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HF CLINICAL REASONING CASE STUDY I. Name _______________________ DATA COLLECTION Chief Complaint/History of Present Problem: Jim Santini is a 68-year-old male who has a 5 year history of systolic heart failure secondary to ischemic cardiomyopathy with a current ejection fraction (EF) of only 15%. He presents to the emergency department (ED) for shortness of breath (SOB) the past 3 days. His shortness of breath has progressed from SOB with activity to becoming SOB at rest. The last two nights he had to sleep in his recliner chair to rest comfortably with his head partially elevated. He is able to speak only a partial sentence and then has to take a breath when talking to the nurse. He has noted increased swelling in his lower legs and has gained 6 pounds in the last 3 days. He is being transferred from the ED to the telemetry unit where you are assigned to care for him. Social/personal history Jim has been married for 45 years and has 4 children. He is a retired baker who had to retire early due to medical problems secondary to his progressive heart failure. His son is running the Italian bakery since Jim retired. The family celebrated two birthdays this week and Jim made it to both parties. His wife does most of the cooking at home and follows his need for sodium restrictions, but during the celebrations Jim made his own dietary choices. Mr. Santini arrives to your telemetry unit from the ED. You have received report from the ED RN regarding the above patient story. 1. What data from the histories is RELEVANT that must be recognized as clinically significant to the nurse? What is the relationship between the data and the patient’s problem and history? RELEVANT Data from Present Problem: Rationale: Why is this clinically significant? RELEVANT Data from Social History: Rationale: Why is this clinically significant? 1 2. What is the clinical relationship of Mr. Santini’s past medical history (PMH) and his current medications? Which medication treats which conditions? Draw lines to connect. PMH: Home Meds: Pharm. Classification Expected Outcome: 1. ASA 81 mg daily 1. 1. Atrial fibrillation Heart failure (systolic) 2. Carvedilol 3.25 mg secondary to ischemic daily 2. 2. cardiomyopathy 3. Simvastatin 20 mg po MI with CABG x3 in daily 2008 4. Hydralazine 25 mg 4x 3. 3. Hyperlipidemia daily Chronic renal 5. Lasix 20 mg daily insufficiency 4. 4. 6. KCL 20 mEq daily Implanted 7. Warfarin 5 mg daily Cardioverter defibrillator (ICD) 5. 5. placed 2008 II. 6. 6. 7. 7. PATIENT CARE BEGINS Current Status: Admission VS T: 98.6 (oral) P: 92 (irregular) R: 26 (regular) BP: 162/54 O2 sat: 90% (on 6 liters N/C) 3. What VS data is RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT VS Data: Rationale: (Why is it clinical significant in this patient’s situation?) 2 4. Analysis of the patient’s Cardiac Telemetry Strip Rate: ________ QRS duration: _____________ Rhythm: ________ Interpretation: _________________________ P wave:_____________ Clinical significance: ___________________ PR interval__________________ _____________________________________ Admission Nursing Assessment: GENERAL APPEARANCE Appears anxious, restless, asking for his wife RESPIRATORY Breath sounds have coarse crackles scattered throughout both lung fields, labored respiratory effort, patient sitting upright and utters 4 words and then takes a breath CARDIAC Rhythm: atrial fibrillation, heart sounds irregular with no abnormal beats pale, cool to the touch, pulses palpable throughout, 3+ pitting edema lower extremities from knees down bilaterally, NEURO Alert & oriented to person, place, time, and situation (x4) GI GU Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants Voiding without difficulty, urine clear/yellow SKIN Skin integrity intact; pale, cool to touch 5. What assessment data above is relevant and must be recognized as clinically significant to the nurse? RELEVANT Assessment data Rationale = Why is the data significant? 