Heart Failure Case Study

Vanessa Joubert
Heart Failure
History of Present Problem: 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struggled with depression the past two years and has been more withdrawn since her husband of 52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:
 Age 72-years
 History of MI
 SOB
 Swelling in her legs and gained 6 pounds in 3 days.
 Irregular pulse
 Increased respiration
 Low oxygen
 S3 notes
Clinical Significance:
 As a woman reach menopause around 50 years old estrogen levels being to slowly disappear,
which places women at higher risk for CAD.
 Sleeping in recliner chair to rest comfortably upright, indicating fluid buildup in the lungs.
 The heart is not pumping blood efficiently causing fluid buildup.
 S3 indicates fluid in the lungs.
Relevant data from social history:
 Patient is depressed.
 Sudden loss of husband
 Retired math teacher
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 Depression can affect patients adheres to recommended lifestyle changes.
 Death can add on to her depression.

 Retired due to heart failure.
T: 98.6 F/37.0 C (oral)

P: 92 (irregular) Quality: Denies Pain
R: 26 (regular)
BP: 162/54 MAP: 90
O2 sat: 90% (6 liters n/c)
What VS data is RELEVANT and must be recognized as clinically significant by the nurse?
Relevant VS Data:
 Patient has irregular pulse.

 High respiration.
Low diastolic pressure
Clinical significance:
 Irregular pulse can be a sign of atrial fibrillation.

 Excessive fluid in the lungs can make it difficult for the lungs to function properly.
 Onset heart failure development from low diastolic pressure.
What assessment data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data:
 Anxious and restless

 Crackle breath sounds, labored respiratory effort, patient sitting upright.
 A Fibrillation, pale, cool, 3+edema, S3. Irregular.
Clinical significance:
 Patient is likely feeling anxious and restless due to edema, and having a hard time breathing.
 Patient sitting up right because the buildup of fluid in the lungs in making it difficult for her to
breath, crackles conform she has fluid in the lungs.
 S3 heart sound indicates heart failure. Irregular pulses stimulate the ventricles to contract
prematurely before diastole is finished.
Cardiac Telemetry Strip:
interpretation: Atrial Fibrillation
Clinical Significance: No visible P wave and irregular QRS complex.
Chest x-ray: Relevant results: Bilateral diffuse pulmonary infiltrates consistent with pulmonary edema
12 Lead EKG
 Interpretation: atrial fibrillation

 The heart is beating too fast and has many contractions. There's no p wave.
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Diagnostic Data:

 Creatinine normal levels are <1.1 Patient levels are high
 Platelets low
 Neuts are low
 Trop 0.12 high
 BNP 155 is high
 Renal failure
 Clotting factors.
 Neutrophils fight off infection.
 High trop. Probable myocardial infarction.
 High BNP most likely represents heart failure.
TREND: Improve/Worsening/Stable:
 Slightly improving
 No improvement
 No improvement.
 No improvement.
 Improved but still high.
Clinical Reasoning Begins…

1. What is the primary problem that your patient is most likely presenting with?
 Heart Failure
2. What is the underlying cause/pathophysiology of this primary problem?

 The heart not pumping enough blood to support heart and other vital organs.
Collaborative Care: Medical Management

Care Provider Orders:
 Titrate oxygen to keep O2 sat >92%
 Furosemide 40 mg IV push
 Nitroglycerin IV drip: titrate to keep SBP <130
 Strict I&O
 Fluid restriction of 2000 mL PO daily
 Low sodium diet
Rationale:
 In the management of hypoxemic.
 It can treat fluid retention (edema) and swelling caused by congestive heart failure, liver disease,
kidney disease, and other medical conditions.
 Reduces cardiac oxygen demand by decreasing left ventricular end-diastolic pressure (preload)
and, to a lesser extent, systemic vascular resistance (afterload). Also increases blood flow
through the collateral coronary vessels.
 Patient has edema would want to monitor so the patient does have more edema.
 Consuming too much sodium can cause the body to retain water.
Expected Outcome:
 Patient will increase oxygen levels and reduce the work of breathing
 Furosemide will cause the patient to urinate lower edema and swelling
 Irregular pulse will return to regular.
 Fluid restriction will allow the patient to not consume too much fluid cause her edema to
worsen.
 Low sodium diet will help in edema and swelling.
Collaborative Care: Nursing

