Video Case Study - Caring for Patients With Left-sided Heart Failure

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, Ranna, 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 BPM, respirations 22 breaths per minute, BP 100/60 millimeters of mercury, and pulse oximetry 89% on 2 L 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 picograms per milliliter and ejection fraction was 40%.

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 non-pharmacologic interventions, and they establish the expected outcome that after intervening, many will demonstrate decreased dyspnea by the end of the shift.

Nurse Alex then takes action to implement these solutions. Ranna contacts the healthcare provider who prescribes an increase in Manny's oxygen, a stat dose of IV furosemide, and a sodium and fluid restricted diet.

Next, Aranna administers the IV furosemide, while nurse Alex increases Manny's oxygen to 4 L nasal cannula and raises his bed to a high fowler position to promote lung expansion and ease Manny's breathing.

Then nurse Alex reinforces education that Ranna initially provided about Manny's new diet order. Hi, Manny.

I know R and Donna taught you about your sodium and fluid restriction earlier, so I wanted to help you order a lunch tray that follows these guidelines.

Sure. Now I understand why I can't have extra fluids, but remind me why I need to limit how much salt I'm eating.

Sodium or salt can make your body hold on to extra fluid, so restricting it helps get rid of the extra fluid. This should help with your breathing by making it easier for your heart to pump blood.

OK, that makes sense. Now you'll want to limit foods high in sodium, like canned foods, cheese, deli meat, and soy sauce.

Also avoid adding table salt to foods or eating salted snacks like popcorn or nuts. Let's look at your menu and see what you could pick for lunch.

Nurse Alex and Manny look at the menu together, and Manny chooses a salad with grilled chicken to eat for lunch, along with a cup of unsweetened tea.

Throughout the rest of their shift, Nurse Alex and Aanna monitor Manny's heart and lung sounds and intake and output. Since the increased furosemide dose causes fluid and electrolyte loss, they monitor for signs of fluid and electrolyte imbalances like muscle weakness, twitching, or cramps, altered mental status, and cardiac dysrhythmias.

At the end of the shift, nurse Alex enters the room to evaluate the outcome of their actions. They take Manny's vital signs, which are temperature 98.6 °F or 37 °C, heart rate 90 BPM, respirations 18 breaths per minute, BP 108/66 millimeters of mercury, and pulse oximetry 96% on 4 L nasal cannula.

Manny's breathing is non-labored, and he no longer pauses mid-sentence to catch his breath. All right, as a quick recap, nurse Alex recognized and analyzed cues related to Manny's fluid volume overload and in collaboration with Ranna, prioritized hypotheses and generated solutions to address this problem.

Nurse Alex and RN Donna then implemented pharmacologic and non-pharmacologic measures, evaluated Manny's outcomes, and compared them to the expected outcome.

Since Manny's dyspnea improved by the end of the shift, they determined the plan of care was successful.