Heart Failure
JoAnn Smith, 72 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
1. Gas Exchange
2. Fluid and Electrolyte Balance
3. Clinical Judgment
4. Patient Education
5. Communication
6. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
, UNFOLDING Reasoning Case Study: STUDENT
Heart Failure
History of Present Problem:
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more withdrawn since her husband of 52 years died unexpectedly three months ago from a myocardial infarction.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?
RELEVANT Data from Present Problem: Clinical Significance:
1. Patient has a history of myocardial 1. Heart failure is present due to the patients current ejection
infarction (MI) from four years ago and fraction of only 15% supports the indication of heart failure.
systolic heart failure secondary to ischemic
cardiomyopathy.
2. Left side damage due to the heart being over worked
2. ER for shortness of breath caused fluid to be trapped causing shortness of breath.
3. shes only able to sleep upright 3. signs of abnoramilities, orthopeana
4. Gaining 6 pounds 4. sign for Edema ( fluid retension in the tissues)
RELEVANT Data from Social History: Clinical Significance:
- Patient struggles with depression - husband died a few months ago, and changes of life style
due to having heart failure
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
x Diabetes mellitus type II 1. ASA 81 mg PO daily 1. NSAID 1. prevents heart
x Hypertension 2. Carvedilol 3.25 mg PO 2. alpha and beta attacks/ strokes
daily blockers 2. controls heart
x Atrial fibrillation
3. Lisinopril 5 mg PO
x Hyperlipidemia 3. ACE Inhibitor failure
daily
x Chronic renal insufficiency 4. Ezetimide 10 mg PO 4.HMG-CoA reductase 3. controls vessels
inhibitors 4. Controls chloestrol
(baseline creatinine 2.0) daily
5. Hydralazine 25 mg PO 5. Vasodilator 6. treat renal
x Cerebral vascular accident 6. Diuretic insufficency
(CVA) with no residual 4x daily
6. Torsemide 20 mg PO 7.electrolytes 7. increase potassium
deficits bid 8. anticoagulants levels
x Heart failure (systolic) 7. KCL 20 meq PO daily 9. sulfonylureas 8. blood thinner for
secondary to ischemic 8. Warfarin 5 mg PO daily blood clots
cardiomyopathy 9. Glyburide 5 mg PO 9. lower blood sugar
x MI with stent x2 to LAD 4 daily
years ago
© 2016 Keith Rischer/www.KeithRN.com
JoAnn Smith, 72 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
1. Gas Exchange
2. Fluid and Electrolyte Balance
3. Clinical Judgment
4. Patient Education
5. Communication
6. Collaboration
© 2016 Keith Rischer/www.KeithRN.com
, UNFOLDING Reasoning Case Study: STUDENT
Heart Failure
History of Present Problem:
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?
RELEVANT Data from Present Problem: Clinical Significance:
1. Patient has a history of myocardial 1. Heart failure is present due to the patients current ejection
infarction (MI) from four years ago and fraction of only 15% supports the indication of heart failure.
systolic heart failure secondary to ischemic
cardiomyopathy.
2. Left side damage due to the heart being over worked
2. ER for shortness of breath caused fluid to be trapped causing shortness of breath.
3. shes only able to sleep upright 3. signs of abnoramilities, orthopeana
4. Gaining 6 pounds 4. sign for Edema ( fluid retension in the tissues)
RELEVANT Data from Social History: Clinical Significance:
- Patient struggles with depression - husband died a few months ago, and changes of life style
due to having heart failure
What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Draw lines to connect)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
x Diabetes mellitus type II 1. ASA 81 mg PO daily 1. NSAID 1. prevents heart
x Hypertension 2. Carvedilol 3.25 mg PO 2. alpha and beta attacks/ strokes
daily blockers 2. controls heart
x Atrial fibrillation
3. Lisinopril 5 mg PO
x Hyperlipidemia 3. ACE Inhibitor failure
daily
x Chronic renal insufficiency 4. Ezetimide 10 mg PO 4.HMG-CoA reductase 3. controls vessels
inhibitors 4. Controls chloestrol
(baseline creatinine 2.0) daily
5. Hydralazine 25 mg PO 5. Vasodilator 6. treat renal
x Cerebral vascular accident 6. Diuretic insufficency
(CVA) with no residual 4x daily
6. Torsemide 20 mg PO 7.electrolytes 7. increase potassium
deficits bid 8. anticoagulants levels
x Heart failure (systolic) 7. KCL 20 meq PO daily 9. sulfonylureas 8. blood thinner for
secondary to ischemic 8. Warfarin 5 mg PO daily blood clots
cardiomyopathy 9. Glyburide 5 mg PO 9. lower blood sugar
x MI with stent x2 to LAD 4 daily
years ago
© 2016 Keith Rischer/www.KeithRN.com
