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 p
...
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past two years and has been more withdrawn since her husband of 52 years died unexpectedly three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.
This study source was downloaded by 100000852290574 from CourseHero.com on 01-30-2023 13:42:29 GMT -06:00
https://www.coursehero.com/file/61007192/Heart-Failure-SKINNY-Reasoning-1docx/
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
-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?
This study source was downloaded by 100000852290574 from CourseHero.com on 01-30-2023 13:42:29 GMT -06:00
https://www.coursehero.com/file/61007192/Heart-Failure-SKINNY-Reasoning-1docx/
-3+ pitting edema in lower extremities
from knees down bilaterally
-S3 gallop
-Edema indicates right-sided heart failure
-S3 ventricular gallop is associated with left-sided heart failure
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