HF CLINICAL REASONING CASE STUDY Name _______________________

I. 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: Atrial fibrillation Heart failure (systolic)

secondary to ischemic cardiomyopathy

MI with CABG x3 in 2008

Hyperlipidemia Chronic renal

insufficiency Implanted

Cardioverter defibrillator (ICD) placed 2008

Home Meds:1. ASA 81 mg daily2. Carvedilol 3.25 mg

daily3. Simvastatin 20 mg po

daily4. Hydralazine 25 mg 4x

daily5. Lasix 20 mg daily6. KCL 20 mEq daily7. Warfarin 5 mg daily

Pharm. Classification1.

2.

3.

4.

5.

6.

7.

Expected Outcome:1.

2.

3.

4.

5.

6.

7.

RELEVANT VS Data: Rationale: (Why is it clinical significant in this patient’s situation?)

Rate: ________Rhythm: ________

P wave:_____________PR interval__________________

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QRS duration: _____________Interpretation: _________________________

Clinical significance: ________________________________________________________

Admission Nursing Assessment: GENERAL APPEARANCE Appears anxious, restless, asking for his wifeRESPIRATORY 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 Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants

GU 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?

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?

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8. Compare and contrast the pathophysiology and the signs & symptoms of left vs. right heart failure. HF Pathophysiology Signs & symptomsLeft 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

#3 Nursing PRIORITY: Interventions

#4 Nursing PRIORITY: Interventions 4

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 orderedCare Provider’s Orders Rationale:Titrate oxygen to keep O2 sat > 95%

2 gram Na diet

Fluid restriction of 1500 mL/24 hours

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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 Action:

Side Effects Nursing Implications

Patient education

Furosemide (Lasix) 40 mg IV push x1

Nitroglycerin IV drip: titrate to keep

SBP < 130

Captopril 6.25 mg po daily

Digoxin 0.25mg po daily

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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 Severely enlarged heart. Bilateral diffuse pulmonary infiltrates consistent with

pulmonary edema

Lab/Diagnostic Results:Basic Metabolic panel Current Sodium (135-145) 133Potassium (3.5-5.0) 5.5 Glucose (70-110) 105Calcium (8.5-10.5) 8.8 Magnesium (1.8-2.6) 1.9BUN (7-25) 48Creatinine (0.6-1.2 ) 2.7

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

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Cardiac Current Troponin (<0.04 ng/mL) 0.01 CK total (26-140): 40 CK-MB (<5%): 0 BNP (<100): 1855

Misc Chemistries Current INR ( 0.9-1.1 ) 2.5

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)

Lab results

Potassium 5.9 mEq/dLCreatinine 3.1 mg/dL

Current Assessment: GENERAL APPEARANCE 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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