ࡱ> #` cbjbjmm 4Z3{{{8{dV}\&h~~~~~~~~$hhp=~~=~~R~~2~~ Pѥ{[.kh0\x74~LЀ~~~==~~~&&&CVjd&&&Vj^| Heart Failure Clinical Reasoning Case Study FACULTY KEY (answers in italics) Mr. Kelly Chief Complaint/History of Present Illness: 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 but does at least 4-5 times a week. 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 cooridinates a direct admission to the hospital by EMS. Past Medical History: 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 Social/personal history Lives alone in own home. He is divorced with three grown children. He has had to cut back working to only 4 hours a day as a mechanic because of fatigue and weakness since the first of the year. Mr. Kelly arrives to your telemetry unit You are the telemetry floor nurse and you have just received him as a direct admit. You review his history through the electronic medical record. The paramedics relate the above story of why he is being admitted. Current Status: Admission VS: T:98.4 P:126-regular R:28/labored BP:184/108 O2 sats:90% 2l per n/c Admission Nursing Assessment: CV: pale, cool to the touch. Pulses 2+ throughout. 2-3+ pitting edema lower extremities Resp: course crackles scattered throughout both lung fields. Labored resp. effort Neuro: anxious, a/o x4 GI/GU: WNL What data above is important and relevant that must be recognized as clinically significant to the nurse? HR 126-Pale cool to the touch 2-3+ pitting edema Coarse crackles in both lungs Rr/28-Labored resp effort 90% on RA Anxious Rationale: HR 126-Pale cool to the touchsympathetic nervous system stimulation to maintain cardiac outputremember CO=SVxHR 2-3+ pitting edemafluid volume overload with left sided HF transferring over and causing biventricular failure (both right and left failure) Coarse crackles in both lungsincreased hydrostatic pressure in pulmonary vessels due to left sided HF that results in fluid in the alveolar space Rr/28-Labored resp effortsee above 90% on RAsee above Anxious likely related to hypoxia and resp. distress sue to acute pulmonary edema secondary to HF Clinical Reasoning Begins Based on the data you have collected, what is your primary concern right now? In obvious resp distress that must be addressed but the UNDERLYING cause must be addressed in order to remedy this effectively. NEED TO IMMEDIATELY DECREASE THE WORKLOAD OF THE HEART by getting rid of excess fluid volume (reducing preload) What is the underlying rationale/patho of this concern? Fluid volume overload that must be immediately addressed as the heart is unable to indefinently maintain this pace as a tired pump. To accomplish this clinical objective need to reduce the cardiac output determinant of preload (volume reduction through diuresis) and lower afterload (systolic BP) to decrease the resistance that the LV needs to overcome to pump each contraction to the body. By lowering afterload and systolic BP you can immediately decrease the workload and stress of the heart. What medical or nursing interventions will you initiate based on this priority concern? Preload reduction-accomplished through aggressive diuresis-usually a loop diuretic such as Furosemide (Lasix) Afterload reduction-accomplished through medications that directly/indirectly lower systolic BP that can include Nitroglycerin gtt/or subl. or patch depending on severity. Nursing interventions will focus on the need for frequent assessment of response to these therapies including urine output, systolic BP and resp. assessment data. Is there any more nursing assessment data or information you need? A 12 lead EKG is essential to determine if current decompensation was influenced by another Acute MI or is primary heart failure What nursing diagnostic statement(s) will guide your plan of care? What will be your nursing interventions based on this concern? IMPAIRED GAS EXCHANGE increase O2 to to at least 4l and assess response Continually monitor O2 sats Frequently monitor RR and resp status place on cardiac monitor, ensure patency and adequacy of PIV EXCESS FLUID VOLUME Contact MD for SBARwhat is your recommendation to physician??? Consider foley catheter INEFFECTIVE CARDIAC TISSUE PERFUSION Monitor HR-BP closely-Need to watch AFTERLOAD and reduce!!! Need to decrease workload of the heart. In addition to Lasix what other meds are needed? NTG as a gtt ANXIETY Morphine or Ativan What is the worst possible complication to anticipate? Will continue to deteriorate