Case Study

Topics: Hypertension, Myocardial infarction, Coronary artery disease Pages: 82 (33979 words) Published: May 27, 2015
PART ONE Medical-Surgical Cases

1 Cardiovascular

Cardiovascular Disorders
Case Study 1 Heart Failure
Difficulty: Beginning
Setting: Emergency department, hospital
Index Words: heart failure (HF), cardiomyopathy, volume overload, quality of life

X Scenario

M.G., a “frequent flier,” is admitted to the emergency department (ED) with a diagnosis of heart failure (HF). She was discharged from the hospital 10 days ago and comes in today stating, “I just had to come to the hospital today because I can't catch my breath and my legs are as big as tree trunks.” After further questioning, you learn she is strictly following the fluid and salt restriction ordered during her last hospital admission. She reports gaining 1 to 2 pounds every day since her discharge.

1. What error in teaching most likely occurred when M.G. was discharged 10 days ago? A breakdown of successful communication occurred regarding when to call with early weight gain. It is imperative that patients understand when to call their provider after being discharged from the hospital for exacerbated HF. Comprehensive patient education starting at admission is considered a standard of care and is mandated by The Joint Commission when providing care to hospitalized patients. The goal of the discharge treatment plan is to facilitate successful patient selfmanagement, minimize symptoms, and prevent readmission.

During the admission interview, the nurse makes a list of the medications M.G. took at home.

■ Chart View
Nursing Assessment: Medications Taken at Home
Enalapril (Vasotec) 5 mg PO bid
Pioglitazone (Actos) 45 mg PO every morning
Furosemide (Lasix) 40 mg/day PO
Potassium chloride 20 mEq/day PO

2. Which of these medications may have contributed to M.G.'s heart failure? Explain. Thiazolidinediones, such as pioglitazone, may increase the risk of heart failure and should not be used in patients with symptoms of heart failure. They commonly cause peripheral edema and weight gain (which are the result of both water retention and increased deposit of adipose tissue).

Copyright © 2013 by Mosby, an affiliate of Elsevier Inc.
Copyright © 2009, 2005, 2001, 1996, by Mosby, Inc. an affiliate of Elsevier Inc. All rights reserved.




1 Cardiovascular

3. How do angiotensin-converting enzyme (ACE) inhibitors, such as enalapril (Vasotec), work to reduce heart failure? (Select all that apply.) ACE inhibitors: a. prevent the conversion of angiotensin I to angiotensin II. b. cause systemic vasodilation.

c. promote the excretion of sodium and water in the renal tubules. d. reduce preload and afterload.
e. increase cardiac contractility.
f. block sympathetic nervous system stimulation to the heart. Answers: A, B, D
ACE inhibitors prevent the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. This results in systemic vasodilation, thereby reducing preload (reducing the volume of blood entering the left ventricle) and afterload (reducing the resistance to the left ventricular contraction) in patients with HF. ACE inhibitors do not promote the excretion of sodium and water, and they do not cause increased cardiac contractility or block the sympathetic nervous system to the heart.

After reviewing M.G.'s medications, the physician writes these medication orders:

■ Chart View
Medication Orders
Enalapril (Vasotec) 5 mg PO bid
Carvedilol (Coreg) 100 mg PO every morning
Glipizide (Glucotrol) 10 mg PO every morning
Furosemide (Lasix) 80 mg IV push (IVP) now, then 40 mg/day IVP Potassium chloride (K-Dur) 20 mEq/day PO

4. What is the rationale for changing the route of the furosemide (Lasix)? M.G. is fluid overloaded and needs to decrease fluid volume in a short period. IV administration is delivered directly into the vascular system, where it can start to work immediately. In HF, blood flow to the entire gastrointestinal (GI) system is...
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