Question

Background Jeraldine Yates is a 70-year-old woman originally from Alabama. She lives alone and is able to manage herself independently. She is active in her community and church. Mrs. Yates was admitted to the hospital two months ago with heart failure. Since her discharge, a visiting nurse visits every other week to assess for symptoms of heart failure and see that Mrs. Yates is continuing to manage well on her own. Case Study The visiting nurse stops in to see Mrs. Yates today. The nurse immediately notices that Mrs. Yates’s legs are very swollen. Mrs. Yates states, “I noticed they were getting a bit bigger. They are achy, too.” The nurse asks Mrs. Yates if she has been weighing herself daily to which Mrs. Yates replies, “I got on that scale the last time you were here, remember?” The nurse weighs Mrs. Yates and she has gained 10 pounds. Additional assessment findings indicate that Mrs. Yates gets short of breath when ambulating from one room to the other (approximately 20 feet) and must sit down to catch her breath. Her oxygen saturation is 95% on room air. Bibasilar crackles are heard when auscultating her lung sounds. The nurse asks Mrs. Yates if she is currently or has in the past few days experienced any chest, arm, or jaw pain or become nauseous or sweaty. Mrs. Yates states, “No, I didn’t have any of that. I would know another heart attack. I didn’t have one of those.” The nurse asks about any back pain, stomach pain, con- fusion, dizziness, or a feeling that Mrs. Yates might faint. Mrs. Yates denies these symptoms stating, “No. None of that. Just a little more tired than usual lately.” Her vital signs are temperature 97.6 F, blood pressure 140/70, pulse 93, and respirations 22. The nurse reviews Mrs. Yates’s list of current medications. Mrs. Yates is taking aspirin, clopidogrel bisulfate, lisinopril, and carvedilol. The nurse calls the health care provider who asks the nurse to draw blood for a complete blood count (CBC), basic metabolic panel (BMP), brain natriuretic pep- tide (B-type natriuretic peptide assay or BNP), troponin, creatine kinase (CPK), creatine kinase-MB (CKMB), and albumin. The health care provider also prescribes oral (PO) furosemide and asks the nurse to arrange an outpatient electrocardiogram (ECG, EKG), chest X-ray, and echocardiogram.

6. Heart failure can be classified as left or right ventricular failure, systolic versus diastolic, according to the New York Heart Association (NYHA) and using the ACC/AHA (American Heart Association) guidelines. Explain these four classification systems and the signs and symptoms that characterize each.

7.According to each classification system discussed above in question #6, how would you label the type of heart failure Mrs. Yates is experiencing?

8. Discuss Mrs. Yates’s predisposing risk factors for heart failure. Is her age, gender, or ethnicity significant?

9. Provide a rationale for why each of the following medications are included in Mrs. Yates’s medication regimen: aspirin, clopidogrel bisulfate, lisinopril, and carvedilol.

10. The nurse is teaching Mrs. Yates about her newly prescribed furosemide. Explain the rationale for adding furosemide to Mrs. Yates’s medication regimen, when she should expect to see the therapeutic results (urination), and instructions regarding the administration of furosemide.

11. The visiting nurses asks the primary health care provider if he/she will prescribe potassium chloride for Mrs. Yates. Why has the nurse suggested this? What information will each of the following blood tests provide: CBC, BMP, BNP, troponin, CPK, CK-MB, and albumin?

12. Mrs. Yates’s son comes to stay with his mother so she will not be alone. What should the nurse tell Mr. Yates about when he should bring his mother to the hospital?

13. The visiting nurse returns the next day. Mrs. Yates does not seem to be diuresing as well as the nurse anticipated. Mrs. Yates is not worse, but the swelling in her legs is still considerable and there is no change in her weight. When asked about her frequency of voiding, Mrs. Yates does not seem to have noticed much difference. While the nurse is unpacking her stethoscope to assess lung sounds, Mrs. Yates says, “Honey, I was just making myself a ham salad sandwich. Would you like one?” The nurse declines and becomes concerned because of this offer. Why is the nurse concerned?