and will require Bi-pap or possible intubation to prevent resp arrest What nursing assessment(s) will you need to initiate to identify and respond quickly if this complication develops? Assess RR and effort of breathing Assess HR and any dysrhythmias that may present or if tachycardia continues to be present Assess O2 sats and amount of oxygenation needed Assessment of breath sounds frequently Optional QSEN/National Patient Safety Goals Questions: What can you as the nurse do to demonstrate intentional caring and promote patient centered care with sensitivity and respect for your patient in the context of this clinical presentation? (QSEN-Patient Centered care) How can you as the nurse ensure and assess the effectiveness of communication with the patient and family? (QSEN-Patient Centered care) What simple steps must the nurse initiate to reduce the risk of any health care-associated infections while the patient is in the hospital? (2011 Hospital National Patient Safety Goals-#7) Foam in/foam out (frequent hand hygiene). Identify need for contact precautions based on prior documentation of MRSA, VRE or c. diff What type of HF does Mr. Kelly likely have based on his previous documented history? Biventricularleft sided initially that progressed to right Compare & contrast patho and symptoms of left sided vs. right sided HF. Left side: Most common Impaired LV function blood pressure backs up into left atrium and pulmonary veins Increased pressure causes fluid from capillary bed to leak into alveoli with resultant pulmonary edema SX:respiratory Tachypnea SOB Anxious Pale-cool clammy Coarse crackles-rhonchi/wheezingmay be audible Elevated HR-BP Right side: Most common cause is LVF Backup of blood on right side due to RV failure causes venous congestion SX JVD Peripheral edema Cor pulmonale if hx COPD What clinical manifestations did Mr. Kelly present with that are consistent with biventricular HF? Fatigue, weakness, orthopnea, edema, fluid retention with edema, SOB What are other manifestations that also can be seen in HF? CP, behaviorial changes-increased restlessness or confusion The cardiologist is on the floor and you update her with your history and current assessment findings. She orders the following medications: Furosemide (Lasix) 40 mg IV x1 Nitrodur patch 0.4 mg topically Digoxin 0.25mg po Hydralazine 10-20 mg IV prn for SBP >150 Lorazepam 1 mg po every 4 hours for anxiety Describe the rationale for each of these interventions: PPT Med Rationale Furosemide-aggressive diuresis-get rid of volume quickly Nitrodur-venous dilator-displace excess volume through decreasing PRELOAD Digoxin-improve CO by increasing contractility Hydralazine-decrease workload of heart through AFTERLOAD reduction Lorazepam-decrease anxiety-decrease HR- which will decrease workload of the heart Describe the action, side effects, nursing implications, and pt. education for each of these medications: Furosemide CATEGORY: Loop diuretic ACTION-inhibits Na reabsorption in the loop of henle-excretes water, Na, K, Mg SE-hypotension, low K, Mg, Na NSG IMP-assess fluid status-I&O-daily wt, monitor electrolytes, BP, fall risk in elderly PT ED-ortho changes, foods high in K+ Nitrodur CATEGORY:Nitrate ACTION-dilates coronary arteriesvasodilates venous> arterialPRELOAD OR AFTERLOAD reducer??? Decreases cardiac O2 consumption SE-dizzinesss-HA-hypotension-tachycardia NSG IMP-monitor BP-HR closely after giving. Rotate patch sites daily-off at bedtime PT ED-risk of ortho hypotension-HA common-tablets should be replaced q 6 months and avoid heat-humidity, keep in dark bottle to prevent breakdown Digoxin CATEGORY:Cardiac Glycosides ACTION-increases force of myocardial contraction-positive inotropic effect, slows AV node conduction SE-fatigue, brady, anorexia, N&V NSG IMP-monitor AP 1 before giving,hold if HR <60 PT ED-take pulse before taking-hold if <60, know sx of dig toxicity Hydralazine CATEGORY: Arterial vaso-dilator ACTION-direct acting peripheral arteriolar vaso dilator SE-tachy NSG IMP-monitor BP closely after giving PT ED-avoid ortho changes Lorazepam CATEGORY: benzodiazepine ACTION-depresses CNS SE-dizziness, drowsiness, lethargy NSG IMP-assess LOC closely PT ED-avoid ETOH with med, avoid driving or activity requiring alertness until response determined Furosemide comes in a 20mg/2 mL vial. What will be the volume you will administer, over what timeframe and how much volume every 15 seconds? 