chf case study for nursing students

Heart Failure Case Study (45 min)

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What initial nursing assessments need to be performed for Mr. Jones?

• Full set vital signs
• Heart sounds
• Lung Sounds

What diagnostic tests do you anticipate being ordered by the provider?

• Chest X-ray
• 12-lead EKG
• Echocardiogram
• Cardiac Enzymes

Upon further assessment, the patient has crackles bilaterally and tachycardia. A chest X-ray shows cardiomegaly and bilateral pulmonary edema. An ECG revealed atrial fibrillation. His vital signs were as follows:

BP 150/72 mmHg Urine Yellow and Cloudy

HR 102-123 bpm and irregular BUN 17 mg/dL

RR 24-32 bpm Cr 1.2 mg/dL

Temp 37.3°C H/H 11.8 g/dL / 36.2%

Ht 175 cm LDH 705 U/L

Wt 79 kg ** BNP 843 pg/mL

Mr. Jones was admitted to the cardiac telemetry unit.

Mr. Jones states that this weight is approximately 3 kg more than it was 3 days ago.

What is the significance of Mr. Jones' weight gain?

• 1 kg weight gain is equal to 1 liter of weight gain. This means Mr. Jones has gained 3 liters of fluid (as volume excess) in just 3 days.
• This likely means that there is a new onset or exacerbation of heart failure

What medications do you anticipate the provider ordering for Mr. Jones? Why?

• Diuretics – he is volume overloaded and it is affected his lungs. Diuretics can help relieve fluid retention by promoting excretion of water from the kidneys.
• Beta-Blockers – his blood pressure is high and his heart rate is fast. The beta-blocker can help slow this down and relieve some of the workload of his heart

About three hours after admission to the telemetry unit, Mr. Jones’s skin becomes cool and clammy. His respirations are labored and he is complaining of abdominal pain. Upon physical examination, Mr. Jones is diaphoretic and gasping for air, with jugular venous distension, bilateral crackles, and an expiratory wheeze.  His SpO 2 is 88% on room air and it was noted that his urine output had been approximately 20 mL/hr since admission. His BP is 190/100 mmHg, HR 130 bpm and irregular, RR 43 bpm.

What nursing interventions should you perform right away for Mr. Jones?

• Place into High Fowler’s position 
• Apply oxygen
• Administer any PRN medications available for blood pressure (like hydralazine or metoprolol) if criteria are met
• Notify the provider

Describe what is happening to Mr. Jones physiologically.

• Because his heart cannot pump blood efficiently to the body, the blood is backing up into the lungs. This causes pulmonary edema. His pulmonary edema is so severe that he is struggling to breathe and struggling to oxygenate appropriately.
• His heart is trying to work extra hard to compensate for the low cardiac output, that’s why his blood pressure and heart rate are so elevated. This is perpetuated by the RAAS.
• We also see that his kidneys are not being perfused as his urine output has decreased

What medications should be given to decrease Mr. Jones’s preload? Improve his contractility? Decrease his afterload?

• Preload – diuretics (furosemide, bumetanide, spironolactione), ACE inhibitors (captopril, enalapril), ARB’s (losartan, valsartan), ARNI’s (sacubitril/valsartan)
• Contractility – Inotropes (dobutamine), cardiac glycosides (digoxin)
• Afterload – Beta Blockers (metoprolol, carvedilol), vasodilators (hydralazine, nitrates)

What is the expected outcome of administration of Furosemide? Digoxin?

• Furosemide – should see increase in urine output and decrease in respiratory symptoms – may also see a decrease in any peripheral edema
• Digoxin – decrease heart rate and increase the force of contraction – should see evidence of improved peripheral perfusion.

Melander, S. (2004). Case studies in critical care nursing: A guide for application and review, 3 rd ed. Philadelphia, PA: Saunders Elsevier.

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Nursing Case Studies

This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

Nursing Case Studies Introduction

Cardiac nursing case studies.

• 6 Questions
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GI/GU Nursing Case Studies

• 2 Questions
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Obstetrics Nursing Case Studies

Respiratory nursing case studies.

• 10 Questions

Pediatrics Nursing Case Studies

• 3 Questions
• 12 Questions

Neuro Nursing Case Studies

Mental health nursing case studies.

• 9 Questions

Metabolic/Endocrine Nursing Case Studies

Other nursing case studies.

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Mr. Grinch is a 68 year old male who presented to the Emergency Department (ED) with severe shortness of breath (SOB), fatigue, and recent weight gain of 5 kg. It is two days after Thanksgiving and Mr. Grinch has been eating salted ham and a large amount of leftovers for every meal. He is having trouble speaking, but reports he has been having difficulty sleeping and states, “I feel like I’m drowning. I’ve tried using multiple pillows to get rid of this feeling, but the only way for me not to feel so SOB is if I sleep sitting up”. This is Mr. Grinch’s second admission this year for a similar complaint. He has a history of heart failure, Ischemic heart diseases [with his last echo showing an EF 25%], hyperlipidemia, Coronary Artery Disease (CAD) [CABG 2 vessel 2 years prior], hypertension (HTN), and Type II diabetes. The patient’s son, who is also his main caregiver and lives nearby,  has accompanied him to the ED and reports that Mr. Grinch is not adherent to either diet nor medication regimens. He also reports that Mr. Grinch likes to eat fast food or frozen dinners for most of his meals a week. He refuses to exercises and generally lives a sedentary lifestyle. Home meds include Lisinopril 5mg, Metoprolol 25mg, Spironolactone 25mg, Atorvastatin 10mg Daily.

