Download File - Sasha Yunick`s E

Stenberg College NURS 201-3 Weekly Case Study and Care Plan
Clinical group Members: Sasha Yunick, Michelle Couper, Jillian Shaw, Lorna Muenz, Kristina Day
& Andrea Geib__________________________________________________________
Date: June 29 2014___________________
Case Study Critical thinking questions
1. Explain the pathophysiology of Mrs E’s heart disease.
Mrs. Estrela has acute decompensated heart failure (ADHF) of systolic origin that has
resulted in impaired ventricular emptying, as evidenced by her EF being 20% when
normal values are greater than 55% (p. 929) (Bouffard, 2014). . If the functioning
myocardium cannot compensate for this loss, the ventricle is unable to generate enough
pressure to eject blood forward through the high-pressure aorta. Inability to move blood
forward through the aorta results in (1) a decreased left ventricular ejection fraction (EF),
(2) an increase in left ventricular end-diastolic pressure (LVEDP), (3) an increase in
preload and pulmonary vascular resistance, and (4) an increase in fluid accumulation in
the pulmonary vascular bed (pulmonary edema). The pulmonary edema results in
dyspnea (shortness of breath) and may result in the development of pink, frothy sputum.
The left-sided failure will eventually result in right-sided failure. The pulmonary
congestion and increased pulmonary hypertension lead to right-sided hypertrophy and
failure resulting in peripheral edema and weight gain.
Ventricular dilation is the “enlargement of the chambers of the heart” (Bouffard,
2014, p.930) this happens when there is a elevated volume of blood over time , the
chambers of the heart will lose their elasticity, and remain dilated reducing cardiac
output.
Ventricular hypertrophy is “the increase in the muscle mass and cardiac wall thickness”
(Bouffard, 2014, p.930) this is due to chronic dilation of the heart ventricles. The
thickened heart muscle helps to increase the strength of the heart contractions, yet the
thickened heart muscle has “poor contractility” (Bouffard, 2014, p.931) needs more
oxygen to work, has poor circulation and is prone to dysrhythmias (Bouffard, 2014).
Increase in the SNS activity due to low cardiac output, will activate the release of
epinephrine and norepinephrine, resulting in an “increase in the heart rate, myocardial
contractility and peripheral vascular dilation” (Bouffard, 2014, p.931). This works to
increase the CO initially but over time the efficiency of the heart declines.
Neurohormonal responses to decreased CO are the releasing of hormones to facilitate
balance in the body including; sodium and water retention and increased peripheral
vascular constriction to increase blood pressure, and stronger contractibility of the heart
(Bouffard, 2014). All of these functions over time can lead to damaged heart tissue and
an elevated fluid amount in the body.
2/2
2. What clinical manifestations of heart failure did Mrs E. exhibit?
The clinical manifestations of heart failure that Mrs. E shows are edema, including
pulmonary edema. Mrs E shows signs of chronic heart failure by her admissions of
increasing dyspnea on exertion during the last 2 years accompanied by a frequent cough,
as an adaptive measure to deal with the shortness of breath and the retained pulmonary
fluid she noted that she has to sleep with head elevated on 3 pillows. This chronic
condition is also noted in the behavioral changes that she seems to have, as she does not
always remember to take medication. In recent weeks we see peripheral edema as
evidenced by the swelling in her legs. Upon admittance to the hospital it is noted that she
is in in respiratory distress, an she is using accessory muscles to breathe, with an
increased respiratory rate 36 breaths/min. Upon auscultation the nurse finds moist
crackles in both lungs and a systolic heart murmur, and while reviewing the diagnostic xray it was noted that she had fluid in lower lung fields.
Bouffard, L. (2014) Nursing Management: Heart Failure. In M. Barry, S. Goldsworthy &
D. Goodridge (Ed.) Medical-Surgical Nursing in Canada: Assessment and management
of clinical problems (3rd Canadian ed.) (pp. 928-949) Toronto, ON: Elsevier Canada.
1.5/2 cyanosis of her lips and extremities
3. What is the significance of the findings of the diagnostic studies?
The findings of Mrs. E’s x-ray shows: an increased blood pressure can make the heart
pump inefficiently which would affect the strength of the heart, damages the heart
muscle, give the patient heart problems and defects. The x-ray shows the patient having
an enlarged heart (cardiomegaly) due to high blood pressure with in the left and right
ventricles. The heart enlarges because it is trying to pump more blood to the body, due to
the thickening and stiffening of the heart muscles. The fluid in the lower left and right
ventricles shows us that she has a buildup of fluid.
Mayo Clinic (2014) Diseases and Conditions: Enlarged heart. Retrieved
from http://www.mayoclinic.org/diseases-conditions/enlarged-heart/basics/causes/con20034346
Bouffard, L.D., Kaan, A.F. (2014). Stress and stress management. In Barry, M. A.,
Goldsworthy, S. & Goodridge, D. (Eds.), Medical-Surgical nursing in Canada:
Assessment and management of clinical problems (3rd Canadian Ed.) (pp. 928-947).
Toronto, CA: Elsevier.
1/1
4. Explain the rationale for each of the medical orders prescribed for Mrs. E.
•Enalapril (Vasotec) 5mg PO daily -a vasodilator usedto treat high blood pressure and
is an ACE inhibitor. “It works by decreasing certain chemicals that tighten the blood
vessels, so blood flows more smoothly and the heart can pump blood more
efficiently”(nlm.gov,2012)
•Digoxin 0.25mg PO daily- improves contraction of the heart and should not be given to
patient unless the heart rate is over 50-60 BPM depending on location of the patient
