Ignatavicius: Medical-Surgical Nursing, 8th Edition
Chapter 33: Assessment of the Cardiovascular System
Assessment of the Cardiovascular System – Heart Failure
A 67-year-old Hispanic-American woman is admitted to the hospital for dyspnea and progressive fatigue. The patient’s history reveals that she is 45 pounds overweight from her previously recorded weight 1 year ago. She has had type 1 diabetes mellitus for 23 years that is controlled with daily insulin. A 24-hour account by the patient of her diet reveals an intake of high-sodium and high-cholesterol foods. Her exercise routine includes walking a half-mile for 20 minutes 1 to 2 times a week. She states she smokes one pack of cigarettes per day and has done so for 40 years. She reports no alcohol consumption. At night she sleeps with three pillows and gets up urgently to void at least once each night. Professional Custom Writing Services from the Experts!
The patient is slightly dyspneic while speaking one to two sentences and then must stop to rest for 2 minutes before she can resume answering questions. On assessment, she has anasarca and ascites. Jugular vein distention is 4 mm above the sternal angle with the head of bed elevated at 45 degrees. A right ventricular heave is observed at the sternal border with the patient in a semi-Fowler’s position. Her skin is pale and cool to the touch. Her apical pulse is not palpable. Radial pulses and pedal pulses are 1+ bilaterally on palpation. Auscultation of the heart reveals S1, S2, and S3 sounds. She denies any chest pain.
Vital signs are: pulse oximeter reading 90%, but after administering 2 liters of oxygen per nasal cannula the pulse oximeter reading elevates to 93%; temperature, 97.3° F (36.3° C); heart rate, 88 beats/min, cardiac monitor shows sinus arrhythmia with occasional premature ventricular contractions (PVCs); respirations, 28 breaths/min.
1. Document a nursing note for the case study above using the following format:
2. What kind of heart failure (which side) does this patient’s assessment reveal?
3. What does the auscultation of an S3 sound indicate?
4. The patient reports that she sleeps on three pillows at night. What does this indicate?
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