Heart Failure

JoAnn Smith, 72 years old

Primary Concept

Perfusion

Interrelated Concepts (In order of emphasis)

1. Gas Exchange

2. Fluid and Electrolyte Balance

3. Clinical Judgment

4. Patient Education

5. Communication

6. Collaboration

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UNFOLDING Reasoning Case Study: STUDENT

History of Present Problem:

Heart Failure

JoAnn Smith is a 72-year-old woman who has a history of myocardial infarction (MI) four years ago and systolic heart

failure secondary to ischemic cardiomyopathy with a current ejection fraction (EF) of only 15%. She presents to the

emergency department (ED) for shortness of breath (SOB) the past three days. Her shortness of breath has progressed

from SOB with activity to becoming SOB at rest. The last two nights she had to sleep in her recliner chair to rest

comfortably upright. She is able to speak only in partial sentences and then has to take a breath when talking to the nurse.

She has noted increased swelling in her lower legs and has gained six pounds in the last three days. She is being

transferred from the ED to the cardiac step-down where you are the nurse assigned to care for her.

Personal/Social History:

JoAnn is a retired math teacher who is unable to maintain the level of activity she has been accustomed to because of the

progression of her heart failure the past two years. She has struggled with depression the past two years and has been

more withdrawn since her husband of 52 years died unexpectedly three months ago from a myocardial infarction.

What data from the histories is RELEVANT and has clinical significance to the nurse?

RELEVANT Data from Present Problem: Clinical Significance:

MI four years ago,

increase shortness of breath at rest; can only

speak in partial sentences,

ischemic cardiomyopathy with EF of 15%

last two nights slept in recliner

increased swelling in lower legs

gained 6 pounds in last 3 days

MI is significant because it decreases heart function due to death of

myocardial muscle

EF of 15% shows that the heart is having a hard time pumping blood out to

rest of the body therefore starving it of oxygenated blood.

Weight gain and increased swelling signifies she is fluid overloaded and it

can be reason why she is having a hard time talking, breathing, being

active and why she has to sleep in a recliner the past 2 nights

RELEVANT Data from Social History: Clinical Significance:

Retired math teacher, recent widow, history of

depression, decreasing activity level

Depression might affect her enthusiasm to recover, to stick to a therapy

regimen

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?

(Which medication treats which condition? Draw lines to connect)

PMH: Home Meds: Pharm. Classification: Expected Outcome:

 Diabetes mellitus type II

 Hypertension

 Atrial fibrillation

 Hyperlipidemia

 Chronic renal insufficiency

(baseline creatinine 2.0)

 Cerebral vascular accident

(CVA) with no residual

deficits

 Heart failure (systolic)

secondary to ischemic

cardiomyopathy

 MI with stent x2 to LAD 4

years ago

1. ASA 81 mg PO daily

2. Carvedilol 3.25 mg PO

daily

3. Lisinopril 5 mg PO

daily

4. Ezetimide 10 mg PO

daily

5. Hydralazine 25 mg PO

4x daily

6. Torsemide 20 mg PO

bid

7. KCL 20 meq PO daily

8. Warfarin 5 mg PO daily

9. Glyburide 5 mg PO

daily

 Antiplatelets

 Beta blocker

 ACE inhibitor

 Cholesterol

medication

 Vasodilator

 Diuretic

 Electrolyte

replacement

 Anticoagulant

 Antidiabetic

 Decrease chance of

clot formation

 Decrease blood

pressure

 Decrease blood

pressure, helps with

heart failure,

decrease chance of

death from heart

attack

 Decrease

cholesterol

 Decrease blood

pressure

 Decrease swelling,

decrease fluid

overload

 Increase serum

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