STUDENT-HF-ARF Unfolding Reasoning

STUDENT-HF-ARF Unfolding Reasoning

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

UNFOLDING Reasoning Case Study: STUDENT

History of Present Problem:

Heart Failure

© 2016 Keith Rischer/www.KeithRN.com

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more withdrawn since her husband of 52 years died unexpectedly three months ago from a myocardial infarction.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

1)prev MI

2)systolic heart failure secondary to ischemic

cardiomyopathy EF 15%

3)SOB at rest the last 3 days

4)weight gain 6lbs the last 3 days

5)edema to BLE

1)damage to her heart causing it to not function properly

2)heart failure and low EF mean the heart isn’t able to pump and meet the

demands of her body

3)evident body isn’t receiving what it needs and possibility of fluid on her

lungs

4)evidence of fluid buildup and worsening heart failure

5)evidence of worsening heart failure

RELEVANT Data from Social History: Clinical Significance:

1)previously active lifestyle but not so much

lately due to prog HF

2)depression for the last 2 yrs

3)isolation since husbands unexpected death

from MI

1)sedentary lifestyle not healthy for the heart

2)depression has an overall effect on the body

3)no support system

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

1)NSAID

2)beta blacker

3)ACE inhibitor

4)lipid lowering agent

5)vasodilator

6)diuretic

7)electrolyte

8)anticoagulant

9)sulfonylureas

1)no complications

involving blood clots

2)lower BP and prevent

death after MI

3)lower BP by relaxing

vessels and help prevent

death following MI

4)lower cholesterol

5)lowers BP by relaxing

vessels

6)rid body of fluid buildup

r/t HF

7)help heart function

following MI

8)no clotting issues

9)maintain normal glucose

levels

© 2016 Keith Rischer/www.KeithRN.com

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