Case Study: HF Patient Assessment, Medication Review, and Teaching Plan

Concerning Results and Further Questions

1.  As you review these results, which ones are of possible concern, and why?

2.  Knowing his history and seeing his condition this morning, what further questions are you

going to ask J.M. and his daughter?

Case Study Progress: J.M. tells you he becomes exhausted and has shortness of breath climbing the stairs to his bedroom and has to lie down and rest (“put my feet up”) at least an hour twice a day. He has been sleeping on two pillows for the past 2 weeks. He has not salted his food since the physician told him not to because of his high blood pressure, but he admits having had ham and a small bag of salted peanuts 3 days ago. He states that he stopped smoking 10 years ago. He denies having palpitations but has had a constant, irritating, nonproductive cough lately:

3.  You think it's likely that J.M. has heart failure (HF). From his history, what do you identify as probable causes for his HF?

4.  You are now ready to do your physical assessment. For each potential assessment finding for HF, indicate whether the finding indicates left-sided HF (L) or right-sided HF (R).

1. ______  Fatigue, weakness, especially with activity

2. ______ Jugular (neck) vein distention

3. ______ Dependent edema (legs and sacrum)

4. ______ Hacking cough, worse at night

5. ______ Enlarged liver and spleen

6. ______ Exertional dyspnea

7. ______ Distended abdomen

8. ______ Weight gain

9. ______ S3/S4 gallop

10. ______ Crackles and wheezes in lungs

Chart View:

Medication Orders:

Enalapril (Vasotec) 10mg PO twice a day

Furosemide (Lasix) 20mg PO every morning

Carvedilol (Coreg) 6.25mg PO twice a day

Digoxin (Lanoxin) 0.5mg PO now, then 0.125mg PO daily

Potassium chloride (K-Dur) 10mEq tablet PO once a day

Case Study Progress: The physician confirms your suspicions and indicates that J.M. is experiencing symptoms of early leftsided heart failure. A two-dimensional (2D) echocardiogram is ordered. Medication orders are written:

5.  For each medication listed, identify its class and describe its purpose for the treatment of HF

6.  When you go to remove the medications from the automated dispensing machine, you see that carvedilol (Coreg CR) is stocked. Will you give it to J.M.? Explain.

7.  As you remove the digoxin tablet from the automated medication dispensing machine, you note that the dose on the tablet label is 250 mcg. How many tablets would you give?

8.  Based on the new medication orders, which blood test or tests should be monitored

carefully? Explain your answer.

9.  When you give J.M. his medications, he looks at the potassium tablet, wrinkles his nose, and tells you he “hates those horse pills.” He tells you a friend of his said he could eat bananas instead. He says he would rather eat a banana every day than take one of those pills. How will you respond?

10.  The 2D echocardiogram shows that J.M.'s left ventricular ejection fraction (EF) is 49%.

Explain what this test results mean with regard to J.M.'s heart function.

Case Study Progress: This is J.M.'s first episode of significant HF. Before he leaves the clinic, you want to teach him about lifestyle modifications he can make and monitoring techniques he can use to prevent or minimize future problems:

11.  List five suggestions you might make and the rationale for each.

12.  You tell J.M. that the combination of high-sodium foods he had during the past several days might have contributed to his present episode of HF. He looks surprised. J.M. says, “But I didn't add any salt to them!” To what health care professional could J.M. be referred to help

him understand how to prevent future crises? State your rationale.

13.  You also include teaching about digoxin toxicity. When teaching J.M. about the signs and

symptoms of digoxin toxicity, which should be included? Select all that apply.

a. Dizziness when standing up

b. Visual changes

c. Loss of appetite or nausea

d. Increased urine output

e. Diarrhea