# Heart Failure

UNFOLDING Reasoning Case Study: STUDENT

History of Present Problem:

# Heart Failure

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 She has struggled with depression the past two years and has been more withdrawn since her husband of 52 years died unexpectedly three months ago from a myocardial infarction.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?

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?

(Which medication treats which condition? Put number next to PMH that connects to Medication)

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:

What VS data is RELEVANT and must be recognized as clinically significant by the nurse?

What assessment data is RELEVANT and must be recognized as clinically significant by the nurse?

What diagnostic results are RELEVANT and must be recognized as clinically significant by the nurse?

Lab Results:

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

Lab Planning: Creating a Plan of Care with a PRIORITY Lab:

# >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…

What is the primary problem that your patient is most likely presenting with?

What is the underlying cause/pathophysiology of this primary problem?

Collaborative Care: Medical Management

PRIORITY Setting: Which Orders Do You Implement First and Why?

Collaborative Care: Nursing

What nursing priority(ies) will guide your plan of care? (if more than one-list in order of PRIORITY)

What interventions will you initiate based on this priority?

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?
1. How can the nurse address these psychosocial needs?

Medication Dosage Calculation:

# 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…

1. What clinical data is RELEVANT that must be recognized as clinically significant?
• 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

New Orders from Primary Care Provider:

• Stat potassium, creatinine, arterial blood gases
• Transfer to ICU

RESULTS:

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

# Education Priorities/Discharge Planning

1. 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

1. 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.

1. 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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