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Heart Failure Case Study with Answers (23 Solved Questions)

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    Heart Failure JoAnn Smith, 72 years old Primary Concept Perfusion Interrelated Concepts (In order of emphasis) 1. Gas Exchange 2. Fluid and Electrolyte Balance 3. Clinical Judgment 4. Patient Education FUNDAMENTAL Reasoning: STUDENT History of Present Problem: Heart Failure

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    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 She has struggled with depression the past two years and has been more withdrawn since her husband of 52 years died unexpectedly three months ago from a myocardial infarction.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: Systolic hearth failure Ischemic cardiomyopathy Ejection fraction of 15% Increased SOB, even at rest Speak in partial sentences Increased edema in legs Gained six pounds in last 3 days Her heart is not pumping blood to the tissues and organs as it should Her heart muscle was damaged and is weakened, probably due to her MI four years ago Ejection fractions should be above 50%; her heart is doing a poor job at pumping out blood to her body It is not normal to be SOB, especially at rest; her lungs are struggling She is so short of breath that she can not even speak without stopping to breathe Increased edema means that fluid is stuck in third spaces in the tissue (not is the vascular system or the cells, but in between) Gaining weight is a sure sign of fluid retention RELEVANT Data from Social History: Clinical Significance: Unable to maintain level of activity Depression past two years She is unable to properly care for herself or perform ADL’s if she gets so out of breath Depression slows the healing process, especially when patients are less likely to comply with therapies Developing Nurse Thinking by Identifying Significance of Clinical Data

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    Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 98.6 F/37.0 C (oral) P rovoking/Palliative: P: 92 (irregular) Q uality: Denies Pain R: 26 (regular) R egion/Radiation: BP: 162/54 MAP: 90 S everity: O2 sat: 90% (6 liters n/c) T iming: What VS data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: Pulse of 92 Respiration rate of 26 BP of 162/54 O2 sat 90% on 6 liters NC Although within normal rang, her pulse is still on the higher end and causing her heart to work harder She is breathing quickly because her lungs are hungry for air and want more O2 to send to the tissues BP is higher than normal, which is putting more strain on her heart Oxygen levels are unable to be kept in a therapeutic range, even with the assistance of O2

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    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: Appears anxious, restless Coarse crackles in both lungs Labored respiratory effort, sitting up In atrial fibrillation Pale, cool skin Edema in lower extremities (3+) S3 gallop, irregular pulse It is obvious she is uncomfortable and possibly scared; sometimes anxiety can cause more breathing issues; the nurse should be there to support and comfort the patient Crackles can indicate that there is fluid buildup in the lungs She is having a hard time breathing, and needs to sit up to be able to breathe more easily Atrial fibrillation can attribute to the ventricle being unable to fill with blood as they normally should Pale, cool skin is an indicator that there is poor tissue perfusion Edema indicates that there is fluid buildup, or third spacing in the extremities; the nurse needs to try to determine why this is happening S3 occurs from the blood swishing back against the valves; irregular pulses can occur from an alteration in the electrical system of the heart due to stretching 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 There is a fluid buildup in the lungs that is causing infiltration and edema in the lungs; this makes it harder for gas exchange to occur in the alveoli

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