Case Study #1
History of Presenting Illness (HPI)
James is a 66-year-old First Nations man who came to the emergency department with 5 days of progressing shortness of breath. He is now short of breath at rest, has orthopnea, and a decreased appetite. He is feeling increasingly fatigued and has swollen legs bilaterally. Today he started to feel lightheaded with palpitations which brough him to seek medical help. He states he used to weight 86kg but in the past few weeks has an increased weight gain of 92kg.
Coronary artery disease
NIDDM (non insulin dependent diabetes mellitus)
Infrequent social ETOH
No illicit drug misuses
Half pack per day smoker
BMI at baseline 27 (overweight)
ASA 81mg Daily
Rosuvastatin 10mg Daily
Perindopril 4mg Daily
Amlodipine 5mg Daily
Metformin 500mg BID
Gliclazide 80mg Daily
Physical Assessment and Diagnostics on Admission
General Appearance: Appears fatigued and anxious. Is walking in a steady but slow gait.
Neurological: Alert and orientated x3. GCS 15.
Respiratory: Speaking in short, clipped sentenced. Accessory muscle use. Short of breath at rest. Scattered coarse crackles throughout lung fields bilaterally. No cyanosis
Cardiovascular: S1 S2 and S3 auscultated, heartrate is rapid and irregular. Pulses palpable and weak. Skin pink, moist, and cool to extremities, with +3 edema from knees to feet bilaterally. Cap refill 3 seconds.
Gastrointestinal: Abdomen soft, non-tender. Regular BM today, passing flatus, bowel sounds present x4 Decreased appetite. Moist mucus membranes.
Genitourinary: Voiding without difficulty, urine clear yellow. No bladder distention noted
Integumentary/ Musculoskeletal: Motor power strong x4. Skin is intact, no visible lesions, rashes, or wounds
Psychosocial: Lives with wife and 3 grandchildren. States he often forgets to take medications or pick up refills at the pharmacy. He is concerned over expenses of caring for his young grandchildren. He states he is also worried about who will care for the children when he is in hospital or going to follow-up appointments. He states his wife cannot handle the 3 children on her own. He is covered under the non-insured health benefits (NIHB) program of Indigenous services Canada.
Vital Signs: Temp. 36.5, HR 138, RR 26, BP 158/72, 02 saturation 86% RA. Denies pain
12 lead ECG demonstrated Atrial fibrillation
(Chiorescu et al, 2017).
ECHO demonstrated Ejection fraction of <40%
CBC: Hemoglobin 142g/L (120-160), Platelets 160 (130-380), WBC 5.2 (3.5-10.5)
Electrolytes: Sodium 136 mEq/L (135-145), Potassium 4.2 mEq/L (3.5-5.0), Chloride 100 mEq/L (98-107), fasting glucose 8.2 mmol/L (<5.6 =normal, 5.6- 6.9 = impaired glucose, >7 = diabetes)
A1C 7.6% (<5.7= normal, 5.7-6.4% = Pre diabetes or at risk, >6.5% = diabetes)
Renal panel: Creatine 178 (53-106mcmol/L) , eGFR 36 ml/min (>60 ml/min)
Cardiac markers: Troponin T high sensitivity 38 (3-14 ng/L) , NT proBNP >1800 pm/ml (<100pg/ml)
New onset Congestive Heart Failure (systolic heart failure with ejection fraction <40%)
New diagnosis uncontrolled Atrial fibrillation
In-hospital Treatment and Course
Oxygen applied to maintain 02 saturations >92% (successfully weaned off day 3 of admission)
IV diuretics, furosemide 40mg IVPB BID x3 days (successfully decreased fluid volume)
Cardiac Ablation was performed once stable on day 5 due to persistent Atrial fibrillation not managed with pharmacologic interventions (successfully resulting in restored Normal Sinus rhythm)
Low sodium diet and fluid restriction 1.5L/day
Daily weights (discharge weight 88kg)
Medication adjustments (see new discharge medication list)
Vital signs at discharge: Temp. 36.7, HR 86, RR 18, O2 95% RA, BP 135/68.
