PN Case Study Answer: Heart Failure 1

Title: Heart Failure

Scenario: A 62-year-old man presents to the emergency department. He is a “frequent flier” and

was just discharged from hospital one week ago after a diagnosis of congested heart failure. He

presents today with complaints of fatigue, shortness of breath and increased swelling to his legs.

He has been doing his best to restrict fluid and salt intake at home since being discharged but has

gained 1 pound each day since going home.

He has a past medical history of myocardial infarction 8 months ago and osteoarthritis in the left

hip. He quit smoking tobacco 6 months ago and denies the use of alcohol consumption. His

current medications include atorvastatin 40 mg QD, ASA 81 mg QD, lisinopril 10 mg QD,

furosemide 40mg PO OD, Potassium Chloride 20mEq OD, Acetaminophen Arthritis 1000mg prn

for hip pain. The nurse documents the following assessment findings:

 Heart rate = 98

 Reports 2/10 pain on a 0–10 pain scale

 Blood pressure = 141/90 mmHg

 Reports approximate 7lb weight gain over past 7 days, current weight 202 lbs.

 Fine crackles auscultated in the bilateral lower lobes of the lung

 SpO2 92% on room air

 Reports increased difficulty breathing when lying flat in the bed

 Reports he recently completed treatment for conjunctivitis

 Bilateral lower leg edema, pitting 2+

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PN Case Study Answer: Heart Failure 2

1. Item Type: Multiple Choice – Select all that Apply

The nurse recognizes that the following symptoms are seen in individuals with right-sided heart

failure. (Select all that Apply)

Answer(s):

The nurse recognizes that the following symptoms are seen in individuals with right-sided heart

failure. (Select all that Apply)

A. Ascites

B. Dependent Edema

C. Cough

D. Crackles

E. Weight gain

F. Distended Jugular Veins

Rationale:

The heart's pumping action moves oxygen-rich blood as it travels from the lungs to the left

atrium, then on to the left ventricle, which pumps it to the rest of the body. The left ventricle

supplies most of the heart's pumping power, so it's larger than the other chambers and essential

for normal function. In left-sided or left ventricular (LV) heart failure, the left side of the heart

must work harder to pump the same amount of blood.

The heart's pumping action moves blood that returns to the heart through the veins through the

right atrium into the right ventricle. The right ventricle then pumps the blood back out of the

heart into the lungs to be replenished with oxygen.

In left-sided heart failure, the heart can’t pump enough oxygenated blood from the lungs to the

rest of the body, or there’s a higher pressure inside the heart because it’s stiffer. This causes blood

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PN Case Study Answer: Heart Failure 3

to back up into the pulmonary veins. Left-sided heart failure may cause symptoms that tend to

worsen during physical activity. These symptoms include fatigue, shortness of breath, coughing,

crackles in the lungs, pulmonary edema and other symptoms.

Right-sided or right ventricular (RV) heart failure usually occurs as a result of left-sided failure.

When the left ventricle fails, increased fluid pressure is, in effect, transferred back through the

lungs, ultimately damaging the heart's right side. When the right side loses pumping power,

blood backs up in the body's veins. This usually causes edema, swelling within the abdomen

such as the GI tract and liver (causing ascites), weight gain, jugular vein distension and other

symptoms.

Client Needs: Physiological Integrity

Scenario: Thirty minutes later, the prescriber places orders for compression stockings, a 2 g low-

sodium diet, 2 L fluid restriction, intravenous (IV) access, oxygen 2L/min via nasal prongs to be

titrate to keep saturations greater than 94%, and blood work to further evaluate the client’s

condition. While placing the IV, the nurse notices the patient sitting forward in the tripod position

with a respiratory rate of 24 and an SpO2 89% on room air. The client is now having difficulty

speaking in complete sentences and pauses frequently when communicating with the nurse. He

reports he is hungry because he skipped breakfast this morning to come right to the hospital and

is also requesting something for pain, the arthritis in his left hip is becoming uncomfortable on

the hospital mattress. He rates his pain as 4/10 on a 0–10 pain scale.

