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Case Study 5.pdf copy
Fundamentals of Nursing (Keiser University)
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Heart Failure: Critical Care
SKINNY Reasoning
Peter Sanford, 32 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
• Clinical Judgment
• Patient Education
NCLEX Client Need Categories
Percentage of Items from Each
Category/Subcategory
Safe and Effective Care Environment
• Management of Care
• Safety and Infection Control
Health Promotion and Maintenance
Psychosocial Integrity
Physiological Integrity
• Basic Care and Comfort
• Pharmacological and Parenteral Therapies
• Reduction of Risk Potential
• Physiological Adaptation
Covered in
Case Study
17-23%
9-15%
6-12%
6-12%
✓
6-12%
12-18%
9-15%
11-17%
✓
✓
✓
✓
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✓
✓
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SKINNY Reasoning
Part I: Recognizing RELEVANT Clinical Data
History of Present Problem:
Peter Sanford is a 32-year-old Caucasian male with a history of hypertension, mitral regurgitation, and alcoholic
cardiomyopathy with EF 20%. He came to the ED because of increased SOB and weight gain of 10 pounds in the last
week. For the past two months, he has not taken his prescribed medications of lisinopril 5 mg, carvedilol 2.5 mg,
furosemide 80 mg, and spironolactone 25 mg.
Peter is admitted to the ICU from the ED for treatment of exacerbation of heart failure and for consideration of
advanced therapies including left ventricular assist device (LVAD) to manage his heart failure in the future. You are the
critical care nurse responsible for his care.
Personal/Social History:
Peter is single but has a supportive girlfriend. He works three part-time jobs and does not have health insurance because
his annual income is just over the threshold to receive government assistance with health care. He has not taken his
prescribed medications for the past two months because he could not afford them and had to choose between housing/food
and his medicines. Peter was a heavy drinker since the age of 18 but has been sober the past two years.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Present Problem:
Clinical Significance:
-History of HTN, mitral regurgitation, and alcoholic
cardiomyopathy
-Increased SOB
-Weight gain of 10lbs in one week
-Not medication compliant
-Admitted to ICU for trx of HF exacerbation
-EF 20%
Patient has a history of multiple cardiac co-morbidities. His weight gain of 10lbs in the
last week is indicative of fluid overload which is an expected finding in a patient with
HF. SOB is an expected finding associated with his history of mitral regurgitation.
-Non-medication compliance is going to cause his afterload to be increased causing
further deterioration of heart function
-EF 20% indicated weakened heart muscles and is in end stage heart failure
RELEVANT Data from Social History:
Clinical Significance:
-Works several jobs
-No health insurance
-Cannot afford medications
-Hx of alcohol abuse, but sober for two
years
A referral should be placed for social work to set up insurance
and case management to help coordinate the patients care. The
patient is not able to afford his medication due to financial
barriers. Increased stress and poor health are also risk factors to
ETOH abuse relapse.
Patient Care Begins:
Current VS:
T: 97.7 F/36.6 C (oral)
P: 104 (regular/irreg)
R: 20 (regular)
BP: 148/94-MAP 112
O2 sat: 94% 2 liters n/c
P-Q-R-S-T Pain Assessment:
Provoking/Palliative:
Denies
Quality:
Region/Radiation:
Severity:
Timing:
What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS Data:
Clinical Significance:
P: 104
RR: 20
BP: 148/94
O2: 94% on 2L n/c
-Pulse is tachycardic likely due to discomfort and stress; rhythm is reg/irreg due to PVCs?
-Patient has a hx of HTN and is not compliant with his medication so his elevated BP is an
expected finding.
-Monitor RR, as it is on the high-normal side. Determine baseline.
-O2 is low normal, but a baseline O2 should be assessed. Concern for oxygenation to organs.
This is a red flag in a patient with HF and edema.
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Cardiac Telemetry Strip:
Regular/Irregular:
Interpretation:
P wave present?
PR:
QRS:
Sinus tachy, P-wave is present, QRS is narrow, normal PR
Clinical Significance:
Sinus tach with frequent uni-focal PVCs (monitor potassium and magnesium levels)
Current Assessment:
GENERAL SURVEY:
NEUROLOGICAL:
HEENT:
RESPIRATORY:
CARDIAC:
ABDOMEN:
GU:
INTEGUMENTARY:
Flat affect, appears tense, uncomfortable, grooming normal for age and gender.
