NURS 1410Cardiac Clinical Reasoning: Assisting a patient with cardiovascular conditions

Name:

__________________________________________________

Assignment: Cardiac Clinical Reasoning

Data Collection:

Patient History

1. What is the relationship of the patient’s past medical history and his current medications?

Complete the table on page

2

for this patient’s home medications.

(2 points each = 8 pts total)

Classification: List the medication’s therapeutic and pharmacologic classification that is appropriate to the condition from the patient’s medical history.

Indications: Of Mr. Hart’s home medications listed in the table, identify the condition(s) that it is treating from this list below from the patient’s medical history. There may be more than one answer. (In other words, why is this patient taking this medication?)

Past Medical History for Mr. Hart:

Hypertension

Heart Failure

Hyperlipidemia

Myocardial infarction

Coronary Artery Disease

Medication

a. Therapeutic Classification
b. Pharmacologic Classification of the medication

Indications

simvastatin/Zocor

a.

b.

sacubitril/valsartan/Entresto

a.

b.

acetylsalicylic acid/aspirin

a.

b.

eplerenone/Inspra

a.

b.

Data Collection:

Patient’s Primary Symptoms, Vital Signs, and Diagnostic Tests

2.

Primary Symptoms:

Patient comes to the clinic concerned that is experiencing episodes of chest tightness and a rapid heartbeat on exertion, has developed a persistent cough, and is increasingly fatigued with occasional dizziness. He reports that he is noticing shortness of breath on exertion with some chest discomfort and is becoming increasingly SOB even at rest. He has had to sleep with 3 pillows to keep from becoming SOB at night the last 2 weeks. He reports difficulty getting his shoes on the last month because of increased swelling around his ankles. He weighs himself once a week and today his weight has increased from 255 lbs. to 264 lbs. over the last 7 days.

a. Which findings in this patient indicate Left-sided failure and which indicate Right-sided failure? (4 points)

Left-sided failure findings in this patient:

Right-sided failure findings in this patient:

b. Explain what is happening physiologically to this patient and how it is resulting in his symptoms. Be specific and complete.

(1 point)

c. Of these patient’s reported signs and symptoms in his history and in the Nurse’s Notes, which 3 findings require the
most immediate
attention by the nurse? (1 point)

_______ Weight gain

_______ Ankle swelling

_______ Persistent cough

_______ Increasing fatigue

_______Irregular heart rhythm

_______ Chest tightness, Chest discomfort

_______ Shortness of breath on exertion and rest

3. What is the relationship or clinical significance between this patient’s vital signs and the problem of heart failure?

(a. and b. 3 points each = 6 points total).

Relevant Vital Signs: a. Heart rate and character What is normal: The patient’s data (rate, character): b. Respirations: Rate and lung sounds What is normal: Rate: Sounds: The patient’s data: Rate: Sounds:

Relationship or clinical significance to Heart Failure: (What is causing the abnormality in this patient? Or is it normal?) a. b.

4. What is the relationship or clinical significance between this patient’s diagnostic test results and his heart failure?

(a., b. c. and d = 3 points each = 12 total pts)

Diagnostic test results:	Clinical significance of these results and the relationship to the patient’s Heart Failure or to the patient’s symptoms: (Why were these tests ordered? What do the tests reveal about this patient’s condition? What do the tests mean for this patient?)
a. BNP What is normal: The patient’s data: b. Ejection fraction What is normal: The patient’s data: c. Troponins What is normal: The patient’s data:	a. b. c.

d. Electrocardiogram: Rhythm: Is it Regular or Irregular? ___________________________ P wave present (yes or no)? ______________________________________

What is the interpretation of this rhythm:

Identifying the problem

(2 points)

5. Based on the data collection findings, the primary medical diagnosis for Mr. Hart is:

· An exacerbation of heart failure.

The nurse notes the patient’s problems of activity intolerance and fluid volume overload.

a.

