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The patient is experiencing respiratory failure and hypoxia due to heart failure. Signs include decreased mobility, swelling, shortness of breath, increased work of breathing, and crackles in the lungs. Vital signs show tachycardia, hypertension, and low oxygen saturation. The patient requires urgent clinical review and supplemental oxygen.

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Natasha Tegelaar
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23 views

Assignment Notes

The patient is experiencing respiratory failure and hypoxia due to heart failure. Signs include decreased mobility, swelling, shortness of breath, increased work of breathing, and crackles in the lungs. Vital signs show tachycardia, hypertension, and low oxygen saturation. The patient requires urgent clinical review and supplemental oxygen.

Uploaded by

Natasha Tegelaar
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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1.

Discuss your assessments on this patient, identify signs of deterioration and clearly state if the
patient requires a clinical review or rapid response as per Between the Flags (BTF). Justify your
decision with data from the case and relevant support.

Objective & subjective data

Decreased mobility
Heart failure
Swelling on knees – few days
SOB
Speak in short sentences
Increase work of breathing
intercostal recession and crackles at the lung bases (reasoning and justify back to the HF)

Warm to touch, diaphoretic


Pink
Capaillary refill – less then 2 seconds
passed urine in shower

BGL 6.4 MMOL

History: Acute kidney failure due to heart failure


Findings

Pt is in respiratory failure.

breathlessness resting and active ( Tachypnea - High respiration rate) Normal respiration 12-20 over
a minute. In conjunction with other evidence such (shortness of breath - dyspnea, speaking in short
sentences, exhaustion / fatigue, diaphoretic, increase in accessory muscles). = Acute respiratory failure
(link evidence back to heart failure) = damaged heart cannot pump blood as effectively from
your lungs out to your body. Blood backs up, raising pressure in the veins inside your lungs. This
pushes fluid into your air sacs. As liquid builds up, it gets harder to breathe. Pt could also be anemia or
developing chest infection or possible pneumonia

BP: 182/102 – Hypertensive ( a systolic BP of 130mmHh or higher, or dialostic pressure of 80mmHg


or higher is considered as hypertension. It is increasing the workload on the heart inducing structural
and functional changes in myocardium progressing to heart failure. Acute Kidney failure could be
having an impact on the BP as it changes the way the kidneys handle salt resulting in hypertension.

Low oxygen sats 88% is considered Hypoxic. With HF, the heart muscle might be weaker and not
pump blood the way is normally would resulting in the body not receiving the oxygen it requires.

Supplemental Oxygen therefore should be commenced.

If the heartbeat is very fast, known as tachycardia, there is less time for the heart chamber to fill with
blood between beats.

swelling of the knees (Peripheral oedema) – heart is not pumping efficiently, which can lead to a
build up of fluid. Oedema is one of the fundamental features of heart failure.

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