Chronic Heart Failure ExacerbationPNCI - LearnerIvan EmotoAge: 67Weight: 100 kgLocation: Medical-Surgical UnitBackgroundPatient HistoryPast Medical History: Chronic heart failure for past 6 years. Had an inguinal hernia repair 15 years agoAllergies: Penicillin, cephalosporin and midazolamMedications: States he is on several water pills and heart pills but doesnt know their names and didnt bring them to the hospital. His neighbor states he will bring the patients bottles of medicine from home later. Per his pharmacy, his prescribed medications include furosemide 20 mg daily, potassium 20 mEq daily and metoprolol 100 mg dailyCode Status: Full codeSocial/Family History: The patient is a veteran who retired from the United States Navy as a Chief Petty Ofcer 16 years ago. After military service, he worked as a bookkeeper at the local box factory. He retired 16 months ago after his wife was diagnosed with Alzheimers disease. He is the sole caregiver for his 70-year-old wife, who has mild Alzheimers with moderate cognitive decline. They have three grown sons who live out of stateHandof ReportSituation:The patient is a 67-year-old male with a history of chronic heart failure who is being admitted directly to the Medical-Surgical Unit. He called his healthcare provider this morning complaining of increasing shortness of breath, fatigue and swelling in his ankles and feet. He states the shortness of breath is worse, especially at night and with walking. He reported a recent weight gain and stated he had not been taking all of his prescribed medications. A neighbor brought him to the hospital to be admitted. Admission orders have been written and are on the chart. He is awake, alert and anxious. His neighbor is at the bedside.Background:The patients primary diagnosis is chronic heart failure exacerbation. Upon questioning the patient about the events leading up to this morning, he stated he did not take his water pill for the last fve days because his wifes ankles were swollen and he gave the pills to her. He also admitted to being out of one of his heart pills but cannot remember which one. He states he is on several heart medications. HeProgram for Nursing Curriculum Integration (PNCI)1 2012 CAE Healthcare, Sarasota, FL v.5Chronic Heart Failure ExacerbationPNCI - LearnerHandof Report Continueddid not bring any of his medications with him. A physical examination revealed mild respiratory distress and edema of the ankles and feet. The 12-lead ECG revealed sinus tachycardia without ectopy. His chest x-ray and echocardiogram showed cardiomegaly with perihilar infltrates.Assessment:Vital signs: HR 100, BP 158/100, RR 32, SpO2 is 94% on room air, Temperature 36.8C General Appearance: Cachectic and anxious. Appears older than stated age Cardiovascular: Sinus tachycardia. Circumoral and peripheralCyanosis. Pedal pulses difcult to palpate. Bilateral peripheral edema in lower extremities 3+ Respiratory: Crackles in lower lung feldsGI: Active bowel sounds, poor appetite GU: Has not voided since arrivalExtremities: Movement is weak in all four extremities (3+) Skin: Cool, dry and pale, with poor turgorNeurological: Alert and oriented to person, place and time. Pupils equal, round and reactive to light and accommodation. No neurological defcitsIVs: 20-gauge IV to saline lock in the right arm, patent and non-reddened Labs: Admission lab results are pendingFall Risk: High riskPain: Denies painRecommendations:Complete admission orders and monitor for instability.Program for Nursing Curriculum Integration (PNCI)2 2012 CAE Healthcare, Sarasota, FL v.5Chronic Heart Failure ExacerbationPNCI - LearnerOrdersInitial Healthcare Providers Orders:Admit to Medical-Surgical UnitDiagnosis: Chronic heart failure exacerbation Full codeSodium-controlled dietFluid restriction of 1000 mL per day Bathroom privileges with assistance Vital signs every 4 hoursDaily weightsNotify healthcare provider of heart rate less than 60 or greater than 120, development of arrhythmias, SpO2 less than 95% or acute changesTelemetry monitoring Continuous pulse oximetryOxygen at 2 to 5 LPM per nasal cannula Incentive spirometry every 4 hours while awake Saline lockDigoxin 0.25 mg PO dailyCaptopril 12.5 mg PO 3 times per day Metoprolol 25 mg PO 2 times per day Furosemide 40 mg PO 2 times per day Potassium 20 mEq PO 2 times per day Docusate sodium 100 mg PO dailyNitroglycerin 0.4 mg sublingual prn every 5 minutes up to 3 doses for chest pain Morphine sulfate 2 mg IV, 1 dose prn for unrelieved chest pain (notify healthcare provider) Sequential compression devices (SCDs) while in bedLabs to be done NOW: CBC, basic metabolic panel, partial thromboplastin time and activated partial thromboplastin time, prothrombin time, magnesium, urinalysis, troponins and arterial blood gases Echocardiogram NOWElectrocardiogram 12-lead NOWChest x-ray: Posteroanterior and lateral views NOW Intake and output every shiftProgram for Nursing Curriculum Integration (PNCI)3 2012 CAE Healthcare, Sarasota, FL v.5Chronic Heart Failure ExacerbationPNCI - LearnerPreparationLearning Objectivest Describes the pathophysiologic changes that result in right-sided heart failure and left-sided heart failure (REMEMBERING)t Uses history information and assessment data to plan and provide care for the patient with acute exacerbation of chronic heart failure (APPLYING)t Anticipates diagnostic orders and therapies, including medications, for the patient with acute exacerbation of chronic heart failure (UNDERSTANDING)t Evaluates efectiveness of treatment plan and revises as necessary (EVALUATING)Recommended eDose modules for learners to complete before the