PRIORITY Nursing Interventions:
 Maintain clear lung sounds and edema using the 1+ to 4+ scale to quantify edema.
Rationale:
 Auscultate breath sounds for crackles monitor reporation effort and determine the presence and
severity of orthopnea. Pulmonary edema may be due to increased permeability of the alveolar
capillary barrier or to increased pulmonary microvascular hydrostatic pressure.
Expected outcome
 Patient will have clear breath sounds and remain free of edema.
Most people with low literacy are very ashamed of it and therefore have become very good at hiding
the problem. Many do not tell their bosses, coworkers, or even life partners. 9 Patients with limited
health literacy are well served by a psychologically safe environment so that they do not feel ashamed.
What body system(s) will you most thoroughly assess based on the primary/priority concern?
The heart
What is the worst possible/most likely complication to anticipate?
A fatal heart attack
What nursing assessments will identify this complication EARLY if it develops?
 An EKG will detect abnormal heart rhythms
What nursing interventions will you initiate if this complication develops?
 Nitroglycerin for chest pain but if the patient is having a heart attack they should chew
 an aspirin until paramedics arrive. If patient is unconscious without a pulse then
 perform CPR.
What psychosocial needs will this patient and/or family likely have that will need to be
addressed?
 Supportive measures and reassurance that their family member is getting the best care.
How can the nurse address these psychosocial needs?
 Not being judgmental and hearing the family out and addressing their concerns.
Evaluation:
What clinical data is RELEVANT that must be recognized as clinically significant?
 02 saturation has decreased and they patient is on 12L n/c., BP is low, and
patient has increased respirations.
1. may need to decrease the 02 the patient is getting too much oxygen at
once and the heart can’t pump the blood that fast.
Relevant assessment data: Coarse crackles scattered throughout both lung
fields, labored respiratory effort, atrial fibrillation, pale, cool to the touch, pulses
palpable throughout, 3+ pitting edema in lower extremities
1. Patient is retaining fluid.
25. Has the status improved or not as expected to this point?
 no
26. Does your nursing priority or plan of care need to be modified in any way after this evaluation
assessment?
 Yes, the patient needs to be further examined.
27. Based on your current evaluation, what are your nursing priorities and plan of care?
 Plan to have patient go for an EKG and an echocardiogram and a chest x ray.
Situation:
Name/age: joAnn smith 72yr old woman.
BRIEF summary of primary problem: patient complaining of chest pain and SOB while resting.
Day of admission/post-op #: 05/02/2020
Background:
Primary problem/diagnosis: heart failure
RELEVANT past medical history: previous MI
Assessment:
Most recent vital signs: T 98.4, P 88, R 24, BP 112/50, 02sat 91% (12L high flow N/C)
RELEVANT body system nursing assessment data: heart
RELEVANT lab values: creatinine 2.9 high, BNP high 1855, troponin high 0.10, potassium Is low.
INTERPRETATION of current clinical status (stable/unstable/worsening): patient will not remain stable
having hard time breathing and has severe chest pain.
Recommendation:
Suggestions to advance plan of care: go for echocardiogram and an EKG and get a ABG. And electrolytes.
1. New Orders from Primary Care Provider:  Stat potassium, creatinine, arterial blood gases  Transfer
to ICU
 Relevant labs: potassium which puts patient at risk for heart dysrhythmias and also
creatinine whish shows signs of renal failure when so high.
2. ABG labs
 Relevant: ph, pca02, hco3, 02

