Your client: Chester Payne Age: 78 years old Past medical history. History of persistent atrial fibrillation, hypertension, hyperlipidemia and osteoarthrosis. Yesterday: Client was admitted for a diagnosis of atrial fibrillation with rapid ventricular response (RVR). Later in the day, the client's heart rhythm was converted to normal sinus rhythm using intravenous medication therapy. 0900 today: Client is sitting up in the bedside recliner. Client reports "racing heartbeat" and feeling "like I can't get a good deep breath" Upon auscultation the nurse hears an irregular heart rhythm. Assessment is as follows: Neurological: Alert and oriented x 4 Eyes, Ear, Nose, and Throat (EENT): Normocephalic, denies sore throat, denies nasal congestion, denies vision changes. No swelling or drainage visualized. Pulmonary: Reports some shortness of breath (SOB), no cough. Lungs sound clear in all fields. Cardiovascular: Irregular heart rhythm auscultated. Denies chest pain. Skin is warm and dry to the touch. Capillary refill > 3 seconds. 2+ bilateral lower extremity edema. Peripheral pulse 1+ equal bilaterally. Jugular vein distention (JVD) is noted Gastrointestinal: Abdomen rounded and firm. Reports slight nausea, bowel sounds hypoactive x 4 quadrants. Reports bowel movement prior to admission. Genitourinary: Voiding clear yellow urine without issues as per client self-report. Musculoskeletal: Full range of motion against resistance. When the nurses reassesses the patient, which finding demonstrates that the intervention was successful?
Explanation & Rationale
A. Irregular heart beat with a rate of 86 bpm: While a rate of 86 is within the normal range, the persistence of an irregular rhythm indicates that the client has not returned to normal sinus rhythm. The primary goal of therapy includes rhythm stabilization or better rate control. An irregular rhythm still suggests a deviation from the previous day's successful conversion. B. No edema noted in the bilateral extremities: The resolution of peripheral edema is a direct indicator that diuretic therapy and heart failure management have been effective. It demonstrates that the excess fluid has been successfully mobilized and excreted from the body. This finding confirms an improvement in the client's congestive state. C. hypoactive bowel sounds in all 4 quadrants: Hypoactive bowel sounds were present at the start of the assessment and their persistence does not indicate a successful cardiovascular intervention. This finding is likely unrelated to the primary cardiac issue or may be a side effect of other medications. Improvement in cardiac output usually improves systemic perfusion, including the gut. D. Decreased urine output: Successful treatment with a diuretic like furosemide should result in increased, not decreased, urine output. A decrease in output would suggest worsening renal perfusion or a lack of response to the medication. Effective management of heart failure aims to reduce fluid volume through diuresis.