Case study - Left-sided heart failure: Nursing

Nurse Alex works on an inpatient cardiac unit and is caring for Manny, a 65-year-old with a history of hypertension, who was admitted for left-sided heart failure. In collaboration with the registered nurse, RN Donna, Nurse Alex goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Manny’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Alex recognizes important cues, including Manny’s vital signs, which are temperature 98.9 F or 37.1 C, heart rate 100 beats per minute, respirations 22 breaths per minute, blood pressure 100/60 mmHg, and pulse oximetry 89 percent on 2 liters nasal cannula. Upon auscultation, they note extra heart sounds, S3 and S4, as well as crackles throughout Manny’s lungs, which is consistent with RN Donna’s assessment. They also notice that Manny’s breathing is labored, and he reports increasing fatigue over the last week.

Next, Nurse Alex analyzes these cues. They review the electronic health record, or EHR, and see that Manny’s most recent brain natriuretic peptide, or BNP, was 600 pg/mL and ejection fraction was 40 percent. Nurse Alex also notes that Manny is prescribed the loop diuretic, furosemide, and received his last PO dose yesterday.

Nurse Alex understands that heart failure is a condition where the heart is unable to pump effectively enough to maintain cardiac output to meet the demands of the body. With left-sided heart failure, the left ventricle isn’t able to pump with enough force to push blood into the aorta and the rest of the body. When this happens, the blood remaining in the left side of the heart can back up into the lungs, causing pulmonary problems such as dyspnea, tachypnea, crackles, decreased oxygen saturation, and fatigue. Nurse Alex also knows that the heart’s extra workload and inability to pump out the excess fluid can cause extra heart sounds.

Nurse Alex realizes Manny needs effective fluid volume regulation.

Now, using the information they gathered, along with Manny’s medical history, Nurse Alex reports their findings to RN Donna, and they choose a priority hypothesis of fluid volume overload.

Then they generate solutions that will include pharmacologic and nonpharmacologic interventions; and they establish the expected outcome that after intervening, Manny will demonstrate decreased dyspnea by the end of the shift.

Nurse Alex then takes action to implement these solutions. RN Donna contacts the health care provider who prescribes an increase in Manny’s oxygen, a STAT dose of IV furosemide as well as a sodium and fluid restricted diet.

Next, RN Donna administers the IV furosemide while Nurse Alex increases Manny’s oxygen to 4 liters nasal cannula, raises his bed to a high Fowler position to promote lung expansion and ease Manny’s breathing.

Then, Nurse Alex reinforces education that RN Donna initially provided about Manny’s new diet order.