Gas ExchangeFluid and Electrolyte BalanceClinical JudgmentPatient EducationCommunicationCollaboration
UNFOLDING Reasoning Case Study: STUDENT
History of Present Problem:
Heart Failure
5. Vasodilator.
6. Diuretic
7. Electrolyte replacement
8. Anticoagulant
9. Anti diabetic.
5. Decreases blood pressure.
6. Decreases fluid overload.
7. Increases serum potassium
8. Blood thinner, decreases chances of clot formation
9. Treats diabetes, control blood sugar.
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 She has struggled with depression the past two years and has been more withdrawn since her husband of 52 years died unexpectedly three months ago from a myocardial infarction.
72 yrs old female patient with the history of MI 4 yrs ago and systolic heart failure secondary to ischemic cardiomyopathy with current EF of 15 %. Pt presented to ED with SOB, progressed from SOB with activity to becoming SOB at rest. Able to speak in partial sentences.. Pt gained 6 lbs in last 3 days and increased swelling in lower legs.
History of MI, EF of 15 % indicating heart having difficulty pumping blood out to the body. Wt gain and increased swelling to lower legs indicating fluid overload.
What data from the histories is RELEVANT and has clinical significance to the nurse?
RELEVANT Data from Present Problem:
Clinical Significance:
RELEVANT Data from Social History:
Clinical Significance:
Retired math teacher, depression, Widow, unable to maintain activities level.
Depression can be the cause of decreasing activity level and can lead to self isolation and affect enthusiasm to recover.
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
1. Antiplatelets.
2. Beta Blocker.
3. ACE inhibitor.
4. Cholesterol Lowering meds.
1. Decreases risks of clot formation.
2. Decreases blood pressure
3. Decreases blood pressure and makes it easy for heart to pump blood.
4. Decreases cholesterol levels.
(Which medication treats which condition? Put number next to PMH that connects to Medication)
PMH:
Home Meds:
Pharm. Classification:
Expected Outcome:
Diabetes Mellitus type II Hypertenson Artial afibrillation Hyperlipidemaia Chronic renal insufficency (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
ASA 81 mg PO dailyCarvedilol 3.25 mg PO dailyLisinopril 5 mg PO dailyEzetimide 10 mg PO dailyHydralazine 25 mg PO 4x dailyTorsemide 20 mg PO bidKCL 20 meq PO dailyWarfarin 5 mg PO dailyGlyburide 5 mg PO daily
What medications treat which conditions?
One disease process often influences the development of other illnesses. Based on your knowledge of
pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in her life?
Write what PMH problem likely started FIRST
Write what PMH problems(s) FOLLOWED as domino(s)
Patient Care Begins:
Current VS:
P-Q-R-S-T Pain Assessment (5th VS):
T: 98.6 F/37.0 C (oral)
Provoking/Palliative:
P: 92 (irregular)
Quality:
Denies Pain
R: 26 (regular)
Region/Radiation:
BP: 162/54 MAP: 90
Severity:
O2 sat: 90% (6 liters n/c)
Timing:
Pulse is 92 and irregular, respiration 26, B/P 162/64 and O2 sats 90% with 6 L via NC.
What VS data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data:
Clinical Significance:
Arrhythmia, elevated respiration and decreasing O2.
Current Assessment:
GENERAL APPEARANCE:
Appears anxious, restless
RESP:
Breath sounds have coarse crackles scattered throughout both lung fields ant/post, labored respiratory effort, patient sitting upright
CARDIAC:
Rhythm: atrial fibrillation, pale, cool to the touch, pulses palpable throughout, 3+ pitting edema lower extremities from knees down bilaterally, S3 gallop, irregular, no jugular venous distention (JVD) noted
NEURO:
Alert and oriented to person, place, time, and situation (x4)
GI:
Abdomen soft/nontender, bowel sounds audible per auscultation in all four quadrants
GU:
Voiding without difficulty, urine clear/yellow
SKIN:
Skin integrity intact, skin turgor elastic, no tenting present
Pt appears anxious, restless. Breath sounds have coarse crackles scattered throughout both lung fields ant/post, labored breathing effort. Rhythm: A-fib, pale, cool to touch, pulses palpable throughout 3+ pitting edema to BLE, S3 gallop, irregular, no JVD noted.
Pt is having Dyspnea which is causing anxiety. Fluid is backed up.
What assessment data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data:
Clinical Significance:
Cardiac Telemetry Strip:
Interpretation:
Atrial Fibrilation.
Clinical Significance:
QRS is not regular and T is not regular.
Radiology Reports: Chest x-ray
What diagnostic results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Results:
Clinical Significance:
Bilateral diffuse pulmonary infiltrates consistent with pulmonary edema
Pulmonary edema.
Lab Results:
Complete Blood Count (CBC):
Current:
High/Low/WNL?
