NURSING 6550 iHuman Carter Cardiovascular

NURSING 6550 iHuman Carter Cardiovascular

• Primary (1) Left-sided Heart Failure (2) Right-sided Heart failure secondary to LV

dysfunction (3) Acute Renal Injury (AKI) Differential Dx (1) Hypothyroidism (2) Viral Cardiomyopathy (3) Pulmonary Embolism (4) Lung Neoplasm (5) Hyperthyroidism (6) Pneumonia (7) Interstitial Lung Disease

• Admit to: Cardiovascular Unit (CVU) , stable, Dr. Moore – Hospitalist, call upon arrival

with rm#

• Vitals: continuous cardiac and pulse oximetry monitoring, Blood pressure checks q2hrs

4. Isolation/Precautions: Standard precautions

5. Allergies: NKDA

• Diet: Cardiac with 2,000 mg/d Sodium restriction and 1500 ml fluid restriction/24hr
• Intake/Output: insert foley catheter, strict q4h I&Os, notify physician if urine output is

<120 ml in 4 hours.

• Activity: Bedrest with active and passive range of motion while awake, keep HOB

elevated at least 30º or higher

9. IV: Total of 2 - 18 gauge right antecubital; 20g left mid-anterior forearm

10. IVF: none

11. Respiratory: titrate to maintain oxygen saturation >94% by nasal cannula

12. LABS: BMP q4hr

13. AM LABS: BMP, BNP, NT-proBNP

14. RADS/Diagnostic tests: AM CXR PA and lateral, AM EKG, Echocardiogram

15. PT/OT/Nutrition/SW/Pysch: Nutrition, PT, Respiratory

• Consult: Specialty services: Cardiology, Nephrology

17. Screening (s): PNA vaccine

18. Medications:

Lisinopril 2.5 mg oral twice daily, continue as home medication no end date Valsartan mg oral once daily, end date 06/24/18 or discharge date Metoprolol 50 mg oral twice daily, continue as home medication no end date Lasix 80 mg IVP now, one-time schedule dose, end date 06/20/18 Lasix 20 mg IVP twice daily, end date 06/24/18 or discharge date

Diovan HCT 80/12.5 mg oral daily, prescription to be given on day of discharge

Plan Rationale and Supporting Documentation

• Primary (1) Left-sided Heart Failure: the patient presented with some predominant

features such as exertional dyspnea progressing to orthopnea, paroxysmal nocturnal dyspnea, cough w/ fine crackles in the lungs, fatigue and activity intolerance, cold hands and feet, AKI (low cardiac output), EKG changes show possible BBB. (Papadakis, McPhee, & Rabow, 2018).(2) Right-sided Heart failure secondary to LV dysfunction: the patient presented with a few symptoms of right-sided HF these included: 2+ bilateral pitting lower extremity edema extending up to mid-shin, JVD 12 cm above sternal angle, + Hepatojuglar Reflux, weight gain despite decreased appetite. (Papadakis et al., 2018).(3) Acute Renal Injury: Acute kidney injury (AKI) occurring during heart failure (HF) has been labelled cardiorenal syndrome (CRS) (Cruz, Giuliani, & Ronco, 2015).Decreased cardiac output reduces blood flow to the kidney’s resulting in injury. Diuretics are still a cornerstone in the management of HF. Intravenous administration by bolus or continuous infusion appears to be equally efficacious (Cruz et al., 2015).

• Patient was admitted to the CVU because of his current heart rate, admitting diagnosis,

and consult to cardiology. Furthermore, his cardiac history was taken in to consideration.

• Vitals: continuous cardiac monitoring for this patient is needed although he is stable at

this time, he is tachycardic. Pulse oximetry monitoring is ordered because on admission the patient was 91% on room air and CXR shows pulmonary edema which causes SOB, Blood pressure checks q2hrs ordered to monitor for hypotension from treatment therapy.

