Case study 1 PRIMARY CARE SETTING

▪ You are a Nurse in the community and you have been asked to go and dress Mrs Smith's legs for the second time this week due to leaky legs.

▪ Mrs Smith is 83 and has carers x 4 per day; she walks with a Zimmer frame around her 1 bedroom ground floor flat. She doesn’t leave the flat

▪ When you visit Mrs Smith says she has been "out of puff" for the last week and her legs are more swollen. She says she is also finding it hard to walk to the toilet.

▪ She manages her own pills. Her medications are all over the place and Mrs Smith is a little hesitant about what she is taking.

▪ You notice incontinence pads in the corner of the room.

Past Medical History

▪Osteoarthritis, Diabetes Mellitus (type II)

▪COPD, Hypertension, CKD III,

▪Ex-smoker – 40 pack years

▪No Echo – no history of heart disease/failure/rhythm problems

Medications

▪ Adcal

▪ Alendronic Acid

▪ Amlodipine

▪ Metformin

▪ Furosemide 40 mg – has been on this for 1 year due to swollen ankles and breathlessness

▪ Co-codamol 30/500 mg QDS, PRN

▪ OTC medications – Ibuprofen 400 mg prn for her arthritis

Feedback any suggestions for action/treatment

▪Consider:

▪assessment,

▪investigations and

▪referrals

Plan

▪ Advise to take the furosemide as prescibed

▪ Educate why she needs them

▪ Refer to incontinence nurse

▪ Ask GP to review and do U&E and NT pro BNP

▪ Refer to Diagnostic HF clinic if NT pro BNP raised

▪ If she has heart failure then:

▪ Restrict fluid intake to 1.5 litres daily

▪ Daily weight recording

Scenario 2 IN-PATIENT SETTING

• He was admitted to AMU, but was transferred to a medical ward who want to discharge him.

• His Bumetanide 2 mg BD was stopped on admission and he was on 80 mg IV Furosemide BD, lost 3

kg since admission.

• Changing to orals as responding, weight increased by 1kg on oral furosemide 80mg BD

• Mr White is not known to the heart failure service.

• He is mobile and independent. Lives with wife and has 2 children visit regularly and live nearby.

• Mr White would like to go home, he is worried his wife will not tend to his tomatoes in the greenhouse

properly and his dog is missing him.

Mr White is 73 and was admitted 2 days ago due to increased shortness of breath over the weekend. He has a one month history of leg swelling.

Past Medical History Medications

▪ Echo – Severe LVSD and moderate RVSD– 2012

▪ IHD, CABG – 1998

▪ Hypertension

▪ AF

▪ CKD III

▪ Ex-smoker – stopped 48 years ago

▪ Bumetanide 2 mg BD – switched to IV furosemide 80 mg BD

▪ Bisoprolol 10 mg OD

▪ Doxazosin 8 mg OD

▪ Spironolactone 12.5 mg OD

▪ Warfarin as per INR and on the instructions of the anticoagulant clinic (stable)

▪ Paracetamol PRN

Examination and findings 1

▪ Weight 86 kg (Mr White weighs himself weekly at home and states it has increased by at least 1 and half stones (10 kg) in the last month).

▪ Blood Pressure 105/65 mmHg (sitting)

98/57 mmHg (standing)

Feels dizzy on standing, but no loss of consciousness or falls

▪ Pulse 93 bpm – irregular (LBBB, QRS 166 ms)

▪ JVP Visible at jaw

▪ Oedema Moderate/severe oedema to upper thigh

Sacral oedema

Abdomen soft non-tender, but feels more swollen than normal

▪ Chest Quiet bases, Oxygen saturations 93% on air, apyrexial

Examination and findings 2

▪ Sodium: 136

▪ Potassium: 4.5

▪ Urea: 10.6 (n 8.0)

▪ Cr: 130 (n 110)

▪ eGFR 42

▪ Normal LFT’s and albumin

▪ Hb 97

▪ Normal WCC,

▪ CRP 12.4 (raised a bit)

▪ Normal thyroid function

▪ ECG- QRS 166ms (broad) LBBB

▪ Admission chest X ray- small bilateral pleural effusions

Feedback any suggestions for action/treatment

▪Consider:

▪assessment,

▪investigations and

▪referrals

Plan

▪ Refer to HFSN

▪ Stop Doxazosin

▪ Start ramipril 1.25mg on

▪ Daily weights

▪ Restrict fluid to 1.5 litres daily

▪ Check haematinics/iron stores

▪ HFSN to review for Ambulatory HF unit

▪ HF MDT

▪ HFSN clinic booked

▪ Up-titration of ACE inhibitor

▪ Up-titrate spironolactone

▪ DNACPR and ceiling of care

▪ Consider IV Ferinject

▪ Sacubitril/Valsartan

▪ CRT (P/D)