Critical Thinking Questions

Jimmy G., a 69-year-old white man, presents with dyspnea on exertion and since his last visit 9 months ago, has gained weight and lost his appetite.

  • CC: “I have a terrible time sleeping even with three pillows because of coughing at night, and lately I’ve been coughing up frothy pink stuff.”
  • Past medical history: Coronary artery disease, hypertension, myocardial infarction, alcoholism, prior smoker
  • Physical examination: Bilateral dependent 3+ edema with cool extremities, Hacking cough, Neck vein distention,Expiratory crackles, S3 gallop rhythm,Hepatomegaly, Abdominal bloating

Critical Thinking Questions:

  1. What additional subjective data do you think the patient will share?
  2. What additional objective data will you assess for?
  3. What National Guidelines are appropriate to consider?
  4. What tests will you order?
  5. Will you be looking for a consult?
  6. What are the medical diagnoses?
  7. What is your plan of care?
  8. What additional patient teaching is needed?

1. What additional subjective data do you think the patient will share?

  • dyspnea that worsens with activity or when lying down
  • A feeling of suffocating or drowning
  • Anxiety, restlessness or a sense of apprehension
  • Awakening at night with a cough or breathless feeling that may be relieved by sitting up
  • Rapid weight gain
  • Fatigue
  • Confusion, trouble concentration

2. What additional objective data will you assess for?

  • Wheezing or gasping for breath
  • Cold, clammy skin
  • A cough that produces frothy sputum that may be tinged with blood
  • Blue-tinged tone of lips or skin
  • A rapid, irregular heartbeat or palpitations
  • Peripheral edema

3. What National Guidelines are appropriate to consider?

The goals of therapy are to improve oxygenation, maintain an adequate blood pressure for perfusion of vital organs, and reduce excess extracellular fluid. The underlying cause must be addressed.

4. What tests will you order?(depending on availability)

Most likely I would send this individual to the Emergency Department ASAP!

But First I would assess O2 Saturation and get a 12 lead ECG.

  • Pulse oximetry- Will likely be the first test to measure the O2 saturation determines how much oxygen is in your blood.
  • 12 lead electrocardiogram (ECG) as soon as possible
  • Chest X-ray (portable, if available)
  • troponin
  • B-type natriuretic peptide (BNP)
  • Echocardiogram at earliest opportunity (depending on access and patient stability)
  • urea and electrolytes, liver function tests, glucose, urinalysis
  • arterial blood gases
  • CBC
  • Kidney function
  • Thyroid function
  • Serum creatinine
  • Quantiferin

5. Will you be looking for a consult?

Yes, I would be looking for a Cardiologist and Pulmonology consult.

6. What are the medical diagnoses?

  • Upper Resp tract infection
  • Reactive airway
  • Decompensated HF
  • Bronchiolitis
  • Lung Cancer
  • Atelectasis
  • Exacerbation of chronic obstructive pulmonary disease (COPD)
  • Acute asthma
  • Pneumothorax
  • Pneumonia
  • Acute coronary syndrome/myocardial infarction
  • Pericarditis
  • Endocarditis

7. What is your plan of care?

Oxygen. Immediately assess the oxygen saturation and put oxygen on the patient. Oxygen for the patient can range up to 10–15 L/min via Hudson type mask and reservoir bag even for a patient with known COPD because the risk of hyperoxic hypercapnia as oxygenation is the priority. You must monitor the patients conscious state, respiratory rate and oxygenation. I would also plan for home O2 2L nasal cannula to and to be assessed periodically with breaks so that the body does not become dependent on it.

Diuretics. Such as furosemide (Lasix), will decrease the pressure caused by excess fluid in the heart and lungs. May also use spironolactone as an add on if symptom control is inadequate.

Blood pressure medications. Some blood pressure medications will ease the pressure going into (preload reducers) or out of (afterload reducers) the heart. Nitroglycerin is a preload reducer that helps decrease the pressure going into the heart. Medications such as nitroprusside

(Nitropress) are afterload reducers that dilate the blood vessels and take a pressure load off the heart's left ventricle.

  • angiotensin converting enzyme inhibitor (ACEI): all patients with CHF (if not tolerated use angiotensin II receptor blocker)
  • beta blocker: patients with systolic failure; COPD is not a contraindication (bisoprolol, carvedilol, metoprolol, nebivolol)
  • digoxin: consider for atrial fibrillation, or as add on therapy for sinus rhythm with severe CHF

Morphine (MS Contin). Relieves shortness of breathe and anxiety.

Anticoagulant. Low Molecular Weight Heparin for DVT prevention

8. What additional patient teaching is needed?

Lifestyle modifications includes:

  • Controlling high blood pressure. Taking medications as prescribed and checking blood pressure regularly. Record the results and following guidelines regarding optimal blood pressure
  • Continue to stay away from smoking and individuals that do smoke
  • Eating a healthy diet. Follow a low-salt diet. Also eat a healthy diet of fruits, vegetables and whole grains
  • Referral to a dietitian for help evaluating the salt content in foods
  • Maintain a healthy weight and exercise regularly
  • fluid restriction: maximum 2 L/day (1.5 L/day if severe CHF)
  • alcohol: no more than one unit per day
  • Vaccinations: influenza & pneumococcal

References

Dains, J. E., Baumann, L. C., & Scheibel, P. (2020). Advanced Health Assessment and Clinical Diagnosis in Primary Care (6th ed.). St. Louis, Missouri: Elsevier.

Purvey, M., & Allen, G. (2017). Managing acute pulmonary edema. Australian Prescriber, 40(2), 59–63. https://doi.org/10.18773/austprescr.2017.013

Stern, S. D. C., Cifu, A. S., & Altkorn, D. (2015). Symptom to Diagnosis An Evidence-Based Guide (3rd ed.). New York City, NY: McGraw-Hill.

Woo, T. M., & Robinson, M. V. (2016). Pharmacotherapeutics for Advanced Practice Nurse Prescribers (4th ed.). Philadelphia, PA: F.A. Davis Company.

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