George Brown, 72 years of age, is a male patient who is admitted with the diagno

Question

George Brown, 72 years of age, is a male patient who is admitted with the diagnosis of acute pulmonary edema secondary to acute left ventricular heart failure. The patient has a history of coronary artery disease that has been treated medically. The patient is anxious, pale, cold, clammy, and dyspneic. The vital signs are: blood pressure 88/50 mm Hg, heart rate 110 bpm, respiratory rate 32 breaths/min, and temperature 97°F. There are bubbling crackles and wheezing throughout the lung fields and the patient is raising frothy blood-tinged clear sputum. The patient’s admission weight is 100 kg.

a. What first actions should the nurse take and what are the rationales for these actions?

The physician ordered furosemide (Lasix) 40 mg IVP STAT.

b. What are the actions of furosemide that will help the patient?

c. What nursing actions should be implemented when administering a diuretic?

Explanation / Answer

a. The first action is to lower the amount of blood returning to heart as lowering of sympathetic activity can lower the acute pressure on heart.

A. Check the patient airway and administratin of high flow oxygen through air reservoir bag.

B. Looking for fatigue evidence and checking patient breathing.

C. Repeatedly checking BP and pulse rate and monitoring peripheries in order to check perfusion.

b. Action of furosemide:It will help in maintaining hypertension and edema linked with congestive heart failure. As per above symptoms patient heart rate is 110 bpm, and blood pressure is 88/50 mm Hg along with anxiety, dyspenic condition.

c. Nursing action are as follows:

Hypertension: Monitoring of BP and pulse before and during administration of dieurtic. As well as monitoring prescription refill in order to determine compliance in patient treated with hypertension. Monitoring electrolytes, blood glucose, BUN and serum uric acids before and throughout the therapy.

Check patient for numbness, thirst, muscle weakness etc. need to access regularly.

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