Thelma Walters is a 77-year-old woman who arrives via EMS at the emergency department (ED) after experiencing increasing

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Thelma Walters is a 77-year-old woman who arrives via EMS at the
emergency department (ED) after experiencing increasing dyspnea for
the past 2 days. She has also noticed swelling in her feet
and ankles. Due to her onset of shortness of breath, she has
had to sleep in a recliner and is unable to lie flat in bed at
night. Her past medical history includes a mild stroke
occuring 8 years ago with mild residual weakness on her right side,
MI 3 years ago, and an episode of HF 1 year ago. The HF was
treated with captopril (Capoten) and furosemide (Lasix), which she
has been taking since that time. Her surgical history
includes a hysterectomy 20 years ago. She has never used
tobacco or alcohol.
As the nurse performs the initial physical assessment, the
following relevant findings are discovered. The patient is
1.7 m (5 feet 6 inches) tall and weighs 82 kg (180 lbs). She
uses a walker or a cane to feel more secure and avoid falls, due to
the mild residual weakness on her right side. The patient's
blood pressure is 162/92 mmHg, her heart rate is 148 beats/min and
irregular, and her respiratory rate is 38 breaths/min and labored.
The neck veins of the patient are distended when she is
placed at a 45-degree incline. She is orthopedic and cannot
tolerate the head of the bed being lowered below 45 degrees.
The nurse notes scattered cracks bilaterally throughout the
lung fields. The patient has a productive cough with frothy,
pink-tinged sputum; 4+ pitting edema of both hands and legs is
noted with the nail beds moderately cyanotic. Circumoral
cyanosis is also noted.
Immediately upon arrival at the ED, the patient received oxygen
therapy and an IV line was started. Blood was collected for
initial laboratory data with the following results: serum sodium
136 mEq/L (normal: 135-147 mEq/L), serum potassium 3.1 mEq/L
(normal: 3.5-5.2 mEq/L), and arterial blood gases on room air: pH
7.32, PaO2 54, PaCO2 48, SpO2 68%, indicating overall hypoxemia.
Thelma is in acute distress and admitted to the intensive
care unit (ICU) with a diagnosis of HF. She is given a dose
of furosemide (Lasix) 20 mg IV and she will receive milrinone
(Primacor) by IV infusion after admission to the ICU.
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