3mL, 4, 0.5 mL every 15 seconds You have been assessing Mr. Kelly every 15 minutes for any change in status. After receiving all of these medications, including the Lorazepam, 1 hour later he is resting more comfortably, fine crackles are present in the bases, has diuresed 700mL urine. His VS: P-82 R-20 BP-136/88 sats 95% on 4l per n/c Based on this assessment data, what will be your nursing diagnostic priorities and plan of care (think maintenance-ongoing)? Priorities are still present but condition has stabilized so that he does not need to be assessed as frequently. All previous diagnostic priorities remain valid and must continue to be assessed closely but not as frequently. Mr. Kelly puts his call light on and notifies you that he feels palpitations in his chest, lightheaded and that his heart is racing. He appears pale, anxious and slightly diaphoretic. What is your primary concern right now? Think ABCs (airway-breathing-circulation) Support breathing with increased O2 but primary focus is cardiac because of the palpitations and lightheadedness What is the underlying cause/patho of this concern? Likely rapid HR that is caused by atrial fibrillation-the most common rhythm disturbance seen in HF Is there any more nursing assessment data or information you need? Absolutelyneed set of VS, 12 lead EKG and need to do assessment of breath sounds and heart sounds What is a nursing diagnostic statement that correlates with this concern? Decreased cardiac output r/t decreased preload What will be your nursing interventions based on this concern? Need to slow the heart rate through medications either beta blockers, digoxin or cardizem Need to contact physician with SBAR once get more assessment data Continue to stay with patient and if have Rapid response Team call overhead Obtain immediate set of VS and focused cardiac assessment Current VS: P:146-irreg R:28-labored BP:88/60 O2 sats: 93% 4l per n/c Current Assessment: CV: pale, cool with slight diaphoresis on forehead. Irreg/rapid HR w/S1S2 Resp: labored resp. effort with crackles persistent throughout Neuro: anxious a/o x4 GI/GU: WNL Is atrial fibrillation an expected complication of HF? Yes Explain the patho of atrial fibrillation? AFib is a result of total disorganization of atrial electrical activity due to multiple ectopic foci resulting in loss of effective atrial contraction and loss of atrial kick and decrease in cardiac output of up to 30% Atrial rate of 350-600/minute, but the AV node slows down what reaches the ventricles is usually <150/min. A 12 lead EKG is ordered and shows that he is in atrial fibrillation-rate 130-150s. You contact the physician who gives you an order for Diltiazem (Cardizem) 20 mg IV push What is the rationale, action, side effects, and nursing implications for this medication? RATIONALE- effective agent to SLOW AV node conduction and therefore lower heartrate. Can also convert to sinus rhythm without cardioversion ACTION-inhibits transport of calcium into myocardial and vascular smooth muscle cells causing systemic vasodilation as well as coronary vasodilation decreasing BP SE-CHF, peripheral edema NSG IMP-monitor VS closely-sx of CHF, and have get up slowly to prevent ortho changes This medication comes in a vial of 25mg/5mL. What will be the dose in mL you will administer, how quickly can you administer this IV push and how much volume every 15 seconds? 4 mLover 2 0.5 mL every 15 seconds What are other medical complications commonly seen as a result of HF? pleural effusion, life threatening dysrhythmias Ventricular Tach-Ventricular Fib, hepatomegaly, renal failure After 30 minutes you note the rate has slowed to 76 and is regular. A 12 lead confirms he is back in sinus rhythm. The cardiologist adds Cardizem CD 240 mg po daily to be given now. He diureses another 700 mL overnight and remains clinically stable. Before the end of your shift you receive the results of the labs that were ordered: Basic Metabolic panel CurrentSodium (135-145)144Potasium (3.5-5.1)3.2Glucose (65-100)189Calcium (8.5-10.5)8.8Magnesium (1.8-2.6)1.2BUN (7-25)35Creatinine (0.5-1.3)2.28 Liver Panel and GI labs CurrentALT (10-42):144AST (10-42):225 CardiacCurrentTroponin (<0.05):0.03CK total (26-140):44CK-MB (<8):0BNP (<101):1254 CBCCurrentWBC (4.5-11.0)9.5HGB (12-16)15.2PLTS (140-440)259 Identify the lab results that are elevated/abnormal and their clinical significance: Creatinine 2.28-renal function continues to worsen BNP-1254-LV is stressed