RNSG 2022 Heart_Failure-SKINNY_Reasoning (1) Latest
Part I: Recognizing RELEVANT Clinical Data
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 cu...
RNSG 2022 Heart_Failure-SKINNY_Reasoning (1) Latest
Part I: Recognizing RELEVANT Clinical Data
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struggled with depression the past two years and has been more withdrawn since her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 Clinical Significance:
Problem:
-Ms. Smith’s history of -A current ejection fraction (EF) of only 15%
myocardial infarction (MI) from supports the indication of heart failure. Anything less
four years ago and systolic heart than 45-55% supports this claim.
failure secondary to ischemic
cardiomyopathy.
-Left-sided heart failure is most likely what is causing
-She came into the ER for SOB the pulmonary edema. The fluid being trapped is
the past 3 days which has now affecting her breathing resulting in the SOB.
went from SOB during activity to
SOB at rest.
-The only way she has been able -Orthopnea is often associated with the progression of
to rest comfortably is by sleeping left-sided heart failure.
upright in her recliner. She can
only speak partial sentences
before having to take a breath in -Edema is present here. This is an indicator that left-
order to have a conversation with sided heart failure is beginning to affect the right side.
the nurse.
,-Increased swelling in the lower
legs and a weight gain of 6
pounds in the past 3 days.
RELEVANT Data from Social Clinical Significance:
History:
-JoAnn can no longer tolerate the -Her activity intolerance is secondary to the
level of activity she’s used to due to progression of heart failure.
dealing with the progression of her
heart failure for the past two years.
-The fact that she has been -The death of her husband added to her inability to
battling depression over the effectively cope with and find ways to overcome her
past two years and losing her depression. Instead, it caused her to push back even
husband not too long ago has further.
caused her to withdraw even
more.
urseHero.com on 09-12-2022 07:55:08 GMT -05:00
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100000802531269 from Co
What VS data is RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS `Data: Clinical Significance:
-A pulse of 92 (irregular) -Atrial fibrillation can cause this to be considered irregular
-26 breaths/minute (regular) -Way too fast for this to be her respiratory rate at rest
-BP 162/54 - During heart failure the higher the BP higher the
afterload which increases the overall workload of the heart
-O2 sat of 90% 6 L via nasal -90% is too low
cannula
Current
Assessment:
GENERAL Appears anxious, restless
APPEARAN
CE:
RESP: Breath sounds have coarse crackles scattered throughout both lung
fields ant/post, labored respiratory effort, patient sitting upright
CARDIAC: Rhythm: atrial fibrillation, pale, cool to the touch, pulses palpable
throughout, 3+ pitting edema lower extremities from knees down
bilaterally, S3 gallop, irregular, no
jugular venous distention (JVD) noted
NEURO: Alert and oriented to person, place, time, and situation (x4)
GI: Abdomen soft/nontender, bowel sounds audible per auscultation in all
four quadrants
GU: Voiding without difficulty, urine clear/yellow
SKIN: Skin integrity intact, skin turgor elastic, no tenting present
What assessment data is RELEVANT and must be recognized as clinically significant by the
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