Vanessa Joubert Heart Failure
History of Present Problem: JoAnn Smith is a 72-year-old woman who has a history of myocardial infarction (MI) four years ago and systolic heart failure secondary to ischemic cardiomyopathy with a current ejection fraction (EF) of only 15%. She presents to the emergen...
History of Present Problem: JoAnn Smith is a 72-year-old woman who has a history of myocardial
infarction (MI) four years ago and systolic heart failure secondary to ischemic cardiomyopathy with a
current ejection fraction (EF) of only 15%. She presents to the emergency department (ED) for shortness
of breath (SOB) the past three days. Her shortness of breath has progressed from SOB with activity to
becoming SOB at rest. The last two nights she had to sleep in her recliner chair to rest comfortably
upright. She is able to speak only in partial sentences and then has to take a breath when talking to the
nurse. She has noted increased swelling in her lower legs and has gained six pounds in the last three
days. She is being transferred from the ED to the cardiac step-down where you are the nurse assigned
to care for her.
Personal/Social History: JoAnn is a retired math teacher who is unable to maintain the level of activity
she has been accustomed to because of the progression of her heart failure the past two years. She has
struggled with depression the past two years and has been more withdrawn since her husband of 52
years died unexpectedly three months ago from a myocardial infarction.
What data from the histories is RELEVANT and has clinical significance to the nurse?
RELEVANT Data from Present Problem:
• Age 72-years
• History of MI
• SOB
• Swelling in her legs and gained 6 pounds in 3 days.
• Irregular pulse
• Increased respiration
• Low oxygen
• S3 notes
Clinical Significance:
• As a woman reach menopause around 50 years old estrogen levels being to slowly
disappear, which places women at higher risk for CAD.
• Sleeping in recliner chair to rest comfortably upright, indicating fluid buildup in the lungs.
• The heart is not pumping blood efficiently causing fluid buildup.
• S3 indicates fluid in the lungs.
Relevant data from social history:
• Patient is depressed.
• Sudden loss of husband
• Retired math teacher
, Clinical Significance:
• Depression can affect patients adheres to recommended lifestyle changes.
• Death can add on to her depression.
• Retired due to heart failure.
What VS data is RELEVANT and must be recognized as clinically significant by the nurse?
Relevant VS Data:
• Patient has irregular pulse.
• High respiration.
Low diastolic pressure
Clinical significance:
• Irregular pulse can be a sign of atrial fibrillation.
• Excessive fluid in the lungs can make it difficult for the lungs to function properly.
• Onset heart failure development from low diastolic pressure.
What assessment data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data:
• Patient is likely feeling anxious and restless due to edema, and having a hard time breathing.
• Patient sitting up right because the buildup of fluid in the lungs in making it difficult for her
to breath, crackles conform she has fluid in the lungs.
• S3 heart sound indicates heart failure. Irregular pulses stimulate the ventricles to
contract prematurely before diastole is finished.
Cardiac Telemetry
Strip:
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