Oral and Parenteral Medication Administration Skills & Reasoning

History of Present Problem: Jerry Williams is a 62-year old obese (BMI 35.2) Caucasian male with a history of diastolic heart failure and type II diabetes. Last evening, he began having difficulty breathing with activit ...

History of Present Problem: Jerry Williams is a 62-year old obese (BMI 35.2) Caucasian male with a history of diastolic heart failure and type II diabetes. Last evening, he began having difficulty breathing with activity. He thought he might be getting a cold because he had a runny nose. He reports more swelling in his lower legs the past couple days. He woke up this morning with increased difficulty breathing when he woke up and his wife called 911. Paramedics report that his initial VS: HR:92 RR: 28 BP: 172/88 O2 sat: 80% on room air with scattered expiratory wheezing bilat. He was placed on oxygen by facemask and albuterol nebulizer administered with some improvement in his breathing. His RR is now 24 upon arrival to the emergency department ED). His initial labs have resulted; creatinine of 2.5 (last adm. 1.8), K+ 3.5 (last adm. 3.7) and BNP 944 (last adm. 322). Jerry is given furosemide 40 mg IV in the ED and had 800 mL urine output in the last hour. He is admitted to cardiac telemetry, and you are the nurse responsible for his care. What data from the present problem do you NOTICE as RELEVANT and why is it clinically significant? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT Data: Clinical Significance: History of diastolic heart failure and type II diabetes. Last evening, he began having difficulty breathing with activity. He thought he might be getting a cold because he had a runny nose. He reports more swelling in his lower legs the past couple days. He woke up this morning with increased difficulty breathing when he woke up and his wife called 911. Paramedics report that his initial VS: HR:92 RR: 28 BP: 172/88 O2 sat: 80% on room air with scattered expiratory wheezing bilat. He was placed on oxygen by facemask and an albuterol nebulizer given with some improvement in his breathing. His RR is 24 upon arrival. His initial labs included a creatinine of 2.5 (last adm. 1.8), K+ 3.5 (last adm. 3.7), BNP 944 (last adm. 322). PMH is always relevant and needs to be noted by the nurse. Understanding the pathophysiology of heart failure will help the nurse recognize what clinical data is the most important/relevant in this scenario. SOB with a history of heart failure is always a clinical RED FLAG and the most likely reason for this chief complaint. Difficulty breathing with activity is an EARLY RED FLAG of decompensating heart failure if that is the primary problem. His difficulty breathing was significant enough to warrant a 911 call which is another clinical RED FLAG. Difficulty breathing at rest is a progression and worsening that is expected with exacerbation of heart failure. His RR is too high and his O2 sat too low! Has no known history of asthma or COPD. Why does he have wheezing? Discuss cardiac asthma and how acute exacerbation of heart failure can cause bronchoconstriction and wheezing with heart failure. His blood pressure is also too high! Discuss the correlation of systolic blood pressure to afterload and how increased afterload increases the workload of the heart and can continue to exacerbate the underlying problem of heart failure. If patient has “cardiac asthma” will albuterol help significantly? Not really. EMS decision making is driven by protocol and not always benefits the patient. His RR has decreased but is still too high at rest. This is a clinical RED FLAG. • His creatinine is too high and trending upwards. This is a clinical RED FLAG that represents worsening renal function most likely as a result of heart failure exacerbation and impaired diffusion to the kidneys. • This potassium is within normal limits but is low normal. This is a clinical red flag that needs to be noted because of the loop diuretic that has already been given that will deplete this potassium even