Mrs. Brown, a 82 year old woman was admitted to the hospital complaining of shortness of breath and palpitations.  The preliminary diagnosis is uncontrolled hypertension with atrial fibrillation and heart failure.  She had been taking propanolol and furosemide to control her blood pressure. Her health has been fairly good until the last year when she has become increasingly fatigued with minimal exertion.  She woke last night with a feeling of breathlessness about three hours after falling asleep.  For the last several years she has preferred to sleep in a recliner.  Her breathlessness was relieved by getting out of the recliner and walking around.  She also reports a feeling of heaviness in her arms and legs.  Her daughter reported hat her mother has become increasingly forgetful during the last year.  She has been told that her blood  pressure was up.  she reports that she is short of breath when lying flat.  She likes to walk to the grocery store, but she is having difficulty in going out because she is so very tired when she comes home. Sometimes she even has chest discomfort, and now she notices that her heart feels funny and she has palpitations.
    On arrival to the emergency room, Mrs. Brown was alert and oriented. Her skin was cool and dry and her nail beds were pink.  Her blood pressure was 200/96.  Her heart rate was 110 and her respirations were 30 and labored.  An IV was started and oxygen was administered.  Nitroglycerin 0.4 mg. was administered sublingually 3 times.  The cardiac monitor displayed atrial fibrillation.  The EKG was negative.  She was stable and transferred to the telemetry unit.
    On telemetry, Mrs. Brown's blood pressure was 130/76.  Her heart rate was 126 and respirations were 32.  Oxygen was administered by nasal cannula at 5l/min. Mrs. Brown was placed in semi-Fowler's position.  She had crackles in the posterior bases of her lungs.  Her central venous pressure was judged to be 15 because her jugular veins were distended to 9 cm. above the sternum.  Her abdomen was soft, but her liver was enlarged.  Mrs. Brown's abdomen was distended and she reported tenderness.  Nonpitting edema was noticed in the sacral area.  Pedal pulses were present, but difficult to palpate because of the 3+ edema in her feet.
    Mrs. Brown's blood pressure continued to drop over the next several hours and her systolic blood pressure was 88.  She was placed on digoxin and a dopamine drip.  Furosemide was administered intravenously.  Once Mrs. Brown was stabilized, her heart rhythm converted to normal sinus rhythm.  Her blood pressure stabilized and then the dopamine drip was discontinued.  Mrs. Brown was placed on enalapril 2.5 mg. twice a day, furosemide 40 mg. daily and digoxin 0.125 mg. daily.  Mrs. Brown was placed on a low sodium diet and eventually discharged.

1.    What are five symptoms of left heart failure?
 
 

2.    What are five symptoms of right heart failure?
 
 

3.    Which position for Mrs. Brown reduces venous return and maximizes oxygenation?
 
 

4.    Identify significant findings from the history of the above situation.
 
 

5.    Describe elements to be included in the cardiac assessment.
 
 

6.    Which of the above elements of the assessment are a priority when a rapid assessment must be done (i.e. when she cannot talk or breathe easily)?
 

7.    What was the rationale for the administration of sublingual nitroglycerin?

8.    Morphine was ordered for Mrs. Brown during the acute phase of hospitalization.  When telling her what is going to be administered,  Mrs. Brown's comment is "I don't have any pain."  How would you respond?
 
 

9.    Mrs. Brown is placed on a 2 Gm. sodium diet.  How would this be implemented?
 
 

10.    Just before discharge, Mrs. Brown has a 3 lb. weight gain. What other observations should be made at this time?
 
 

11.  Mrs. Brown is encouraged to walk after discharge.  Under what circumstances should she be taught that she should stop walking and rest?  What would you do to encourage her to walk?
 
 

12.  In preparation for discharge, what would you teach Mrs. Brown about the following:

    Activity
    Weight
    Digoxin toxicity

Digoxin and Hospitalization for Heart Failure
Living with Heart Failure
13.   Identify five nursing diagnoses for Mrs. Brown.
 

Copyright 1998 © Margarete Lieb Zalon

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