ati video case study heart failure

ATI RN Medical Surgical Heart Failure Video Case Studies 3.0 With Answers-5 Solved Questions

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ATI MED SURG VIDEO CASE STUDIES RN 3.0 HEART FAILURE 1. A nurse is assessing a client who has left-sided heart failure with decreased cardiac output. Which of the following manifestations should the nurse expect? a. Flushing of the skin on exertion The client who has left-sided heart failure with decreased cardiac output will appear pale in color on exertion due to poor tissue perfusion. b. Nocturia at night The client who has left-sided heart failure with decreased cardiac output can have oliguria during the day and nocturia at night due to poor tissue perfusion to the kidneys. c. Warm lower extremities The client who has left-sided heart failure with decreased cardiac output will have cool extremities due to poor tissue perfusion. d. Respiratory rate of 16/min The client who has left-sided heart failure with decreased cardiac output will have tachypnea due to intra-alveolar fluid causing engorgement of pulmonary vessels. Answer: b. Nocturia at night The client who has left-sided heart failure with decreased cardiac output can have oliguria during the day and nocturia at night due to poor tissue perfusion to the kidneys. 2. A nurse is assessing a client who is restricted to bedrest for manifestations of right-sided heart failure. Which of the following findings should the nurse expect? a. Weak peripheral pulses A client who has left-sided heart failure will have manifestations of weak peripheral pulses due to decreased cardiac output. b. Angina A client who has left-sided heart failure will have manifestations of angina due to decreased cardiac output. c. Sacrum edema

A client who has right-sided heart failure and is restricted to bedrest will often have fluid accumulation in the sacral area when compared to a client who is ambulatory. The edema is due to increased systemic venous pressures and congestion. d. Crackles in the lungs A client who has left-sided heart failure will have manifestations of crackles in the lungs due to decreased cardiac output. Answer: c. Sacrum edema A client who has right-sided heart failure and is restricted to bedrest will often have fluid accumulation in the sacral area when compared to a client who is ambulatory. The edema is due to increased systemic venous pressures and congestion. 3. A nurse is monitoring a client who has received enalapril for heart failure. The nurse should identify which of the following findings as an adverse effect? a. Bradycardia Tachycardia is an adverse effect of enalapril. b. Orthostatic hypotention Enalapril, which is an angiotensin-converting enzyme, prevents conversion of angiotensin I to angiotensin II, causing dilation of the arterial and venous vessels. This can lead to the client developing orthostatic hypotension. c. Increased perspiration Decreased perspiration is an adverse effect of enalapril. Clients who are taking enalapril should avoid becoming overheated in warmer weather. d. Somnolence Insomnia is an adverse effect of enalapril. Answer: b. Orthostatic hypotention Enalapril, which is an angiotensin-converting enzyme, prevents conversion of angiotensin I to angiotensin II, causing dilation of the arterial and venous vessels. This can lead to the client developing orthostatic hypotension.

4. A nurse is reviewing the laboratory values for a client who is taking an ACE inhibitor and spironolactone for heart failure. The nurse should notify the provider for which of the following laboratory values? a. Creatinine 1.8 mg/dL The nurse should notify the provider of a creatinine 1.8 mg/dL. Clients receiving an ACE inhibitor and spironolactone together, may develop hyperkalemia and dysthymias. b. Potassium 4.2 mEq/L A potassium level of 4.2 mEq/L is within the expected reference range; however, the nurse should monitor for hyperkalemia when the client is receiving an ACE inhibitor and spironolactone together. c. BNP 98 pg/mL A BNP of 98 pg/mL is within the expected reference range; however, BNP of greater than 100 mg/mL is a critical value indicating ventricular stretching that can lead to congestive heart failure. d. d-Dimer 0.3 mcg/mL A d-Dimer of 0.3 mcg/mL is within the expected reference range; however, d-Dimer of greater than 0.4 mcg/mL can indicate formation of a thrombus, leading to a pulmonary embolus. Answer: a. Creatinine 1.8 mg/dL The nurse should notify the provider of a creatinine 1.8 mg/dL. Clients receiving an ACE inhibitor and spironolactone together, may develop hyperkalemia and dysthymias. 5. A nurse is planning care for a client who has heart failure. Which of the following interventions should the nurse include in the plan of care? a. Maintain sodium intake at 3.5 gm daily. The nurse should plan to limit the client's sodium level between 2 to 3 gm daily to decrease fluid retention, which decreases the workload of the heart. b. Limit fluid intake to 2 L per day. The nurse should plan to limit the client's fluid intake to 2 L daily to decrease fluid retention, which decreases the workload of the heart. c. Administer NSAIDs for minor discomfort. The nurse should avoid administering NSAIDs to prevent sodium and fluid retention.

d. Place the client in a lateral recumbent position. The nurse should elevate the head of the client's bed 45° to promote expansion of the chest wall and facilitate breathing. Answer: b. Limit fluid intake to 2 L per day. The nurse should plan to limit the client's fluid intake to 2 L daily to decrease fluid retention, which decreases the workload of the heart.

