This patient presented with fluid overload due to heart failure and renal failure. On examination, the patient had pedal edema, decreased breath sounds, and hypotension. Laboratory tests showed electrolyte abnormalities including hypokalemia and hyponatremia. An ECG found ST elevations and echocardiogram found reduced ejection fraction. The patient was started on diuretics and other heart failure medications. Nursing care involved monitoring fluid status, vital signs, and providing respiratory support.
10. Medications
• Tab Plavix 75 mg OD
• Tab Colchicine 0.6 mg OD PO
• Stator 80mg OD PO
• Deplatt A 75 OD PO
• Inj Lasix- infusion
• Inj Noradrenaline – Infusion
• Injection piptaz 4.5 gm OD IV
• Syp Kmac
12. • Fluid volume excess
• Hyper volemia
• Isotonic expansion of the extracellular fluid
Abnormal retention of water & sodium
13. Pathophysiology
Related to :
• Simple fluid overload
• Diminished function of the homeostatic mechanisms – responsible for
regulating fluid balance
14. Contributing factors
Book picture Patient picture
Heart failure
✔
Renal failure
Cirrhosis of the liver
Consumption/Administration of excessive sodium
27. Ineffective airway clearance related to presence of fluid in
the plural cavity secondary to pericardial effusion
Assessed the lungs for adventitious breath sounds – crepts found in the B/L lungs
Assessed the RR, rhythm , & depth – used accessory muscles for breathing , has shallow
breathing
Monitored spo2 – 89-RA
Performed chest physio
Auscultated lungs for bilateral equal air entry
28. Ineffective breathing pattern related to altered oxygen supply secondary to
presence of fluid in the pericardial space & increased intra thoracic pressure
Assessed RR, depth , effort &use of accessory muscles RR=36/min
Used pulse oximeter & ABG to assess the status of the patient – respiratory acidosis
Positioned him in semi fowlers
Administered oxygen – NIV bipap – fio2 – 60%
Monitored chest x ray & ECHO findings
Ensured that o2 supply is intact
29. Decreased cardiac output related to increased pressure on the heart resulting
in inefficient and impaired ventricular filling & decreased ejection fraction
Assessed heart rate & BP- HR-140/mt, BP-80/70
Checked peripheral pulses – present
Auscultated for abnormal heart & breath sounds – crepts present B/L
Assessed for presence of paroxysmal nocturnal dyspnea – present
Monitored urine output – has positive balance
30. Activity intolerance related to imbalance between oxygen supply & demand
secondary to increased thoracic pressure leading to inadequate expansion of lungs
Assessed the patients level of physical activity & mobility – he is tired , unable
to perform any activity
Assessed cardio pulmonary status before initiating activity
Observed & documented response of activity
Used pulse oximetry to assess for o2 desaturation during activity
31. Fatigue related to poor physical condition , decreased
nutritional status , decreased cardiac output
Assessed the patients description of fatigue – He felt tired even on rest periods
Assessed the possible cause of fatigue – disease condition , breathing difficulty
Assessed his ability to perform ADL- he is unable to do
Assessed his emotional response to fatigue – he is very fearful
Minimized the environmental stimuli
32. Anxiety related to change in health status and fear of death
Assessed his level of anxiety- very anxious
Determined how he used the defense mechanism – he cries
Assured that he is safe and he is not alone – his wife was with him
Gave spiritual & psychological support
33. Imbalanced nutrition less than body requirement related to decreased
appetite , increased metabolic needs caused by disease process
Auscultated for bowel sounds – heard
Recognized the signs of hypoglycemia
Monitored the laboratory studies
Performed GRBS -286mg/dl
34. Impaired spontaneous ventilation related to non complainant lung tissue as
evidenced by adventitious breath sounds , dyspnea , apnea, decreased spo2 levels
& decreased RR rates
Monitored ABG values – respiratory acidosis
Monitored GCS periodically – 15/15
Assessed his ability to breath- unable to breathe on his own
Monitored the parameters of the ventilators – fio2 – 60%
Explained to the relatives about the future treatment plan