Alert & oriented to person, place, time, and situation (x4)
Head normocephalic with symmetry of all facial features. PERRLA, sclera white
bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and
moist.
Coarse bibasilar crackles posteriorly with equal aeration on inspiration and expiration in
all lobes anteriorly, posteriorly, and laterally, respiratory effort slightly labored 2 liters
n/c.
Warm & dry, 2+ pitting edema in lower extremities from feet to mid-calf. Heart sounds
regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk
cap refill. Heart tones audible and regular, systolic murmur noted over the apex.
Abdomen round, tender in RLQ to gentle palpation. Rebound tenderness present BS + in
all four quadrants.
Voiding without difficulty, urine clear/yellow
Skin warm, dry, intact, normal color for ethnicity. Cap refill <3 seconds. Hair softdistribution normal for age and gender. Skin integrity intact, skin turgor elastic, no
tenting present.
What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS Data:
Clinical Significance:
-Appears tense, uncomfortable
-Coarse bi-basilar crackles on inspiration and
expiration in all lobes
-Increased respiratory effort
-2+ pitting edema in BLE
-Systolic murmur
-RLQ abdominal tenderness
-Excessive fluid in the lungs indicative of left sided heart failure
(progresses into pulmonary edema)
-Pitting edema due to fluid volume overload
-Evaluate if the edema is dependent
-Expected murmur due to mitral valve regurgitation
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Radiology Reports:
What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
Echocardiogram
Results:
Clinical Significance:
Moderate to severely increased left
-Concern for end stage heart failure
ventricular size, normal wall
thickness, severely reduced global -Worsening EF is a red flag
systolic function, calculated EF of -Left ventricle size is expected due to increased work
15%.
Severe mitral valve regurgitation.
Lab Results:
Current:
Last Adm.:
WBC
5.5
6.4
Complete Blood Count (CBC)
HGB
PLTs
11.8
228
12.2
275
% Neuts
78
65
Bands
0
0
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Lab(s):
Clinical Significance:
TREND:
Improve/Worsening/Stable:
-Hgb 11.8 low-normal -Indicative of poor perfusion, bleeding or anemia
Current:
Last Adm.:
Na
130
135
Basic Metabolic Panel (BMP)
K
Gluc.
4.5
98
4.2
115
-Worsening
Creat.
1.8
1.3
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Lab(s):
Clinical Significance:
TREND:
Improve/Worsening/Stable:
-Na 130 L
-Creatinine 1.8 H
-Hyponatremia is due to HF which is causing the
body to hold onto fluids as exemplified by the
BLE pitting edema
-Elevated creatinine level indicates poor renal
perfusion and dehydration. Red flag for
secondary acute kidney injury due to kidney
hypoperfusion
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-Worsening
-Worsening
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Current:
Most Recent:
Albumin
3.2
3.5
Total Bili
2.4
1.8
Liver Panel
Alk. Phos.
125
114
ALT
85
25
AST
79
35
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Lab(s):
Clinical Significance:
TREND:
Improve/Worsening/Stable:
-Albumin 3.2 L
-Total bili 2.4 H
-ALT 85 H
-AST 79 H
Current:
Most Recent:
-Elevated albumin is indicative of dehydration,
infection, and stress
-Hyperbilirubinema, elevated Alk phos, ALT, and
AST are all indicative of poor liver function
-Liver is congested due to excess fluid
Trop.
0.01
0.02
BNP
2250
512
Cardiac
Mg
1.8
1.7
-Worsening
-Worsening
-Worsening
-Worsening
PT/INR
1.2
1.1
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Lab(s):
Clinical Significance:
TREND:
Improve/Worsening/Stable:
-BNP 2250 H
-An elevated BNP is an indicator in diagnosing
heart failure. Level of 2250 indicates severe HF.
-How much stretching is going on in myocardial
cells?
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Part II: Put it All Together to THINK Like a Nurse!
1. Interpreting relevant clinical data, what is the primary problem? What primary health-related concepts does this
primary problem represent? (Management of Care/Physiologic Adaptation)
Problem:
Pathophysiology of Problem in OWN Words:
Primary Concept:
Exacerbation of
congestive heart
failure
The left ventricle is not able to pump blood effectively out of the ventricle
causing fluid to back up into the lungs causing pulmonary congestion and
shortness of breath
-Inadequate cardiac output
-Can result from factors that after preload and afterload
Poor perfusion
due to left and
right heart failure
Right sided heart failure occurs when the right ventricle fails and the blood
cannot be ejected effectively causing increased venous pressure. This leads
to hepatomegaly, ascites, dependent edema, and weight gain.