SCE:Medication Dosage Calculation SkillsX Medication Orders & S. I. UnitsX Tablets & CapsulesX Liquid MedicinesInjectionsI.V. InfusionsInjectable Medicines TherapyX Slow I.V. InjectionsIntermittent InfusionsContinuous InfusionsPediatricsThis SCE addresses the following QSEN Competencies:X Patient-Centered CareX Teamwork and CollaborationX Evidence-Based PracticeX Quality ImprovementX Safety Informatics Program for Nursing Curriculum Integration (PNCI)4 2012 CAE Healthcare, Sarasota, FL v.5Chronic Heart Failure ExacerbationPNCI - LearnerPreparation QuestionsList the risk factors for chronic left-sided heart failure related to coronary artery disease. Explain the cause of the compensations for chronic heart failure.Describe the manifestations and efects of right-sided and left-sided heart failure. t List the goals in the interdisciplinary care of a patient with chronic heart failure.List the two hormones released by the heart muscle in response to changes in blood volume. t Explain the nursing implications for the client receiving echocardiography with Doppler fowstudies.t Defne refractory heart failure.t List the nursing implications and education needs for each of the following categories of medication related to heart failure:o Angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB) o Beta-adrenergic receptor blockerso Diureticso Positive inotrope agents o Sympathomimetic agentso Phosphodiesterase inhibitorst List the interdisciplinary interventions for each of the following nursing diagnoses related to chronic heart failure.o Decreased cardiac output o Excessive fuid volumeo Activity intoleranceo Inefective health maintenance o Defcient community healtht List the signs and explain the interdisciplinary interventions for each of the following nursing diagnoses related to pulmonary edema.t Impaired gas exchange t Decreased cardiac output t AnxietyProgram for Nursing Curriculum Integration (PNCI)5 2012 CAE Healthcare, Sarasota, FL v.5Chronic Heart Failure ExacerbationPNCI - LearnerReferencesAckley, B.J., & Ladwig, G.B. 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(2009). 2009 Focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults: A report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines: Developed in collaboration with the International Society for Heart and Lung Transplantation. Journal of the American College of Cardiology, 53, 1-90. doi:10.1016/j.jacc.2008.11.013Johnson-Russell, J. (2010). Facilitated debriefing. In W.M. Nehring & F.R. Lashely (Eds.), High fidelity patient simulation in nursing education, pp. 369-385. Sudbury, MA: Jones and Bartlett.Leff, B., Burton, L., Mader, S., Naughton, B., Burl, J., Greenough, W., . . . Steinwachs, D. (2009). Comparison of functional outcomes associated with hospital at home care and traditional acute hospital care. Journal of the American Geriatrics Society, 57(2), 273-278. doi:10.1111/j.1532-5415.2008.02103.xLewis, S.L., Dirkse, S.R., Heitkemper, M.M., & Bucher, L. (2011). Medical-surgical nursing: Assessment and management of clinical problems (8th ed.). St. Louis, MO: Elsevier Mosby.Lindenfeld, J., Albert, N.M., Boehmer, J.P., Collins, S.P., Ezekowitz, J.A., Givertz, M.M., . . . Walsh, M.N. (2010). Executive summary: HFSA 2010 comprehensive heart failure practice guideline. Journal of Cardiac Failure, 16(6), 475-539. doi:10.1016/j.cardfail.2010.04.005Lockwood, C., Conroy-Hiller, T., & Page, T. (2004). Vital signs. International Journal of Evidence-Based Healthcare, 2(6), 207-230. doi:10.1111/j.1479-6988.2004.00012.xMelnyk, B.M., & Fineout-Overholt, E. (2010). Evidence-based practice in nursing & healthcare: A guide to best practice (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.National Council of State Boards of Nursing. (2010). 2010 NCLEX-RN test plan. Retrieved from https:// www.ncsbn.org/2010_NCLEX_RN_Testplan.pdfQuality and Safety Education for Nurses. (2011). Quality and safety competencies. Retrieved July 6, 2011 from http://www.qsen.org/competencies.phpRodriguez, K., Appelt, C., Switzer, G., Sonel, A., & Arnold, R. (2008). Veterans decision-making preferences and perceived involvement in care for chronic heart failure. Heart & Lung, 37(6), 440-448. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18992627Sanders, T., Harrison, S., & Checkland, K. (2010). Personalizing protocol-driven care: The case of specialist heart failure nurses. Journal of Advanced Nursing, 66(9), 1937-1945. doi:10.1111/j.1365-2648.2010.05368.xThe Joint Commission. (2012). National patient safety goals. Retrieved January 26, 2012 from http:// www.jointcommission.org/standards_information/npsgs.aspxProgram for Nursing Curriculum Integration (PNCI)7 2012 CAE Healthcare, Sarasota, FL v.5Chronic Heart Failure ExacerbationPNCI - LearnerReferences ContinuedThomas, S., Chapa, D., Friedmann, E., Durden, C., Ross, A., Lee, M., & Lee, H.J. (2008). Depression in patients with heart failure: Prevalence, pathophysiological mechanisms, and treatment. Critical Care Nurse, 28(2), 40.Washburn, S., & Horneberger, C. (2008). Nurse educator guidelines for the management of heart failure. Journal of Continuing Education in Nursing, 39(6), 263-267. doi:10.3928/00220124-20080601-10Wilson, B., Shannon, M., & Shields, K. (2010). Pearson Nurses Drug Guide 2010. New York, NY: Pearson Education Inc.AuthorsThomas J. Doyle, CAE Healthcare - Sarasota, FL. Reviewed by Margaret Peters, Texas Womans University - Dallas, TX, and Christie Schrotberger, Diane Mathe, Lynde Rabine, Gwen Leigh and Donna Walls, CAE Healthcare - Sarasota, FL, 2012Program for Nursing Curriculum Integration (PNCI)8 2012 CAE Healthcare, Sarasota, FL v.5