whether they are in LTC or the hospital.(Nnama,H.2010) Digoxin is a positive inotropic
agent that increases the strength of cardiac contraction, decreases the conduction speed
within the myocardium, and slows the heart rate, allowing for more complete emptying of
the ventricles and an increase in cardiac output.
•Furosemide (Lasix) 40 mg IV BID-a loop diuretic which is used a water pill for fluid
retention in the lungs and legs as in the case of Mrs. E. It is also used to treat high blood
pressure and causes the kidneys to release unwanted water and salt throughout the body
by way of urine output.( Nlm.gov,2010) Digoxin is a positive inotropic agent that
increases the strength of cardiac contraction, decreases the conduction speed within the
myocardium, and slows the heart rate, allowing for more complete emptying of the
ventricles and an increase in cardiac output. 
-Potassium 40 mEq PO BID-is used for function of the heart and muscle contractions.
Potassium is an important and necessary use for a patient in order to avoid a drop in
blood pressure (WebMD, 2012) Potassium supplements are prescribed for Mrs. E. to
replace potassium lost through the use of furosemide and to prevent hypokalemia, which
may lead to digitalis toxicity.
-2-g sodium diet- a low sodium diet helps prevent the buildup of extra water in the body(
that causes swelling and possible fluid retention in limbs) and is beneficial for patients
with high blood pressure, heart failure, kidney disease. (Bouffard, et al, 2014) 
-Oxygen 6 L/min-is needed for Mrs. E due to her dyspnea (shortness of breath). She will
also need to be positioned in a semi-Fowlers position as it improves her ventilation by
decreasing venous return to the heart and increases her thoracic capacity (Bouffard, et al,
2014) 
Daily weights are taken to monitor the effectiveness of therapy, as well as to identify
early signs of fluid retention.
Nnama,H.(2010)Contraindications for Digoxin. Retrieved
from http://www.livestrong.com/article/162594-contraindications-for-digoxin/
Nlm.gov(2010).Furosemide. Retrieved
from http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682858.html
Nlm.gov(2014)Enalapril. Retrieved
from http://www.nlm.nih.gov/medlineplus/druginfo/meds/a686022.html#if-i-forget
WebMB(2012) Potassium and your Heart. Retrieved from http://www.webmd.com/heartdisease/potassium-and-your-heart
Bouffard, L.D., Kaan, A.F. (2014). Stress and stress management. In Barry, M. A.,
Goldsworthy, S. & Goodridge, D. (Eds.), Medical-Surgical nursing in Canada:
Assessment and management of clinical problems (3rd Canadian Ed.) (pp. 928-947).
Toronto, CA: Elsevier.
1.5/2
5. What teaching measures should be instituted to prevent recurrence of an acute
episode of heart failure?
The patient should be taught about her heart failure so she fully understands what it is,
how it affects her, and about certain risks. She should learn about the importance of
taking her medications on time and regularly, especially because she tends to forget. In
addition to this, she should be taught about nutritional therapy including information
about diet and weight management. The nurse should help the patient to create a diet plan
which consists of mostly low sodium foods. The reason for teaching the patient about her
diet is because reducing sodium intake can treat edema related to heart failure. To make
this easier for the client, she should be taught about the DASH diet, which is rich in
fruits, vegetables, low fat or nonfat dairy. The client should also be taught about
restricting her fluid intake to 1.5-2 litres of water per day. The nurse should teach the
patient about the importance of weighing herself daily around the same time, preferably
before breakfast to monitor fluid retention. Setting up an exercise program for her once
she can tolerate it a bit better will be important, and teaching her about the benefits of
regular exercise and set rest periods as well. These are all important things to teach the
patient to prevent recurrence of an acute episode of heart failure.
Martinez, L. G. & Bucher, L. (2010). Nursing management: Coronary artery disease and
acute coronary syndrome. In Lewis, S., Heitkemper, M., Dirksen, S. R., O'Brien, P. G.,
Barry, M., Goldsworthy, S., & Goodridge, D. (Eds.). Medical-surgical nursing in Canada
(2nd ed. pp. 884-902). Toronto, ON: Mosby Elsevier
1/2 •
For her impaired gas exchange, the nurse should provide the following care:
Elevate the head of the bed to Fowler’s position, with her arms
supported on pillows away from her chest
-
Administer oxygen as prescribed
-
Use pulse oximetry to monitor oxygenation status
Provide emotional and physical rest to decrease oxygen
consumption
Provide small, frequent feedings to decrease oxygen needed for
digestion
Monitor her lung and heart sounds and vital signs frequently to
evaluate her response to treatment
•
For her fluid volume excess, the nurse should provide the following care:
-
Evaluate her peripheral edema and measure abdominal girth daily
-
Assess intake and output every shift and weigh client daily
-
Provide sodium-restricted diet as ordered
•
For her risk for impaired skin integrity, the nurse should provide the
following care:
-
Assess edematous areas for skin breakdown
Turn and reposition q2h and perform passive range of motion to
extremities q4h
•
Pad bony prominences to reduce pressure
For her activity intolerance, the nurse should provide the following care:
Assess her dyspnea, fatigue, and pulse rate to determine
appropriate activity
-
Provide emotional and physical rest to relieve dyspnea and fatigue
6. Based on the assessment data presented, write 3 appropriate nursing diagnoses.
Nursing Focus of Care / Nursing Diagnosis
Rationale for Priority
Risk for Excess fluid volume.
- Mrs. E has recently had a respiratory tract
infection with frequent coughing.

