Mr. CHF

Two more days folks. Two days until I go back through the gates of hell...nursing school. I drove to school the other day to pick up my books and the second I saw the school sitting on top of that hill I felt sick. Ugh. It looked all dark and ominous. Not a good sign. I hope I don't scare any of the hopeful nursing students away with my posts. LOL It's not that bad really.........well, yeah it is, but I promise it's worth it. Don't judge your school program by my own and don't take anything I say to heart because I'm really negative when it comes to school. I always get this way before a semester, so don't let me frighten you too bad. He he. Once I get there I'll be ok...I hope.

I have yet to complete my care plans... I plan on starting them tonight. Judging my my case studies I'll be up until the wee hours of the morning. Here is one of them:

A 85 yo man is admitted to the hospital with a diagnosis of congestive heart failure.
Nursing assessment findings include: A & O times three. B/P 170/100. Apical/radial pulse of 130 and irregular. Respiratory rate 22 and shallow at rest with increase to 30 a minute and irregular with exertion of walking to bathroom. Oxygen at 3 liter per nasal cannula. Bilateral coarse crackles in bases anteriorly and bilaterally half way up in posterior lung fields. Heart sounds distant S1 S2. 3+ pitting pedal edema. Radial pulses 2+ and pedis pulses 1+. Extremities slightly cool to touch. Skin turgor loose over sternum. Requires assist of one with bath and help of one to ambulate. Weight of 170 on admit and noted 160 upon discharge one week ago. States “no appetite” and admits to maybe “one good meal” each day consisting of “some taters, ham and beans” with “some cola and coffee”. Lives alone. Daughter lives four hours away. Attends local church regularly. Denies regular checkups to family physician. “I go when I have a problem.”
Reports “I have only two vices. Smoking and a few beers now and then.” Does confirm when questioned that he has smoked 2 PPD for 45 years. This is his fifth admission in 9 months to the hospital for CHF. Admits he gets up “four or five times a night to pee”. Medications sent home with him last admit were: Lopressor 50 mg BID, Lasix 40 mg qam, vasotec 5 mg daily and nitcotine patch to wear daily. Diet to be 2gm Na.
You administered Lasix 40 mg IV at 8am and Lopressor 50mg po at 9am.
Initial labs results: HCT 31%, BUN 26, Sodium 136, Potassium 3.0.
Four days after admit: HCT is now 35%,sodium of 136, potassium 3.4 and the patient has lost 3 pounds.
Thinking question: Why was the initial HCT 31% and the potassium 3.0? Why did the sodium remain the same?

Okie dokie! I'll get right on top of that.

My first impression is that he has .....obviously...fluid volume excess r/t CHF..but I'm sure that's too simple of a dx for them. How about Impaired breathing pattern r/t CHF? I think the reason why his HCT is low is because he's holding onto all of his fluid in his extracellular space and it isn't in the cells, therefore he's dehydrated ( As evidenced by: poor skin turgor), low cell volume = poor O2 echange = resp rate of 22-30 (trying to compensate). The weight he gained is obviously because he's holding on to the fluid and the weight loss is because of the Lasix. Was he not taking his meds properly? Hmmm. The edema, crackles in the lungs and distant pulses are r/t the excess fluid. Anyhow, getting to the NA (sodium) and the K ( potassium). I have no idea why his NA remained the same. This stumps me. Normally if you have excess fluid you have a low NA. My critical thinking tells me (and what do I know, I'm only a student?) that because there isn't much fluid in the cells that the NA has shifted there, but that wouldn't make sense either really b/c it says it's NORMAL. Hell...that needs to be investigated. Listen to me trying to sound all smart. He he. Anyway..... I think the K was low because he's getting up all night to "pee", therefore losing the K. If it were me I would have put the man on aldactone because it's a K sparer instead of the lasix, but again....I'm could be wrong, I'm only a student. I think a secondary diagnosis would be noncompliance...seems as though he comes to the hospital to be corrected and is somewhat stable then he goes downhill again....but this is only an assumption and assumptions aren't to be made, according to our student handbook. (HA!) Well, here I have sat trying to work on my care plan all while blogging to you fine people. Maybe I'll do all of my homework on my blog so it won't seem like work, but fun.
I kid. Don't worry, I won't put you through the agony!

Incase you haven't noticed, I have updated this blog to make it look better. It was so boring before. I've also discovered how to add videos and I've become obsessed. I cannot stop adding them. Many of my videos are some of my favorite songs that hold special meaning to me...in one way or another. ;-) What would we do without music? I can be in a foul mood and listen to the Dead and feel better instantly. It's my happy pill.....music. Therapy for the soul. Sometimes we get so caught up with life that we forget the more important things. I admit that I do it often. So, when I feel disconnected I just pop in some tunes and heal my soul, and dagummit you should too!

My advice to Mr. CHF: Take one happy pill q day every day for the rest of your life...and oh...take your other meds as ordered, visit your phsycian regularly and stop smoking and drinking too!

Until next time....
Peace!