2. Item Type: Critical Thinking and Decision Making

Answer(s):

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PN Case Study Answer: Heart Failure 4

Nursing Action Critical Urgent Normal

Initiate oxygen therapy. X

Order meal tray. X

Address pain. X

Educate patient on fluid X

restriction.

Alert prescriber of change X

in respiratory status.

Apply compression X

stockings.

Rationale: Critical actions by the nurse should include the initiation of oxygen therapy and

notification to the prescriber on the change in the client’s respiratory status. Interventions related

to the ABC’s (airway, breathing, and circulation) are always a top priority. Addressing the client’s

pain is an urgent consideration but does not pose an imminent threat to the client’s health status.

Addressing basic needs such as hunger and education, and performing prophylactic measures are

considered a “normal” priority level.

This question type is similar to a ‘select all that apply’ question type that reflects the quantity and

quality of a student’s knowledge about nursing. This particular question reflects the student’s

ability to critically think and prioritize nursing care.

Client Need: Safe and Effective Care Environment

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PN Case Study Answer: Heart Failure 5

Scenario: The prescriber orders include continuous telemetry monitoring, ibuprofen 600 mg PO

× 1, and an order for diuretic therapy, IV push furosemide 40 mg × 1. One hour later, the client’s

breathing stabilized and he rests comfortably on 4L nasal prongs. He is admitted to a cardiac

telemetry floor for further testing and observation after the prescriber determines he is suffering

from acute heart failure.

3. Item Type: Multiple Choice

The nurse is assessing a client admitted with congestive heart failure who is currently on 4L of

oxygen nasal prongs. The client is normally not on oxygen at home. The client has no complaints

at this time. The client’s oxygen saturation is currently 99%. The order states “oxygen to keep

saturations greater than 94%.” Which action should the nurse take next?

Answer(s):

The nurse is assessing a client admitted with congestive heart failure who is currently on 4L of

oxygen nasal prongs. The client is normally not on oxygen at home. The client has no complaints

at this time. The client’s oxygen saturation is currently 99%. The order states “oxygen to keep

saturations greater than 94%.” Which action should the nurse take next?

A. Titrate the oxygen down to 2-3L and reassess

B. Keep the oxygen at 4L as the saturations are 99%

C. Call the physician to notify them of the oxygen saturations and to obtain further orders

D. Increase the client’s oxygen to achieve a target of 100%

Rationale(s):

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PN Case Study Answer: Heart Failure 6

Prior to initiating oxygen therapy, if conditions warrant, the nurse should briefly obtain a history

of respiratory conditions and collect data regarding current symptoms associated with the

patient’s feeling of shortness of breath. The duration of this focused assessment should be

modified based on the severity of the patient’s dyspnea. Supplemental oxygen is typically

initiated in nonemergency situations with a nasal cannula at 1-2 liters per minute (L/min) and can

be titrated according to oxygen saturations. Oxygen delivery should be reduced when a patient is

clinically stable and oxygen saturation is above the target range or has been within target range

for several hours.

Client Need: Safe and Effective Care Environment

4. Item Type: Multiple Choice

Answer(s):

The nursing student asks the nurse preceptor how they will know if the heart failure if

progressing. Which of the following is a late sign of heart failure?

A. Shortness of breast

B. Orthopnea

C. Edema

D. Frothy-blood tinged sputum

Rationale:

The heart pumps blood around the body to supply all of the organs with oxygen. When it doesn’t

work the way it should anymore, that is what’s known as heart failure. The heart may not be strong

enough to gather enough oxygen from the lungs, or to pump oxygen-rich blood around the body.

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PN Case Study Answer: Heart Failure 7

Over time, advanced heart failure, also known as end-stage heart failure can occur. This is the most

advanced stage of congested heart failure.

Frothy- blood tinged sputum is a sign of end stage heart failure and pulmonary edema. Pulmonary

edema is a condition caused by too much fluid in the lungs. This fluid collects in the many air

sacs in the lungs, making it difficult to breathe.

In most cases, heart problems cause pulmonary edema. The other symptoms noted, while still

signs and symptoms of congestive failure, they are not indicative of worsening of the disease nor

are they late signs.

Client Need: Health Promotion and Maintenance

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