVD.
• 
  GI:
  
  
  
  Soft, non-distended, non-tender, no rebound or guarding. Normoactive bowel sounds heard on all quadrants.

GU:

Voiding pattern is frequent due to diuretics, urine is clear yellow/straw and there is no foul smell present. Urine output of 1450 mL/kg in the past 12 hours. Patient uses bedside commode.

Skin:

Appropriate for ethnicity. Skin is warm and dry. No pallor, capillary refill less than 3 seconds. Has a peripheral IV (left anticubital)

• 
  Extremities:
  
  Bilateral +1 LE edema; diminished pulses 2+ symmetric and intact. ROM and motor strength grossly normal, high fall risk.

Lab Results:

Lab Test	Patient’s Results	Normal Range	Pathophysiology
WBC	6/22: 5.60	3.5 – 10.8 mcL	Normal
HBG	8.3	13 – 17 g/dL	Most likely due to history of anemia
HCT	29.5	42 – 54%	Possibly due to 1,000 mL fluid restriction and CHF.
PLT	227	140 – 400 mcL	Normal
RBC	4.32	4.7 – 6.0 mcL	Normal
Glucose	102	70 – 100 mg/dL	Hyperglycemia. Pt. has diabetes mellitus.
BUN	47	9.0 – 28.0 mg/dL	BUN is typically elevated due to CHF, acute kidney injury, and chronic kidney disease
CREAT	2.2	0.7 – 1.3 mg/dL	Creatinine is typically elevated due to CHF, acute kidney injury, and chronic kidney disease
Sodium	137	136 – 145 mEq/L	Normal
Potassium	4.0	3.5 -5.1 mEq/L	Normal
Chloride	92	100 – 111 mEq/L	Hypochloremia- Most likely due to CHF, chronic kidney disease, and diuretics.
CO2	34	22 – 29 mEq/L	Elevated most likely due to chronic respiratory failure.
Calcium	8.9	8.5 – 10.5 mg/dL	Normal
Magnesium	2.0	1.6 – 2.6 mg/dL	Normal
AST	10	5 – 34 U/L	Normal
ALT	13	0 – 55 U/L	Normal
Alkaline Phosphatase	58	38 – 106 U/L	Normal
Albumin	3.1	3.5 – 5.0 g/dL	Hypoalbuminemia – Most likely due to CHF, acute kidney injury, chronic kidney disease.
`Protein, Total	: 7.5	6.0 – 8.3 g/dL	Normal
Globulin	3.8	2.0 – 3.6 g/dL	Elevated most likely due to chronic kidney disease and acute kidney injury.
Bilirubin, Total	0.9	0.2 – 1.2 mg/dL	Normal
pH, arterial	7.36	7.35 – 7.45	On 11/01 pt was in compensated respiratory acidosis On 11/02 pt was in Partially compensated respiratory acidosis. Pt. uses BIPAP.
pCO2, arterial	47.1	35 – 45 mmhg	Same as above
pO2, arterial	60.6	80 – 90 mmhg	Same as above
HCO3, arterial	26.7	23 – 29 mmhg	Same as above
02 sat, arterial	89.1	95 – 100 %	On 11/01 pt oxygen sat is low, most likely due to chronic respiratory failure.

• XR Chest AP portable was done on Oct. 29
  
  ^th
  
  . Findings showed patchy nodular regions of airspace disease predominantly in in the mid and lower lung zones; pulmonary edema. Findings also showed moderate cardiomegaly and no pneumothorax present.

• Chest CT without contrast was done on Oct. 30
  
  ^th
  
  . Findings showed cardiomegaly, a small amount of pericardial fluid, and nonspecific hepatosplenomegaly

Nursing Diagnosis	Individualized Nursing Interventions	Rationale
Actual: Excess fluid volume RT congestive heart failure  AEB bilateral lower extremity swelling, dyspnea, hepatomegaly, crackles, and pulmonary edema.	Maintain strict fluid intake and output measurements. Assess for leg swelling/edema and report if abnormal. Monitor daily weights. Administer diuretics per MD order. Maintain patient on strict fluid restrictions as prescribed. Maintain sodium diet intake as prescribed.	Diuretic therapy can cause a sudden loss of fluid. Edema occurs when there is excess buildup of fluid in the extravascular spaces. Sudden weight gain may indicate fluid retention. Diuretics aids in the excretion of excess fluids in the body. Excess fluid can result in pulmonary edema and excess fluid volume. Restriction of sodium aids in decreasing fluid retention.
Actual: Impaired gas exchange RT acute on chronic respiratory failure and pulmonary edema AEB dysnpnea, aroxysmal nocturnal dyspnea, respiratory acidosis, and low Sp02	Complete a full respiratory assessment (ex. lung sounds, breathing pattern, and depth of breaths ect.) Monitor respiratory rates, and oxygen saturations every 30 minutes. Teach and encourage the patient to practice breathing techniques. Elevate head of the bed so patient is in optimal position to decrease work of breathing. Provide supplemental oxygen support to facilitate gas exchange when needed (ex. BIPAP, non-rebreather).	To detect changes or further decompensation. To determine whether the patient is hypoxic. Respiration rates should be 12-20 breaths per minute and oxygen saturation should be 90-100%. So patient can utilize breathing techniques during dyspneic episodes. To enable appropriate lung expansion and allow for adequate inspiration and expiration, facilitating better gas exchange. To assist the delivery of higher concentrations of oxygen.
Educational: Knowledge deficit regarding condition RT chronic diastolic heart failure AEB questioning, lack of understanding.	Assess patient’s knowledge base of chronic diastolic heart failure. Provide teachable moments to encourage health promotion and understanding about chronic diastolic heart failure. Provide patient with appropriate resources and information about complications of disease and support.	To determine how much or little the patient knows about her diagnosis. To allow patient to better understand the disease process and potential complications of chronic diastolic heart failure. In order for patient to initiate necessary lifestyle changes and encourange patient to participate in treatment regimen.
Potential: Risk for impaired skin integrity RT edema, fluid retention, and obesity.	Encourage frequent position changes (patient is able to reposition self). Assess skin condition throughout every shift for color, edema, or breakdown. Increase mobility as tolerated by assisting patient with active and passive ROM exercises. Educate on the importance of keeping the skin clean and dry.	To prevent skin breakdown. Redness, pain, and swelling may indicate inflammation to localized tissue trauma. To improve circulation throughout the body. Moisture softens the skin and its integrity can be compromised.

References

• Ackley, B. J., Ladwig, G. B., & Makic, M. B. (2017).
  
  Nursing diagnosis handbook: an evidence-based guide to planning care
  
  (11th ed.). St. Louis: Elsevier.
• Lewis, S. M., Bucher, L., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2017).
  
  Medical-surgical nursing: assessment and management of clinical problems
  
  (9th ed.). St. Louis, MO: Elsevier, Inc.