 Indicating compensation
 ABG interpretation: respiratory alkalosis
Situation:
Name/age: JoAnn smith 72yrs old. Came into the emergency room presenting chest pain and SOB. Her
SOB has progressed from shortness of breath with activity to become SOB at rest
Day of admission/post-op #: 05/02/2020
Background:
Primary problem/diagnosis: heart failure
RELEVANT past medical history: previous MI
Assessment:
Most recent vital signs: T 98.4, P 88, R 24, BP 112/50, 02sat 91% (12L high flow N/C)
RELEVANT body system nursing assessment data: heart
RELEVANT lab values: ABGs indicating respiratory alkalosis
TREND of any abnormal clinical data (stable increasing/decreasing): decreasing
INTERPRETATION of current clinical status (stable/unstable/worsening): worsening
Recommendation:
Suggestions to advance plan of care: have patient go for an echocardiogram.
Education Priorities/Discharge Planning
1. What will be the most important discharge/education priorities you will reinforce with the
patient’s medical condition to prevent future readmission with the same problem.
 Instructions with Lasix and nitroglycerin.
2. What are some practical ways you as the nurse can assess the effectiveness of your teaching
with this patient?
 Have them either demonstrate or repeat back what was said.
Caring and the “Art” of Nursing
1. What is the patient likely experiencing/feeling right now in this situation?
 a. Scared that they might be dying.
2. What can you do to engage yourself with this patient’s experience, and show that she matters
to you as a
 Be empathetic and caring.
Use Reflection to THINK Like a Nurse
Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to
an intervention in the moment as the events are unfolding to make a correct clinical judgment.
1. What did I learn from this scenario?
 a. Heart failure can come put extreme stress on the body.
2. How can I use what has been learned from this scenario to improve patient care in the future?
 a. I will have a better understanding on how to respond.
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Vanessa Joubert

RELEVANT Data from Present Problem:

Relevant data from social history:

 Depression can affect patients adheres to recommended lifestyle changes.

 Death can add on to her depression.

T: 98.6 F/37.0 C (oral)

 Patient has irregular pulse.

 Irregular pulse can be a sign of atrial fibrillation.

RELEVANT Assessment Data:

 Anxious and restless

Cardiac Telemetry Strip:

Clinical Significance: No visible P wave and irregular QRS complex.

 Interpretation: atrial fibrillation

RELEVANT Diagnostic Data:

Clinical Reasoning Begins…

2. What is the underlying cause/pathophysiology of this primary problem?

Collaborative Care: Medical Management

Collaborative Care: Nursing

What is the worst possible/most likely complication to anticipate?

A fatal heart attack

 An EKG will detect abnormal heart rhythms

What nursing interventions will you initiate if this complication develops?

How can the nurse address these psychosocial needs?

What clinical data is RELEVANT that must be recognized as clinically significant?

patient has increased respirations.

Relevant assessment data: Coarse crackles scattered throughout both lung

palpable throughout, 3+ pitting edema in lower extremities

1. Patient is retaining fluid.

25. Has the status improved or not as expected to this point?

 Yes, the patient needs to be further examined.

Name/age: joAnn smith 72yr old woman.

Day of admission/post-op #: 05/02/2020

Primary problem/diagnosis: heart failure

RELEVANT past medical history: previous MI

RELEVANT body system nursing assessment data: heart

having hard time breathing and has severe chest pain.

creatinine whish shows signs of renal failure when so high.

 Relevant: ph, pca02, hco3, 02

Day of admission/post-op #: 05/02/2020

Primary problem/diagnosis: heart failure

RELEVANT past medical history: previous MI

RELEVANT body system nursing assessment data: heart

RELEVANT lab values: ABGs indicating respiratory alkalosis

TREND of any abnormal clinical data (stable increasing/decreasing): decreasing

INTERPRETATION of current clinical status (stable/unstable/worsening): worsening

Suggestions to advance plan of care: have patient go for an echocardiogram.

Education Priorities/Discharge Planning

 Instructions with Lasix and nitroglycerin.

with this patient?

 Have them either demonstrate or repeat back what was said.

Caring and the “Art” of Nursing

1. What is the patient likely experiencing/feeling right now in this situation?

 a. Scared that they might be dying.

Use Reflection to THINK Like a Nurse

1. What did I learn from this scenario?

 a. Heart failure can come put extreme stress on the body.

 a. I will have a better understanding on how to respond.