Heart Failure Case Study (45 min)
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Outline
Mr. Jones, a 69-year old male, presents to the Emergency Department (ED) after visiting his primary physician complaining of general fatigue for 4 days, shortness of breath, and abdominal discomfort. Mr. Jones’s medical history includes hypertension and coronary artery disease. He had a previous 90% LAD blockage and 50% RCA blockage with stent placements in both.
What initial nursing assessments need to be performed for Mr. Jones?
What diagnostic tests do you anticipate being ordered by the provider?
Upon further assessment, the patient has crackles bilaterally and tachycardia. A chest X-ray shows cardiomegaly and bilateral pulmonary edema. An ECG revealed atrial fibrillation. His vital signs were as follows:
BP 150/72 mmHg Urine Yellow and Cloudy
HR 102-123 bpm and irregular BUN 17 mg/dL
RR 24-32 bpm Cr 1.2 mg/dL
Temp 37.3°C H/H 11.8 g/dL / 36.2%
Ht 175 cm LDH 705 U/L
Wt 79 kg ** BNP 843 pg/mL
Mr. Jones was admitted to the cardiac telemetry unit.
Mr. Jones states that this weight is approximately 3 kg more than it was 3 days ago.
What is the significance of Mr. Jones' weight gain?
What medications do you anticipate the provider ordering for Mr. Jones? Why?
About three hours after admission to the telemetry unit, Mr. Jones’s skin becomes cool and clammy. His respirations are labored and he is complaining of abdominal pain. Upon physical examination, Mr. Jones is diaphoretic and gasping for air, with jugular venous distension, bilateral crackles, and an expiratory wheeze. His SpO2 is 88% on room air and it was noted that his urine output had been approximately 20 mL/hr since admission. His BP is 190/100 mmHg, HR 130 bpm and irregular, RR 43 bpm.
What nursing interventions should you perform right away for Mr. Jones?
Describe what is happening to Mr. Jones physiologically.
What medications should be given to decrease Mr. Jones’s preload? Improve his contractility? Decrease his afterload?
Mr. Jones was transferred to the CCU for hemodynamic monitoring and aggressive therapy. His Central Venous Pressure (CVP) was found to be 19 mmHg, Cardiac Output was 4.5 L/min, Cardiac Index was 2.3 L/min/m2. He has been placed in high-fowler’s position, and his SpO2 is now 96% on 4L nasal cannula. Mr. Jones received Furosemide 80 mg IV and Digoxin 0.5 mg IV.
What is the expected outcome of administration of Furosemide? Digoxin?
References
Melander, S. (2004). Case studies in critical care nursing: A guide for application and review, 3rd ed. Philadelphia, PA: Saunders Elsevier.
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Nursing Case Studies
This nursing case study course is designed to help nursing students build critical thinking. Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process. To help you increase your nursing clinical judgement (critical thinking), each case study includes answers laid out by Blooms Taxonomy to help you see that you are progressing to clinical analysis.
We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs. If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding. In the end, that is what nursing case studies are all about – growing in your clinical judgement.
