NUPP 700 Cardiac Case Study
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NUPP 700 Cardiac Case Study
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History of Present Problem:
Mary 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:
Mary 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 She has struggled with depression the past two years and has been more withdrawn since her husband of 52 years died unexpectedly three months ago from a myocardial infarction.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? /8
| RELEVANT Data from Present Problem: | Clinical Significance: |
| Example- The last two nights she had to sleep in her recliner chair to rest comfortably. She is able to speak only in partial sentences and then has to take a breath when talking to the nurse.
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Example: Orthopnea is a clinical RED FLAG that is commonly seen as left-sided heart failure continues to progress. The ability to speak only in partial sentences is also consistent with increased respiratory distress.
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| RELEVANT Data from Social History: | Clinical Significance: |
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2. |
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NUPP 700 Cardiac Case Study
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What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds?
Fill in the Pharmacological classification section /Expected Outcomes /9
| PMH: | Home Meds: | Pharm. Classification: | Expected Outcome of medication : |
| Diabetes Mellitus type II Hypertension
Atrial fibrillation Hyperlipidemia Chronic renal insufficiency (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 |
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|
Based on the client’s home medications and past medical history as listed above, align the medication used to treat each condition /5
| Medical Condition | Medication used to treat |
| Diabetes Mellitus type II | |
| Atrial fibrillation | |
| Hyperlipidemia | |
| Chronic renal insufficiency (baseline Creatinine 2.0) | |
| Heart Failure (systolic) secondary to ischemic cardiomyopathy | |
| MI with stent x2 to LAD 4 years ago | |
| Diabetes Mellitus type II | |
| Hypertension | |
| Hyperlipidemia | |
| Cerebral vascular accident (CVA) with no residual deficits | |
Patient Care Begins:
| Current Vital Signs: | Pain assessment P-Q-R-S-T | |
| 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 np) | Timing: | |
What Vital Sign data is RELEVANT and must be recognized as clinically significant by the nurse? /4
| RELEVANT Vital Signs Data: | Clinical Significance: |
| 1.
2.
3.
4. |
| Current Assessment: | Assessment findings |
| 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? /3
| RELEVANT Assessment Data: | Clinical Significance: |
| 1.
2.
3. |
| Cardiac Telemetry Strip: |
| Interpretation: |
| Atrial fibrillation |
| Clinical Significance: |
| Because of the loss of atrial kick that is present in any sinus rhythm, 30% of cardiac output can be lost |
Radiology Reports: Chest x-ray
What diagnostic results are RELEVANT and must be recognized as clinically significant by the nurse?
/2
| RELEVANT Results: | Clinical Significance: |
| Bilateral diffuse pulmonary infiltrates consistent with
pulmonary edema |
1. |
Lab Results:
| Complete Blood Count (CBC): | Yesterday | Today |
| WBC (4.5-11.0 mm 3) | 4.8 | 5.8 |
| Hgb (120-160 mmol/l) | 129 | 132 |
| Platelets (150-450x 103/µl) | 228 | 202 |
| Neutrophil % (42-72) | 68 | 65 |
| Basic Metabolic Panel (BMP): | Yesterday | Today |
| Sodium (135-145 mEq/L) | 133 | 138 |
| Potassium (3.5-5.0 mEq/L) | 3.9 | 3.2 |
| Glucose (7.0-11.0 mg/L) | 11 | 10.8 |
| Creatinine (60-120 mg/L) | 93 | 93 |
| Misc. Chemistries: | ||
| Magnesium (1.6-2.0 mEq/L) | 1.9 | 1.8 |
| PT/INR (0.9-1.1 nmol/L) | 2.5 | 2.4 |
| Cardiac Labs: | Yesterday: | Today |
| Troponin (<0.05 ng/mL) | 0.10 | 0.12 |
| BNP (B-natriuretic Peptide) (<100
ng/L) |
1555 | 1855 |
| Arterial Blood Gas: | Current: | |
| pH (7.35–7.45) | 7.46 | |
| pCO2 (35–45) | 30 | |
| pO2 (80–-100) | 72 | |
| HCO3 (18–26) | 22 | |
| O2 sat (>92%) | 91% | |
ABG Interpretation:
/1 |
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What lab results are RELEVANT and must be recognized as clinically significant by the nurse? /4
| RELEVANT
Lab(s): |
Clinical Significance: | TREND: Identify if the results are Improved/Worsening/Stable: |
| 1.
