Transcript keithRN_examplex

Heart Failure:
Interactive Fundamental
Clinical Reasoning Study
Dara Lanman, MSN, RN, CNE
Assistant Profesor
Galen College of Nursing, Louisville, KY
You have been assigned to your
patient this am and have been
given report. Go to the Patient’s
chart and review the most recent
information regarding this patient.
Go to patient’s room
Patient’s Chart
Go to end of scenario
questions
Patient’s Chart (click on what you want to
review in your patient’s chart.)
Physician Orders
Patient History
Vital Signs
Diagnostic Tests
MAR
Patient History
It has now been 3 years since Mr. Kelly has been discharged from
the hospital for CAD & MI. He is now 56 years old. He has not had
any recurrent CP, but has had to sleep with 3 pillows to keep from
becoming SOB at night the last 2 weeks. He has had difficulty
getting his shoes on the last month because of increased swelling
around his ankles. He forgets to take his medications every day. He
weighs himself once a week and today his weight has increased
from 255 lbs. to 264 lbs. the last 7 days. He makes an appt.
through his clinic when he becomes concerned that he is now
becoming SOB at rest and is more fatigued. The clinic physician
recognizes that he will need acute inpatient care and coordinates a
direct admission to the hospital by EMS.
PMH: heart failure, HTN, hyperlipidemia, CAD, MI, DM – type II
Main
Patient’s
Chart
Diagnostic Tests:
Today
Yesterd
ay
Creatinine
2.1
1.2
Potassium
5.1
4.2
CXR: diffuse infiltrates
consistent with pulmonary
edema
Echocardiogram:
Current ejection fraction is
30% with the most recent
ejection fraction at 45%
Main
Patient’s Chart
0700
HR
RR
Lung
Sounds
BP
Pulse Ox
126 regular
28
labored
Crackles
184/108
90%
2LNC
Main
Patient’s Chart
Physician Orders:
Titrate oxygen for O2 sats >92%
Insert Foley Catheter
Furosemide 40 mg one time IV push
Continue home meds
Main
Patient’s Chart
Medication
0700-1500
Furosemide
(Lasix)
0900
40 mg one
time IV push
Simvastatin
0900
20 mg po daily
Glyburide
0900
10 mg po daily
HCTZ
0900
50 mg po daily
Lisinopril
0900
20 mg po daily
1500-2300
Click on the drug to
the left and you will
be linked to a PDR for
reference!
ASA
1300
81 mg po daily
Fish oil
1300
1000 mg po 2
tabs daily
Lasix
HOLD TODAY
40 mg po daily
2300-0700
Main
Patient’s Chart
Click on the buttons below to find out your assessment
information.
Neuro
GI /
GU
Cardiac/
Respiratory
Misc
Click on the buttons below to find out your assessment
information.
Anxious, Alert & Oriented X4
Temp 98.4
GI /
GU
Cardiac/
Respiratory
Misc
Click on the buttons below to find out your assessment
information.
Neuro
Cardiac – pale, cool to the touch, Pulses 2+
throughout, 2-3+ pitting edema lower
extremities
Resp – course crackles scattered
throughout both lung fields. Labored
respiratory effort
GI /
GU
Misc
Click on the buttons below to find out your assessment
information.
Neuro
GI – Active bowel sounds in
all 4 quads. Abd. Soft/nontender
GU – Voiding without
difficulty, urine clear/yellow
Cardiac/
Respiratory
Misc
Click on the buttons below to find out your assessment
information.
Neuro
MISC- denies pain, skin
integrity intact
GI /
GU
Cardiac/
Respiratory
Main
Patient’s
Chart
First
Question
On the next several slides, you will have some questions.
Complete these questions and submit to your instructor
per the instructions of your educator.
What is the relationship of your patient’s past medical
history (PMH) and current medications?
(Which medication treats which disease?)
PMH:
Heart failure
HTN
Hyperlipidemia
CAD
MI
DM-type II
Home Medications:
Simvastatin 20 mg po daily
Glyburide 10 mg po daily
HCTZ 50 mg po daily
Lisinopril 20 mg po daily
ASA 81 mg po daily
Fish oil 1000 mg po 2 tabs
daily
Lasix 40 mg po daily
Main
Patient’s
Chart
Next
Question
One disease process often influences the development of other
illnesses. Based on your knowledge of pathophysiology, in your
patient (if applicable) which disease likely developed first that
then initiated a “domino effect” in their life? (Refer to the list of
PMH listed for you in the patient history portion of the chart.
What came first:
What then followed:
Main
Patient’s
Chart
Next
Question
What is the relationship of your patient’s PMH and current
chief complaint?
What prior medical history above is relevant and likely influenced his
current problem and chief complaint? Explain your rationale
Relevant PMH
Rationale:
Main
Patient’s
Chart
Next
Question
What is the relationship between your patient’s chief
complaint & identified primary medical problem? (look at
pathophysiology and how it influences what you are seeing with your
assessment findings)
Chief Complaint:
Relationship to primary
Has had to sleep with 3
medical problem:
pillows to keep from becoming
SOB at night the last 2 weeks.
He has had 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. the last 7 days.
He makes an appt. through
Main
his clinic when he becomes
concerned that he is now
becoming SOB at rest and is
Patient’s
Next
more fatigued.
Chart
Question
What is the relationship between your patient’s abnormal VS
and assessment data & identified primary medical problem?
RELEVANT
VS/assessment data:
Relationship to
primary medical
problem:
Main
Patient’s
Chart
Next
Question
What is the relationship between your patient’s RELEVANT
abnormal diagnostic labs& identified primary medical
problem?
RELEVANT Diagnostic
results:
Relationship to
primary medical
problem:
Main
Patient’s
Chart
Next
Question
What is the relationship between the following physician
orders/meds and your patient’s primary medical problem?
(how will mech. of action of these meds/treatments impact this
patient at a pathophys level to help resolve his primary problem?)
Physician orders:
Titrate oxygen for O2
sats >92%
How it will help
resolve primary
problem:
Foley catheter
Furosemide (Lasix)
40mg IV push
Main
Patient’s
Chart
Next
Question
What is the relationship between your patient’s RELEVANT
abnormal diagnostic labs& identified primary medical
problem?
RELEVANT Diagnostic
results:
Relationship to
primary medical
problem:
Main
Patient’s
Chart
Next
Question
You have completed this
scenario. Thank you for
your hard work.