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82 yo M, SOB and swollen legs who is scheduled for CABG.
DX: CHF (Signs…
82 yo M, SOB and swollen legs who is scheduled for CABG.
DX: CHF
Signs and Symptoms, Assessment
Rapid Weight Gain, bilateral pitting edema +4
Shortness of breath, SPO2 88% on RA, Diminished lung sounds
Pedal pulses weak, left radial pulse weak
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Congestive heart failure is when the heart either isn’t pushing out enough blood out into the circulation of the body or the chambers of the heart not filling with enough blood. Both circumstances cause a backup of fluid. This backup of fluid can lead to peripheral edema, pulmonary congestion (identified by dyspnea, crackles in the lungs). COPD and HTN are both possible causes of CHF.
could have lead to
PMH: A-fib
A rapid and irregular rate of heart rhythm. The heart “quivers” instead of beating properly and reduces ventricular filling and cardiac output. This allows for blood to pool, raising concerns about clotting. A-fib can lead to embolic stroke, DVT and PE
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could've caused
BUN 23
Indicates poor renal function. This is an issue because medications cannot be excreted properly. The patient is taking two diuretics to eliminate excess fluid, which work in the kidneys. If kidney function is impaired these meds may not work like they should.
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PMH: Diabetes
increases risk of
PMH: HTN
Due to fluid volume overload or vasoconstriction, the pressure in the arteries is elevated. This leads to an increased risk of a MI, which is when myocardial tissue is abruptly and severely deprived of oxygen. HTN can also lead to CHF due to the narrowing of blood vessels.
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A progressive disorder characterized by insulin resistance, causing impaired glucose regulation. DM can cause slowed healing, diabetic neuropathy, hypertension, hyperlipidemia and other complications.
PMH: COPD
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Chronic obstructive pulmonary disease is a term used to cover both emphysema and chronic bronchitis. Gas exchange is affected, hypoxemia is a result. Hypoxemia leads to cardiac dysrhythmias. Air trapping, airway collapse and stiff alveolar walls from COPD can result in cardiac failure.
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Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans guidelines for individualizing client care across the life span. Philadelphia: FA. Davis Company.
used in developing nsg dx, interventions, and goals
Ignatavicious, D. D., & Workman, L.M. Medical Surgical Nursing: Concepts for INterprofessional Collaborative Care, 9th Edition (2018.) Elsevier Inc
used for pathophysiology, disease processes.
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