7am hand off report. Pt admitted 2 days ago with CHF. Restless night with dyspne

Question

7am hand off report.

Pt admitted 2 days ago with CHF. Restless night with dyspnea. Dry non productive cough. craclkles both lungs. 3+ pitting edema both legs and sacrum. 0600 am vital signs T 97.6 degrees farenhight, P 110 irregular, Res 34, BP 150/100, Pulse oximetry 94% with oxygen 3L per min NP. IV site looks slighty puffy with good blood return. Denies pain but just started to complain nausea. Serum potassium 3.0meq might be low because retaining fluids. Physician always comes in early so I posted results infront of patient chart.

1. What are the major issues. 2. What data I am missing. 3. What data I would like to learn more about. 4. What is going on that I can plan care. 5. What do I anticipate I can do with this care.

Explanation / Answer

1. Can be toxicity of digoxin(digitalis) Early signs of toxicity may be irregular heartbeat, nausea and vomiting, stomach pain, fatigue, visual disturbances (such as yellow vision, seeing halos around lights, flickering or flashing of lights), and emotional and mental disturbances. So patient is having nausea which indicates toxicity.

The second problem is to maintain blood pressure below 140/90mm of Hg. But the patient has150/100.which should be looked.

2) The data i am missing is digoxin level, BUN level, serum sodium level, ECG, ABG level.

3) the data i should learn more about it digoxin level for toxicity. And the medications given and its dosage.

4) patient is on digoxin toxicity. So plan according to that.

5) The primary intervention i can do is to stop the digoxin. Check digoxin level, meep pt on oxygen bedrest. Inform physician as soon as possible.

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