2.
3.
4. |
Clinical Reasoning Begins… (This section must be accompanied by scholarly references) /20
- What is the primary cardiac problem that your patient is most likely presenting with?
- What is the underlying cause/pathophysiology of this primary problem?
- What are the compensation mechanisms that occur in the identified primary problem and why or how can they worsen the primary problem?
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Collaborative Care: Medical Management
Review the orders and describe the rationale for the order and the expected outcome from this treatment/ intervention /6
| Orders: | Rationale: | Expected Outcome: |
| Titrate oxygen to keep O2 sat >92%
Furosemide 40 mg IV push
Nitroglycerin IV drip: titrate to keep SBP <130
Strict I&O
Fluid restriction of 1500 mL PO daily
Low sodium diet max 2g/day |
- What body system(s) will you most thoroughly assess based on the primary problem and why? /4
All orders have all been implemented and 4 hours have passed.
Evaluation:
Evaluate the response of your patient to nursing and medical interventions during your shift. All orders have been implemented that are listed under medical management.
| Current Vital Signs: | Most Recent: | Current PQRST: | |
| T: 98.4 F/36.9 C (oral) | T: 98.6 F/37 C (oral) | Provoking/Palliative: | |
| P: 88 (irregular) | P: 82 (irregular) | Quality: | Denies pain |
| R: 24 (regular) | R: 26 (regular) | Region/Radiation: | |
| BP: 112/50 MAP: 71 | BP: 162/54 MAP: 90 | Severity: | |
| O2 sat: 91% (12 liters
high flow n/c) |
O2 sat: 90% (6 liters n/c) | Timing: |
| Current Assessment: | |
| GENERAL
APPEARANCE: |
Not as anxious, but appears restless at times |
| RESP: | Coarse crackles scattered throughout both lung fields, labored respiratory effort |
| CARDIAC: | Rhythm: atrial fibrillation, pale, limbs are cool to the touch, pulses palpable throughout, 3+ pitting edema in lower extremities |
| NEURO: | Alert and oriented to person, place, time, and situation (x4) |
| GI: | Abdomen soft/nontender, bowel sounds audible per auscultation in all 4 quadrants |
| GU: | 30 mL of urine out in the last 4 hours after furosemide IV given, 50 mL residual urine in bladder as assessed with bladder scan |
| SKIN: | Skin integrity intact |
What clinical data is RELEVANT that must be recognized as clinically significant? /6
| RELEVANT Vital Signs Data: | Clinical Significance: |
| 1.
2.
3.
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1.
2.
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| RELEVANT assessment data
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Clinical Significance: |
Current State
The client is now in acute-on-chronic renal failure and unable to adequately diurese. This state compromises her respiratory status. She is in need of care beyond the abilities of her current inpatient location and will be transferred to ICU for other interventions, including furosemide IV drip, continuous renal replacement therapy (CRRT), or even hemodialysis.
Final Activity: Hand-over report to ICU
Your knowledge and application of the pathophysiology of heart failure and renal failure have allowed you to make a series of needed assessments and judgments that have facilitated the treatment and care of your patient. You recognize that an SBAR is needed to update the primary care provider with your concerns.
NUPP 700 Cardiac Case Study
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Use the SBAR template below to determine the priorities to communicate to the ICU primary care provider
SBAR: Nurse-to-Primary Care Provider /4
| Situation: |
| Name/age:
BRIEF summary of primary problem:
Day of admission/post-op #: |
| Background: |
| Primary problem/diagnosis:
RELEVANT past medical history: |
| Assessment: |
| Most recent vital signs:
RELEVANT body system nursing assessment data:
RELEVANT lab values:
INTERPRETATION of current clinical status (stable/ unstable/worsening): |
| Recommendation: |
| Suggestions to advance plan of care: |
NUPP 700 Cardiac Case Study
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