What nursing interventions are appropriate for Mrs. J. at the time of her admission?
Mrs. J. is being admitted to the ICU due to acute decompensated heart failure. The subjective and objective data obtained is the following: Mrs. J is overweight based on her height and weight (5 feet 9 inches and weighs 210.5 pounds). For three days she has been experiencing a low grade fever (99.68), pharyngitis, and malaise. She denies pain but feels that she cannot breathe due to dyspnea. She claims that her heart is running away which indicates tachycardia (HR 118 and irregular). Her heart rate is working harder to compensate for the low blood pressure of 90/58. Her peripheral pulses are +1, demonstrating jugular distention, and ventricular rate of 132 with atrial fibrillation. She has crackles at auscultation, decreased breath sounds on right lower lobe, coughing frothy blood-tinged sputum, with and a very low oxygen saturation level of 82%. This patient is having left sided heart failure based on the subjective and objective data obtained.
Intervention: Place patient on continuous oxygen 2-4 LPM via n/c.
Rationale: To alleviate dyspnea symptoms and allow patient not to work as hard breathing
Intervention: Establish guidelines and goals of daily activity.
Rationale: Patient will most likely be more willing to cooperate if she is included in the goals being set.
Intervention: Assess patient’s mentation regularly.
Rationale: This is to determine if the patient is becoming more severe. Anxiety and confusion are late signs when a patient is having decreased cardiac output.
Intervention: Keep patient semi to high-fowlers position.
Rationale: This will help alleviate some of the shortness of breath.
Intervention: Asses heart rate and blood pressure frequently.
Rationale: Sinus tachycardia and increased arterial blood pressure are in the early stages and the blood pressure decreases as the condition worsens.
Intervention: Assess peripheral pulses frequently.
Rationale: weak pulses are indicators of low cardiac output.
Intervention: Assess skin color and temperature.
Rationale: Cold and clammy skin is an indicator of low cardiac output and desaturation.
Intervention: Assess fluid balance and weight gain.
Rationale: A compromised regulatory system can result in sodium and fluid retention.
Intervention: Continuous assessment of lung sounds.
Rationale: Crackles are indicative of fluid accumulation and secondary to left ventricular failure.
Intervention: Asses urine input and output.
Rationale: Decreased urine output is an indicator of lack of renal perfusion.
Intervention: Assess for chest pain.
Rationale: Indicates lack of oxygen supply. (Ackley & Ladwig, 2011).
What is the rationale for the administration of each of the following medications?
IV furosemide (Lasix) – Furosemide is a loop diuretic and used to decrease fluid volume (pre-load). Patient is demonstrating. It is also used as an adjunct therapy. Mrs. J has crackles and coughing frothy blood-tinged sputum that is indicative of pulmonary edema. Nurse must check patient’s urine input and output and electrolytes due to possible dehydration, depletion of potassium, and metabolic alkalosis.
Enalapril (Vasotec) – is an angiotensin-converting enzyme (ACE) inhibitor. Enalapril is used for congestive heart failure which is a weakness of the heart that leads to buildup of fluid in the lungs and the surrounding tissues. Patient has crackles, and she is coughing frothy blood-tinged sputum (McKenry, 2006).
Metoprolol (Lopressor) – Lopressor is a beta blocker and the standard use for heart failure. Beta blockers are used in patients with heart failure because it helps improve the hearts ability to relax, decrease the production of harmful substances produced by the body in response to heart failure, and slows down the heart rate. Mrs. J has a ventricular rate of 132 and atrial fibrillation (WebMD, 2015).
IV morphine sulphate (Morphine)- Morphine is an opioid and it is used to alleviate Mrs. J’s dyspnea. Morphine lowers the breathing rate in the brains respiratory center. This will help Mrs. J’s heart not work so hard. Morphine does this by widening the blood vessels in the extremities which will allow the heart not to work hard and use less oxygen. It is also great use for anxiety. Mrs. J is experiencing anxiety due to dyspnea and fear of complications (McKenry, 2006).