Heart Failure:Interactive Fundamental

Clinical Reasoning ActivityDara Lanman, MSN, RN, CNE

Assistant ProfessorGalen College of Nursing, Louisville, KY

You have been assigned to your patient this am and have been given report. Go to the Patient’s chart and review the most recent information regarding this patient.

Go to patient’s room

Patient’s Chart

Go to end of scenario questions

Patient’s Chart (click on what you want to review in your patient’s chart.)

Vital Signs

Patient History

Diagnostic Tests

Physician Orders

MAR

Patient History

Patient’s Chart

Main

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. 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.

PMH: heart failure, HTN, hyperlipidemia, CAD, MI, DM – type II

Diagnostic Tests:

Main

Patient’s Chart

Today Yesterday

Creatinine 2.1 1.2

Potassium 5.1 4.2

CXR: diffuse infiltrates consistent with pulmonary edema

Echocardiogram:Current ejection fraction is 30% with the most recent ejection fraction at 45%

HR RR Lung Sounds

BP Pulse Ox

0700 126 - regular

28 labored

Crackles 184/108 90% 2LNC

Main

Patient’s Chart

Main

Patient’s Chart

Physician Orders:Titrate oxygen for O2 sats >92%Insert Foley CatheterFurosemide 40 mg one time IV pushContinue home meds

Medication 0700-1500 1500-2300 2300-0700

Furosemide (Lasix)

090040 mg one time IV push

Simvastatin 0900 20 mg po daily

Glyburide 0900 10 mg po daily

HCTZ 090050 mg po daily

Lisinopril 090020 mg po daily

ASA 130081 mg po daily

Fish oil 13001000 mg po 2 tabs daily

Lasix HOLD TODAY40 mg po daily Main Patient’s Chart

Click on the drug to the left and you will be linked to a PDR for reference!

Neuro

Click on the buttons below to find out your assessment information.

Cardiac/Respiratory

GI /GU

Misc

Click on the buttons below to find out your assessment information.

Anxious, Alert & Oriented X4Temp 98.4

Cardiac/Respiratory

GI /GU

Misc

Click on the buttons below to find out your assessment information.

Cardiac – pale, cool to the touch, Pulses 2+ throughout, 2-3+ pitting edema lower extremitiesResp – course crackles scattered throughout both lung fields. Labored respiratory effort

Neuro

GI /GU

Misc

Click on the buttons below to find out your assessment information.

GI – Active bowel sounds in all 4 quads. Abd. Soft/non-tenderGU – Voiding without difficulty, urine clear/yellow

Neuro

Cardiac/Respiratory Misc

Click on the buttons below to find out your assessment information.

MISC- denies pain, skin integrity intact

First Question

Patient’s Chart

Main

Cardiac/Respiratory

Neuro

GI /GU

What is the relationship of your patient’s past medical history (PMH) and current medications? (Which medication treats which disease?)

On the next several slides, you will have some questions. Complete these questions and submit to your instructor per the instructions of your educator.

PMH: Heart failure 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 Lasix 40 mg po daily

Next Question

Patient’s Chart

Main

One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, in your patient (if applicable) which disease likely developed first that then initiated a “domino effect” in their life? (Refer to the list of PMH listed for you in the patient history portion of the chart.

What came first:

What then followed:

Next Question

Patient’s Chart

Main

What is the relationship of your patient’s PMH and current chief complaint? What prior medical history above is relevant and likely influenced his current problem and chief complaint? Explain your rationale

Relevant PMH Rationale:

Next Question

Patient’s Chart

Main

What is the relationship between your patient’s chief complaint & identified primary medical problem? (look at pathophysiology and how it influences what you are seeing with your assessment findings)

Chief Complaint: 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 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.

Relationship to primary medical problem:

Next Question

Patient’s Chart

Main

What is the relationship between your patient’s abnormal VS and assessment data & identified primary medical problem?

RELEVANT VS/assessment data:

Relationship to primary medical problem:

Next Question

Patient’s Chart

Main

What is the relationship between your patient’s RELEVANT abnormal diagnostic labs& identified primary medical problem?

RELEVANT Diagnostic results:

Relationship to primary medical problem:

Next Question

Patient’s Chart

Main

What is the relationship between the following physician orders/meds and your patient’s primary medical problem? (how will mech. of action of these meds/treatments impact this patient at a pathophys level to help resolve his primary problem?)

Physician orders:

Titrate oxygen for O2 sats >92%

Foley catheter

Furosemide (Lasix) 40mg IV push

How it will help resolve primary problem:

Next Question

Patient’s Chart

Main

What is the relationship between your patient’s RELEVANT abnormal diagnostic labs& identified primary medical problem?

RELEVANT Diagnostic results:

Relationship to primary medical problem:

Next Question

Patient’s Chart

Main

You have completed this scenario. Thank you for your hard work.