Adult & Elder II
Pre-Simulation Assignment
Module IV
Learning Outcomes:
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Identify the focused assessment of a patient with heart failure exacerbation.
Identify priority nursing diagnoses for a patient with heart failure.
Describe priority nursing interventions for a patient with heart failure.
Discuss adverse effects of commonly prescribed heart failure medications.
Review health promotion and maintenance for patients at risk for heart failure
exacerbations.
The patient is Ivan, a 67-year-old male who is being transferred from the ED to the Medical Unit
for acute exacerbation of heart failure. He has a history of congestive heart failure (CHF) and
hypertension, coronary artery disease and hyperlipidemia. In the ED, the patient reported fatigue,
shortness of breath, especially at night and when walking. He also had swelling of his ankles and
feet. The patient shared that the last time he took his prescribed medications was 7 days ago.
His prior to admission medication list is:
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Lisinopril 20 mg PO daily
Metoprolol CR/XL 100 mg PO daily
Atorvastatin 80 mg PO daily
Furosemide 20 mg PO daily
Spironalactone 50 mg PO daily
● Aspirin 81 mg PO daily, CAD
His current vital signs are:
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Blood pressure (BP) – 152/101
Heart Rate (HR) - 104/min, regular
Respiratory Rate (RR) 32/min
SpO2 – 91% on 2L via nasal cannula
Temperature -37 C
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1. The patient’s cardiac monitor shows the ECG rhythm below (it is a six-second strip).
What is the correct interpretation of the patient’s ECG rhythm?
The patient’s ECG shows that he is in Sinus Tachycardia.
Atrial rate/Rhythm = 120 bpm/regular
Ventricular rate/Rhythm = 120 bpm/regular
P wave = visible before each QRS
PR Interval = 0.16 secs/ normal, each P wave is followed by a normal QRS
QRS Duration = 0.06 secs/normal
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Apart from the rapid rate, there are no abnormalities.
2. Based on the above information/data, identify two priority nursing diagnoses for
this patient.
- Decreased tissue perfusion related to congestive heart failure as evidence by
peripheral edema
- Decreased cardiac output related to congestive heart failure as evidenced by ECG
changes.
3. What will you focus on in your physical assessment of the patient?
I would focus on assessing the patient’s respiratory system, checking lung sounds, and
ensuring that the airway is clear. My priority would be that he can breathe and has
peripheral pulses. I will check lower extremities edema to see if it worsens and a capillary
refill. I would also monitor ABGs.
4. Which abnormal findings do you expect to find other than those already described
above? If fluid has backed up into the lungs, I may hear abnormal lung sounds such as
crackles. I would also anticipate a reduced urine output due to decreased kidney function.
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Due to the ankle edema, there would be a capillary refill reduction and potential pitting.
If the patient's oxygen level is not improved, he may develop cyanosis.
5. Which of the prior to admission medications is the priority treatment for heart
failure exacerbation and what route should this medication be given?
To reduce the edema in this patient, an IV push of a diuretic such as furosemide (Lasix)
should be administered. However, because of its link to deafness, this medication should
be used carefully. Fluid retention (edema) and swelling caused by congestive heart failure
can be treated with this drug (Msn Np, 2021).
6. Which findings will you see in the patient if the medications you gave above have
been effective?
Because furosemide is a diuretic, it removes excess water and salt from the body,
resulting in less edema in the patient. This may help his breathing, which is our top
priority. It will also reduce blood pressure and allow the heart to rest and work less hard.
The patient's respiration will improve, as will his heart rate, blood pressure, and edema.
His renal function will start producing urine.
7. The patient is complaining of a nagging, dry cough. How would you address his
concerns?
I would explain to the patient that this is a frequent side effect of his ACE
inhibitor(Lisinopril), and I would call his provider to propose that he switch to an ARBs,
which essentially accomplishes the same objective without the "ace-cough." I would
reassure the patient that the cough will go away after the drug is discontinued.
8. The patient is ordered a stat dose of Furosemide 40 mg IV Push. You have the
following vial below stocked in the medication room. How much will you
administer?
40 mg / 10 mg x ml
= 4 mL
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Reference
Msn Np, S. L. R. (2021). Mosby’s 2022 Nursing Drug Reference (Skidmore Nursing Drug
Reference) (35th ed.) [E-book]. Mosby.
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