RNSG 2022 Heart_Failure-SKINNY_Reasoning (1)

RNSG 2022 Heart_Failure-SKINNY_Reasoning (1) Part I: Recognizing RELEVANT Clinical Data 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 She has struggled with depression the past two years and has been more withdrawn since her husband of 52 years died unexpectedly three months ago from a myocardial infarction.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: -Ms. Smith’s history of myocardial infarction (MI) from four years ago and systolic heart failure secondary to ischemic cardiomyopathy. -She came into the ER for SOB the past 3 days which has now went from SOB during activity to SOB at rest. -The only way she has been able to rest comfortably is by sleeping upright in her recliner. She can only speak partial sentences before having to take a breath in order to have a conversation with the nurse. -Increased swelling in the lower legs and a weight gain of 6 pounds in the past 3 days. -A current ejection fraction (EF) of only 15% supports the indication of heart failure. Anything less than 45-55% supports this claim. -Left-sided heart failure is most likely what is causing the pulmonary edema. The fluid being trapped is affecting her breathing resulting in the SOB. -Orthopnea is often associated with the progression of left-sided heart failure. -Edema is present here. This is an indicator that left-sided heart failure is beginning to affect the right side. RELEVANT Data from Social History: Clinical Significance: -JoAnn can no longer tolerate the level of activity she’s used to due to dealing with the progression of her heart failure for the past two years. -The fact that she has been battling depression over the past two years and losing her husband not too long ago has caused her to withdraw even more. -Her activity intolerance is secondary to the progression of heart failure. -The death of her husband added to her inability to effectively cope with and find ways to overcome her depression. Instead, it caused her to push back even further. 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: What VS data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS `Data: Clinical Significance: -A pulse of 92 (irregular) -26 breaths/minute (regular) -BP 162/54 -O2 sat of 90% 6 L via nasal cannula -Atrial fibrillation can cause this to be considered irregular -Way too fast for this to be her respiratory rate at rest - During heart failure the higher the BP higher the afterload which increases the overall workload of the heart -90% is too low 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 What assessment data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: -Appears anxious, restless -Scattered coarse crackles throughout both lungs, labored respiratory effort -Atrial fibrillation, pale/clammy to the touch -3+ pitting edema in lower extremities from knees down bilaterally -S3 gallop -Must determine is this a result of SOB or underlying anxiety -Increased pressure from left sided failure increase pressure in alveoli pushing fluid in the alveoli space -Should be determined if this is a result of a past or current cause? -Edema indicates right-sided heart failure -S3 ventricular gallop is associated with left-sided heart failure