Question

Mr. Morgan is a client who has been coming to the clinic for several years for management of coronary artery disease (CAD) and hypertension (HTN). A cardiac catherization done a year ago showed 50% stenosis of the circumflex coronary artery. He has had episodes of dizziness for the past 6 months and orthostatic hypotension, shoulder discomfort, and decreased exercise tolerance for the past 2 months. On his last clinic visit 3 weeks ago, a chest x-ray (CXR) showed cardiomegaly, and a 12 lead electrocardiogram (ECG) showed sinus tachycardia. You review his morning labs and initial assessment.

Chemistry
	Sodium	142 mEq/L
	Chloride	95 mEq/L
	Potassium	3.9 mEq/L
	Creatinine	0.8 mg/dL
	Glucose	82 mg/dL
	BUN	19 mg/dL
CBC
	WBC	5400/mm3
	Hgb	13g/dL
	Hct	41%
	Platelets	229,999/mm3
Initial Assessment		Complains of increased fatigue and shortness of breath, especially with activity, and “waking up gasping for breath” at night, for the past 2 days.
Vital Signs	Temperature	97.9 F
	Blood pressure	142/83 mmHg
	Heart rate	105 beats/min
	Resp rate	18 breaths/min

1. As you review these results, which ones are of possible concern, and why? (5 points)

2. Knowing his history and seeing his condition this morning, what further questions are you going to ask Mr. Morgan and his daughter? (5 points)

Mr. Morgan tells you he becomes exhausted and has shortness of breath climbing the stairs to his bedroom and has to lie down and rest (“Put my feet up”) at least an hour twice a day. He has been sleeping on two pillows for the past 2 weeks. He has not salted his food since the physician told his not to because of his high blood pressure, but he admits having had ham and a whole bag of salted peanuts 3 days ago. He denies having palpitations but has a constant, irritating nonproductive cough lately.

3. You think it’s likely that Mr. Morgan has heart failure (HF). From his history, what do you identify as probable causes for his HF? What risk factors does he have for heart failure? (5 points)

4. You are ready to do your physical assessment. For each potential assessment finding for HR, indicate whether the finding indicates left-sided (L) or right -sided heart failure (R). (5 points)

__1. Fatigue, weakness, especially with activity

__2. Jugular (neck vein distention)

__3. Dependent edema (legs and sacrum)

__4. Hacking cough, worse at night

__5. Enlarged liver and spleen

__6. Exertional dyspnea

__7. Distended abdomen

__8. Weight gain

__9. S3/S4 gallop

__10. Crackles/wheezes in lungs

5. What diagnostic tests will be ordered and provide a rationale for the test? (5 points)

Chart view/Medication Orders

Enalapril	10 mg PO twice a day
Furosemide	20 mg PO every morning
Carvedilol	6.25 mg PO twice a day
Digoxin	0.5 mg now, then 0.125 mg PO daily
Potassium chloride	10 mEq tablet PO once a day

The physician confirms your suspicions and indicates that Mr. Morgan is experiencing symptoms of early left-sided heart failure. Medication orders are listed above.

6. For each medication listed, identify its class, and describe its purpose for the treatment of HF. (10 points)

7. As you remove the digoxin tablet from the automated medication dispensing machine, you note that the dosage on the table label is 250mcg. What will you do? How much will be given? (5 points)

8. Based on the medication orders, which blood test or tests should be monitored carefully? Explain your answer. (7 points)

9. When you give him his medications, he looks at the potassium tablet, wrinkle his nose, and tells you he “hates those horse pills.” He tells you a friend of his said he could eat bananas instead. He says he would rather eat a banana every day than take one of those pills. How will you respond? (3 points)

10. This is Mr. Morgan’s first episode of significant HF. Before he leaves the clinic, you want to teach him about lifestyle modifications he can make and monitoring techniques he can use to prevent or minimize future problems or hospital admissions. List five suggestions you might make and the rationale for each. (10 points)

11. You tell Mr. Morgan the combination of high sodium foods he had during the past several days might have contributed to his present episode of HF. He looks surprised and says, “But I didn’t add any salt to them!” What specific diet teaching can be done with Mr. Morgan? (5 points)

12. You also include teaching about digoxin toxicity. When teaching Mrs. Morgan about the signs and symptoms of digoxin toxicity, which should be included? (Select all that apply.) (3 points)

1. Dizziness when standing up
2. Visual changes
3. Loss of appetite or nausea
4. Increased urine output
5. Diarrhea

13. What is the action of digoxin? Digoxin: (2 points)

        a. causes systemic vasodilation.

        b. promotes the excretion of sodium and water in the renal tubules.

        c. increases cardiac contractility and cardiac output.

        d. blocks sympathetic nervous system stimulation to the heart.

14. Which findings would indicate an increased possibility of digoxin toxicity? Explain your answer. (5 points)

          a. Serum potassium level of 2.2mEq/L

            b. Serum sodium level of 139mEq/L

            c. Apical heart rate of 64 beats/minute

            d. Digoxin level of 1.6ng/mL

15. How do angiotensin-converting enzyme (ACE) inhibitors, such as enalapril, work to reduce heart failure? (Select all that apply) ACE inhibitors: (5 points)

            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.

16. What patient teaching should be included for a patient on an ACE inhibitor? (5 points)

17. What are three parameters you would assess before/after administration of Furosemide? (3 points)

18. What patient teaching should be included for a client on Furosemide? (5 points)

19. What is the purpose of the beta blocker carvedilol? It is given to: (2 points)

            a. increase the contractility of the heart.

            b. cause peripheral vasodilation.

            c. increase urine output.

            d. reduce cardiac stimulation by catecholamines.

20. What patient teaching should be included for a client on a beta blocker? (5 points)

Answer 1

1, patient chest X ray showing cardiomegaly that need more attention. if heart size increases patient will be under risk for heart failure. so that patient is having associated symptoms of shortness of breath, dizziness and irregular heart beat, hypertension etc.
2, Ask patient when is his last visit to cardiologist.
Ask patient whether he is adhere with following medications.
Ask patient about family hisootry of cardiomegaly
colec the patient diet history, exercise and various activity level.
3, Patient history of coronary aretey disease, hypertension most probable cause of heart failure. Patient 50% stensis in the coronary artery shows a heart valve defects that is the main cause for getting risk of heart failure.
4, It is showing left-sided heart failure because patient having most symptoms of left-sided heart failure like awakening at night due to gasping of breath, shortness of breath during activity, dizziness, sinus tachycardia, cardiomegaly, high blood pressure, etc.
1, Fatigue, weakness, especially with activities(left-sided heart failure)
2, Jugular(neck vein distension)-right sided heart failure
3, Dependent edema(legs and sacrum)- left-sided heart failure
4, Hacking cough, worse at night -left-sided heart failure
5, enlarged liver and spleen -right-sided heart failure
6, Exertional dyspnea -right-sided heart failure
7, distended abdomen-right sided heart failure
8, Weight gain- left-sided heart failure
9, s3/s4 gallop- left-sided heart failure
10, crackles/wheezes in lungs -left-sided heart failure.