Download mr-santini-student-case-study

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?
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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?)
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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?
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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
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#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?
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