Nursing Care Process Case Study

Running Head: HEART FAILURE CASE STUDY 1
Nursing Care Process:
Heart Failure Patient
Eunice Rosales
Herzing University
Adult Health 2
Professor Crystal Fisher MSN, RN
October 31, 2019

HEART FAILURE CASE STUDY 2
Patient Profile
G.A. is 83 year old female who presents with congestive heart failure. She was admitted to the
intermediate care unit with complaints of increasing shortness of breath, fatigue and weight gain.
She also complained of weakness 2 weeks prior, unable to get out of bed today on admission.
A. Subjective Data
 History of hypertension, congestive heart failure with the pacemaker, COPD, obstructive
sleep apnea
 Multiple hospital admissions in the past for various reasons including CHF exacerbation
and Pneumonia
 History of right-sided shoulder surgery, A-fib, Asthma, COPD, GERD, HTN,
Hypothyroid, Chronic cough, Sleep Apnea and Osteoarthritis.
 Social History: Lives with adult daughter, non-smoker, no substance abuse, good family
support from friends and family.
B. Objective Data
Physical Examination
 Vitals: Temp: 98.2 F (oral), HR: 61, RR: 30, BP: 152/94
 Alert, oriented x 3
 Moderate respiratory distress, Bilateral lower extremity swelling, Cyanotic lips and
extremities. Skin cool and diaphoretic
 Bilateral crackles in all lung fields
 Systolic heart murmur
Diagnostic Studies
 Chest x-ray results: cardiomegaly with right and left ventricular hypertrophy; fluid in
lower lung fields
 Echocardiogram results: EF 20%, Mild aortic valve stenosis, Moderate tricuspid and
mitral valves regurgitation. Pacemaker in place in the past 3 years.
C. Inter-professional care
 Furosemide 40 mg. IV Twice a day
 Potassium 40 mEq PO twice a day
 Enalapril 5 mg/day PO
 Digoxin 125 mcg PO daily
 Eliquis 5 mg. 2 tabs PO BID
 Nesiritide 2 mcg/kg IV bolus followed by a continuous infusion of 0.01 mcg/kg/min
 Continuous ECG monitoring
 Diet: 2-g sodium diet
 Titrate oxygen to keep > 93 %
 Monitor intake and output, and daily weights
 Serum electrolytes; cardiac biomarkers every 8 hours x 3
Discussions
A. Pathophysiology of G.A.’s heart disease and symptoms
Heart failure, sometimes known as congestive heart failure, is a “syndrome in which the
heart is unable to pump enough blood to meet the body’s needs for oxygen and
nutrients”(Ehrlich & Schroeder, 2005). Narrowed arteries in the heart, a condition called
coronary artery disease or high blood pressure gradually leave the heart too weak or stiff to
fill and pump efficiently. Left and right ventricles of the heart are the main pumping
chambers of the heart and if both are impaired the term “biventricular dysfunction”(Nicholas,
2014) is used. One way to prevent heart failure is to prevent and control conditions that cause
heart failure, such as coronary artery disease, high blood pressure, diabetes or obesity.
B. Clinical manifestations of heart failure
Mayo clinic website shows a picture of common manifestations of heart failure:
In the case of G.A.’s objective data, she presents all of the above symptoms and more.
C. Significance of diagnostic studies: WebMD website listed the following diagnostic studies
for heart failure: Blood test, Urine test, ECG, Chest x-ray, MRI, Exercise stress test, and
cardiac catherization. Two of these tests were performed on G.A. Her x-ray revealed an
enlarged heart, lungs congested with fluids and hypertrophy. Her ECG detected the abnormal
rate and rhythm, aortic stenosis, valves regurgitations and abnormal ejection fraction.
D. Nursing Care Plan (Separate attachment)
Conclusion
My Doctor once explained to me that Heart Failure can be acute without underlying
chronic heart failure. Commonly acute heart failure presentations are due to other diseases
that are not well managed like diabetes, hypertension, kidney or liver disease, lung problem
and much more.
For G.A., her heart failure is chronic. Her symptoms suddenly became worse including
severe weakness and cyanotic lower extremities which prompted her to seek medical care.
G.A. has other chronic diseases that may have caused her heart failure including A-fib,
Asthma, COPD, Depression, GERD, HTN, Hypothyroid, TIA, and more.
G.A. needed the following self-care at home to feel better and live longer: Take
prescribed medicine regularly; reducing sodium (salt) in her diet; checking her weight every
day; and making life style changes like starting light exercise. Lastly, follow up care is a big
part of her treatment and safety.

References
Ehrlich, A. & Schroeder, C.L. (2005). Medical terminology for health professions (5th
Ed.)Congestive Heart Failure, 138-148.
Jaffe, M.S., (1996). Medical-Surgical nursing care plans, (3rd Ed.). Heart Failure/Pulmonary
Edema, 138-148.
Mayo Clinic. https://www.mayoclinic.org › diagnosis-treatment › drc-20373148
Nicholson, C. (2014). Chronic heart failure: Pathophysiology, diagnosis and
treatment. Nursing Older People (2014+), 26(7), 29.
doi:http://dx.doi.org/10.7748/nop.26.7.29.e584
https://www.webmd.com › heart-disease › guide › heart-disease-symptoms
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Running Head: HEART FAILURE CASE STUDY 1

Nursing Care Process:

Heart Failure Patient

Professor Crystal Fisher MSN, RN

October 31, 2019

 History of right-sided shoulder surgery, A-fib, Asthma, COPD, GERD, HTN,

Hypothyroid, Chronic cough, Sleep Apnea and Osteoarthritis.

support from friends and family.

extremities. Skin cool and diaphoretic

 Bilateral crackles in all lung fields

 Systolic heart murmur

lower lung fields

mitral valves regurgitation. Pacemaker in place in the past 3 years.

 Furosemide 40 mg. IV Twice a day

 Potassium 40 mEq PO twice a day

 Digoxin 125 mcg PO daily

 Eliquis 5 mg. 2 tabs PO BID

 Nesiritide 2 mcg/kg IV bolus followed by a continuous infusion of 0.01 mcg/kg/min

 Continuous ECG monitoring

 Diet: 2-g sodium diet

 Titrate oxygen to keep > 93 %

 Monitor intake and output, and daily weights

 Serum electrolytes; cardiac biomarkers every 8 hours x 3

A. Pathophysiology of G.A.’s heart disease and symptoms

B. Clinical manifestations of heart failure

Mayo clinic website shows a picture of common manifestations of heart failure:

D. Nursing Care Plan (Separate attachment)

and much more.

Asthma, COPD, Depression, GERD, HTN, Hypothyroid, TIA, and more.

part of her treatment and safety.

Ed.)Congestive Heart Failure, 138-148.

Mayo Clinic. https://www.mayoclinic.org › diagnosis-treatment › drc-20373148

Nicholson, C. (2014). Chronic heart failure: Pathophysiology, diagnosis and

treatment. Nursing Older People (2014+), 26(7), 29.

https://www.webmd.com › heart-disease › guide › heart-disease-symptoms

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