Collaborative Care: Medical Management
2. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies)
Medical Management:
Continue home medications:
Lisinopril 5 mg PO BID
Carvedilol 2.5 mg PO daily
Spironolactone 25 mg PO
daily
New Orders:
Lorazepam 0.5 mg PO every
6 hours PRN anxiety/sleep
Furosemide 10 mg
continuous IV infusion
Nitroprusside 0.3-3
mcg/kg/minute. Titrate for
MAP 65-75
Potassium replacement
protocol
Magnesium replacement
protocol
Rationale:
-Decrease blood pressure and after load
Expected Outcome:
-Patient will maintain an
expected daily weight
-Management of CHF by dilating blood vessels loss with diuretic use.
and decreasing after load
-Patient's electrolyte levels
will improve and stabilize.
-Diuretic to treat fluid retention in advanced HF -The patient will remain
free of further HF
-To reduce anxiety and promote sleep
exacerbation.
-Decreases fluid volume overload, decreases
signs and symptoms of HF
-IV vasodilator
-Potassium and magnesium replacement is
indicated when using diuretics to replace
electrolytes
-Low sodium heart healthy diet and fluid
restriction to discourage fluid overload
-Catheter is likely planned due to diuretic use
and increased need to urinate
Cardiac/Low sodium diet
Fluid restrictions 1.5 liters
daily
Placement of Swan-Ganz
catheter tomorrow
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Collaborative Care: Nursing
3. What nursing priority (ies) will guide your plan of care? (Management of Care)
Nursing PRIORITY:
Decreased cardiac output
PRIORITY Nursing Interventions:
Rationale:
Expected Outcome:
-Auscultate apical pulse, assess
heart rate and rhythm
-Monitor vitals
-Monitor I and O
-Assess skin and peripheral
pulses
-Assess for JVD
-Monitor results of laboratory and
diagnostic tests
-Give oxygen as indicated
-Reposition every 2 hours
-Administer medications as
prescribed
-Decreased cardiac output may cause
changes in EKG readings and pulses
-Kidneys respond to reduced cardiac
output by retaining water and sodium
Improved cardiac
output
4. What psychosocial/holistic care PRIORITIES need to be addressed for this patient?
(Psychosocial Integrity/Basic Care and Comfort)
Psychosocial PRIORITIES:
Encourage rest and therapeutic communication
PRIORITY Nursing Interventions:
Rationale:
Expected Outcome:
Provide quiet environment and
privacy, support patients family or
friends, gf, ect., answer questions
and allow time for reflection
Maintain an
therapeutic
relationship with
the patient and
family
CARE/COMFORT:
Caring/compassion as a nurse
Physical comfort measures
EMOTIONAL (How to develop a therapeutic
Active listening
relationship):
Discuss the following principles needed as
conditions essential for a therapeutic relationship:
• Rapport
• Trust
• Respect
• Genuineness
• Empathy
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Maintain an
therapeutic
relationship with
the patient and
family
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SPIRITUAL Assessment (FICA):
• F-Faith or beliefs: What are your spiritual
beliefs? Do you consider yourself spiritual?
What things do you believe in that give
meaning to life?
• I-Importance and influence: Is faith
important to you? How has your illness or
hospitalization affected your belief practices?
• C-Community: Are you connected to a faith
center in the community? Does it provide
support/comfort for you during times of stress?
Is there a person/group who assists you in your
spirituality?
• A-Address: What can I do for you? What
support can healthcare provide to support your
spiritual beliefs/practices?
5. What educational/discharge priorities need to be addressed to promote health and wellness for this
patient and/or family? (Health Promotion and Maintenance)
Education PRIORITY:
Healthy heart lifestyle
PRIORITY Topics to Teach:
Rationale:
-Encourage activity that reduces
Helps the patient provide the most optimal lifestyle for his
cardiac workload such as regular
condition to support
exercise
-Work on achieving and maintaining a
health BMI
-Follow a low sodium, low fat diet
-Keep follow up appointments with PCP
and any specialists
-Follow medication regimen as
prescribed
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