9
Case Study
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)
References
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).
