Heart Failure: Interactive Fundamental Clinical Reasoning Activity Dara Lanman, MSN, RN, CNE Assistant Professor Galen College of Nursing, Louisville, KY

Go to end of scenario questions You have been assigned to your patient this am and have been given report. Go to the Patient’s chart and review the most recent information regarding this patient. Patient’s Chart Go to patient’s room Go to end of scenario questions

Patient’s Chart (click on what you want to review in your patient’s chart.) Patient History Physician Orders Vital Signs Diagnostic Tests MAR

Patient History It has now been 3 years since Mr. Kelly has been discharged from the hospital for CAD & MI. He is now 56 years old. He has not had any recurrent CP, but has had to sleep with 3 pillows to keep from becoming SOB at night the last 2 weeks. He has had difficulty getting his shoes on the last month because of increased swelling around his ankles. He forgets to take his medications every day. He weighs himself once a week and today his weight has increased from 255 lbs. to 264 lbs. the last 7 days. He makes an appt. through his clinic when he becomes concerned that he is now becoming SOB at rest and is more fatigued. The clinic physician recognizes that he will need acute inpatient care and coordinates a direct admission to the hospital by EMS. PMH: heart failure, HTN, hyperlipidemia, CAD, MI, DM – type II Main Patient’s Chart

CXR: diffuse infiltrates consistent with pulmonary edema Diagnostic Tests: Today Yesterday Creatinine 2.1 1.2 Potassium 5.1 4.2 CXR: diffuse infiltrates consistent with pulmonary edema Echocardiogram: Current ejection fraction is 30% with the most recent ejection fraction at 45% Main Patient’s Chart

HR RR Lung Sounds BP Pulse Ox 0700 126 - regular 28 labored Crackles 184/108 90% 2LNC Main Patient’s Chart

Physician Orders: Titrate oxygen for O2 sats >92% Insert Foley Catheter Furosemide 40 mg one time IV push Continue home meds Main Patient’s Chart

Medication 0700-1500 1500-2300 2300-0700 Furosemide (Lasix) 0900 40 mg one time IV push Simvastatin 20 mg po daily Glyburide 10 mg po daily HCTZ 50 mg po daily Lisinopril ASA 1300 81 mg po daily Fish oil 1000 mg po 2 tabs daily Lasix HOLD TODAY 40 mg po daily Click on the drug to the left and you will be linked to a PDR for reference! Main Patient’s Chart

Click on the buttons below to find out your assessment information. Neuro GI / GU Cardiac/ Respiratory Misc

Click on the buttons below to find out your assessment information. Anxious, Alert & Oriented X4 Temp 98.4 GI / GU Cardiac/ Respiratory Misc

Click on the buttons below to find out your assessment information. Neuro Cardiac – pale, cool to the touch, Pulses 2+ throughout, 2-3+ pitting edema lower extremities Resp – course crackles scattered throughout both lung fields. Labored respiratory effort GI / GU Misc

Click on the buttons below to find out your assessment information. Neuro GI – Active bowel sounds in all 4 quads. Abd. Soft/non-tender GU – Voiding without difficulty, urine clear/yellow Cardiac/ Respiratory Misc

Click on the buttons below to find out your assessment information. Neuro MISC- denies pain, skin integrity intact GI / GU Cardiac/ Respiratory Main Patient’s Chart First Question

On the next several slides, you will have some questions On the next several slides, you will have some questions. Complete these questions and submit to your instructor per the instructions of your educator. What is the relationship of your patient’s past medical history (PMH) and current medications? (Which medication treats which disease?) PMH: Heart failure HTN Hyperlipidemia CAD MI DM-type II Home Medications: Simvastatin 20 mg po daily Glyburide 10 mg po daily HCTZ 50 mg po daily Lisinopril 20 mg po daily ASA 81 mg po daily Fish oil 1000 mg po 2 tabs daily Lasix 40 mg po daily Main Patient’s Chart Next Question

One disease process often influences the development of other illnesses. Based on your knowledge of pathophysiology, in your patient (if applicable) which disease likely developed first that then initiated a “domino effect” in their life? (Refer to the list of PMH listed for you in the patient history portion of the chart. What came first: What then followed: Main Patient’s Chart Next Question

What is the relationship of your patient’s PMH and current chief complaint? What prior medical history above is relevant and likely influenced his current problem and chief complaint? Explain your rationale Relevant PMH Rationale: Main Patient’s Chart Next Question

What is the relationship between your patient’s chief complaint & identified primary medical problem? (look at pathophysiology and how it influences what you are seeing with your assessment findings) Chief Complaint:  Has had to sleep with 3 pillows to keep from becoming SOB at night the last 2 weeks.  He has had difficulty getting his shoes on the last month because of increased swelling around his ankles.  He weighs himself once a week and today his weight has increased from 255 lbs. to 264 lbs. the last 7 days.  He makes an appt. through his clinic when he becomes concerned that he is now becoming SOB at rest and is more fatigued. Relationship to primary medical problem: Main Patient’s Chart Next Question

What is the relationship between your patient’s abnormal VS and assessment data & identified primary medical problem? RELEVANT VS/assessment data: Relationship to primary medical problem: Main Patient’s Chart Next Question

What is the relationship between your patient’s RELEVANT abnormal diagnostic labs& identified primary medical problem? RELEVANT Diagnostic results: Relationship to primary medical problem: Main Patient’s Chart Next Question

What is the relationship between the following physician orders/meds and your patient’s primary medical problem? (how will mech. of action of these meds/treatments impact this patient at a pathophys level to help resolve his primary problem?) Physician orders: Titrate oxygen for O2 sats >92% Foley catheter Furosemide (Lasix) 40mg IV push How it will help resolve primary problem: Main Patient’s Chart Next Question

What is the relationship between your patient’s RELEVANT abnormal diagnostic labs& identified primary medical problem? RELEVANT Diagnostic results: Relationship to primary medical problem: Main Patient’s Chart Next Question

You have completed this scenario. Thank you for your hard work.