Recognize the symptoms of heart failure

Level of difficulty: Moderate
Overview: This case requires the nurse to recognize the symptoms of heart failure and collaborate
with the primary care provider to initiate treatment. The pathophysiology of heart failure is reviewed.
Several heart failure classification systems are defined. Rationales for prescribed diagnostic tests and
medications are provided. The nurse must consider the impact of the client’s diet on the exacerbation
of symptoms and provide teaching. Nursing diagnoses are prioritized to guide care.
■ Widow; lives alone; able to care for
self independently; nonsmoker
■ Aspirin (acetylsalicylic acid, ASA);
clopidogrel bisulfate (Plavix);
lisinopril (Prinivil, Zestril); carvedilol
(Coreg); furosemide (Lasix);
potassium chloride (KCl)
■ Home
■ Black American
■ The impact of diet on heart failure
■ Hypertension (HTN); heart failure
(HF, CHF); coronary artery disease
(CAD); myocardial infarction (MI)
five years ago; ejection fraction (EF)
of 55%
Mrs. Yates
Client Profile 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, confusion, 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 97.6ºF (36.4ºC), 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 peptide (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.
1. Which assessment findings during the nurse’s
visit are consistent with heart failure?
2. Why did the visiting nurse ask Mrs. Yates about
back pain, stomach pain, confusion, dizziness, or a
feeling that she might faint?
3. Discuss anything else the nurse should assess
during her visit with Mrs. Yates.
4. Explain what the following terms indicate and
include the normal values: cardiac output, stroke
volume, afterload, preload, ejection fraction, and central
venous pressure.
5. Discuss the body’s compensatory mechanisms
during heart failure. Include an explanation of the
Frank-Starling law and the neurohormonal model
in your discussion.
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
9. Provide a rationale for why each of the following
medications are included in Mrs. Yates’s medication
regimen: aspirin, clopidogrel bisulfate, lisinopril, and
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 nurse asks the primary health care
provider if he/she will prescribe potassium chloride
for Mrs. Yates. Why has the nurse suggested this?
12. What information will each of the following
blood tests provide: CBC, BMP, BNP, troponin, CPK,
CK-MB, and albumin?
13. What will the health care provider look for on
the electrocardiogram, chest X-ray, and echocardiogram? What will each diagnostic test tell the
14. 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?
15. 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?
16. 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?
17. 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.
18. 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?
19. Since changing her diet, Mrs. Yates has responded
to her outpatient treatment plan and has noticed
marked improvement in how she feels. The nurse
wants to make sure that Mrs. Yates understands the
importance of monitoring her weight. What instructions should the nurse give Mrs. Yates regarding
how often to weigh herself, and what weight change
should be reported to her health care provider or
the nurse?
20. Prioritize five nursing diagnoses that the visiting
nurse should consider for the recent events regarding
Mrs. Yates’s care.
Questions (continued)

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