3 III. CLINICAL REASONING BEGINS… 6. What is the primary medical problem that Mr. Santini is most likely presenting with? 7. What is the underlying rationale/pathophysiology of this concern? 8. Compare and contrast the pathophysiology and the signs & symptoms of left vs. right heart failure. HF Pathophysiology Signs & symptoms Left heart failure Right heart failure 9. Based on the data you have collected, what nursing priorities will guide your plan of care? You may put the priorities in your own words! Then list the nursing interventions for each priority. #1 Nursing PRIORITY: Interventions #2 Nursing PRIORITY: Interventions 4 #3 Nursing PRIORITY: Interventions #4 Nursing PRIORITY: Interventions 10. What body systems will you most thoroughly assess based on the patient’s chief complaint and primary/priority concern? 11. What is the worst possible complication to anticipate? 12. What nursing assessment(s) will you need to initiate to identify and respond quickly if this complication develops? IV. MEDICAL MANAGEMENT The cardiologist is on the floor and you update her with Mr. Santini’s history and current assessment findings. She orders the following medications and treatments. 13. Describe the rationale for each of these treatments ordered Care Provider’s Orders Rationale: Titrate oxygen to keep O2 sat > 95% 5 2 gram Na diet Fluid restriction of 1500 mL/24 hours Daily weights Strict I & O Echocardiogram today Chest x-ray today Electrolytes, blood glucose, BUN, creatinine, magnesium level, CBC, BNP cardiac enzymes now Repeat potassium & creatinine in 4 hours 14. Describe the action, side effects, nursing implication and patient education for each of these medications ordered: Medication/Dose: Pharmacologic Side Effects Nursing Patient education Action: Implications Furosemide (Lasix) 40 mg IV push x1 Nitroglycerin IV drip: titrate to keep SBP < 130 6 Captopril 6.25 mg po daily Digoxin 0.25mg po daily Hydralazine 20 mg PRN IV for SBP > 150 Potassium 20 mEq po daily Metoprolol 12.5 mg po daily Lorazepam 1 mg po every 4 hours PRN anxiety 15. Furosemide comes in a 20mg/2 mL vial. What will be the volume you will administer? Over what time frame will be safe to administer? How much volume will be IV pushed over 15 seconds? V. DIAGNOSTICS & LABS Chest X ray Lab/Diagnostic Results: Basic Metabolic panel Sodium (135-145) Potassium (3.5-5.0) Glucose (70-110) Calcium (8.5-10.5) Magnesium (1.8-2.6) BUN (7-25) Creatinine (0.6-1.2 ) Severely enlarged heart. Bilateral diffuse pulmonary infiltrates consistent with pulmonary edema Current 133 5.5 105 8.8 1.9 48 2.7 7 Cardiac Troponin (<0.04 ng/mL) CK total (26-140): CK-MB (<5%): BNP (<100): Current 0.01 40 0 1855 Misc Chemistries INR ( 0.9-1.1 ) Current 2.5 16. What lab/diagnostic results are RELEVANT and that must be recognized as clinically significant to the nurse? RELEVANT diagnostic & labs Relationship to primary medical problem VI. Evaluation Evaluate the response of Mr. Santini to nursing & medical interventions during your shift. All MD’s orders have been implemented. Four hours later… Current vital signs: T: 98.4 (oral) P: 88 (irregular) R: 24 (regular) BP: 122/64 O2 sat: 90% (on high flow N/C) Current Assessment: GENERAL APPEARANCE Lab results Potassium 5.9 mEq/dL Creatinine 3.1 mg/dL Not as anxious, but appears restless at times RESPIRATORY Course crackles scattered throughout both lung fields, labored resp effort CARDIAC atrial fibrillation, pale, cool to the touch, pulses palpable throughout, 3+ pitting edema in lower extremities NEURO Alert & oriented to person, place, time, and situation (x4) GI Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants GU Has had 30 mL of urine out in the last 4 hrs, even after Lasix given. Bladder scan=50mL residual urine in bladder. SKIN Skin integrity intact 17. What assessment data above is relevant and must be recognized as clinically significant to the nurse? RELEVANT Assessment data Rationale = Why is the data significant? 8 9