Heart Failure Clinical Reasoning Case Study

Heart Failure Clinical Reasoning Case Study Mr. Kelly

Chief Complaint/History of Present Illness:

It has now been 3 years since Mr. Kelly has been discharged from the hospital for CAD & MI. He is now 56 years old. He has not had any recurrent CP, but has had to sleep with 3 pillows to keep from becoming SOB at night the last 2 weeks. He has had difficulty getting his shoes on the last month because of increased swelling around his ankles. He forgets to take his medications every day but does at least 4-5 times a week. He weighs himself once a week and today his weight has increased from 255 lbs. to 264 lbs. the last 7 days. He makes an appt. through his clinic when he becomes concerned that he is now becoming SOB at rest and is more fatigued. The clinic physician recognizes that he will need acute inpatient care and coordinates a direct admission to the hospital by EMS.

Past Medical History:

• HTN - HCTZ, lisinopril • Hyperlipidemia – simvastatin and fish oil

• CAD -

• MI

• DM-type II - glyburide

Home Medications:

• Simvastatin 20 mg po daily • Glyburide 10 mg po daily • HCTZ 50 mg po daily • Lisinopril 20 mg po daily • ASA 81 mg po daily • Fish oil 1000 mg po 2 tabs daily Social/personal history Lives alone in own home. He is divorced with three grown children. He has had to cut back working to only 4 hours a day as a mechanic because of fatigue and weakness since the first of the year.

I. Pre-Clinical Critical Thinking: Identifying Relationships

• What is the relationship of his medical history and current medications? 1 / 3

• Which medication treats which disease? Draw a line to connect )

Past Medical History:

• HTN

• Hyperlipidemia

• CAD

• MI

• DM-type II

Home Medications:

• Simvastatin 20 mg po daily • Glyburide 10 mg po daily • HCTZ 50 mg po daily • Lisinopril 20 mg po daily • ASA 81 mg po daily • Fish oil 1000 mg po 2 tabs daily

• One disease process often influences the development of other illnesses.

Based on your knowledge of pathophysiology, in Mr. Kelly which disease likely developed first that initiated a “domino effect” in his life?

Past Medical History:

• HTN,

• Hyperlipidemia

• CAD

• MI

• DM-type II • Heart failure (new dx)

What Came First:

Hyperlipidemia

What then followed:

DM, HTN, CAD, MI, Heart Failure

• What is the relationship of his past medical history and current chief

complaint? Are there any pre-existing conditions that directly influenced his current problem? Explain your rationale if present

Past Medical History:

• HTN,

• Hyperlipidemia

• CAD

• MI

• DM-type II • Heart failure (new dx)

Chief Complaint:

• Has had to sleep with 3 pillows to keep from becoming SOB at night the last 2 months. Heart failure • He has had difficulty getting his shoes on the last month because of increased swelling around his ankles. Heart failure (right) • His weight has increased from 255 lbs. to 264 lbs. the last

• days. Heart failure (left)

• Becomes concerned that he cannot get out of his chair without becoming more SOB and is more fatigued heart failure 2 / 3

Mr. Kelly arrives to your telemetry unit You are the telemetry floor nurse and you have just received him as a direct admit. You review his history through the electronic medical record. The paramedics relate the above story of why he is being admitted.

Current Status:

Admission VS:

• T:98.4 o P:126-regular o R:28/labored

o BP:184/108

o O2 sats:90% 2l per n/c

Admission Nursing Assessment: o CV: pale, cool to the touch. Pulses 2+ throughout. 2-3+ pitting edema lower extremities

o Resp: course crackles scattered throughout both lung fields. Labored

resp. effort o Neuro: anxious, a/o x4 o GI/GU: WNL What data above is important and relevant that must be recognized as clinically significant to the nurse?HR 126 Pale. Cool to touch. Coarse crack

Rationale:

• HR 126 pale cool to touch…SNS stimulation to maintain CO (CO=SV*HR )

-2-3 pitting edema…fluid volume overload with left sided failure transferring causing bi-v failure. Edema in scrotum and sacrum is he has been lying/sitting -Coarse crackles in both lungs…increased hydrostatic pressure in pulmonary vessels due to left sided HF that results in fluid in alveolar space

• RR 28 labored resp effort…see above
• 90% on RA…see above
• Anxious likely related to inability to breathe/lay flat

II. Clinical Critical Thinking: Identifying Relationships

• What is the relationship of his current chief complaint and VS changes?
• / 3