Case study

Case Study

Heart Failure

Patient Profile

M.G. is a 77 year old woman who saw her health care provider for dyspnea. She is now being admitted to the hospital for acute heart failure. She was diagnosed once before with heart failure 6 years ago. She is currently taking the following medications:

Furosemide 40mg po daily

Potassium chloride 20meq po daily

Enalapril 10mg po BID

Subjective data

Was taking furosemide at home but ran out two days ago and has not been able to refill her prescription

Complains of difficulty breathing; had to “sleep in the chair” last night

Has some swelling in her feet that is worse than usual

Objective Data

Physical examination

· Temp 98.4 F, pulse 92 irreg., resp. 24 labored, blood pressure 144/86, oxygen saturation 89% on Room air

· Ht. 5’5”, wt. 170 lbs.

· Alert and oriented to person, place, and time

· Fine crackles bilateral lower lobes

· Shortness of breath with minimal exertion

· S1 and S2 without murmur or extra heart sounds

· Capillary refill sluggish in lower extremities, normal in upper extremities

· 2+ pitting edema bilateral lower extremities

Interprofessional Care

Admission orders include: 

· Oxygen 2L/ nasal cannula

· Furosemide 40mg intravenous BID

· Enalapril 10mg po BID

· ECG now

· Vital signs with SPO2 q 4 hrs

· 2 gm sodium diet

· Strict I&O

· Daily weight

Answer the following questions thoroughly and cite resources appropriately in APA format.

Describe a plan for implementing these orders. 

Based on M.G.’s clinical manifestations, what type of heart failure do you suspect? Support your answer

What assessment data will you use to determine the effectiveness of the provider’s orders?

What is the rationale for the oxygen, IV furosemide, and enalapril?

What are the priority nursing diagnoses for this patient? (list at least 3)

What other orders might you anticipate for this patient?

Think about plans for discharge, what are your primary concerns for this patient?

Any other information you need or would like about this patient?