Prior:
WBC (4.5-11.0 mm 3)
4.8
WNL
5.8
Hgb (12-16 g/dL)
12.9
WNL
13.2
Platelets (150-450x 103/µl)
228
WNL
202
Neutrophil % (42-72)
68
WNL
65
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
TREND:Improve/Worsening/Stable:
WNL
N/A
WNL
Basic Metabolic Panel (BMP):
Current:
High/Low/WNL?
Prior:
Sodium (135-145 mEq/L)
133
LOW
138
Potassium (3.5-5.0 mEq/L)
4.9
WNL
4.2
Glucose (70-110 mg/dL)
105
WNL
118
Creatinine (0.6-1.2 mg/dL)
2.9
HIGH
2.2
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANTLab(s):
Clinical Significance:
TREND: Improve/Worsening/Stable:
Creatinine Sodium
Kidney function slightly worse than baseline. Slight Hyponatremia.
Creatinine lab value worsening. Worsening.
Misc. Chemistries:
Current:
High/Low/WNL?
Prior:
Magnesium (1.6-2.0 mEq/L)
1.9
wnl
1.8
PT/INR (0.9-1.1 nmol/L)
2.5
High
2.4
Whatlab results are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Lab(s):
Clinical Significance:
TREND: Improve/Worsening/Stable:
PT/INR
Slow Coagulation.
Worsening.
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
Cardiac Labs:
Current:
High/Low/WNL?
Prior:
Troponin (<0.05 ng/mL)
0.10
0.12
BNP (B-natriuretic Peptide) (<100 ng/L)
1855
155
RELEVANT Lab(s):
Clinical Significance:
TREND: Improve/Worsening/Stable:
Troponin BNP
Possible MI Sign of Heart failure.
Improving Worsening
>2
Worsening kidney function can lead to Kidney failure.
Monitor and record I&O.Monitor BUN, creatinine, urine specific gravity. Administer meds as ordered.
Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
Lab:
Normal Value:
Clinical Significance:
Nursing Assessments/Interventions Required:
Creatinine Value:2.9
Critical value:
Lab:
Normal Value:
Clinical Significance:
Nursing Assessments/Interventions Required:
BNPValue: 1855
Critical value:
>100 Indicates heart failure. Administer meds such as diuretic, betablockers, vasodilators, ACE inhibitors as ordered. Monitor BNP for signs of improvement or worsening HF, Administer O2 as ordered. Clinical Reasoning Begins…
Heart failure.
What is the primary problem that your patient is most likely presenting with?
The underlying cause of this primary problem is EF of 15 % due to cardiomyopathy caused by MI.
What is the underlying cause/pathophysiology of this primary problem?
Supplemental O2 administration. To remove build up fluid. Decreases chest pain, decreases blood pressure.. To record Intake and output to prevent wt gain or swelling. Helps with fluid therapy to control over fluid, control at gain. Sodium retain water and pt is receiving Diuretics.
O2 sats will remain 94-98%. Patient will have no edema. Chest pain will resolve. Swelling decreases. Decrease weight, better kidney function, decrease edema. Decrease blood pressure and fluid overload.
Collaborative Care: Medical Management
Care Provider Orders:
Rationale:
Expected Outcome:
Titrate oxygen to keep O2 sat >92% Furosemide 40 mg IV push Nitroglycerin IV drip: titrate to keep SBP <130 Strict I&O Fluid restriction of 2000 mL PO daily Low sodium diet
Titrate O2 sats >95%Nitro IV drip: titrate to keep SBP<130.Furosemide 40mg IV Push BIDStrict I&0Fluid restriction of 2000 ml PO QDLow Sodium Diet.
Airways and breathing takes priority to ensure patient is getting oxygen to keep heart pumping blood to the body. Nitro will lessen the workload in heart. Furosemide will remove fluids which will decreases edema. I&O, fluid restriction and low sodium diet can be implemented at the same time.
PRIORITY Setting: Which Orders Do You Implement First and Why?
Care Provider Orders:
Order of Priority:
Rationale:
Strict I&OTitrate oxygen to keep O2 sat >95%Furosemide (Lasix) 40 mg IV push bidNitroglycerin IV drip: titrate to keep SBP <130Fluid restriction of 2000 mL PO dailyLow sodium diet
Collaborative Care: Nursing
Maintain O2 sats 94-98 and decrease fluid overload.
What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY)
Administer O2 and monitor O2 sats.Weight pt daily and monitor Vitals.
To provide Oxygen to the body and checking O2 sats will tell how well blood is oxygenating.By checking daily weight, will tell us if diuretics are working well and removing the build up fluid from body and is having overfluid.
O2 sats will remain >95%.Edema will decrease.
What interventions will you initiate based on this priority?
Nursing Interventions:
Rationale:
Expected Outcome:
Cardiovascular system and respiratory system.
What body system(s) will you most thoroughly assess based on the primary/priority concern?
What is the worst possible/most likely complication to anticipate?
What nursing assessments will identify this complication EARLY if it develops?
What nursing interventions will you initiate if this complication develops?
