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heart failure case study
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Heart Failure Case Study (45 min)

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Mr. Jones, a 69-year old male, presents to the Emergency Department (ED) after visiting his primary physician complaining of general fatigue for 4 days, shortness of breath, and abdominal discomfort. Mr. Jones’s medical history includes hypertension and coronary artery disease. He had a previous 90% LAD blockage and 50% RCA blockage with stent placements in both.

Critical Thinking Check
Bloom's Taxonomy: Application

What initial nursing assessments need to be performed for Mr. Jones?

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Critical Thinking Check
Bloom's Taxonomy: Analysis

What diagnostic tests do you anticipate being ordered by the provider?

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Upon further assessment, the patient has crackles bilaterally and tachycardia. A chest X-ray shows cardiomegaly and bilateral pulmonary edema. An ECG revealed atrial fibrillation. His vital signs were as follows:

BP 150/72 mmHg Urine Yellow and Cloudy

HR 102-123 bpm and irregular BUN 17 mg/dL

RR 24-32 bpm Cr 1.2 mg/dL

Temp 37.3°C H/H 11.8 g/dL / 36.2%

Ht 175 cm LDH 705 U/L

Wt 79 kg ** BNP 843 pg/mL


Mr. Jones was admitted to the cardiac telemetry unit.


Mr. Jones states that this weight is approximately 3 kg more than it was 3 days ago.

Critical Thinking Check
Bloom's Taxonomy: Analysis

What is the signficance of Mr. Jones' weight gain?

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Critical Thinking Check
Bloom's Taxonomy: Analysis

What medications do you anticipate the provider ordering for Mr. Jones? Why?

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About three hours after admission to the telemetry unit, Mr. Jones’s skin becomes cool and clammy. His respirations are labored and he is complaining of abdominal pain. Upon physical examination, Mr. Jones is diaphoretic and gasping for air, with jugular venous distension, bilateral crackles, and an expiratory wheeze.  His SpO2 is 88% on room air and it was noted that his urine output had been approximately 20 mL/hr since admission. His BP is 190/100 mmHg, HR 130 bpm and irregular, RR 43 bpm.


Critical Thinking Check
Bloom's Taxonomy: Application

What nursing interventions should you perform right away for Mr. Jones?

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Critical Thinking Check
Bloom's Taxonomy: Analysis

Describe what is happening to Mr. Jones physiologically.

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Critical Thinking Check
Bloom's Taxonomy: Analysis

What medications should be given to decrease Mr. Jones’s preload? Improve his contractility? Decrease his afterload?

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Mr. Jones was transferred to the CCU for hemodynamic monitoring and aggressive therapy. His Central Venous Pressure (CVP) was found to be 19 mmHg, Cardiac Output was 4.5 L/min, Cardiac Index was 2.3 L/min/m2. He has been placed in high-fowler’s position, and his SpO2 is now 96% on 4L nasal cannula. Mr. Jones received Furosemide 80 mg IV and Digoxin 0.5 mg IV. 

Critical Thinking Check
Bloom's Taxonomy: Comprehension

What is the expected outcome of administration of Furosemide? Digoxin?

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References
Melander, S. (2004). Case studies in critical care nursing: A guide for application and review, 3rd ed. Philadelphia, PA: Saunders Elsevier.
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