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Original Question

Case Study #1 Larry is your patient. He is a 76 year old male. Visit reason: shortness of breath, lower leg pitting edema. Dx: Acute exacerbation of congestive heart failure (AECHF). Med. Hx.: COPD, CAD, Pacemaker, ICD (implanted cardioverter defibrillator), HTN, Dyslipidemia, DMII, previous STEMI with stent placement. Admit: January 9, 2022 from home. Lives alone. No known drug allergies. Activity as tolerated (AAT). Full Code. Diabetic Diet with a fluid restriction of 2L/day. Contact/Droplet precautions. Medications: enoxaparin, pantoprazole, furosemide, acetaminophen, rosuvastatin, bisoprolol, mirtazapine, linagliptin. He has BID vital signs and assessments due. He has diagnostic testing that he is going for today including and ECHO, ECG, CXR. A full panel of bloodwork was completed on admission and is pending. You head into Larry’s room for your initial assessment and you notice that he is sitting up at the side of the bed in a tripod position, gasping for breath. You try to quickly count his respiratory rate but it is too fast. He notices you and says “help…I…can’t…breath” between gasps. What are some other things you may notice initially about Larry before even doing vital signs? What do you think you can expect to find when you get a chance to complete your vital signs? What are some likely physical assessment findings for Larry? What are your next steps? Larry continues to have difficulty breathing – he is now diaphoretic and complaining of chest discomfort. What do you think his chest discomfort could be associated with? Do you think it could be demand ischemia or an acute MI? What is your reasoning. If his chest pain is demand ischemia what next? If his chest pain is caused by an acute MI what next? Take the time to look up a pacemaker, ICD, and stent placement in your texts and there are also great YouTube videos from notable hospitals. You will come across these frequently in practice. Think about the effects of magnetism with ICD/pacemakers – research this as well. What nursing considerations can you think of if for example required to pronounce someone who has these devices at time of death or a patient that needs surgery or an MRI who has these devices? After getting Larry settled a bit, giving you time to complete a few tasks like vital signs and an ECG he starts coughing – the cough is congested and productive for frothy, pink tinged mucous. Larry’s breathing starts to get worse again. What do you think is happening with Larry given his admitting diagnosis and medical history? What medication/medications do you think the doctor may order to improve Larry’s condition? Is it possible that Larry may require a permanent medication adjustment? Why? What may have contributed to this acute episode? What are some nursing considerations for Larry while he is feeling so ill? When it comes to Larry’s diagnostic testing what do you think it will tell us (each test)? Do you think we should be looking for anything specific in his bloodwork? What are some important discharge teachings for Larry? There are several

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