Study with the several resources on Docsity
Earn points by helping other students or get them with a premium plan
Prepare for your exams
Study with the several resources on Docsity
Earn points to download
Earn points by helping other students or get them with a premium plan
Heart Failure Clinical Reasoning Case Study/ Heart Failure Clinical Reasoning Case Study/ Heart Failure Clinical Reasoning Case Study
Typology: Exams
1 / 19
This page cannot be seen from the preview
Don't miss anything!
Primary Concept Perfusion Interrelated Concepts (In order of emphasis)
JoAnn Smith is a 72-year-old woman who has a history of myocardial infarction (MI) four years ago and systolic heart failure secondary to ischemic cardiomyopathy with a current ejection fraction (EF) of only 15%. She presents to the emergency department (ED) for shortness of breath (SOB) the past three days. Her shortness of breath has progressed from SOB with activity to becoming SOB at rest. The last two nights she had to sleep in her recliner chair to rest comfortably upright. She is able to speak only in partial sentences and then has to take a breath when talking to the nurse. She has noted increased swelling in her lower legs and has gained six pounds in the last three days. She is being transferred from the ED to the cardiac step-down where you are the nurse assigned to care for her. Personal/Social History: JoAnn is a retired math teacher who is unable to maintain the level of activity she has been accustomed to because of the progression of her heart failure the past two years. She has struggled with depression the past two years and has been more withdrawn since her husband of 52 years died unexpectedly three months ago from a myocardial infarction. What data from the histories is RELEVANT and has clinical significance to the nurse? RELEVANT Data from Present Problem: Clinical Significance: MI four years ago, increase shortness of breath at rest; can only speak in partial sentences, ischemic cardiomyopathy with EF of 15% last two nights slept in recliner increased swelling in lower legs gained 6 pounds in last 3 days MI is significant because it decreases heart function due to death of myocardial muscle EF of 15% shows that the heart is having a hard time pumping blood out to rest of the body therefore starving it of oxygenated blood. Weight gain and increased swelling signifies she is fluid overloaded and it can be reason why she is having a hard time talking, breathing, being active and why she has to sleep in a recliner the past 2 nights RELEVANT Data from Social History: Clinical Significance: Retired math teacher, recent widow, history of depression, decreasing activity level Depression might affect her enthusiasm to recover, to stick to a therapy regimen What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect) PMH: Home Meds: Pharm. Classification: Expected Outcome: Diabetes mellitus type II Hypertension Atrial fibrillation Hyperlipidemia Chronic renal insufficiency (baseline creatinine 2.0) Cerebral vascular accident (CVA) with no residual deficits Heart failure (systolic) secondary to ischemic cardiomyopathy MI with stent x2 to LAD 4 years ago
daily
daily
daily
4x daily
bid
Antiplatelets Beta blocker ACE inhibitor Cholesterol medication Vasodilator Diuretic Electrolyte replacement Anticoagulant Antidiabetic Decrease chance of clot formation Decrease blood pressure Decrease blood pressure, helps with heart failure, decrease chance of death from heart attack Decrease cholesterol Decrease blood pressure Decrease swelling, decrease fluid overload Increase serum potassium
What medications treat which conditions? One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in her life? Circle what PMH problem likely started FIRST Diabetes Type 2 Underline what PMH problem(s) FOLLOWED as domino(s) DMT2>hyperlipidemia>hypertension>afib>CVA>MI>CKI>HF Patient Care Begins:
