A nurse is teaching a client who has osteoporosis about ways to reduce stress on the skeletal system. Which of the following instructions should the nurse include?

• Open wound on right foot with purulent drainage: A non-healing wound with purulent drainage suggests infection, which is a major concern in clients with hyperglycemia. Poor wound healing is common in diabetes due to impaired circulation and immune function.
• Frequent urination, increased thirst, and unexplained 4.5 kg (10 lb) weight loss: Classic symptoms of hyperglycemia and possible diabetes mellitus. Polyuria and polydipsia result from osmotic diuresis due to high blood glucose levels, while unexplained weight loss may indicate the body breaking down fat and muscle for energy.
• Temperature 38.3° C (100.9° F): Fever indicates a possible systemic infection. In diabetic clients, infections can progress rapidly and lead to complications such as cellulitis, osteomyelitis, or sepsis.
• Heart rate 104/min: Tachycardia may be a response to fever, dehydration, or underlying infection. Persistent tachycardia could indicate worsening sepsis or hemodynamic instability.
• Blood pressure 98/74 mm Hg: While not critically low, this blood pressure is on the lower end and could indicate early signs of dehydration from polyuria or systemic infection.
• Blood glucose 250 mg/dL: Significantly elevated blood glucose suggests poor glycemic control, increasing the risk of infection, delayed wound healing, and diabetic ketoacidosis (DKA) if it continues to rise.:

• Respiratory rate 18/min: A normal respiratory rate does not indicate respiratory distress or metabolic compensation.
• Oxygen saturation 97% on room air: Oxygenation is within the normal range, suggesting no immediate hypoxia.
• WBC count 9,500/mm³: Within the normal range, although an infection may still be present given the fever and purulent wound drainage.
• Triiodothyronine (T3) 200 mg/dL: Within normal limits, ruling out thyroid dysfunction as a cause of symptoms.
• BMI 27: Slightly overweight but not directly contributing to the acute condition.

Condition:

• Left-sided heart failure

Actions to Take:

• Administer a loop diuretic.
• Assess for jugular vein distention.

Parameters to Monitor:

• Lung sounds.
• Pulse strength.

Rationale:

Condition Choices

• Right-sided heart failure: Right-sided heart failure primarily leads to systemic congestion, including peripheral edema, jugular vein distension, and hepatomegaly. The client’s symptoms—dyspnea, crackles in the lungs, and activity intolerance—are more indicative of left-sided heart failure, which results in pulmonary congestion.
• Mitral valve prolapse: Mitral valve prolapse can cause palpitations and fatigue but does not typically present with pulmonary congestion, crackles, and significant hypertension. The client’s symptoms suggest a broader issue of ventricular dysfunction rather than isolated valvular pathology.
• Infective endocarditis: Infective endocarditis often presents with fever, systemic embolic events, and new heart murmurs. The client does not have a fever or any indications of embolic complications, making this diagnosis unlikely.
• Left-sided heart failure: Dyspnea, pulmonary crackles, activity intolerance, nocturnal coughing, and hypertension are classic findings of left-sided heart failure. The irregular tachycardia may indicate atrial fibrillation secondary to heart failure. The client’s history of hypertension and coronary artery disease increases the risk of ventricular dysfunction, further supporting this diagnosis.

Actions to Take

• Administer a loop diuretic: Loop diuretics such as furosemide help reduce pulmonary congestion by promoting diuresis and decreasing fluid overload, which is essential for managing left-sided heart failure.
• Assess for jugular vein distention: Although jugular vein distention is more commonly associated with right-sided heart failure, evaluating it can provide insight into overall cardiac function and volume status, especially if biventricular failure is present.
• Obtain the client’s temperature: While temperature monitoring is standard in patient care, fever is not a primary concern in left-sided heart failure. Fever assessment would be more relevant if infection, such as infective endocarditis, was suspected.

Parameters to Monitor

• Lung sounds: Pulmonary congestion from left-sided heart failure causes crackles and respiratory distress. Monitoring lung sounds helps assess the effectiveness of diuretics and other treatments aimed at reducing fluid overload.
• Pulse strength: The client has diminished peripheral pulses, which may indicate poor cardiac output and worsening perfusion. Monitoring pulse strength can help evaluate circulatory status and response to treatment.
• Liver function tests: Liver function tests are more relevant in right-sided heart failure due to hepatic congestion. Since the primary concern here is pulmonary congestion, liver function is not a key monitoring parameter.
• Heart sounds for systolic murmur: While mitral regurgitation can accompany left-sided heart failure, a new murmur is not the primary concern in this client. The focus should be on managing fluid overload and pulmonary symptoms.
• Blood culture: Blood cultures are useful for detecting infections like infective endocarditis, which is not suspected in this client due to the absence of fever and embolic manifestations.