Document Details

• Subject: Nursing
• Exam Authority: ATI

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Heart Failure Case Study (45 min)

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What initial nursing assessments need to be performed for Mr. Jones?

• Full set vital signs
• Heart sounds
• Lung Sounds

What diagnostic tests do you anticipate being ordered by the provider?

• Chest X-ray
• 12-lead EKG
• Echocardiogram
• Cardiac Enzymes

Upon further assessment, the patient has crackles bilaterally and tachycardia. A chest X-ray shows cardiomegaly and bilateral pulmonary edema. An ECG revealed atrial fibrillation. His vital signs were as follows:

BP 150/72 mmHg Urine Yellow and Cloudy

HR 102-123 bpm and irregular BUN 17 mg/dL

RR 24-32 bpm Cr 1.2 mg/dL

Temp 37.3°C H/H 11.8 g/dL / 36.2%

Ht 175 cm LDH 705 U/L

Wt 79 kg ** BNP 843 pg/mL

Mr. Jones was admitted to the cardiac telemetry unit.

Mr. Jones states that this weight is approximately 3 kg more than it was 3 days ago.

What is the significance of Mr. Jones' weight gain?

• 1 kg weight gain is equal to 1 liter of weight gain. This means Mr. Jones has gained 3 liters of fluid (as volume excess) in just 3 days.
• This likely means that there is a new onset or exacerbation of heart failure

What medications do you anticipate the provider ordering for Mr. Jones? Why?

• Diuretics – he is volume overloaded and it is affected his lungs. Diuretics can help relieve fluid retention by promoting excretion of water from the kidneys.
• Beta-Blockers – his blood pressure is high and his heart rate is fast. The beta-blocker can help slow this down and relieve some of the workload of his heart

About three hours after admission to the telemetry unit, Mr. Jones’s skin becomes cool and clammy. His respirations are labored and he is complaining of abdominal pain. Upon physical examination, Mr. Jones is diaphoretic and gasping for air, with jugular venous distension, bilateral crackles, and an expiratory wheeze.  His SpO 2 is 88% on room air and it was noted that his urine output had been approximately 20 mL/hr since admission. His BP is 190/100 mmHg, HR 130 bpm and irregular, RR 43 bpm.

What nursing interventions should you perform right away for Mr. Jones?

• Place into High Fowler’s position 
• Apply oxygen
• Administer any PRN medications available for blood pressure (like hydralazine or metoprolol) if criteria are met
• Notify the provider

Describe what is happening to Mr. Jones physiologically.

• Because his heart cannot pump blood efficiently to the body, the blood is backing up into the lungs. This causes pulmonary edema. His pulmonary edema is so severe that he is struggling to breathe and struggling to oxygenate appropriately.
• His heart is trying to work extra hard to compensate for the low cardiac output, that’s why his blood pressure and heart rate are so elevated. This is perpetuated by the RAAS.
• We also see that his kidneys are not being perfused as his urine output has decreased

What medications should be given to decrease Mr. Jones’s preload? Improve his contractility? Decrease his afterload?

• Preload – diuretics (furosemide, bumetanide, spironolactione), ACE inhibitors (captopril, enalapril), ARB’s (losartan, valsartan), ARNI’s (sacubitril/valsartan)
• Contractility – Inotropes (dobutamine), cardiac glycosides (digoxin)
• Afterload – Beta Blockers (metoprolol, carvedilol), vasodilators (hydralazine, nitrates)

What is the expected outcome of administration of Furosemide? Digoxin?

• Furosemide – should see increase in urine output and decrease in respiratory symptoms – may also see a decrease in any peripheral edema
• Digoxin – decrease heart rate and increase the force of contraction – should see evidence of improved peripheral perfusion.

Melander, S. (2004). Case studies in critical care nursing: A guide for application and review, 3 rd ed. Philadelphia, PA: Saunders Elsevier.

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This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

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Orthostatic hypotension Choose matching term 1 A nurse is reviewing the laboratory values for a client who is taking spironolactone for heart failure. The nurse should notify the provider for which of the following laboratory values? 2 A nurse is collecting data on a client who has left-sided heart failure. Which of the following findings should the nurse expect? 3 A nurse is monitoring a client who received enalapril for heart failure. The nurse should monitor the client for which of the following findings as an adverse effect of medication? 4 A nurse is collecting data for manifestations of the right-sided heart failure for a client who is restricted to bed rest. Which of the following findings should the nurse expect? Don't know?