Assessment in the ED revealed: vitals BP: 198/103, HR 131, RR 22, T 98.4, O2 of 84% on Room Air so the patient is placed on 10L Non rebreather which increases O2 to 94%. The patient is alert, oriented x4, anxious, PERRLA, with facial symmetry and reflexes intact. The EKG shows sinus tachycardia and no new ischemic changes . Cardiac assessment revealed s3, bilateral pitting pedal edema 2+, and 2+ pulses in all extremities. Auscultation of the lungs revealed bibasilar pulmonary rales. There is also use of accessory muscles, nasal flaring, and severe SOB. The abdomen was distended/non tender with positive hepatojugular reflux. All other assessment findings were normal.

In addition to the EKG, a chest x-ray was performed and showed cardiomegaly, vascular engorgement, and mild interstitial edema. Labs: Na 128 mEq/L, K 5.2 mEq/L, BUN 82 g/dL, Crt 1.8 mg/dL, trop I 0.1 ng/mL , BNP 1300 pg/mL, Glu 140 g/dL.

Mr. Grinch receives oxygen by non rebreather mask, is placed on fluid restriction and strict I&O. Therefore, it’s imperative that an indwelling foley catheter is inserted. Orders are made for Furosemide 40 mg IV and Nitroprusside 0.3mcg/kg/min IV.   Upon reassessment in 30 mins, Mr. Grinch reports a decrease in SOB and has put out 500 mls of urine. Lung auscultation shows improved, but still present rales. Vitals are now BP 150/96, HR 89, RR18, T 98.5, and O2 of 97% on 10L non rebreather.  Mr. Grinch is stable and is now being transferred to a telemetry floor for further monitoring.

When setting patient goals for Mr. Grinch, the nurse decides the priorities for the patient will be to improve ventilation, maintain hemodynamic stability, and be able to verbalize understanding of his condition and associated treatments prior to discharge. Case management will be consulted as the patient lives alone and may require home health care upon discharge.

Open Ended Questions

1.What are the modifiable risk factors that placed this patient at risk for CHF and exacerbation?

a. Diet (intake of fast food and frozen meals high in salt)

b. Sedentary lifestyle

c. Nonadherence to medication and diet regimen

2. Which members of the interprofessional team would the patient benefit from collaboration or referral and why?

a.Dietician (to help Mr. Grinch identify healthy food options he will actually eat and to understand which foods have high sodium)

b.Physician (to reinforce educate on the importance of adherence to medication regimen and the consequences of nonadherence, to reinforce educate on why diet changes are needed, to reinforce educate on signs/symptoms that would warrant a call to the provider or hospitalization)

c.Case management (to coordinate home health nurse services upon discharge since the patients main caregiver is his son who does not live with him)

3.What kind of discharge education would this patient require to reduce the chance of readmission for CHF exacerbation?

a.Medication regimen (how to take, when to take, side effects, what happens if he decides not to take)

b.Diet Plan

c. Sign and symptoms of impending exacerbation

d.Daily weights

e.Community resources (home health, support, group, medication payment programs)

Colucci, W. (2018, December 19). Treatment of acute decompensated heart failure: Components of therapy. Retrieved from https://www.uptodate.com/contents/treatment-of-acute-decompensated-heart-failure-components-of-therapy#H1059927093

Heart Failure. (2019). Retrieved from https://www.heart.org/en/health-topics/heart-failure . Hinkle, J. L., Brunner, L. S., Cheever, K. H., & Suddarth, D. S. (2014). Brunner & Suddarths textbook of medical-surgical nursing. Philadelphia, PA: Lippincott Williams & Wilkins.

Mebazaa, A., Yilmaz, M. B., Levy, P., Ponikowski, P., Peacock, W. F., Laribi, S., . . . Filippatos (2015). Recommendations on pre-hospital & early hospital management of acute heart failure: A consensus paper from the heart Failure association of the european society of cardiology, the european society of emergency medicine and the society of academic Emergency. European Journal of Heart Failure,17 (6), 544-558. doi:10.1002/ejhf.289.

Riley, J. (2015). The Key Roles For The Nurse In Acute Heart Failure Management. Cardiac Failure Review,1 (2), 123-127. doi:10.15420/cfr.2015.1.2.123.

Unbound Medicine (Version Nursing Central). (2017).

Nursing Case Studies by and for Student Nurses Copyright © by jaimehannans is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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