31 May Heart Failure Case Study
Mr. Pepper is 74 y/o who presented to the ED with shortness of breath, fatigue, and “swollen legs and stomach”. In assessing his health history, you found out that he smokes a pack a day. His wife reported that he has been sleeping with two pillows propped behind him.
Part I
What other pertinent information might the nurse need in assessing this patient?
Upon further evaluation Mr. Pepper reported that he had not been taking his fluid pill because he ran out. In obtaining his assessment, you noted bilateral crackles, bilateral lower edema of +3 and distended abdomen. His V.S. are: BP 92/48, P 88, R 30, T 98.9, SPO2 of 88% on room air. You decide to supplement him with 2 L of O2.
Part II
What other interventions might the nurse consider? What
procedures, medications and labs do you anticipate? Be brief!
Mr. Pepper was admitted to 6 South for Heart Failure exacerbation and for diuresis. He was administered Lasix with Potassium supplements. He stated relief from his fatigue and shortness of breath. During hospital stay you noted that his wife was bringing him Chinese food. The patient also requested multiple times to go outside and smoke.
Part III
What teaching strategies will you implement in Mr. Pepper’s care? What resources will you consult or utilize? Where do you obtain your resources? Be brief!
Upon discharge, Mr. Pepper was in good spirits and ready to go home. He was educated about his heart failure and disease process and management throughout his hospital stay.
Part IV
List the discharge instruction topics that you would go ove
with Mr. Pepper. What resources will you give him?
Mr. Pepper verbalized understanding from his discharge instructions. He has decided to quit smoking and live a healthier lifestyle. He was sad to leave the excellent nursing staff, but was ready to go home.
The nurse documented that discharge instructions and educational materials were given to Mr. Pepper.
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