What VS data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: P:92 bpm, irregular R: 26, regular O2 sat: 90%, 6L n/c BP: 162/54 c MAP: Pulse is irregular due to atrial fibrillation, increases oxygen demand needs therefore breaths faster and need greater amount of O2 supplied by external oxygen device (nasal canula), Heart has to pump faster to get oxygenated blood out to systemic circulation MAP of 90 suggests that heart has low cardiac output therefore needs higher pressure to get blood to vital organs Current Assessment: GENERAL APPEARANCE: Appears anxious, restless RESP: Breath sounds have coarse crackles scattered throughout both lung fields ant/post, labored respiratory effort, patient sitting upright CARDIAC: Rhythm: atrial fibrillation, pale, cool to the touch, pulses palpable throughout, 3+ pitting edema lower extremities from knees down bilaterally, S3 gallop, irregular, no jugular venous distention (JVD) noted NEURO: Alert and oriented to person, place, time, and situation (x4) GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact, skin turgor elastic, no tenting present What assessment data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: Gen: appears anxious, restless Resp: coarse crackles through out both lung fields, labored respiratory effort though pt is sitting upright Cardiac: A.Fib, 3+pitting edema LE,s gallop, irregular General appearance suggests she is in some distress Lung sounds suggest trouble breathing, fluid overload A.Fib is a dysrhythmia that can impede proper perfusion of blood to body decrease it’s ability to pump oxygenated blood Pitting edema is another sign that pt is fluid overloaded S3 gallop murmur suggest possible mitral stenosis
Cardiac Telemetry Strip: Interpretation: Irregular, atrial fibrillation Clinical Significance: This cardiac dysrhythmia increases chance of stroke occuring Radiology Reports: Chest x-ray What diagnostic results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Results: Clinical Significance: Bilateral diffuse pulmonary infiltrates consistent with pulmonary edema Excess fluid in lungs, fluid overloaded causes pt to exert more energy to breathe 12 Lead EKG Interpretation: Irregular rhythm, some st segment elevation in leads V3, aVR, II, V2, and V Clinical Significance: Irregular rhythm is consistent with diagnosis of atrial fibrillation
Lab Results: Complete Blood Count (CBC): Current: High/Low/WNL? Prior: WBC (4.5-11.0 mm 3) 4.8 WNL^ 5. Hgb (12-16 g/dL) 12.9 WNL^ 13. Platelets (150-450x 103/μl) 228 WNL^202 Neutrophil % (42-72) 68 WNL^65
RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: WBC Platelets Hgb Decrease, no infection Can show sign of bleeding How well O2 is binding to hemoglobin = how well blood is oxygenated Stable Stable Stable Basic Metabolic Panel (BMP): Current: High/Low/WNL? Prior: Sodium (135-145 mEq/L) 133 low^138 Potassium (3.5-5.0 mEq/L) 4.9 wnl^ 4. Glucose (70-110 mg/dL) 105 wnl^118 Creatinine (0.6-1.2 mg/dL) 2.9 high^ 2.
Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Na: 133 mEq/L Creatine: 2.9 mg/dL Slight hyponatremia Kidney function slightly worse than her baseline Worsening worsening Misc. Chemistries: Current: High/Low/WNL? Prior: Magnesium (1.6-2.0 mEq/L) 1.9 wnl^ 1. PT/INR (0.9-1.1 nmol/L) 2.5 high^ 2.
RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: PT/INR Tells how long it take for her blood to clot; in therapeutic range for her medications Stable
Cardiac Labs: Current: High/Low/WNL? Prior: Troponin (<0.05 ng/mL) 0.10 high^ 0. BNP (B-natriuretic Peptide) (< ng/L) 1855 high 155 RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Troponin: 0.10 ng/mL BNP: Increase troponin correlates to injured heart, possible MI Sign of heart failure; inability for heart to pump, higher BNP = worst heart failure Improving Worsening Lab Planning: Creating a Plan of Care with a PRIORITY Lab: Lab: Normal Value: Clinical Significance: (^) **Nursing Assessments/Interventions Required: Creatinine Value:
Critical value:
** Measure kidney function Monitor intake and oputput, give diuretics, monitor creatinine for signs of improvement Lab: Normal Value: Clinical Significance: Nursing Assessments/Interventions Required: BNP Value: 1855 Critical value: 100 The higher the number the more severe of heart failure the patient is exhibiting BNP is a measurement of how well the heart can pump blood Give ACE inhibitors, monitor BNP for signs of improvement or worsening heart failure Clinical Reasoning Begins…
1. What is the primary problem that your patient is most likely presenting with? The primary problem that my patient is most likely presenting with is congestive heart failure. 2. What is the underlying cause/pathophysiology of this primary problem? The underlying cause of this primary problem is her ejection fraction of 15% due to cardiomyopathy caused by an myocardial infarction and atrial fibrillation.
