Case Study of JoAnn Smith 72
years old Heart Failure
(ANSWERED)
,What data from the histories is RELEVANT and has clinical significance to the nurse? RELEVANT
Data from Present Problem: Clinical Significance:
MI four years ago, MI is significant because it decreases heart function due to death of increase shortness
of breath at rest; can only myocardial muscle speak in partial sentences, EF of 15% shows that the
heart is having a hard time pumping blood out to ischemic cardiomyopathy with EF of 15% rest of the body
therefore starving it of oxygenated blood. last two nights slept in recliner Weight gain and increased
swelling signifies she is fluid overloaded and it increased swelling in lower legs can be reason why she
is having a hard time talking, breathing, being gained 6 pounds in last 3 days active and why she has
to sleep in a recliner the past 2 nights RELEVANT Data from Social History: Clinical Significance:
Retired math teacher, recent widow, history of Depression might affect her enthusiasm to recover, to stick
to a therapy depression, decreasing activity level regimen
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: Cerebral vascular accident (CVA) with no residual deficits
Diabetes mellitus type II Heart failure (systolic) secondary to ischemic cardiomyopathy
Hypertension MI with stent x2 to LAD 4 years ago
Atrial fibrillation Home Meds: Pharm. Classification: Expected Outcome:
Hyperlipidemia 1. ASA 81 mg PO daily Antiplatelets Decrease chance of
Chronic renal 2. Carvedilol 3.25 mg PO Beta blocker clot formation
insufficiency (baseline daily ACE inhibitor Decrease blood
creatinine 2.0) 3. Lisinopril 5 mg PO Cholesterol pressure
daily medication Decrease blood
, 4. Ezetimide 10 mg PO 4x daily replacement death from heart
Vasodilator 6. Torsemide 20 mg PO Anticoagulant attack
pressure, helps with bid Antidiabetic Decrease
daily Diuretic heart
failure, 7. KCL 20 meq PO daily cholesterol
5. Hydralazine 25 mg 8. Warfarin 5 mg PO daily Decrease blood
PO Electrolyte
9. Glyburide 5 mg PO pressureDecrease swelling,
decrease chance
of daily decrease fluid
overload
• Increase serum potassium
years old Heart Failure
(ANSWERED)
,What data from the histories is RELEVANT and has clinical significance to the nurse? RELEVANT
Data from Present Problem: Clinical Significance:
MI four years ago, MI is significant because it decreases heart function due to death of increase shortness
of breath at rest; can only myocardial muscle speak in partial sentences, EF of 15% shows that the
heart is having a hard time pumping blood out to ischemic cardiomyopathy with EF of 15% rest of the body
therefore starving it of oxygenated blood. last two nights slept in recliner Weight gain and increased
swelling signifies she is fluid overloaded and it increased swelling in lower legs can be reason why she
is having a hard time talking, breathing, being gained 6 pounds in last 3 days active and why she has
to sleep in a recliner the past 2 nights RELEVANT Data from Social History: Clinical Significance:
Retired math teacher, recent widow, history of Depression might affect her enthusiasm to recover, to stick
to a therapy depression, decreasing activity level regimen
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: Cerebral vascular accident (CVA) with no residual deficits
Diabetes mellitus type II Heart failure (systolic) secondary to ischemic cardiomyopathy
Hypertension MI with stent x2 to LAD 4 years ago
Atrial fibrillation Home Meds: Pharm. Classification: Expected Outcome:
Hyperlipidemia 1. ASA 81 mg PO daily Antiplatelets Decrease chance of
Chronic renal 2. Carvedilol 3.25 mg PO Beta blocker clot formation
insufficiency (baseline daily ACE inhibitor Decrease blood
creatinine 2.0) 3. Lisinopril 5 mg PO Cholesterol pressure
daily medication Decrease blood
, 4. Ezetimide 10 mg PO 4x daily replacement death from heart
Vasodilator 6. Torsemide 20 mg PO Anticoagulant attack
pressure, helps with bid Antidiabetic Decrease
daily Diuretic heart
failure, 7. KCL 20 meq PO daily cholesterol
5. Hydralazine 25 mg 8. Warfarin 5 mg PO daily Decrease blood
PO Electrolyte
9. Glyburide 5 mg PO pressureDecrease swelling,
decrease chance
of daily decrease fluid
overload
• Increase serum potassium
