1. Heart Failure: Interactive Fundamental Clinical Reasoning Activity
Dara Lanman, MSN, RN, CNE
Assistant Professor
Galen College of Nursing, Louisville, KY

2. Go to end of scenario questions
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.
Patient’s Chart
Go to patient’s room
Go to end of scenario questions

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

4. 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

5. CXR: diffuse infiltrates consistent with pulmonary edema
Diagnostic Tests:
Today
Yesterday
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

6. HR RR
Lung Sounds BP
Pulse Ox
0700
126 - regular
28 labored
Crackles
184/108
90% 2LNC
Main
Patient’s Chart

7. 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

8. Medication
Furosemide (Lasix)
0900
40 mg one time IV push
Simvastatin
20 mg po daily
Glyburide
10 mg po daily
HCTZ
50 mg po daily
Lisinopril
ASA
1300
81 mg po daily
Fish oil
1000 mg po 2 tabs daily
Lasix
HOLD TODAY
40 mg po daily
Click on the drug to the left and you will be linked to a PDR for reference!
Main
Patient’s Chart

9. Click on the buttons below to find out your assessment information.
Neuro
GI / GU
Cardiac/
Respiratory
Misc

10. Click on the buttons below to find out your assessment information.
Anxious, Alert & Oriented X4
Temp 98.4
GI / GU
Cardiac/
Respiratory
Misc

11. 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

12. Click on the buttons below to find out your assessment information.
Neuro
GI – Active bowel sounds in all 4 quads. Abd. Soft/non-tender
GU – Voiding without difficulty, urine clear/yellow
Cardiac/
Respiratory
Misc

13. 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

14. On the next several slides, you will have some questions
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

15. 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

16. 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

17. 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:
 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 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.
Relationship to primary medical problem:
Main
Patient’s Chart
Next Question

18. 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

19. 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

20. 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%
Foley catheter
Furosemide (Lasix)
40mg IV push
How it will help resolve primary problem:
Main
Patient’s Chart
Next Question

21. 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

22. You have completed this scenario. Thank you for your hard work.