Heart Failure

History of Present Problem:

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 She has struggled with depression the past two years and has been more withdrawn since her husband of 52 years died unexpectedly three months ago from a myocardial infarction.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:

RELEVANT Data from Social History: Clinical Significance:

What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
(Which medication treats which condition? Put number next to PMH that connects to Medication)
PMH: Home Meds: Pharm. Classification: Expected Outcome:
Diabetes Mellitus type II Hypertenson
Artial afibrillation Hyperlipidemaia
Chronic renal insufficency (baseline Creatinine 2.0) Cerebral vascular accident (CVA) with no residual deficits
Heart Failure (systolic) secondary to ischemic cardiomyopathy
MI with stent x2 to LAD 4 years ago 1. ASA 81 mg PO daily

2. Carvedilol 3.25 mg PO daily
3. Lisinopril 5 mg PO daily
4. Ezetimide 10 mg PO daily
5. Hydralazine 25 mg PO 4x daily
6. Torsemide 20 mg PO bid
7. KCL 20 meq PO daily
8. Warfarin 5 mg PO daily
9. Glyburide 5 mg PO daily

What medications treat which conditions?
One disease process often influences the development of other illnesses. Based on your knowledge of
pathophysiology, (if applicable), which disease likely developed FIRST that created a “domino effect” in her life?

Write what PMH problem likely started FIRST

Write what PMH problems(s) FOLLOWED as domino(s)

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:
Arrhythmia, elevated respiration and decreasing O2.

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: