Case Summary
Subjective Data
A 68-year-old female presents to the ED with shortness of breath and dyspnea on exertion. She reports swelling of the feet and ankles and a weight gain of 10 lbs over the past week, but denies pain. The patient has a history of myocardial infarction 3 years previously, a 30-pack-year smoking history, and obesity. She has no known allergies, and her current medications are metoprolol 50 mg po (orally) daily and aspirin 81mg po daily.
Objective Data
- Heart sounds S1 and S2 are loud and regular with no murmurs.
- No jugular venous distension noted.
- Respirations are shallow and slightly at rest.
- Presence of moist crackles in the anterior and posterior bilateral lower lobes.
- Occasional moist, nonproductive cough.
- 3+ pedal and ankle edema present bilaterally.
- Pedal and radial pulses regular, 4+ and bounding bilaterally.
- Skin of lower extremities is pale and taut bilaterally.
- Laboratory results: Sodium 130mEq/L, Potassium 3.4 mEq/L, Glucose 98mg/dl, Creatinine 1mg/dl, BUN 18mg/dl.
- VS: T 99F, P 126, R 24, O2 sats 88% on RA, BP 188/96, current weight 256 lbs.
Indicators of a Health Alteration
Subjective Assessment Findings
Assessing patients’ health status based on the collection and analysis of objective data enables an accurate diagnosis and the identification of the underlying causes of a particular problem. Using the case of a 68-year-old female patient, her subjective and objective data will be evaluated to determine the background of her health issues and make appropriate recommendations. The proposed interventions are directly based on a comprehensive analysis of the patient’s data.
Among the subjective assessment findings that indicate the client is experiencing a health alteration, one can highlight her shortness of breath, swelling of the feet and ankles, weight gain, and history of myocardial infarction. Smoking and being overweight are additional risk factors that often cause cardiovascular diseases (Malakar et al., 2019). These subjective assessment data serve as the basis for further objective examination of the patient.
Objective Assessment Findings
Based on the objective assessment findings, specific parameters demonstrate that the patient is experiencing a health alteration. A shallow and slightly increased respiratory rate at rest may suggest respiratory distress or difficulty in oxygen exchange. The presence of moist crackles in the anterior and posterior bilateral lower lobes, along with cough, indicates the accumulation of fluid in the lungs, which can be a sign of pulmonary congestion or edema (Alwahdy et al., 2022).
Regular pulses in the pedal and radial arteries bilaterally may indicate increased stroke volume and peripheral vasodilation. The pale and taut skin of the lower extremities may indicate poor perfusion and reduced blood flow to the area (Tathare et al., 2023). The low sodium level (130mEq/L) may indicate hyponatremia, which can be associated with fluid overload or heart failure (Potasso et al., 2022). Elevated blood pressure (188/96) suggests hypertension, which can contribute to cardiac strain. The oxygen saturation of 88% shows inadequate oxygenation, which may be related to impaired gas exchange in the lungs, and the weight gain of 10 lbs over the past week suggests fluid retention and possible worsening of heart failure.
Overhydration vs. Hypervolemia
Overhydration and hypervolemia are conditions that cause excess water in the body. However, they have distinctions and may affect different body systems. Overhydration causes an imbalance of electrolytes, particularly sodium, essential for maintaining proper fluid balance (Veniamakis et al., 2022). The condition is associated with symptoms such as nausea, vomiting, headache, confusion, seizures, and even cerebral edema.
Hypervolemia refers to an abnormal increase in blood volume, which occurs when both water and sodium are retained in the bloodstream in excess (Feraille et al., 2022). Increased blood volume strains the heart and blood vessels, causing symptoms such as edema, shortness of breath, high blood pressure, and increased strain on the heart. As a result, both conditions can adversely affect various body systems.
Primary Nursing Diagnosis
Based on the subjective and objective data provided, the primary nursing diagnosis for this client could be impaired gas exchange related to decreased oxygen saturation and shallow respirations. The patient’s presenting symptoms of shortness of breath, dyspnea on exertion, and low oxygen saturation (88% on room air) indicate impaired gas exchange (Imamura et al., 2023). The presence of moist crackles in the lungs suggests fluid accumulation in the alveoli, which can impair oxygenation. Additionally, the patient’s weight gain, pedal edema, and taut skin in the lower extremities are consistent with fluid retention, which can further contribute to impaired gas exchange.
Interventions
Based on the subjective and objective data provided, the nurse should plan and implement some interventions. Firstly, oxygen therapy should be prescribed, which implies administering supplemental oxygen to improve saturation and relieve dyspnea (Angus, 2020). Continuously monitoring the client’s vital signs, including blood pressure, heart rate, and respiratory rate, may help assess the effectiveness of interventions and identify any changes or deterioration in the patient’s condition. Another essential activity is to auscultate lung sounds regularly to monitor for changes. Documenting the presence and characteristics of crackles is of significant importance.
According to Ielapi et al. (2022), positioning the legs above the level of the heart helps reduce swelling and improve circulation. Administering relevant diuretics is crucial to reduce fluid volume overload and alleviate symptoms of pulmonary congestion and edema (Dobbe et al., 2019). It is also critical to encourage the client to follow a low-sodium diet and educate the patient about foods high in sodium. Keeping track of the patient’s fluid intake and output may be necessary to maintain a fluid balance.
Evaluation of Health Outcomes
The client’s improved respiratory status is one of the main outcomes the nurse can use to evaluate the effectiveness of the interventions. The specialist should also regularly assess the extent of pedal and ankle edema to see if it decreases over time. The nurse can track the client’s weight regularly to evaluate if there is any decrease. This is directly associated with alleviated symptoms related to fluid retention and congestive heart failure (Billingsley et al., 2020). Decreased crackles in the lungs and a maintained electrolyte balance are also crucial outcomes to take into account.
Through a comprehensive assessment of the patient’s case and the analysis of her subjective and objective data, relevant nursing interventions have been presented. Impaired gas exchange is the primary diagnosis, and accompanying symptoms associated with decreased oxygen saturation and shallow respirations support this. Based on specific health outcomes, the nurse can offer the patient appropriate procedures to follow and subsequently evaluate the effectiveness of the proposed interventions.
References
Alwahdy, A. S., Sihombing, I. Y. M., Alfina, F. T., Syahdian, N., Nurbaeti, P., Futihandayani, A., & Ramadhanti, A. (2022). The development of pulmonary edema after recombinant tissue plasminogen activator in acute ischemic stroke patient; neurogenic or non-neurogenic? Case Reports in Neurology, 14(2), 348-358. Web.
Angus, D. C. (2020). Oxygen therapy for the critically ill. New England Journal of Medicine, 382(11), 1054-1056. Web.
Billingsley, H. E., Hummel, S. L., & Carbone, S. (2020). The role of diet and nutrition in heart failure: A state-of-the-art narrative review. Progress in Cardiovascular Diseases, 63(5), 538-551. Web.
Dobbe, L., Rahman, R., Elmassry, M., Paz, P., & Nugent, K. (2019). Cardiogenic pulmonary edema. The American Journal of the Medical Sciences, 358(6), 389-397. Web.
Feraille, E., Sassi, A., Olivier, V., Arnoux, G., & Martin, P. Y. (2022). Renal water transport in health and disease. Pflügers Archiv – European Journal of Physiology, 474(8), 841-852. Web.
Ielapi, N., Andreucci, M., Bracale, U. M., Costa, D., Bevacqua, E., Giannotta, N., Bevacqua, M. G., Serraino, G. F., Mastroroberto, P., Provenzano, M., & Serra, R. (2022). Elevate to alleviate – Evidence based vascular nursing study. Nursing: Research and Reviews, 12, 39-45. Web.
Imamura, S., Inagaki, T., Abe, M., Terada, J., Kawasaki, T., Nagashima, K., Tatsumi, K., & Suzuki, T. (2023). Impaired dynamic response of oxygen saturation during the 6-min walk test is associated with mortality in chronic fibrosing interstitial pneumonia. Respiratory Care, 68(3), 356-365. Web.
Malakar, A. K., Choudhury, D., Halder, B., Paul, P., Uddin, A., & Chakraborty, S. (2019). A review on coronary artery disease, its risk factors, and therapeutics. Journal of Cellular Physiology, 234(10), 16812-16823. Web.
Potasso, L., Refardt, J., De Marchis, G. M., Wiencierz, A., Wright, P. R., Wagner, B., Dittrich, T., Polymeris, A. A., Gensicke, H., Bonati, L. H., & Christ-Crain, M. (2022). Impact of sodium levels on functional outcomes in patients with stroke – A Swiss stroke registry analysis. The Journal of Clinical Endocrinology & Metabolism, 107(2), e672-e680. Web.
Tathare, S. R., Kumbhar, V. N., Panse, R. J., Kumaran, S., Deshmukh, S., & Bidaye, A. (2023). Examination of feet in people with diabetes: A guide for primary care physicians. Chronicle of Diabetes Research and Practice, 2(2), 90. Web.
Veniamakis, E., Kaplanis, G., Voulgaris, P., & Nikolaidis, P. T. (2022). Effects of Sodium intake on health and performance in endurance and ultra-endurance sports. International Journal of Environmental Research and Public Health, 19(6), 3651. Web.
