RNSG 2023 Heart Failure: SKINNY Reasoning 1 Case Study

RNSG 2023 Heart Failure: SKINNY Reasoning 1 Case Study. Ms. Smith’s history of myocardial infarction (MI) from four years ago and systolic heart failure secondary to ischemic cardiomyopathy. -She came into the ER for SOB the past 3 days which has now went from SOB during activity to SOB at rest. -The only way she has been able to rest comfortably is by sleeping upright in her recliner. She can only speak partial sentences before having to take a breath in order to have a conversation with the nurse. -Increased swelling in the lower legs and a weight gain of 6 pounds in the past 3 days. -A current ejection fraction (EF) of only 15% supports the indication of heart failure. Anything less than 45-55% supports this claim. -Left-sided heart failure is most likely what is causing the pulmonary edema. The fluid being trapped is affecting her breathing resulting in the SOB. -Orthopnea is often associated with the progression of left-sided heart failure. -Edema is present here. This is an indicator that left-sided heart failure is beginning to affect the right side. RELEVANT Data from Social History: Clinical Significance: -JoAnn can no longer tolerate the level of activity she’s used to due to dealing with the progression of her heart failure for the past two years. -The fact that she has been battling depression over the past two years and losing her husband not too long ago has caused her to withdraw even more. -Her activity intolerance is secondary to the progression of heart failure. -The death of her husband added to her inability to effectively cope with and find ways to overcome her depression. Instead, it caused her to push back even further. Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): 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 n/c) Timing: What VS data is RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT VS `Data: Clinical Significance: -A pulse of 92 (irregular) -26 breaths/minute (regular) -BP 162/54 -O2 sat of 90% 6 L via nasal cannula -Atrial fibrillation can cause this to be considered irregular -Way too fast for this to be her respiratory rate at rest - During heart failure the higher the BP higher the afterload which increases the overall workload of the heart -90% is too low