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Heart Failure Case StudyÂ

James is a 70-year-old male brought to the emergency department (ED) by ambulance with complaints of shortness of breath. The patient’s medical record shows a past history of hypertension, diabetes, MI X 2, congestive heart failure (CHF), and chronic renal insufï¬ciency. Upon assessment, James has labored breathing at 36 breaths/min and tachycardia at 112 beats/min. His pulse oximetry is 90% on 40% oxygen via a face mask. Crackles are heard throughout his lungs.Â

1. List potential causes and risk factors for his condition.

hypertension, diabetes, MI X 2, congestive heart failure (CHF), and chronic renal insufï¬ciency.

2. Identify the typical symptoms of left-sided heart failure vs. right-sided heart failure with an “L” or an “R” or “B” for both.

Â Â Â Â Â Â Â Â Â Â Â Â Â Cough

Â Â Â Â Â Â Â Â Â Â Â Â Â Blood-tinged sputum

Â Â Â Â Â Â Â Â Â Â Â Â Â Tachycardia

Â Â Â Â Â Â Â Â Â Â Â Â Â Fatigue

Â Â Â Â Â Â Â Â Â Â Â Â Â Nocturnal polyuria

Â Â Â Â Â Â Â Â Â Â Â Â Â Exertional dyspnea

Â Â Â Â Â Â Â Â Â Â Â Â Â Peripheral edema

Â Â Â Â Â Â Â Â Â Â Â Â Â Crackles or wheezes

Â Â Â Â Â Â Â Â Â Â Â Â Â Jugular venous distension

Â Â Â Â Â Â Â Â Â Â Â Â Â Ascites and GI distress

Â Â Â Â Â Â Â Â Â Â Â Â Â Orthopnea

Â Â Â Â Â Â Â Â Â Â Â Â Â Cyanosis

Â Â Â Â Â Â Â Â Â Â Â Â Â Paroxysmal nocturnal dyspnea

The physician orders a chest x-ray, ECG, arterial blood gases (ABGs), and lab work to be done. After an IV is inserted, the nurse administers furosemide 40 mg IV push.

3. Which lab test is a key diagnostic indicator of heart failure?Â

4. Arterial blood gas (ABG) results: pH 7.47, pO2 82, pCO2 30, HCO3 24. Evaluate the ABG above and explain why this is occurring.

James remains short of breath at rest, so he is moved to the intensive care unit (ICU). An EKG is done, which shows an ejection fraction of 40%. The physician orders James to be started on a dobutamine drip and given an additional 20 mg of IV furosemide.

5. Order: Begin a dobutamine drip at 5 mcg/kg/min. James weighs 214 pounds.Â

Available: The dobutamine is supplied as 500 mg in 250 mL of D5W.

Calculate how fast to run the dobutamine in mL/hr:Â

6. Match the medication used to treat heart failure in Column A to its effect in Column B.

Column AÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Column B

A. BenazeprilÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â __ ___Reduces adverse effects from constant stimulation of the sympathetic nervous system (SNS)

B. FurosemideÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â __ ___Catecholamine that increases cardiac contractility

C. DigoxinÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â __ ___Diuretic that removes excess extracellular ï¬‚uid

D. MetoprololÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â __ ___Phosphodiesterase inhibitor that promotes vasodilation

E. DobutamineÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â __ ___Angiotensin converting enzyme (ACE) inhibitor that promotes vasodilation and diuresis

F. MilrinoneÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â __ ___Cardiac glycoside that increases the force of myocardial contraction and slows conduction through the atrioventricular (AV) node

James continues to improve and is moved to a medical ï¬‚oor after spending 2 days in the ICU. He is being prepared for discharge within the next 1 to 3 days.

7. The nurse educating James on his medications for discharge determines that he needs further instruction about his diuretic when he states:

A. “I can hold on taking my Lasix on days that I am traveling.”

B. “I should weigh myself every day at the same time.”

C. “I should take my Lasix early in the day so I am not up all night.”

D. “I need to call the doctor if my legs start swelling more than normal.”

8. Since James will be discharged on digoxin, the nurse needs to discuss which of the following signs of digoxin toxicity? Select all that apply.

A. Fatigue

B. nausea, vomiting

C. Erratic heart beat

D. Changes in vision

9. What key discharge teaching points are necessary to reduce rehospitalization and help the patient manage his heart failure?

SCIENCE
HEALTH SCIENCE
NURSING
NURSING NURS

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