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
Category | Exam (elaborations) |
Release date | 2021-10-08 |
Pages | 7 |
Language | English |
Comments | 0 |
Sales | 0 |
{{ userMessage }}