The Patient with Heart Failure

The Case:

The Case: You are assigned to Mr. T, who was transferred to your unit earlier today. During report you learn that he has Congestive Heart Failure (CHF), 3+ pitting edema of the lower extremities, increasing shortness of breath, and has been demonstrating Cheyne Stokes respirations and periods of confusion. He complains of blurred vision. Vital signs are T 36.4, P 62, R 22, BP 180/102. He has received his 0900 meds. Current orders include:

Think about the case and then respond to the following questions.  Your answers should fully explain the reasons for your response.

1. What is the significance of the IV Flow rate? Why is this rate chosen and what side effect issues are of concern? (1 point)

2. Utilizing the Nova Scotia College of Nurses (NSCN) website (https://www.nscn.ca/), research which IV meds ordered can you (an LPN) administer within your Standards of Practice?  Upon licensure as an LPN do you have the education, training and authority? (1 point)

3. Why does Mr. T have I & O ordered and an indwelling catheter?  Why is this important in this clinical presentation? (1 point)

4. What complications could occur for Mr. T. in relation to having IV Therapy? Consider IV site related issues, fluid issues and which systems and organ that could be negatively affected and why. (1 point)

1. Blood Therapy Case Study (4 questions)

The Case: Mrs. TA is 34 years old, admitted after a motor vehicle collision: pedestrian versus car. She sustained multiple injuries throughout her body. She will receive 2 units of whole blood this morning prior to orthopedic surgery. She has an IV of NS 0.9 % infusing at TKVO through a Y-type blood administration set, and she has a 19-gauge cannula in the right forearm (RFA). The physician’s orders are to infuse each unit over 3 to 4 hours. As you complete report, the lab notifies you that the first unit of blood is ready.

Question 1: Based on your theory knowledge, reading and the case information provided, what protocol is to be followed for initiation of Blood Therapy? (1 point)

Question 2: Based on the following assessment data, identify what is happening to Mrs. TA? (1 point)

You assess the following during the start of transfusion on Mrs. TA:

· VS: T 36.4, P 80, R 18, BP 136/78 (pre-transfusion)

· VS: T 36.8, P 90, R 22, BP 130/70 (15 minutes after start of transfusion)

· No complaints of itching

· Transfusion rate increased to 100 ml/hr

After 20 minutes Mrs. TA’s assessment includes: Skin flushed, P 120, R 32, BP 100/60, complaints of chest pain and chills.  

Question 3: Prioritize the nursing interventions listed in the following chart (related to Question #2 clinical data) and give rationale for each choice. (12 Points)