Circulation (Perfusion)

Heart Failure Clinical Reasoning Case Study

Case Study 2

Carlos Boccerini , 68 years old

Overview

This case study is a common presentation seen by the nurse in clinical practice:

Acute Coronary Syndrome

Concepts

Gas Exchange

Infection

Acid-Base Balance

Thermoregulation

Clinical Judgment

Pain

Acute Coronary Syndrome

I. Data Collection

History of Present Problem:

Carlos Boccerini is a 68-year-old male who has a 5-year history of systolic heart failure secondary to ischemic

cardiomyopathy with a current ejection fraction (EF) of only 15%. He presents to the emergency department (ED) for

shortness of breath (SOB) the past 3 days. His shortness of breath has progressed from SOB with activity to becoming

SOB at rest. The last two nights he had to sleep in his recliner chair to rest comfortably with his head partially elevated.

He is able to speak only a partial sentence and then has to take a breath when talking to the nurse. He has noted increased

swelling in his lower legs and has gained 6 pounds in the last 3 days. He is being transferred from the ED to the cardiac

step-down where you are assigned to care for him.

Personal/Social History:

Carlos has been married for 45 years and has 4 children. He is a retired baker who had to retire early due to medical

problems secondary to his progressive heart failure. The family celebrated two birthdays this week and Jim made it to both

parties. His wife does most of the cooking at home and follows his need for sodium restrictions, but during the

celebrations, Carlos made his own dietary choices.

DATA

Radiology Reports:

Results: Clinical Significance:

Bilateral diffuse

pulmonary infiltrates

consistent with

pulmonary edema

Results indicate fluid like substance within the lungs which correlates to the

diagnosis of pulmonary edema with possible left sided heart failure