Case Study #4: Heart Failure (HF)
Place: Medical Ward
Simone looks over the MAR and double checks the meds she is pulling for Meryl Smith. That all looks right, she thinks to herself. Beta blocker, ACE-I, and Lasix. Along with some vitamins and a proton pump inhibitor. Let’s go see how she is doing this morning.
Walking into the room, Simone can immediately see that things are not right. Looking up at the monitor she sees that Meryl’s heart rate is 50 and that she looks a bit pale.
“Good morning, Mrs. Smith. How are you doing?”
“I don’t feel quite right. I am not sure what is going on?”
Simone carefully listens to Meryl’s chest and hears a few less crackles than yesterday. Nodding to herself she thinks, A bit better but let’s check the BP.
Pressing the NIBP button on the monitor, Simone waits a few seconds and sees the result displayed on the screen: 84/48. Placing her forefinger on Meryl’s wrist, Simone double checks that the pulse is accurate when compared to the monitor.
|Day: 2||Pulse Rate||Blood Pressure||Respiratory Rate||Temperature||O2 Saturation|
|Time: 08h00||50||84/48||18||36.5°C||95% on 3lpm|
“Well, your heart rate is a bit slower than it was yesterday and your BP is a bit lower. All this can be caused by your medications, so before I give out your meds, I’m going to have Dr. Grant take a look.”
“Sure sure.” Meryl leans back against her pillow and closes her eyes.
Hmmm, a bit tired as well. Ok let’s find Dr. Grant, thinks Simone.
Simone steps out of the room and sees Dr. Grant at the nurses’ station.
“Dr. Grant, before you start rounds, can you quickly see Meryl Smith? Her heart rate is 50, BP 84/48, and she is a bit drowsy.”
“Good morning, Simone. That sounds like she is having some issues with her meds. You know me by now: if they can keep their eyes open, I’m ok with whatever BP they have.”
“True enough, but it’s more the heart rate that is concerning me and her drowsiness.”
“Ok, let’s do a quick drive by and see how things are going.”
Dr. Grant and Simone head to Meryl’s room. They find her propped up in bed staring forlornly at her breakfast tray.
“Hello Mrs. Smith. How are you doing?” asks the doctor.
“Would be better with some sausages and pancakes, not the cardboard and watery milk that you’re feeding me here.”
“Ok. Do you mind if I have a listen to your chest and check you out before you dig into breakfast?”
Meryl pushes the bedside table away and adjusts her gown for Dr. Grant to listen to her heart and lungs.
After Dr. Grant finishes checking Meryl out, he steps back. “Ok, Simone, I am good with the BP, as that is not affecting her too much, so the ACE-I is good. She is down another ¾ of a kilo in weight. The heart rate is down a bit more than I would like. Let’s cut her dose of beta blockers in half and then go a bit more slowly up than we have been. Give her body a bit more time to adjust to the new drugs. How does that sound?”
“Great, thank you. Will you write that out as an order?”
“Yes. In the meantime cut the beta blocker pill in half. She needs to get on these drugs to get better.”
“I will do that and give her the half dose with breakfast along with the rest of the meds. Thanks again.”
Both professionals leave Meryl alone with her breakfast tray.
A few minutes later Simone comes in with the medications and explains everything to Meryl and the reason behind the changes. Meryl seems to understand but is still unhappy about her breakfast.
Dorothy peeks around the corner. “Up for a visitor?”
“Oh yes. Someone not dressed in those awful blue pajamas and who will talk to me about something other than my heart. What is that I smell, french fries?”
“Shhh the pajama police will hear!”
Both women share a laugh.
“You shouldn’t. It’s not on my diet!”
“You are doing so well, I thought we could celebrate. I brought a milkshake as well. I looked up on the web to see who had the healthiest French fries and I went there to pick some up to share.”
“Healthy fries? You are looking out for me, eh, or trying to get my life insurance payout?”
“Nothing of the sort. Just celebrating.”
The two women sit close and share what happened over the course of the day. For Meryl, it was a normal hospital day with another ECG, chest X-ray, and lab work. But she did share that she was able to go for a walk with the physio, up and down the hallway. Dorothy shared about the kids’ parent teacher interview and laughed at how awkward her ex-husband felt when he had to explain that Dorothy was not his wife but his wife’s wife.
An hour later with visiting hours almost over, Dorothy cleans up the evidence of the celebration, kisses Meryl, and waves good bye. “Till tomorrow hon.”
“Hello Mrs. Smith. Let’s get you tucked in and taking your final meds of the evening.”
“Ok Siri. Has Dr. Grant changed any meds again?”
“No, everything is the same as it was this morning. We are going a bit lighter on the beta blockers and allowing you to adjust a bit slower to them.”
Siri then helps Meryl to the bedside commode and gives her the PM medications. Checking again with her that everything is fine, she turns the lights off in the room, leaving each patient with control of their own bedside lighting.