Mr Clive Jenkins Congestive Cardiac Failure (CCF) Case Study - Nursing Assignment Help

Assignment Task

Task
Mr Clive Jenkins is a 78 year old retired navy engineer. He has a past medical history of congestive cardiac failure (CCF). This developed after he experienced a severe myocardial infarction 2 years ago. Both ventricles were adversely affected.
The recent death of several close friends have made it difficult for Clive to be concordant with his CCF management and sustain the necessary lifestyle adjustments required to prevent exacerbations. This has resulted in several admissions to hospital for management and review of his CCF.For this current admission, Mr Jenkins was referred to hospital by his GP after rapidly gaining weight since his last visit the previous week (currently 95kg, last visit he was 92kg).
The time now is 0800 and you have just come on for your morning shift in the cardiac ward. Mr Jenkins has been on the ward for only two hours after spending approximately 12 hours in ED waiting for a bed to become available.
Mr Jenkins is slightly disoriented. When repositioning himself in bed you observe that he becomes short of breath. You ask him if he will get out of bed for breakfast but he is reluctant to mobilise as he feels so tired. You also note that his water jug is empty.
Response to PQRST:
P: provoking factor: exercise
Palliative factor: rest and sitting up and using several pllows at night to sleep
Q: pressure in chest when breathing
R: all over chest anterior and posterior. Not radiating
S: 5/10
T: progressively getting worse. Symptoms of shortness of breath are always there but get worse or better depending on activity or position.
Cardiac assessment findings:
Cardiomegaly on CXR
JPV elevated
PMI displaced laterally
S3 heart sound
Murmur over mitral valve
Abdominal assessment findings:
Abdomen soft and non-tender
Bowel sounds present
Respiratory assessment findings:
Dyspnoeic
Increased work of breathing
Bibasilar crackles on auscultation
Patient producing pink-tined frothy sputum
Neurological findings including GCS:
Neurological assessment
LOC: A&Ox3
PERRLA
Gait normal
Motor and sensory function intact
GCS: 14 eye opening 4, verbal response 4, best motor response 6
Fluid assessment findings:
Peripheral pulses difficult to palpate
Presence of pitting oedema bilaterally
Capillary refil-5sec
Current weight 97kg (baseline weight 94 kg)
Raised JVP
Output since midnight 2000ml input: input since midnight: aprox 1672 ml(oral and IV)
BGL 4.7mmol/l
Mr Clive Jenkins Prac A
 

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