Based on the data collection findings, these symptoms are the result of a decreased:

Choose one

________ Blood pressure

_________Cardiac output

_________ Heart rate

b. Understanding the primary physiological problem for this patient currently, the client is at highest risk of:

Choose one

________ Dysrhythmia

________ Pulmonary edema

________ Myocardial Infarction

As evidenced by the patient’s:

Choose one

_______ EKG

_______ BNP level

_______ Troponins

_______ Chest x-ray

Collaborative Care/ Nursing:

Interventions

(2 points)

6.

a. Of these potential nursing interventions, choose if the intervention is indicated at this time or non-essential (not necessary) or contraindicated for this patient.

Place an X or checkmark in the appropriate column. (1 point)

Nursing intervention

Indicated

Non-essential

Contraindicated

Place client in Semi-Fowlers or high Fowler’s position

Keep a water pitcher and ice chips at the client’s bedside

Reposition every 2 hours when in bed

Schedule activities with frequent periods of rest

Observe patient for nausea, anorexia, or visual disturbances

b. Choose one expected outcome for the patient problem. Not all outcomes will be used. (1 point)

Patient problem

Expected outcome

Activity intolerance__________ a. Respiratory rate and oxygen saturation within normal range

Increased fluid volume_________ b. The client performs activities without fatigue

c. Intake and output equal with no peripheral edema

d. The patient reports no dizziness when standing.

Collaborative Care/ Medical Management:

Interventions

7. What is rationale for the healthcare provider’s prescriptions? How is each order helping to resolve or address the problems associated with Heart Failure?

(a.- d., 2 points each = 8 pts)

HCP Prescription

Rationale for this order/ How it helps resolve or address primary problems associated with Heart Failure:

a. Daily weights, I & O, anti-embolism stockings, fluid restriction

a.

b. The daily dose of eplerenone/Inspra

b.

c. The
one-time
stat dose of furosemide/Lasix

c.

d. The consult for possible cardioversion

d.

Evaluation

(5 points)

8. The patient is stabilized and ready for discharge.

A. Explain the classification, purpose, and intended therapeutic effect of adding warfarin/Coumadin to Mr. Hart’s medications:

a. Classification of warfarin and its purpose for Mr. Hart:

b. In reviewing Mr. Hart’s medications, what must be brought to the attention of the HCP?

B. Explain the classification, purpose, and monitoring required when adding digoxin/Lanoxin to Mr. Hart’s medications:

c. Classification of digoxin and its purpose for Mr. Hart:

d. What specifically is monitored by the nurse in a patient taking digoxin?

Evaluation, cont.

C. Which statements by the client indicates that he understands the evidence-based follow-up activities and observations required to promote health and wellness, even with his chronic condition of heart failure? (1 point)

Select all that apply

_________ “I will take a daily walk and rest as needed.”

_________ “I should add more leafy greens into my diet.”

_________ “I will eat my normal diet as long as I do not add table salt.”

________ “I will read the labels on all foods to ensure my diet in low in sodium.”

_________ “I will take a laxative to make sure that I have a bowel movement every day.”

_________ “I will contact my health care provider if I gain more than 3 pounds in a week.”

_________ “I may include red wine in my diet occasionally to prevent further damage to my heart.”

_________ “I will return to the clinic to have my blood checked for potassium and for my digoxin level.”

_________ “I will check my radial pulse every day and hold my heart medication if my pulse is below 65.”

_________ “I will weigh myself once every week on the same scale and at the same time to monitor for changes.”

2

NURS 1410
Cardiac Clinical Reasoning: Assisting a patient with cardiovascular conditions

Mr. Hart is admitted. Review the patient’s chart and the nurse’s notes.
Go to patient’s room and see the nurse’s notes
Patient’s Chart

Patient’s Chart (click on what you want to review in the patient’s chart.)
Vital Signs
Patient History
Diagnostic Tests
Healthcare Provider’s Orders
MAR

