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
5. Communication
6. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
UNFOLDING Reasoning Case Study: STUDENT
Heart Failure
History of Present Problem:
@
55-654
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more withdrawn since her husband of 52 years died unexpectedly three months ago from a myocardial infarction.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:
6lb
weight
NX Of
Ml
gain
risk for
fluid
another
possible fluid
SOB
ejection fraction
RELEVANT Data from Social History:
HF for
retaining
2
years
depression
overload
Clinical Significance:
may
Med
affect
recovery &
regimen
widowed from Mt
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Put number next to PMH that connects to Medication)
PMH:
Home Meds:
Pharm. Classification:
Expected Outcome:
→
1.
ASA
81
mg
PO
daily
↓ Clot formation
NSAID
1.
iabetes Mellit s type
2. Carvedilol 3.25 mg PO
2. beta blocker → HF BP
Hyperte so
daily
→ HF BD
rtial a ibrillatio
3. Lisinopril 5 mg PO
3. ACE
,
Hyperlipidemaia
daily
→
cholesterol
4. Antilipemic
4. Ezetimide 10 mg PO
hro i re al i s i e y
daily
5. Vasodilator > BP
baseli e reati i e
5. Hydralazine 25 mg PO
retention
erebral as lar a ide t
→ fluid
6. diuretic
4x daily
with o resid al
6. Torsemide 20 mg PO
7. Anticoag → prevent clots
bid
de i its
7. KCL 20 meq PO daily
Heart ail re systoli
-3 type 2 diabetes
8. Warfarin 5 mg PO daily 8. anti diabetic
se o dary to is hemi
9. Glyburide 5 mg PO
ardiomyopathy
daily
M with ste t
to
years a o
,
-
© 2016 Keith Rischer/www.KeithRN.com
What medications treat which conditions?
One disease process often influences the development of other illnesses. Based on your knowledge of
pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in her life?
Write what PMH problem likely started FIRST
Write what PMH problems s F
W
diabetes
as domi o s
hypertension ,Ml
Patie t are e i s
Current VS:
T: 98.6 F/37.0 C (oral)
P: 92 (irregular)
R: 26 (regular)
BP: 162/54 MAP: 90
O2 sat: 90% (6 liters n/c)
P-Q-R-S-T Pain Assessment (5th VS):
Provoking/Palliative:
Denies Pain
Quality:
Region/Radiation:
Severity:
Timing:
What VS data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data:
Clinical Significance:
BP
TBP
02
02
RR
+
respiration
irregular
Current Assessment:
GENERAL
APPEARANCE:
RESP:
CARDIAC:
NEURO:
GI:
GU:
SKIN:
Appears anxious, restless
Breath sounds have coarse crackles scattered throughout both lung fields ant/post, labored
respiratory effort, patient sitting upright
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
Alert and oriented to person, place, time, and situation (x4)
Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants
Voiding without difficulty, urine clear/yellow
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:
crackles
could
edema
SOB
labored
breathing
© 2016 Keith Rischer/www.KeithRN.com
show fluid overload
Cardiac Telemetry Strip:
Interpretation:
Afib
irregular
Clinical Significance:
blood
"••i• "
pooling
of
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
12 Lead EKG
Interpretation:
Clinical Significance:
© 2016 Keith Rischer/www.KeithRN.com
Lab Results:
Complete Blood Count (CBC):
WBC (4.5-11.0 mm 3)
Hgb (12-16 g/dL)
Platelets (150-450x 103/µl)
Neutrophil % (42-72)
Current:
4.8
12.9
228
68
High/Low/WNL?
Prior:
5.8
13.2
202
65
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
Basic Metabolic Panel (BMP):
Sodium (135-145 mEq/L)
Potassium (3.5-5.0 mEq/L)
Glucose (70-110 mg/dL)
Creatinine (0.6-1.2 mg/dL)
Current:
133
4.9
105
2.9
TREND:
Improve/Worsening/Stable:
High/Low/WNL?
Prior:
138
4.2
118
2.2
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT
Lab(s):
Clinical Significance:
Misc. Chemistries:
Magnesium (1.6-2.0 mEq/L)
PT/INR (0.9-1.1 nmol/L)
Current:
1.9
2.5
TREND: Improve/Worsening/Stable:
High/Low/WNL?
Prior:
1.8
2.4
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
© 2016 Keith Rischer/www.KeithRN.com
TREND: Improve/Worsening/Stable:
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
Cardiac Labs:
Troponin (<0.05 ng/mL)
BNP (B-natriuretic Peptide) (<100
ng/L)
RELEVANT Lab(s):
Current:
0.10
1855
High/Low/WNL?
Clinical Significance:
Prior:
0.12
155
TREND: Improve/Worsening/Stable:
Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
Lab:
Normal Value:
Clinical Significance:
Nursing Assessments/Interventions
Required:
Clinical Significance:
Nursing Assessments/Interventions
Required:
Creatinine
Critical value:
Value:
2.9
Lab:
Normal Value:
BNP
Critical value:
Value:
1855
Clinical Reasoning Begins…
1. What is the primary problem that your patient is most likely presenting with?
2. What is the underlying cause/pathophysiology of this primary problem?
© 2016 Keith Rischer/www.KeithRN.com
Collaborative Care: Medical Management
Care Provider Orders:
Titrate oxygen to keep O2
sat >92%
Rationale:
Expected Outcome:
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
PRIORITY Setting: Which Orders Do You Implement First and Why?
