Learning Guide for Heart Failure

David Wolkowski is a 58 year old man who immigrated to Austin from Poland in 1989.
He smokes three packs of cigarettes a day, drinks two ounces of vodka every night
after dinner, and had to retire from his job in construction after a back injury in 2002.
His wife, Angelika, 56, also an immigrant from Poland, works night shift as an LVN at
a nursing home. They have five children: David Junior, 36; Paula, 35; Maria, 32;
Alexander, 28; and Natalie, 24. Mr. Wolkowski has not been to see his primary care
physician in eight years. His height is 5'10", and his weight is 220 pounds.
1. What risk factors for heart failure does Mr. Wolkowski have? What other risk
factors would you assess for?
2. Mrs. Wolkowski has noticed her husband can no longer walk up the stairs at their
house without becoming short of breath. She persuades him to go to the doctor for a
check-up. You are the nurse responsible for taking his health history and getting his
vital signs. What questions will you ask?

3. Dr. Emily Tyler, the Wolkowskis' PCP, suspects that Mr. Wolkowski has chronic
heart failure. Mrs. Wolkowski tells you she didn't quite understand Dr. Tyler's
explanation of the pathophysiology of heart failure. "It's been a long time since I was
in school," she says. "Could you please explain it to me?" What will you tell her?

4. Dr. Tyler refers Mr. Wolkowski to a cardiologist, Dr. Scott Willis. Dr. Willis calls the
office to get the lab results faxed to his office. What labs would you expect that Dr.
Tyler ordered? What results might you see in early chronic heart failure?
5. When you are faxing over Mr. Wolkowski's labs, you note the following:
Hemoglobin: 10.2
Hematocrit: 33.1
TSH: 8.8
Blood glucose: 243
LDL: 286
What do these labs mean in regards to Mr. Wolkowski's heart failure diagnosis?
Which of them might make his heart failure worse? What other precipitating factors
should you be looking out for?
6. You also fax Dr. Willis a copy of Mr. Wolkowski's 12 lead ECG. You note that it
shows atrial fibrillation. How will this impact Mr. Wolkowski's heart failure?
7. You work prn at the local hospital and are floated to the telemetry floor. Mr.
Wolkowski is admitted with an acute exacerbation of his heart failure. His daughter,
Natalie, comes to you and says she's in nursing school and is trying to understand

heart failure. "I want to make sure my dad is getting the care he needs, but I'm
confused by what's actually happening," she says. "I've read my textbook, but I still
don't get it." She asks if you can explain the following:
a.
b.
c.
d.

systolic failure
diastolic failure
mixed systolic and diastolic failure
left-sided, right-sided, and biventricular failure

8. Once you've explained that, she says, "Okay, but isn't the body supposed to
compensate when the cardiac output goes down? How does that work?" You talk to
her about the following:
a.
b.
c.
d.
e.

SNS activation
Neurohormonal response
dilation of heart chambers
the Frank-Starling law
cardiac hypertrophy

9. "Thank you so much!" she says. "But doesn't the body have any mechanisms to
counter the problems that its compensatory mechanisms cause?" What will you tell
her?
10. What might you expect to see when you do your shift assessment on Mr.
Wolkowski?
11. You overhear one of the full-time telemetry nurses talking about whether Mr.
Wolkowski is Wet-Warm or Wet-Cold. You're confused until she explains what she
means. What does she tell you? What assessment data can confirm that Mr.
Wolkowski is Wet-Cold instead of Wet-Warm or Dry-Cold? What are the nursing
implications?
12. Mr. Wolkowski is being transferred to the ICU. Natalie and Mrs. Wolkowski ask
you what they can expect in terms of his care. What will you tell them?
13. Alex, who has flown in from Cleveland with his wife, asks why they have to draw
his father's blood every day. What will you tell him?
14. Mr. Wolkowski is administered all of the following drugs at some point during his
hospital stay:
Morphine
Metoprolol (Toprol)
Furosemide (Lasix)
Benazepril (Lotensin)
Losartan (Cozaar)
Dobutamine
Nitroglycerin (Nitro-bid)
Digitalis (Digoxin)

Spirinolactone (Aldactone)
Inamrinone (Inocor)
Nitroprusside (Nipride)
b-type natriuretic peptide (Natrecor)
hydralazine (Apresoline)
Dopamine
Carvedilol (Coreg)
Mrs. Wolkowski says she's lost her drug book and asks you to explain the nursing
implications and mechanisms of actions of these drugs. Which drugs would you
expect Mr. Wolkowski to be discharged on? What side effects will you tell her to
watch out for?
15. Alex comes up to you in the hallway and says, "My best friend's dad has heart
failure, and he's on this drug called BilDil. Why isn't my dad getting that?" What will
you tell him? For whom is BilDil indicated?
16. Mr. Wolkowski has responded well to drug therapy and is being discharged. Mrs.
Wolkowski and Natalie want to talk to you about how chronic heart failure differs from
acute decompensated heart failure. "What symptoms will my husband have?" Mrs.
Wolkowski asks.

17. "What about complications?" Natalie adds.

18. Alex wants to know what his father might do to help his heart that does not
involve drugs. What will you tell him?

19. Three weeks later, Mrs. Wolkowski calls Dr. Tyler's office. "David has been
throwing up," she says, "and he says everything looks a little yellow." How will you
respond?
20. Five years have passed, and Mr. Wolkowski has been admitted to the hospital
three times for acute exacerbation of heart failure. Last year he had an implantable
cardioverter-defibrillator placed, and was placed on a fluid restriction, but his exercise
tolerance has continued to decline. You are now working full time in the telemetry
unit, and you know Mr. Wolkowski and his family well. He is admitted again, with the
following diagnostic test results:
EF: 18%
BNP: 1017
Dr. Willis will be coming to speak to the family about Mr. Wolkowski's prognosis. What
might you expect him to say?

21. List five priority nursing diagnoses for Mr. Wolkowski, with a goal, at least one
outcome criterion, and at least two interventions for each.