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
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.
