Video Case Study - Heart Failure

Nurse Pilar works on an inpatient cardiac unit and is caring for Esperanza, a 72-year-old female admitted for an exacerbation of heart failure with reduced ejection fraction.

After settling Esperanza in her room, Nurse Pilar goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Esperanza’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Pilar recognizes important cues, including Esperanza’s vital signs, which are heart rate 104 beats per minute, respirations 28 breaths per minute, oxygen saturation 87 percent on room air, and pain 3 out of 10, located in her back.

Nurse Pilar also notes that Esperanza’s breathing is labored and she’s using accessory muscles. Upon auscultation, Nurse Pilar notes fine inspiratory crackles in both lung bases.

There’s also 2+ pitting edema in Esperanza’s ankles and feet. Next, Nurse Pilar asks Esperanza about her recent activities and medications.

Nurse Pilar: I see your health care provider has prescribed two medicines for you. When was the last time you took them?

Esperanza: Well, I ran out of my medicines a week ago, and I haven’t been to the pharmacy to get my refills yet. I haven’t gone out of the house much the last two weeks because my back’s been hurting, and I’ve been so tired.

Nurse Pilar: I’m sorry you’ve been having back pain. Has anything helped with the pain?

Esperanza: Yes, ibuprofen helps. I’ve been taking it two times each day.

Nurse Pilar then analyzes these cues. She reviews Esperanza’s electronic health record, or EHR, and sees that she's prescribed two medications to control her heart failure, an ACE inhibitor and a beta blocker.

Because Esperanza has been without her medications for a week, she is now showing symptoms of heart failure. Additionally, Nurse Pilar knows taking non-steroidal anti-inflammatory drugs, or NSAIDs, like ibuprofen, can worsen existing heart failure by increasing sodium retention.

Nurse Pilar realizes that Esperanza is experiencing impaired cardiac function. Prioritizing Hypotheses, Generating Solutions, and Taking Action Now, using the information she's gathered, Nurse Pilar chooses a priority hypothesis of decreased cardiac output.

Then, she generates solutions to address Esperanza’s cardiac function that will include pharmacologic and nonpharmacologic interventions.

Nurse Pilar establishes the expected outcome that after intervening, Esperanza will exhibit signs of increased cardiac output.

Nurse Pilar then takes action to implement these solutions. She reviews the orders from the health care provider and sees Esperanza is prescribed oxygen at 2 liters per minute per nasal cannula; the diuretic furosemide IV push, a continuous IV infusion of the vasodilator, nitroglycerin; and acetaminophen by mouth for back pain.

While she waits for the pharmacy to dispense these medications, Nurse Pilar re-enters Esperanza’s room. Nurse Pilar: Okay, Esperanza, your heart can’t keep up with your body’s oxygen needs right now, so we’re going to give you some oxygen and start IV medications that will help.

Nurse Pilar administers the prescribed oxygen, institutes pulse oximetry, implements continuous heart monitoring, and begins strict intake and output monitoring.

She places Esperanza’s bed in high-Fowler position to promote increased lung expansion during inhalation and then asks Esperanza if she has any questions.

Esperanza: Is this happening because I ran out of my heart medicines? Nurse Pilar: Most likely.

See, your heart depends on those medicines to work properly, so when you don’t take them, your heart has a hard time getting enough oxygenated blood to the rest of your body.

Also, NSAIDs, like ibuprofen, can make heart failure worse, which is why you shouldn’t take them. I can give you acetaminophen for your back pain instead.

And before you go home, I’d like you to visit with our social worker; they can help arrange to have your medications delivered to your home, so you don’t have to worry about traveling to the pharmacy.

Esperanza: That sounds like a good idea. Nurse Pilar then administers the medications according to the principles of safe medication administration.

After leaving the room, Nurse Pilar obtains an order for a social work consultation from the health care provider. Three days later, Nurse Pilar is caring for Esperanza and evaluates the outcome of her actions.

She takes Esperanza’s vital signs, which are heart rate 90 beats per minute, respirations 15 breaths per minute, and oxygen saturation 95 percent on room air.

Esperanza’s breathing is nonlabored, she no longer has crackles upon auscultation and the pitting edema in her ankles and feet is now 1+.

Esperanza’s oxygen and IV medications have been discontinued and she is stable on her oral medications. She is scheduled to be discharged the next day on her oral medications and will follow-up with her health care provider in one week.

Nurse Pilar reviews Esperanza’s treatment plan with her, re-emphasizes the importance of taking her medications regularly, and confirms a plan is in place for medication delivery to her home.

They discuss her back pain, and Nurse Pilar reminds Esperanza to take acetaminophen instead of ibuprofen for pain. Alright, as a quick recap...

Nurse Pilar recognized and analyzed cues related to Esperanza’s exacerbation of heart failure, prioritized hypotheses, and generated solutions to address this problem.

Nurse Pilar then implemented pharmacologic and nonpharmacologic pain measures and