Ambulate if activity is tolerable Walking helps keep strength, gives her something to do, prevents bed sores, improves circulation down, energy level will increase, will not gain more weight
5. What body system(s) will you most thoroughly assess based on the primary/priority concern? I will thoroughly assess her cardiac function, respiratory function, and neurologic functions. 6. What is the worst possible/most likely complication to anticipate? Most likely/worst complication to anticipate would **_be we over correct her too much and she becomes hypovolemic.
10. How can the nurse address these psychosocial needs? Get referral for social worker for group therapy, try to contact a chaplin for her to talk to. Just being there and talking to her like a human being and not just a patient. Medication Dosage Calculation: Medication/Dose: Mechanism of Action: Volume/time frame to Safely Administer: Nursing Assessment/Considerations: Medication/Dose: Furosemide 40 mg IV push loop diuretic that prevent the absorption of sodium IV Push: Volume every 15 sec? 4mg/minute Monitor for signs of hyponatremia Monitor for intake and output Monitor heart rate and blood pressure Daily weights Evaluation: Evaluate the response of your patient to nursing and medical interventions during your shift. All orders have been implemented that are listed under medical management. Four Hours Later…
Current Assessment: GENERAL APPEARANCE: Not as anxious, but appears restless at times RESP: Coarse crackles scattered throughout both lung fields, labored respiratory effort CARDIAC: (^) Rhythm: atrial fibrillation, pale, cool to the touch, pulses palpable throughout, 3+ pitting edema in lower extremities NEURO: Alert and oriented to person, place, time, and situation (x4) GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all 4 quadrants GU: 30 mL of urine out in the last 4 hours after furosemide IV given, 50 mL residual urine in bladder with bladder scan SKIN: Skin integrity intact
1. What clinical data is RELEVANT that must be recognized as clinically significant? RELEVANT VS Data: Clinical Significance: P= 88 bpm, irregular R= 24 breathes/min, regular BP= 112/50; MAP= 71 O2= 91%; 12 high flow n/c Still has A.Fib, breathing has slowed down; blood pressure has decreased therefore heart is not having to pump so hard to get blood out and to organs. O2 saturation still less than 95%; needs twice as much O2 as before and high flow nasal canula. Still might be struggling to get oxygenated blood to other organs RELEVANT Assessment Data: Clinical Significance: Resp: coarse crackles, labored respiratory effort GU: 30 ml of urine in 4 hours even with furosemide IV given Cardiac: no S3 sound, atrial fibrillation persist Pulmonary edema may have worsen, furosemide has not been as effective as thought; renal failure may be more chronic than once thought, should recheck creatinine and BUN. No S3 sound suggests mitral valve functioning more properly. Has not converted out of a. fib, still at risk for clots/stroke developing. 2. Has the status improved or not as expected to this point? Her blood pressure has improved; she still requires a bunch of supplemental oxygen to, coarse crackles can still be heard upon auscultating her lungs. She only managed to produce 30 ml of urine in 4 hours even after receiving 40 ml of furosemide. Has not converted out of atrial fibrillation. 3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? I would say yes. I would contact HCP to see if her dose of furosemide can be increased. See she needs an echocardiogram to **_see if her ejection fraction improved; check and see if there are clots forming due to a. fib.