Patient History
Patient’s Chart
Main
Mr. Hart, 60 years old, was diagnosed with hypertension and CAD three years ago after experiencing a left anterior MI. Two years ago, his condition worsened, and he was diagnosed in early-stage heart failure. Today, he comes to the clinic concerned that is experiencing episodes of chest tightness and a rapid heartbeat on exertion, has developed a persistent cough, and is increasingly fatigued with occasional dizziness. He reports that he is noticing shortness of breath on exertion with some chest discomfort and is becoming increasingly SOB even at rest. He has had to sleep with 3 pillows to keep from becoming SOB at night the last 2 weeks. He reports difficulty getting his shoes on the last month because of increased swelling around his ankles. He weighs himself once a week and today his weight has increased from 255 lbs. to 264 lbs. over the last 7 days. He admits that he sometimes forgets to take his medications every day. The clinic healthcare provider recognizes that Mr. Hart needs acute inpatient care and coordinates a direct admission to the hospital.
Past Medical History: Hypertension, Hyperlipidemia, CAD, MI three years ago with secondary chronic heart failure

4

Diagnostic Tests:
Main
Patient’s Chart
Lab Today Past
BNP 475 300
Troponins Negative
Cholesterol 210 260
PCR for Covid-19 Negative
Potassium 3.6 3.9

Chest x-ray: bilateral diffuse infiltrates consistent with pulmonary edema.
Echocardiogram:
Current ejection fraction is 40% with the past ejection fraction at 49%
Electrocardiogram:

Vital signs Temp HR RR Lung Sounds BP O2 Saturation
0900 98.6 F (oral) 110 – irregular, bounding 28, regular, labored Crackles both lower lobes; cough noted 148/94 91% on 3L Oxygen per nasal cannula

Main
Patient’s Chart

Main
Patient’s Chart
Health Care Provider Orders/ Prescriptions:
Place on pulse oximeter monitoring
Oxygen at 3 liters/minute per nasal cannula
Strict intake and output, daily weights with fluid restriction to 1800 mL PO daily
Apply anti-embolism stockings
Diet: Sodium-restricted, potassium-modified, low-fat, low cholesterol
Lab: Troponins, Cholesterol, BNP, Potassium level, Covid-19 PCR
Tests: Chest x-ray, EKG, Echocardiogram
Consult with Cardiac Electrophysiology for possible cardioversion
Furosemide 60 mg one-time oral dose now (STAT)
Hold dose today only eplerenone 25 mg
Begin TODAY warfarin 3 mg. PO daily
Begin TODAY digoxin 0.125 mg PO daily
Continue home meds

Medication 0700-1500 1500-2300 2300-0700
simvastatin 0800
20 mg po
sacubitril 49mg/valsartan 51 mg 0800 2000
acetylsalicylic acid 1300
81 mg po daily
eplerenone HOLD TODAY
25 mg po
furosemide
1100
60 mg one time oral dose STAT
digoxin
Begin TODAY
0.125 po

warfarin
Begin TODAY 1100
3 mg po

Main
Patient’s Chart

8

Neuro
Click on the buttons below to see the nurse’s notes.
Cardiac/
Respiratory
GI /
GU
General

Click on the buttons below to see the nurse’s notes.
Anxious; Alert & Oriented
Client states that he feels light-headed and a little dizzy when standing. No blurred vision.
Cardiac/
Respiratory
GI /
GU
General

Click on the buttons below to see the nurse’s notes.
Cardiac – Skin pale, cool to the touch, Pulse bounding and noted to be irregular, 2-3+ pitting edema lower extremities. No JVD noted. Capillary refill 2 seconds.
Resp – Coarse crackles scattered throughout both lung fields. Labored respiratory effort. Patient sitting upright. Coughing noted. Client states that he feels short of breath. Oxygen saturation: 91% on 3 l/min oxygen.
Neuro
GI /
GU
General

Click on the buttons below to see the nurse’s notes.
GI – Active bowel sounds in all 4 quadrants. Abdomen soft/non-tender. No appetite. Reports that he had a bowel movement yesterday.
GU – Voiding without difficulty, urine clear/yellow. Reports getting up at night to urinate.
Neuro
Cardiac/
Respiratory
General

Click on the buttons below to see the nurse’s notes.
Other – Denies pain but expresses that his chest feels “tight”. Slight headache. Skin integrity intact. Appears anxious, restless, and reports dizziness.
First Quetion
Patient’s Chart
Main
Cardiac/
Respiratory
Neuro
GI /
GU