Simulation Capstone

Valin Myers Chamberlain College of Nursing NR 452: Capstone Spring 2019

Simulation Capstone

In this simulation scenario, two clients require care and assessment. The first client, Maria Hernandez, is an 81-year-old female who was admitted with altered mental status and abnormal vital signs, which may be secondary to a urinary tract infection (UTI). Her daughter, who brought her in, reports that Maria has not been eating or drinking well. The second client, Keola Akana, is a 71-year-old male who was admitted urgently due to an acute exacerbation of left-sided heart failure. Since his last visit to his healthcare provider, he has gained seven pounds over the past two days.

Prioritization of Care

One of the critical aspects of managing these two patients is determining the order in which they should be assessed. Given the severity of the conditions, Mr. Akana should be prioritized due to his acute left-sided heart failure. Left-sided heart failure poses an immediate risk to his respiratory and cardiovascular systems, which requires prompt assessment and intervention. Mrs. Hernandez, while also requiring attention, can be assessed after ensuring that Mr. Akana is stable.

Key Priority Assessments for Left-Sided Heart Failure

Upon entering Mr. Akana’s room, the nurse should introduce herself, inform him about the change of shift, and ask for his permission to conduct an assessment. The nurse should look for key indicators of left-sided heart failure, including:

• Increased Heart Rate: Tachycardia may occur as the heart attempts to compensate for decreased cardiac output.
• Crackles (Pulmonary Edema): Auscultation may reveal crackles in the lungs, indicating fluid buildup.
• Restlessness and Confusion: These are signs of hypoxia due to inadequate oxygenation.
• S3 (Ventricular Gallop) and S4 (Atrial Gallop): Abnormal heart sounds can indicate heart failure.
• Alternating Pulses: Pulsus alternans may be present, indicating left ventricular dysfunction.
• Dyspnea: Shortness of breath, particularly when lying flat (orthopnea), is a common symptom.
• Cough: A dry or productive cough with frothy sputum may be present.
• Low Saturation Levels: Oxygen saturation may be reduced, indicating poor oxygenation.

If these findings are present, they confirm that Mr. Akana is experiencing an acute episode of left-sided heart failure. Conversely, if the nurse identifies signs such as ascites, weight gain, hepatomegaly, jugular vein distention, or generalized edema, this would indicate right-sided heart failure, necessitating a different approach to care (Lewis, Dirksen, Heitkemper & Bucher, 2014).

Common Medications for Left-Sided Heart Failure

After completing the assessment, the nurse would document the findings and await orders from the healthcare provider regarding medication management. Two common classes of medications used to treat left-sided heart failure include:

1. Angiotensin-Converting Enzyme (ACE) Inhibitors:
   • Examples: Lisinopril, Enalapril
   • Nursing Considerations:
     • Monitor blood pressure closely as these medications can cause hypotension.
     • Assess for the development of a persistent dry cough, a common side effect, and report it to the healthcare provider.
2. Beta-Blockers:
   • Examples: Metoprolol, Carvedilol
   • Nursing Considerations:
     • Monitor heart rate; if it falls below 60 beats per minute, the medication may need to be held.
     • Observe for signs of worsening heart failure, such as increased fatigue or fluid retention, particularly during the initial stages of treatment.

These medications play a critical role in managing left-sided heart failure by improving heart function and reducing the symptoms associated with the condition. The nurse’s role in monitoring and managing these medications is crucial to ensuring patient safety and effective treatment outcomes.

Reference:Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., & Bucher, L. (2014). Medical-surgical nursing: Assessment and management of clinical problems. Elsevier Health Sciences.