Your knowledge and application of the pathophysiology of heart failure and renal failure have allowed you to make a series of needed assessments and judgments that have facilitated the treatment and care of your patient. You recognize that an SBAR is needed to update the primary care provider with your concerns. SBAR: Nurse-to-Primary Care Provider S ituation: Name/age: JoAnn Smith, 72 BRIEF summary of primary problem: exacerbation of CHF due possible PE and chronic renal failure Day of admission/post-op #: 1 B ackground: Primary problem/diagnosis: Congestive heart failure related to cardiomyopathy AEB increase shortness of breath, ejection fraction of 15%, and atrial fibrillation RELEVANT past medical history: MI 4 years ago, type 2 diabetes, hypertension, atrial fibrillation, hyperlipidemia, A ssessment: Most recent vital signs: P: 88 (irregular), R: 24 (regular), BP: 112/50 (MAP= 71), T: 98.4 °F, O2 sat: 91% (12 L high flow n/c), no pain RELEVANT body system nursing assessment data: Resp: coarse crackles, labored respiratory effort GU: 30 ml of urine in 4 hours even with furosemide IV given Cardiac: no S3 sound, atrial fibrillation persist RELEVANT lab values: Creatinine: 2.9 mg/dL, BNP: 1855 ng/L, Troponin:0.10 ng/mL, Na:133 mEq/L, Mg: 1.9 mEq/L INTERPRETATION of current clinical status (stable/unstable/worsening): worsening R ecommendation: Suggestions to advance plan of care: transfer to ICU, check K+ stat, check ABG, check creatinine, new 12 ECG
It is now the end of your shift. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient in ICU: SBAR: Nurse-to-Nurse S ituation: Name/age: JoANN Smith, 72 BRIEF summary of primary problem: exacerbation of CHF due possible PE and chronic renal failure Day of admission/post-op #: 1 B ackground: Primary problem/diagnosis: Congestive heart failure RELEVANT past medical history: MI past 4 years, increase SOB, ejection fraction 15%, hypertension, hyperlipidemia, type 2 diabetes, A. Fib A ssessment: Most recent vital signs: P: 88 bpm (irregular), R: 24 breathes/min (regular), T: 98.4°F, BP:112/50 (MAP:71), O sat:91% on 12 L high flow n/c RELEVANT body system nursing assessment data: Resp: coarse crackles, labored breathing, Cardiac: A.Fib, GU: 30 mL of urine produced in 4 hours even after receiving 40 mg IV push RELEVANT lab values: Creatinine: 3.5 mg/dL, BNP: 1855 ng/L, Troponin:0.10 ng/mL, Na: 133 mEq/L, Mg: 1. mEq/L, K+: 5.9 mEq/L, pH: 7.46, PaCO2: 30, HCO3: 22, INR/PT: 2. . TREND of any abnormal clinical data (stable/increasing/decreasing): creatinine is worsening, K+ is worsening, troponin is stable, PT/INR is stable, BNP is worsening INTERPRETATION of current clinical status (stable/unstable/worsening): unstable, worsening R ecommendation: Suggestions to advance plan of care: transfer to ICU, monitor ABGs q4 hours, blood pressure q15 minutes, monitor K+, creatinine and BNP q4 hours
Education Priorities/Discharge Planning
1. What will be the most important discharge/education priorities you will reinforce with the patient’s medical condition to prevent future readmission with the same problem?
2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient? I would ask her to demonstrate taking her blood pressure, have her tell me what the s/sx of respiratory alkalosis are, s/sx of hyperkalemia. I would have her demonstrate using the supplemental oxygen system and demonstrate how to turn, cough, deep breath Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation? She probably still struggling to breathe but **_not as much as she did when she first got admitted
Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events are unfolding to make a correct clinical judgment.
1. What did I learn from this scenario? I learned that a person can function with a low ejection fraction for a while before it becomes too debilitating. I learned that the domino effect is not something to take lightly and it is our job as RNs to educate a patient as well as possible so that they can understand how a disease may effect them in the future. How it can
The below are recommended subject areas: Reason for hospitalization: Abnormal and pertinent normal on nursing assessment: Nursing Interventions for shift: Patient Education: Discharge plan: JoAnn Smith 72 years old came into the ED due to increase SOB, and not being able to sleep well at night unless she was on her recliner. She has CHF, atrial fibrillation and suffered an MI 4 years ago that was related to cardiomyopathy. Upon assessment her blood pressure was 162/54 (MAP:90), hear rate was 92 and irregular. Coarse crackles were auscultated and S3 heart sound was heard on initial assessment. It has since vanished. Gave nitroglycerin to help vasodilate and lower her BP. Received 40 mg Lasix and only produced 30 ml of urine in 4 hours. Called HCP he ordered ABGs, K+. ABGs revealed she was respiratory alkalotic and had an elevated K. Educated pt on importance of low sodium diet and how that can help with her edema and weight gain. Transferred her to ICU on 12 L high flow n/c. BP 112/50 (MAP:71), P: 88 bpm, R: 24 and regular; coarse crackles can still be auscultated though they have diminished.
