RNSG 2022 Heart Failure: SKINNY Reasoning Case Study.

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 She has struggled with depression the past two years and has been more withdrawn since her husband of 52 years died unexpectedly three months ago from a myocardial infarction.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