Cardiac and Respiratory assessment as discharge: No SOB or accessory muscle use. Lungs clear throughout with adequate air entry. S1 S2, no S3/S4, Skin pink, warm, dry. Cap refill 2-3 seconds. +1 edema to ankles bilaterally. Heart rate regular, and strong.
New Discharge Medications
ASA 81mg Daily
Amlodipine 5mg Daily (discontinued)
Carvedilol 3.125mg PO BID (*new)
Gliclazide MR 80mg PO daily (*new dose/formulation)
Metformin 500mg PO TID (*new dose)
Perindopril 8mg PO daily (*new dose)
Rosuvastatin 10mg PO daily
Spironolactone 25mg PO BID (*new)
Follow-up with Cardiologist in 3 months for repeat ECHO, 12 lead ECG, stress test, blood work, and physical assessment. Return to emergency department if symptoms of SOB, palpitations, weight gain, edema or fatigue return. Monitor and record daily weights and blood glucose. Strict medication compliance, fluid restriction 1.5/day, and low sodium diet.
Concept Map and Nursing Care Plan
For assignment 1 concept map and case analysis you are the RN in charge of James’ care and you want to develop a nursing care plan to provide direction for James’ discharge. Use the assessment data and information in the case scenario to guide your development of the one-page only concept map visual diagram. Identify and outline 6-10 nursing care priorities related to this case scenario and number the care priorities in level of importance. Include lines and arrows to visually display relationships and connections among concepts. Include linking words with the lines to indicate the nature of the connection or relationship (for example: leads to, influences, contributes to, results in, etc.)
Include a full nursing care plan (nursing diagnosis, SMART goals, nursing interventions supported with credible and current sources of evidence, and evaluation statements) with the first nursing care priority you have identified. This can be completed as an appendix attached to the paper portion of the assignment. Refer to the Assignment 1 and 2 marking guide in the Assessment Overview for further direction of the requirements of the concept map as well as case analysis. You may also find it useful to go back to Unit 1 and review the content related to Concept Mapping. Keep in mind the concept map in Unit 1 is not as fully detailed as we expect your concept map to be. The concept map is worth 65% of your entire mark for this assignment, so spend your time constructing this.
Choose three questions from the case analysis list below that correlate to your learning needs. Ensure that you are adequately integrating the case of James into your discussion. Answers for each question are limited to 250 – 400 words (per question) and you are expected to use credible and current sources of evidence to support your discussion. Please refer to the Using Evidence in Scholarly Writing document in the References & Help section of the course homepage. The case analysis discussion must also be written in APA formatting and citation style, you do not need to include and intro or conclusion.
Case Analysis Questions
Canadian Cardiovascular Society. (2021). CCS/CHFS heart failure guidelines: defining a new pharmacologic standard of care for heart failure wit reduced ejection fraction. Retrieved from https://www.onlinecjc.ca/article/S0828-282X(21)00055-6/fulltext#secsectitle0010 doi: https://doi.org/10.1016/j.cjca.2021.01.017
Chiorescu, I.M., Dabija, E., Statescu, C., Grecu, M., & Georgescu, C.A. (2017). Diagnosis and management of wide QRS regular tachycardia. Research Gate DOI: 10.22551/2017.15.0402.10101
Darby, A. (2014). Management of atrial fibrillation in patients with heart failure. Journal of Atrial Fibrillation 7(2):1105. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5135259/#:~:text=Pharmacologic%20options%20for%20controlling%20the,tone%20on%20the%20atrioventricular%20node.
Fine, N.M. (2020). Heart failure (HF). Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary. Merck Manuals Retrieved from https://www.merckmanuals.com/professional/cardiovascular-disorders/heart-failure/heart-failure-hf#v935899
Fine, N.M. (2020). Drugs for heart failure. Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary. Merck Manuals. Retrieved from https://www.merckmanuals.com/professional/cardiovascular-disorders/heart-failure/drugs-for-heart-failure
Pagana, K. D., Pagana, T.J, Pike-MacDonald, S.A. (2013). Mosby’s manual of diagnostic and laboratory tests. 1st Canadian Ed. Elsevier
Hypertension Canada. (2015). XIII. Treatment of hypertension in association with heart failure. Retrieved from https://guidelines.hypertension.ca/prevention-treatment/hypertension-with-heart-failure/
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