- Physical examination confirmed she has moist
crackling in both lungs
- Chest x-ray confirmed fluid in lower lung fields.

Risk for activity intolerance.
- Increased dyspnea on exertion for last two years

- edema in legs 2 weeks ago
- Cannot walk two blocks without getting short of
breath

Risk for impaired gas exchange.
- Increased dyspnea on exertion
- Cannot walk two blocks without getting short of
breath

- Examination showed respiratory distress
- Respiratory rate @ 36 breaths/min
- Cyanotic lips and extremities

5/5
7. Are there any collaborative problems? How will they affect Mrs. E’s treatment?
Collaborative problems include the following: history of heart attack, edema in legs,
shortness of breath, fluid in her lower lungs, and the fact that she does not remember to
take her medications.
First and foremost if Mrs. E does not remember to take her medication, her treatment will
significantly be effected. Remembering to take her medication is the most important
aspect of her treatment. If she continues to not take her medications for the fluid in her
lungs she will continue to have shortness of breath. Mrs. E’s intolerance for activity can
play a part of the reason for the edema in her legs. All of these problems raise her
chances of having a heart attack considerably. Mrs. E needs to be active for a least 30
minutes a day, if she does this, her edema in her legs will decrease, her shortness of
breath will get better, which all lead to decreased chances of having another heart attack.
Martinez, L. G. & Bucher, L. (2010). Nursing management: Coronary artery disease and
acute coronary syndrome. In Lewis, S., Heitkemper, M., Dirksen, S. R., O'Brien, P. G.,
Barry, M., Goldsworthy, S., & Goodridge, D. (Eds.). Medical-surgical nursing in Canada
(2nd ed. pp. 846-882). Toronto, ON: Mosby Elsevier
2/2
Stenberg College RDPN Program
Nursing Care Plan
Nursing
Diagnosis
Desired
Outcomes
Interventions (I)Independent
(C) - Collaborative
Rationale & APA
“Reference
Evaluation of
Interventions
NDX:
(Problem)
Risk for excess
fluid volume
Goal (Reversal
of Problem)
N1-(I) (C)
R1-
E1-
Position to alleviate
dyspnea (e.g., semiFowler’s position with
legs dangling
To improve ventilation
by decreasing venous
return to the heart and
increasing thoracic
capacity and facilitating
breathing(p. 943). 
Patient has regular,
non-labored
respirations
Assess ABC’S and
supplement patient’s
oxygen by mask or
nasal catheter 6 L-min

Patient is in respiratory
distress and has an
increased respiratory
rate. Oxygen will
increase CO and help
relax the pt (p. 935). 
Patient has regular,
non-labored
respirations
Auscultate lungs for
presence of normal or
adventitious sounds
Crackles may indicate
heart failure which can
contribute to decreased
cardiac output (p. 622).

