se the following Case Scenario, Subjective Data, and Objective Data to answer the Critical
Thinking Questions.
Case Scenario
Mrs. J. is a 63-year-old woman who has a history of hypertension, chronic heart failure, and
sleep apnea. She has been smoking two packs of cigarettes a day for 40 years and has
refused to quit. Three days ago, she had an onset of flu with fever, pharyngitis, and malaise.
She has not taken her antihypertensive medications or her medications to control her heart
failure for 4 days. Today, she has been admitted to the hospital ICU with acute
decompensated heart failure.
Subjective Data
1. Is very anxious and asks whether she is going to die.
2. Denies pain but says she feels like she cannot get enough air.
3. Says her heart feels like it is "running away."
4. Reports that she is so exhausted she cannot eat or drink by herself.
Objective Data
1. Height 175 cm; Weight 95.5 kg
2. Vital signs: T 37.6 C, HR 118 and irregular, RR 34, BP 90/58
3. Cardiovascular: Distant S1, S2, S3 present; PMI at sixth ICS and faint; all peripheral
pulses are 1+; bilateral jugular vein distention; initial cardiac monitoring indicates a
ventricular rate of 132 and atrial fibrillation
4. Respiratory: Pulmonary crackles; decreased breath sounds right lower lobe;
coughing frothy blood-tinged sputum; SpO2 82%
5. Gastrointestinal: BS present: hepatomegaly 4 cm below costal margin
Critical Thinking Questions
What nursing interventions are appropriate for Mrs. J. at the time of her admission? Drug
therapy is started for Mrs. J. to control her symptoms. What is the rationale for the
administration of each of the following medications?
Looking at Mrs. Js objective and subjective data the RN can initiate a plan of care
for left sided heart failure. For the patient’s respiratory status, the patients spao2 is 82%.
The patient has decreased breath sounds in the right lower lobe and coughing with frothy
blood tinged sputum. I would expect the nurse to administer oxygen therapy. Also, the
patient’s crackles indicate congestion and fluid overload as well as the JVD. Medication IV
diuretics would be expected to treat this. The Nurse could potentially place an foley
catheter to ensure strict I&Os and possible fluid restriction. Daily weights would also be
initiated to monitor the effectiveness of treatment and patient status. A chest x-ray would
This study source was downloaded by 100000847426977 from CourseHero.com on 06-03-2022 06:12:05 GMT -05:00
https://www.coursehero.com/file/23167476/w3d1/
Thinking Questions.
Case Scenario
Mrs. J. is a 63-year-old woman who has a history of hypertension, chronic heart failure, and
sleep apnea. She has been smoking two packs of cigarettes a day for 40 years and has
refused to quit. Three days ago, she had an onset of flu with fever, pharyngitis, and malaise.
She has not taken her antihypertensive medications or her medications to control her heart
failure for 4 days. Today, she has been admitted to the hospital ICU with acute
decompensated heart failure.
Subjective Data
1. Is very anxious and asks whether she is going to die.
2. Denies pain but says she feels like she cannot get enough air.
3. Says her heart feels like it is "running away."
4. Reports that she is so exhausted she cannot eat or drink by herself.
Objective Data
1. Height 175 cm; Weight 95.5 kg
2. Vital signs: T 37.6 C, HR 118 and irregular, RR 34, BP 90/58
3. Cardiovascular: Distant S1, S2, S3 present; PMI at sixth ICS and faint; all peripheral
pulses are 1+; bilateral jugular vein distention; initial cardiac monitoring indicates a
ventricular rate of 132 and atrial fibrillation
4. Respiratory: Pulmonary crackles; decreased breath sounds right lower lobe;
coughing frothy blood-tinged sputum; SpO2 82%
5. Gastrointestinal: BS present: hepatomegaly 4 cm below costal margin
Critical Thinking Questions
What nursing interventions are appropriate for Mrs. J. at the time of her admission? Drug
therapy is started for Mrs. J. to control her symptoms. What is the rationale for the
administration of each of the following medications?
Looking at Mrs. Js objective and subjective data the RN can initiate a plan of care
for left sided heart failure. For the patient’s respiratory status, the patients spao2 is 82%.
The patient has decreased breath sounds in the right lower lobe and coughing with frothy
blood tinged sputum. I would expect the nurse to administer oxygen therapy. Also, the
patient’s crackles indicate congestion and fluid overload as well as the JVD. Medication IV
diuretics would be expected to treat this. The Nurse could potentially place an foley
catheter to ensure strict I&Os and possible fluid restriction. Daily weights would also be
initiated to monitor the effectiveness of treatment and patient status. A chest x-ray would
This study source was downloaded by 100000847426977 from CourseHero.com on 06-03-2022 06:12:05 GMT -05:00
https://www.coursehero.com/file/23167476/w3d1/
