The nurse coming on duty receives the report from the nurse going off duty. Which of the following clients should the on-duty nurse assess first?
A. The 58-year-old client who was admitted 2 days ago with heart failure, BP of 126/76, and a respiratory rate of 21 breaths a minute.
B. The 88-year-old client with end-stage right-sided heart failure, BP of 78/50, and a DNR order.
C. The 62-year-old client who was admitted one day ago with thrombophlebitis and receiving IV heparin.
D. A 76-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving IV diltiazem (Cardizem).
Correct Answer: D. A 76-year-old client who was admitted 1 hour ago with new-onset atrial fibrillation and is receiving IV diltiazem (Cardizem).
The client with A-fib has the greatest potential to become unstable and is on IV medication that requires close monitoring. After assessing this client, the nurse should assess the client with thrombophlebitis who is receiving a heparin infusion, and then go to the 58-year-old client admitted 2-days ago with heart failure (her s/s are resolving and don’t require immediate attention). The lowest priority is the 89-year-old with end-stage right-sided heart failure, who requires time-consuming supportive measures.
Option A: Heart failure is a serious medical disorder associated with high mortality. Mortality rates at 1 year and 5 years are 22% and 43%, respectively. The highest mortality is in patients with advanced NYHA class. In addition, heart failure associated with an MI carries a mortality of 30-40%. Heart failure that is associated with systolic dysfunction has a 50% mortality over 5 years. Further, patients with heart failure need repeated admissions over the years.
Option B: The mortality rate is higher in HFrEF than HFmrEF and HFpEF, according to OPTIMIZE-HF trial that showed a mortality rate of 3.9% for HFrEF, 3% for HFmrEF, and 2.9% for HFpEF. The mortality rate is also higher in symptomatic patients. There are some predictors of poor prognosis and increased mortality in hospitalized patients, which include systolic blood pressure less than 115 mmHg, serum creatinine greater than 2.7 mg/dL, serum urea over15 mmol/L, NT-pro-BNP exceeding 986 pg/mL, and LVEF under 45%.
Option C: Most patients presenting with pylephlebitis exhibit a fever with abdominal pain; however, nausea, vomiting, and jaundice is rare. Some may present with hypotension, tachycardia, and severe sepsis. Septic emboli may additionally travel to joints or bones, resulting in septic arthritis or osteomyelitis – in which case the patient may complain of joint pains or body aches (e.g., in addition to fever, malaise, and night sweats).
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