and represents significant volume overload Potassium: 3.2-if low this will predispose to cardiac electrical instability-resulting in AF, VT or VF Magnesium: 1.2 if low this will predispose to cardiac electrical instability-resulting in AF, VT or VF Glucose: 189-diabetes not well controlled Triglycerides: 384-lipids elevated-increase rate of atherosclerosis ALT-144-HF has influenced liver function through poor perfusion of organs AST-225-same as above Optional Lab/Fluid & Electrolyte Application For each RELEVANT abnormal lab to this patients condition complete this table: Lab Value High/Low RelevanceNormal value Critical valueWhat caused derangement?TreatmentNsg. assessments required for this abnormal lab finding? CXR- Severely enlarged heart. Diffuse fluffy infiltrates consistent with pulmonary edema present bilat throughout Echo- mild anterior hypokinesis with diffuse LV dysfunction. EF 25%. 26. What radiology data above is important and relevant that must be recognized as clinically significant to the nurse? Pulmonary edema present-confirms initial clinical impression and guides medical therapy Echo hypokinesis (poor wall motion movement of the left ventricle that could be chronic from prior MI or related to new onset of ischemia diffuse LV dysfunction-likely reflective of global left ventricle hypokinesis due to progressive worsening of heart failure EF 25%-ejection fraction is less than half of normal (60-70%). Confirms heart failure 27. How do these radiology findings relate to primary problem: Confirms what CXR reveals that HF is present and is the primary problem It is now the next day and Mr. Kelly is stabilized with VS WNL. Breath sounds are clear bilat, and his edema has decreased to 1+ in ankles after diuresing 1800 mL the last 24 hours. Adm. Weight was 118.8 kg-weight this am was 116.8 kg. After supplementation his morning K+ is 4.0 and Mg+ 2.1. 28.He is planned to be discharged to home tomorrow. What are your nursing diagnostic priorities today? DEFICIENT KNOWLEDGE What will you emphasize with dietary restrictions and fluid restriction with HF management. Diet same as HTNlow Sodium Fluid restrictions-MD will decideweigh daily What will be the most important education priorities you will reinforce with his new diagnosis of worsening HF? Importance of compliance with all aspects of medication regimen, diet and lifestyle changes to promote health This is now his current medication regimen: 31. For each medication identify the rationale, safe dose, action, side effects, and nursing implications to safely administer. Simvastatin 20 mg po daily RATIONALE:treats his hyperlipidemia SAFE DOSE-RANGE?: yes, 5-80 mg daily in the evening MECH OF ACTION: inhibits a specific enzyme in the liver that is responsible for catalyzing an early step in the synthesis of cholesterol SIDE EFFECTS: abd cramps,constipation, diarrhea, heartburn, rashes,RHABDOMYOLOSIS (define what this is and how it presents) NSG IMP: need to monitor liver labs (AST/ALT, total bili). Administer in trhe evening Glyburide 10 mg po daily RATIONALE: treats type II DM SAFE DOSE-RANGE?: yes,1.25-20 mg daily MECH OF ACTION: lowers insulin by stimulating the release of insulin from the pancreas and increasing the sensitivity to insulin at receptor sites. May also decrease hepatic glucose production SIDE EFFECTS: photosensitivity, hypoglycemia NSG IMP: give w/meals to ensure best control and decrease gastric irritation HCTZ 50 mg po daily RATIONALE: treats his HTN through preload reduction SAFE DOSE-RANGE?: yes, 12.5-100 mg daily in 1-2 doses MECH OF ACTION: increases excretion of sodium and water by inhibiting sodium reabsorption in the distal tubule. Also promotes excretion of potassium, hydrogen, magnesium, calcium SIDE EFFECTS: hypokalemia NSG IMP: give in morning to prevent disruption of sleep cycle.give w/food to decrease gastric irritation. Assess for signs of hypokalemiamuscle weakness, cardiac irritability (irregular heart rate secondary to VT, PVCs or atrial fibrillation), increase diet with foods high in K+ Lisinopril 40 mg po daily RATIONALE: treats his HTN by afterload reduction SAFE DOSE-RANGE?: yes, 20-40 mg daily MECH OF ACTION: ACE INHIBITOR-blocks the conversion of angiotensin I to the vasoconstrictor angiotensin II with effect of producing systemic vasodilation (decreases afterload) SIDE EFFECTS: dizziness, cough, hypotension, ANGIOEDEMA NSG IMP: get up slowly to prevent orthostatic changes, hold if SBP <80 ASA 81 mg po daily RATIONALE: decreases risk/size of clots that may form with plaque rupture seen in acute coronary syndromes SAFE DOSE-RANGE?: yes-81-325 mg daily to decrease platelet aggregation in ACS ACTION-decreases platelet aggregation SE-GI bleeding, nausea-epigastric distress NSG IMP-give w/food, assess stools for color (black, tarry to maroon) Fish oil 1000 mg po 2 tabs daily RATIONALE: lowers triglycerides to decrease rate of atherosclerosis SAFE DOSE-RANGE?:yes, 2-4 gm daily MECH OF ACTION: inhibits synthesis of triglcerides as well as decrease platelet aggregation SIDE EFFECTS: fish aftertaste with eructation NSG IMP: may take enteric coated capsules that decrease taste and eructation of fish oil. Is OTC medication New Meds: Furosemide 40 mg po daily Diltiazem CD 240 mg po daily 32.What is the likely reason that his Lisinopril dosage was increased? HF is now Class III and has worsening EF. Need to lower afterload (SBP) through arterial vasodilation to decrease the workload of a weakening heart. 33.What is the rationale for the addition of Furosemide and Diltiazem to his medication regimen? Requires more aggressive diuresis-HCTZ is a wimp in comparison to lasix as a loop diuretic Risk of going back into AF-cardizem will limit this complication as well as provide AFTERLOAD reduction. 34. There were no changes in the status of your patient during the shift of care. It is now the end of your shift. Give a concise SBAR report to the oncoming nurse: (QSEN-Teamwork & Collaboration/Safety) S: B: A: R: Education Priorities/Discharge Planning Your patients status has stabilized and now must prepare for discharge and disposition to home in the next 1-2 days. 1. What will be the most important education priorities you will reinforce with this current medical condition? The importance of compliance of all aspects of medication regimen and to explain how these medications are keeping him from falling off the proverbial tightrope that he is potentially walking with a weakened heart due to HF. In addition a low sodium diet and the rationale for this must be thoroughly explained and its significance to fluid retention that can exacerbate HF The physician has ordered the following medication changes for this patient while hospitalized and for discharge. 2. For each medication identify the rationale, safe dose, action, side effects, and nursing implications to safely administer. Medication: Furosemide 40 mg po daily RATIONALE: Lowers BP. Through aggressive preload reduction. Most potent diuretic because of its action in the loop of Henle (highest concentration of sodium is present in the loop that increases diuresis) SAFE DOSE-RANGE?: yes20-80 mg/day ACTION-inhibits Na reabsorption in the loop of henle-excretes water, Na, K, Mg SE-hypotension, low K, Mg, Na NSG IMP-assess fluid status-I&O-daily wt, monitor lytes, BP, fall risk in elderly Medication: Cardizem CD 240 mg po daily RATIONALE: slows AV node conduction, which controls heart rate SAFE DOSE-RANGE?: yes, 180-240 mg po daily ACTION: inhibits transport of calcium into myocardial and vascular smooth muscle cells which then inhibits excitation-contraction coupling and contractions. SE: arrythmias, CHF, peripheral edema NSG IMP: can be given with no regard for meals, use with caution w/pre-existing HF. Increases fall risk due to risk of orthostatic changes 3. What will be the most important 1-2 points you will emphasize in your patient education relating to each of any new medications that your patient is now on? Medication: Furosemide 40 mg po daily Increases fall risk due to ortho chages-get up slowly and take in morning not before bedtime Need to take potassium replacement if ordered and to take this with food to decrease gastric irritation. Increase diet with foods high in K such as dried apricots, prunes, raisins, bananas, avocado, pistachios and almonds Medication: Cardizem CD 240 mg po daily Take daily at each time and check HR before giving-hold if <50/minute Change positions slowly to avoid orthostatic changes 4. Why should a complete and reconciled list of the patients medications be provided to the patient/and or family at time of discharge? (2011 Hospital National Patient Safety Goals-#8) 5. What modifications will you need to make related to your teaching methods based on the patients developmental stage, age, culture, preferences, and level of health literacy? 6. 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