• Isolation/Precautions: Standard because no infectious disease process exist with this

patient

5. NKDA

• Diet ordered because current guidelines advise that patients with symptomatic HF should

restrict sodium intake to 2,000 to 3,000 mg/d and restrict fluid intake to 1 – 1.5 L/d (Doukky et al., 2016). Dietary sodium is considered a common and potentially modifiable precipitant of HF decompensation. I spoke with both the cardiologist and

nephrologist on staff at my hospital and they agreed with this patient scenario in ordering this diet with NA and fluid restrictions having HF and AKI.

• Intake/Output: restrictive fluids ordered and need to be measured and monitored. Strict

urinary output measurement ordered requiring a Foley Catheter to guide titration of Lasix IV therapy to treat pulmonary edema and peripheral edema.

• Activity ordered for bedrest because all medications can potentially cause hypotension

leading to lightheadedness, dizziness, and lead to a fall. HOB ordered to assist patient with breathing and comfort. Range of motion helps maintain movement by stretching the muscles and moving the joints while the patient remains on bedrest.

• IVs ordered because 2 large bore IVs is standard protocol for patient safety should ACLS

protocol need to be initiated. IVs are also necessary to administer IV medications.

• IVFs not ordered because HF patients do not receive maintenance fluids due to fluid

volume overload.

• Respiratory: 02 by nasal canal ordered because on admission patients oxygen saturation

was 91% on RA. Until the pulmonary edema is resolved from the IV Lasix, O2 BNC will assist in oxygenating the patient.

• BMP ordered every 4 hours to monitor renal function and electrolytes. Per Nephrology

on staff, this order would continue until all values returned to normal. He said the interval would change to every 6, 8, or 12 hours.

13. AM LABS: repeat BNP and NT-proBNP for comparison for any improvement

• RADS/Diagnostic tests: repeat CXR PA and lateral for comparison for any improvement,

repeat EKG for comparison for any changes from the previous, Transthoracic Echocardiogram to assess ejection fraction, heart valves, heart muscle, pulmonary HTN, etc.

• I consulted PT to provide isometric and isotonic exercises for the patient while he is

hospitalized. There is significant evidence of a link between the enhancement of peak oxygen uptake and an increase in exercise tolerance seen after training and correction of skeletal muscle derangements in patients with heart failure (Chung & Schulze, 2011).Also, PT can provide additional education of exercises the patient can do in the home to increase his stamina and regain muscle tone.

I consulted Nutrition to provide education in regards to his new diet restrictions. He needs to consume foods, drinks, and condiments with little or no sodium such as: fresh, unprocessed beef, pork, fish, and chicken; fresh, unprocessed fruits and vegetables; low- sodium dairy products; egg-whites, whole grains (brown rice, oatmeal, bulgur, quinoa).Educate to read the label and basically anything processed contains sodium such as orange juice and apple juice.

• Consult: Specialty service to cardiology for cardiac diagnosis of HF and history; consult

to nephrology for diagnosis of AKI

• Screening (s): patient is not up-to-date with PNA vaccine. Given his PMH and current

medical diagnosis, the pneumococcal vaccine is greatly indicated.

18. Medications:

Patient will need to be instructed to take his blood pressure before taking medications, record them in a journal, and bring the journal with him to his follow-up visit in 1-2 weeks to adjust his medication dosage.Lisinopril 2.5 mg oral twice daily, continue as home medication no end date ACEIs should be started at a low dose and titrated upwards at short intervals of at least one to two weeks until the optimal tolerated or target dose is achieved (Arcangelo, & Peterson, 2013).

Diovan HCT 80/12.5 mg oral daily Patient admitted to not taking medications because he doesn’t like taking pills. I would order this hopefully to encourage compliance.

Metoprolol 50 mg oral twice daily, continue as home medication no end date This is a previous home medication continued as ordered and is part of the heart failure guideline treatment therapy. Dose will only be changed if patient is not tolerating the addition of the other medications.

Lasix 80 mg IVP now, one-time schedule dose, end date 06/20/18 Bolus dose ordered as a one-time dose to initiate treatment for HF and AKI to alleviate symptoms of SOB and peripheral edema. Loop diuretics exert their