What psychosocial needs will this patient and/or family likely have that will need to be addressed?
How can the nurse address these psychosocial needs?
Medication Dosage Calculation:
Medication/Dose:
Mechanism of Action:
Volume/time frame to Safely Administer:
NursingAssessment/Considerations:
Medication/Dose: Furosemide 40 mg IV push
.
IV Push: Volume every 15 sec?
Evaluation:
Evaluate the response of your patient to nursing and medical interventions during your shift. All orders have been implemented that are listed under medical management.
Four Hours Later…
Current VS:
Most Recent:
Current PQRST:
T: 98.4 F/36.9 C (oral)
T: 98.6 F/37 C (oral)
Provoking/Palliative:
P: 88 (irregular)
P: 82 (irregular)
Quality:
Denies pain
R: 24 (regular)
R: 26 (regular)
Region/Radiation:
BP: 112/50 MAP: 71
BP: 162/54 MAP: 90
Severity:
O2 sat: 91% (12 liters high flow n/c)
O2 sat: 90% (6 liters n/c)
Timing:
Current Assessment:
GENERAL APPEARANCE:
Not as anxious, but appears restless at times
RESP:
Coarse crackles scattered throughout both lung fields, labored respiratory effort
CARDIAC:
Rhythm: atrial fibrillation, pale, cool to the touch, pulses palpable throughout, 3+ pitting edema in lower extremities
NEURO:
Alert and oriented to person, place, time, and situation (x4)
GI:
Abdomen soft/nontender, bowel sounds audible per auscultation in all 4 quadrants
GU:
30 mL of urine out in the last 4 hours after furosemide IV given, 50 mL residual urine in bladder with bladder scan
SKIN:
Skin integrity intact
What clinical data is RELEVANT that must be recognized as clinically significant?
RELEVANT VS Data:
Clinical Significance:
RELEVANT Assessment Data:
Clinical Significance:
Has the status improved or not as expected to this point?
Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?
Based on your current evaluation, what are your nursing priorities and plan of care?
Your knowledge and application of the pathophysiology of heart failure and renal failure have allowed you to make a series of needed assessments and judgments that have facilitated the treatment and care of your patient. You recognize that an SBAR is needed to update the primary care provider with your concerns.
SBAR: Nurse-to-Primary Care Provider
Situation:
Name/age:BRIEF summary of primary problem:Day of admission/post-op #:
Background:
Primary problem/diagnosis:RELEVANT past medical history:
Assessment:
Most recent vital signs:RELEVANT body system nursing assessment data:RELEVANT lab values:INTERPRETATION ofcurrent clinical status (stable/ unstable/worsening):
Recommendation:
Suggestions to advance plan of care:
New Orders from Primary Care Provider:
Stat potassium, creatinine, arterial blood gases
Transfer to ICU
RESULTS:
Current
High/Low/WNL?
Most Recent
Potassium (3.5-5.0 mEq/L)
5.9
high
5.5
Creatinine (0.6-1.2 mg/dL)
3.5
high
2.7
RELEVANT Lab(s):
Clinical Significance:
TREND: Improve/Worsening/Stable:
Potassium
Arterial Blood Gas:
Current:
pH (7.35–7.45)
7.46
pCO2 (35–45)
30
pO2 (80–-100)
72
HCO3 (18–26)
22
O2 sat (>92%)
91%
RELEVANT Lab(s):
Clinical Significance:
pCO2 7.46 pH 7.46 O2 sats 91%
Measure of CO2 within arterial or venous blood. pH of 7.35-7.45 is requires for homeostais. >92% O2 sats needed for the organs to get enough supply via RBC’s to thrive.
Respiratory Alkalosis.
ABG Interpretation:
It is now the end of your shift. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, now finish strong and give the following SBAR report to the nurse who will be caring for this patient in ICU:
SBAR: Nurse-to-Nurse
Situation:
Name/age:BRIEF summary of primary problem:Day of admission/post-op #:
Background:
Primary problem/diagnosis: RELEVANT past medical history:
Assessment:
Most recent vital signs:RELEVANT body system nursing assessment data: RELEVANT lab values:TREND of any abnormal clinical data (stable-increasing/decreasing):INTERPRETATION of current clinical status (stable/unstable/worsening):
Recommendation:
Suggestions to advance plan of care:
Education Priorities/Discharge Planning
What will be the most important discharge/education priorities you will reinforce with the patient’s medical
condition to prevent future readmission with the same problem?
What are some practical ways you as the nurse can assess the effectiveness of your teaching with this patient?
Caring and the “Art” of Nursing
What is the patient likely experiencing/feeling right now in this situation?
What can you do to engage yourself with this patient’s experience, and show that she matters to you as a
Use Reflection to THINK Like a Nurse
Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention
in the moment as the events are unfolding to make a correct clinical judgment.
What did I learn from this scenario?
How can I use what has been learned from this scenario to improve patient care in the future?
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