Patients lung sounds
are clear to
auscultation in all
lobes
Decrease
intravascular
volume (p. 934).
R/T:
(etiology/factor)
Client will list
:
measurable
Cardiac failure
outcomes;
reverse signs
Pulmonary
and symptoms
Edema
Restrict sodium
Right and Left
to 2-g per day
Ventricular
Hypertrophy
Restrict fluids to
100 mL per day

Take
AEB:
medications as
In respiratory
prescribed –
distress, use of
Enalapril
accessory
(Vasotec) 5mg
PO daily
muscles,
Nursing
Diagnosis
Desired
Outcomes
respiratory rate
36 breaths/min
Digoxin 0.25mg
PO daily
Moist crackles
in both lungs
Furosemide
(Lasix) 40 mg
IV BID
The patient’s
statement, “I’m
short of breath
and my ankles,
are so big and
puffy!”
Cyanotic lips
and extremities
Frequent
coughing
Has to sleep
with head
elevated on 3
pillows
Increasing
dyspnea on
exertion during
the last 2 years.

Potassium 40
mEq PO BID
Interventions (I)Independent
(C) - Collaborative
Rationale & APA
“Reference
Evaluation of
Interventions
N2-(I) (C)
R2-
E2-
Administer diuretic
(Lasix) as per doctors’
orders
Diuretics mobilize
edematous fluid,
reduces pulmonary
venous pressure, &
reduces preload
improving CO (p. 937).

Left ventricular
function has
improved
Daily Weight
Measurements

Evaluation of
Outcomes
(address each
outcome)
Fluid and electrolyte
management – Monitor
serum electrolytes
especially sodium and
potassium
1.restricted
sodium intake
will reduce fluid
volume
2. measuring
weight daily and
restricting fluid
intake to 6-8
glasses fluid a
day helps
monitor fluid
retention
3. Drug
adherence is
necessary to
reduce and treat
signs and
symptoms of
CHF.
Serum Sodium levels
will determine if
therapeutic measures
have been effective or
not as volume
imbalances are often
associated with changes
in serum sodium levels
and serum potassium
levels indicate
secondary HTN
Monitor respiratory
pattern for symptoms of
respiratory difficulty
Enables early detection
of pulmonary
congestion (p. 943). 
Evaluates the
effectiveness of therapy
(p. 943). 

Monitor hemodynamic
status, including CVP,
MAP, and PAOP, if
available
Evaluation of
Goal:
Monitor renal function
and intake and output
Goal met if
patient adheres
to care plan
Monitor for the
therapeutic effect of a
diuretic (↑ urine
output,↑ CVP,
To monitor fluid
balance (p. 943). 
To assess the patient’s
response to treatment
Pt’s serum electrolyte
levels came back with
normal results
ensuring that her
treatment plan has
been effective
Pt responded to
treatment well and no
longer displays
symptoms associated
with hypovolemia and
edema 
Nursing
Diagnosis
Desired
Outcomes
Interventions (I)Independent
(C) - Collaborative
Rationale & APA
“Reference
Continuation of
plan:
improvement of breath
sounds) 
(p. 943). 
Ensures valid
Weigh the patient, same comparisons day to day
and identifies early
time every day, before
signs of fluid retention
breakfast making sure
as a sudden weight gain
they are wearing the
of more than 2 kg in 2
same thing (p. 940). 
days is often indicative
of exacerbated HF
(p. 940).

Patient’s weight has
been consistent since
day after admission
and she doesn’t appear
to be retaining any
water
N4-(I) (C)
R4-
E4-
Appraise the patients
current level of
knowledge related to
specific disease
process
This will open
conversation and assist
in identifying what
areas the patient may
require some more
information in (p. 944).

Pt will understand and
can explain disease
process and will know
what signs and
symptoms to report to
HCP. 
N5- (I) (C)
R5-
R5-
Nutritional Therapy :
obtain a diet history
from patient and
appraise their current
knowledge regarding
sodium restricted diet 
To assess areas needing
additional instruction
and clarification (p.
944). 
Pt will show
collaboration of low
sodium recipes and
food journal
documenting daily
intake. 
Continue plan
and closely
monitor patient.
Will make
adjustments
accordingly
Evaluation of
Interventions
4.5/5
References
Bouffard, L. (2014) Nursing Management: Heart Failure. In M. Barry, S. Goldsworthy &
D. Goodridge (Ed.) Medical-Surgical Nursing in Canada: Assessment and management
of clinical problems (3rd Canadian ed.) (pp. 928-949) Toronto, ON: Elsevier Canada
18.5/20