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Heart Failure Case Study

J.D. is a 67-year-old female with a history of heart failure who presented to the emergency department with increased shortness of breath and heart palpitations. Her physical exam revealed crackles in her lungs, irregular pulse, edema, and her weight had increased by 15 pounds in the past month. She had discontinued her heart failure medications last week against medical advice. Diagnostic tests showed a pleural effusion on her chest x-ray and abnormal electrolyte and glucose levels.

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851 views2 pages

Heart Failure Case Study

J.D. is a 67-year-old female with a history of heart failure who presented to the emergency department with increased shortness of breath and heart palpitations. Her physical exam revealed crackles in her lungs, irregular pulse, edema, and her weight had increased by 15 pounds in the past month. She had discontinued her heart failure medications last week against medical advice. Diagnostic tests showed a pleural effusion on her chest x-ray and abnormal electrolyte and glucose levels.

Uploaded by

RC
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
  • Clinical Activity – Heart Failure: Presents a clinical case study involving heart failure, detailing the patient's history, physical assessment, medications, and diagnostic results along with follow-up questions.

Clinical Activity Heart Failure

Name: _________________________
J. D. is a 67 year old female with a history of heart failure. Her last
Echocardiogram was 2 years ago and showed an EF of 40%. She is an exsmoker and has committed to living a healthy lifestyle. She is careful with her diet
and exercise and her goal is to be able to discontinue her cardiac medications.
J.D. believes that if she can get back into shape, her body will no longer require
medical intervention.
J. D. has been noticing an increase in shortness of breath when doing simple
tasks around the house and also has noticed some "heart skipping". She comes
to the Emergency Department for evaluation.
Physical Assessment:
Neuro: AAOx 3, moves all extremities to command, and exhibits equal strength.
Pulmonary: Exhibits shortness of breath when walking; lung auscultation reveals
bilateral crackles in the bases.
GI: Bowel sounds normal; abdomen is non-tender to palpation.
GU: Clear yellow urine, no abnormalities.
CV: Pulse irregular, nailbeds pink, peripheral pulses strong. 2+ edema in lower
extremities
Vitals: HR 90-95, Respiratory rate 30, BP 156/88, Temp 98.4 F, Weight 165
(note: her weight has increased by 15 lb since her last check up 1 month ago).
History: J.D. states that she discontinued her digoxin and her lasix last week
because she felt like she didnt need them any more. She lives alone in a two
story home, but her daughter and son both live nearby. Her son takes care of
her yardwork, and her daughter assists with grocery shopping and housework
when J.D. is unable to do it.
Medications: Digoxin 0.125 mg PO qd
Lasix 40 mg PO qd
KCL 20mEg PO qd
Multivitamin PO qd
ASA 80mg PO qd
Diagnostic Studies:
CXR: reveals a right lower lobe pleural effusion.
Labs: Glucose 287, Na 137, K 3.8, Cl 104, CO2 28, BUN 18 and Creatinine 0.7.

1. What might be an appropriate medical treatment for J.D.?

2. What are 4 appropriate nursing interventions?

3. Describe the action, use, nursing considerations and side effects of each
medication that J.D. is prescribed.

4. What individualized health teaching would you provide for J.D. and her
family?

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