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Heart Failure Case Study.Vanessa Joubert Heart Failure

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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 c ... urrent 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 She has struggled with depression the past two years and has been more withdrawn since her husband of 52 years died unexpectedly three months ago from a myocardial infarction.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:  Age 72-years  History of MI  SOB  Swelling in her legs and gained 6 pounds in 3 days.  Irregular pulse  Increased respiration  Low oxygen  S3 notes Clinical Significance:  As a woman reach menopause around 50 years old estrogen levels being to slowly disappear, which places women at higher risk for CAD.  Sleeping in recliner chair to rest comfortably upright, indicating fluid buildup in the lungs.  The heart is not pumping blood efficiently causing fluid buildup.  S3 indicates fluid in the lungs. Relevant data from social history:  Patient is depressed.  Sudden loss of husband  Retired math teacher [Show More]

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