Nokea
Nurses' Notes
Outpatient Clinic
Initial
visit
The child recently started attending a new preschool and hit a teacher during lunch. The parent says,
"My
child has never been aggressive before but has always been particular about food."
The client was born at full term without complications and has no significant medical history. The child
started babbling at age 6 months, and the parent reports that the first words were spoken around age 12
months. The client then became quiet and "obsessed" with stacking blocks and organizing toys by color.
The child can kick a ball, draw a circle, pedal a tricycle, and now says two-word phrases. Vitals signs are
normal, and the client is tracking adequately on growth curves.
During the evaluation, the child sits in the corner of the room playing with blocks. The client does not follow
the parents gaze when the parent points to toys in the office. The child begins screaming and rocking back
and forth when the health care provider comes near.
Laboratory Results
Laboratory Test and
Reference Range
1030
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)
110 mg/dL (6.1 mmol/L)
Sodium
136-145 mEq/L
(136-145 mmol/L)|
133 mEq/L (133 mmol/L)|
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L)
4.5 mEq/L (4.5 mmol/L)
B-type natriuretic peptide
<100 pg/mL
(<100 ng/L)
640 pg/mL (640 ng/L)
Diagnostic Results
Chest X-ray
1030:Mild cardiomegaly
Echocardiogram
1100:Mild left ventricular hypertrophy with left ventricular ejection fraction of 30%
For each potential intervention, click to specify if the intervention is expected or not expected for the care of the client.
Correct Answer:
Rationale: Expected interventions for acute decompensated heart failure (HF) focus on reducing cardiac workload and improving
oxygenation. These include:
• Daily weights should be performed to monitor fluid volume status and guide treatment. Ideally, daily weights should be
performed at the same time of day, on the same scale, and with the client wearing the same amount of clothing.
• Diuretics (eg, furosemide) prevent reabsorption of sodium and chloride in the kidneys, which increases fluid excretion in
urine and decreases preload. Diuretics provide symptomatic relief by reducing pulmonary congestion and peripheral
edema. These are the cornerstone of therapy and often a priority after oxygen therapy.
• Fluid restriction is indicated to decrease circulating fluid volume and prevent excess strain on the heart.
• Supplemental oxygen should be administered to improve oxygen delivery in clients with HF due to impaired gas
exchange from pulmonary edema.
• Antihypertensive medications reduce cardiac workload and improve contractility by lowering blood pressure (ie,
afterload).
Nebulized albuterol is a bronchodilator administered to improve oxygenation in clients with reactive airway disease (eg.
asthma, chronic obstructive pulmonary disease). Bronchodilators will not improve oxygenation in clients with pulmonary
edema and are not expected for treatment of HF.