Care Provider Orders:
 Strict I&O
 Titrate oxygen to keep
O2 sat >95%
 Furosemide (Lasix) 40
mg IV push bid
 Nitroglycerin IV drip:
titrate to keep SBP <130
 Fluid restriction of 2000
mL PO daily
 Low sodium diet
Order of Priority:
Rationale:
Collaborative Care: Nursing
3. What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY)
4. What interventions will you initiate based on this priority?
Nursing Interventions:
Rationale:
© 2016 Keith Rischer/www.KeithRN.com
Expected Outcome:
5.
What body system(s) will you most thoroughly assess based on the primary/priority concern?
6. What is the worst possible/most likely complication to anticipate?
7. What nursing assessments will identify this complication EARLY if it develops?
8. What nursing interventions will you initiate if this complication develops?
9. What psychosocial needs will this patient and/or family likely have that will need to be addressed?
10. How can the nurse address these psychosocial needs?
Medication Dosage Calculation:
Medication/Dose:
Medication/Dose:
Mechanism of Action:
Volume/time frame to
Safely Administer:
Nursing Assessment/Considerations:
.
Furosemide 40
mg IV push
IV Push:
Volume every 15 sec?
Evaluation:
Evaluate the response of your patient to nursing and medical interventions during your shift. All orders have been
implemented that are listed under medical management.
Four Hours Later…
Current VS:
T: 98.4 F/36.9 C (oral)
P: 88 (irregular)
R: 24 (regular)
BP: 112/50 MAP: 71
O2 sat: 91% (12 liters
high flow n/c)
Most Recent:
T: 98.6 F/37 C (oral)
P: 82 (irregular)
R: 26 (regular)
BP: 162/54 MAP: 90
O2 sat: 90% (6 liters
n/c)
© 2016 Keith Rischer/www.KeithRN.com
Current PQRST:
Provoking/Palliative:
Quality:
Region/Radiation:
Severity:
Timing:
Denies pain
Current
Assessment:
GENERAL
APPEARANCE:
RESP:
CARDIAC:
NEURO:
GI:
GU:
SKIN:
Not as anxious, but appears restless at times
Coarse crackles scattered throughout both lung fields, labored respiratory effort
Rhythm: atrial fibrillation, pale, cool to the touch, pulses palpable throughout, 3+ pitting edema
in lower extremities
Alert and oriented to person, place, time, and situation (x4)
Abdomen soft/nontender, bowel sounds audible per auscultation in all 4 quadrants
30 mL of urine out in the last 4 hours after furosemide IV given, 50 mL residual urine in bladder
with bladder scan
Skin integrity intact
1. What clinical data is RELEVANT that must be recognized as clinically significant?
RELEVANT VS Data:
Clinical Significance:
RELEVANT Assessment Data:
Clinical Significance:
2. Has the status improved or not as expected to this point?
3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?
4. Based on your current evaluation, what are your nursing priorities and plan of care?
© 2016 Keith Rischer/www.KeithRN.com
Your knowledge and application of the pathophysiology of heart failure and renal
failure have allowed you to make a series of needed assessments and judgments that
have facilitated the treatment and care of your patient. You recognize that an SBAR
is needed to update the primary care provider with your concerns.
SBAR: Nurse-to-Primary Care Provider
Situation:
Name/age:
BRIEF summary of primary problem:
Day of admission/post-op #:
Background:
Primary problem/diagnosis:
RELEVANT past medical history:
Assessment:
Most recent vital signs:
RELEVANT body system nursing assessment data:
RELEVANT lab values:
INTERPRETATION of
current clinical status (stable/
unstable/worsening):
Recommendation:
Suggestions to advance plan of care:
© 2016 Keith Rischer/www.KeithRN.com
New Orders from Primary Care Provider:
 Stat potassium, creatinine, arterial blood gases
 Transfer to ICU
RESULTS:
Current
5.9
3.5
Potassium (3.5-5.0 mEq/L)
Creatinine (0.6-1.2 mg/dL)
RELEVANT Lab(s):
Clinical Significance:
Arterial Blood Gas:
pH (7.35–7.45)
pCO2 (35–45)
pO2 (80–-100)
HCO3 (18–26)
O2 sat (>92%)
Current:
7.46
30
72
22
91%
RELEVANT Lab(s):
Clinical Significance:
ABG Interpretation:
© 2016 Keith Rischer/www.KeithRN.com
High/Low/WNL?
Most Recent
5.5
2.7
TREND: Improve/Worsening/Stable:
It is now the end of your shift. Effective and concise handoffs are essential to excellent care and
if not done well can adversely impact the care of this patient. You have done an excellent job to
this point, now finish strong and give the following SBAR report to the nurse who will be
caring for this patient in ICU:
SBAR: Nurse-to-Nurse
Situation:
Name/age:
BRIEF summary of primary problem:
Day of admission/post-op #:
Background:
Primary problem/diagnosis:
RELEVANT past medical history:
Assessment:
Most recent vital signs:
RELEVANT body system nursing assessment data:
RELEVANT lab values:
TREND of any abnormal clinical data (stableincreasing/decreasing):
INTERPRETATION of current clinical
status (stable/unstable/worsening):
Recommendation:
Suggestions to advance plan of care:
© 2016 Keith Rischer/www.KeithRN.com
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?
2. What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?
Caring and the “Art” of Nursing
1. What is the patient likely experiencing/feeling right now in this situation?
2. What can you do to engage yourself with this patient’s experience, and show that she matters to you as a
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?
2.
How can I use what has been learned from this scenario to improve patient care in the future?
© 2016 Keith Rischer/www.KeithRN.com