14. The nurse asks Mrs. Yates to tell her more about how she cooks. Specifically, the nurse asks Mrs. Yates about the types of foods and food preparation. With great pride, Mrs. Yates leads the nurse to the kitchen and explains, “Honey. I am from the South and we cook soul food. Today I am cooking my famous pea soup for the church dinner tonight. I use ham hocks. Have you ever had those? My son says they are not good for me. He has been trying to get me to eat healthier foods. Last week he brought me turkey sausage to try instead of my pork sausage in the morning. I know he means well but some foods are tradition and you don’t break soul food tradition.” What information has the nurse gathered that is of concern?

15. The nurse arranges for Mrs. Yates’s son to be present at the next home visit so that the nurse can teach them both about proper dietary choices and fluid restrictions. List five points of information that the nurse should include in the teaching. Suggested teaching points include: 16. During the dietary teaching, the nurse asks Mrs. Yates to describe a typical day of meals and snacks. Mrs. Yates lists coffee with whole milk, eggs and sausage for breakfast, a sandwich or soup for lunch, fried chicken with vegetables for dinner, and fruit, pretzels, or rice pudding for snacks. Which of these foods will the nurse instruct Mrs. Yates to limit and are there alternatives that the nurse can suggest?

17. Prioritize five nursing diagnoses that the visiting nurse should consider for the recent events regarding Mrs. Yates’s care.

Answer 1

6. Heart failure is a group of symptoms with features of fluid overload or ineffective tissue perfusion.

Left sided heart failure:

The heart pumps oxygenated blood via lungs to the left atrium, then from left atrium to the left ventricle, which pumps it to the rest of the body. The left ventricle supplies to most of the body so it's larger than the other chambers with thicker walls . Due to some factors like hypertension ,CAD,myocarditis ,etc may destroy or weaken the heart muscle in left ventricle may make it stiff too. These may lead left-sided or left ventricular (LV) heart failure, the left side of the heart must work harder to pump the same amount of blood .Due to weaken muscles blood maynot be pumped at specific rate results in regurgitation and fluid buildup in the lungs and oedema may seen in other parts of body.The signs and symptoms include

• Shortness of breath during night and during climbing steps, exercise
• Chronic cough
• Wheeze
• Difficulty concentrating
• Fatigue
• Edema in legs ,ankles
• Anorexia and nausea
• Rapid or irregular heartbeat
• Sudden weight gain

• Heart failure with reduced ejection fraction (HFrEF), also called systolic failure: The left ventricle loses its ability to contract normally because of weakened or stiff heart muscles. The heart can't pump with enough force to push enough blood into circulation.Ejection fraction is the percentage of the blood pumped out of ventricles with each contraction.
• Heart failure with preserved ejection fraction (HFpEF), also called diastolic failure (or diastolic dysfunction): The left ventricle loses its ability to relax normally as the walls of cardiac muscles are weak and stiff. The heart can't properly fill with blood during the resting period between each beat.

Right sided heart failure:

The deoxygenated blood that returns to the heart through the veins through the right atrium into the right ventricle. The right ventricle then pumps the blood back out of the heart into the lungs to oxygenate it.

Right-sided or right ventricular (RV) heart failure may result from left-sided failure. When the left ventricle failure occurs, fluid accumulates in the body .When the fluid pressure increases ,fluid is pushed into the lungs which damages the heart's right side .The fluid overload burden the right side of heart and right side loses pumping power, blood backs up in the body's veins. This usually causes swelling or congestion in the legs, ankles and swelling within the abdomen such as the GI tract and liver (causing ascites).

Symptoms may be similar to left sided heart failure:

• Sudden shortness of breath with chest pain, a rapid or irregular heartbeat or fainting    
• Coughing up white or pink phlegm while experiencing severe shortness of breath
• Severe weakness and diffuculty concentration
• Fainting and syncope
• Rapid or irregular heartbeat        
• Chest pain caused by a heart attack

7.Yates may be experiencing left sided heart failure.Bibsilar cracles picturize two symptoms pleurisy or pneumonia and pulmonary edema. These all are due to fluid overload .And Yates weight also has increased.

8.Yates has hypertension and her age 70 yrs may be the predisposing factor.The medications she is taking may also a factor for causing heart failure