Heart Failure Case Study
79-year-old male admitted to Kearsley Rehabilitation and Healthcare Center from Penn Presbyterian Medical Center, where he initially presented with shortness of breath and oxygen requirement of 6L, he was previously on 2L oxygen at baseline. Patient with hypoxia and found to be experiencing a CHF exacerbation s/p IV Lasix with positive response. Patient transitioned to oral Bumex prior to discharge and oxygen weaned as tolerated. Patient with recent fall prior to admission. Course complicated by continued weakness. Past medical history significant for idiopathic pulmonary fibrosis, restrictive lung disease, HFpEF, CAD, Afib s/p pacemaker implantation, and HTN. Patient transferred to Kearsley Rehab for continued medical optimization and ongoing therapy services.
Nursing Interventions:
Medication Management – Bumex, Allopurinol, Lisinopril, Sertraline, Pirfenidone, Xarelto
Close Monitoring of Vital Signs including pulse ox and weights
Maintain Adequate Oxygenation – 2L of oxygen via nasal cannula and CPAP at HS
Cardiology Interventions:
Patient was followed closely by our in-house Cardiologist, Dr. Steven Domsky. Acute on chronic diastolic heart failure – patient now euvolemic, continue Bumex and BP control. Afib – continue Xarelto and Coreg. HTN – BP controlled on Coreg and Lisinopril. SSS – pacemaker in place. Patient remained stable from a cardiac perspective.
Therapy Interventions:
Upon admission, he required Min A for transfers and able to ambulate 20ft with RW. He also required assistance with self-care including Min A for bathing, toileting, and lower body dressing. Individualized therapy plan was developed, and he actively participated with physical and occupational therapy. At discharge, he was Mod I for bed mobility and transfers. With supervision, he was able to ambulate 275 feet with SPC and safely ascend/descend 16 steps. He also regained his independence with self-care including being Mod I for bathing, toileting, and dressing.
After a successful stay at Kearsley Rehab, the patient was discharged to Atria Center City assisted living community. He will continue to follow with his PCP, Dr. Kristin Gales in the community.
Renal / Cardiac Case Study
69-year-old female admitted to Kearsley Rehabilitation and Healthcare Center from Mercy Fitzgerald Hospital, where she initially presented after a fall. In the ED, patient found to be hypoxic with pulse ox 88%. Work-up revealed COVID pneumonia. Patient s/p Decadron and was initially placed on 2L oxygen via nasal cannula. ID consulted and recommended no renal dosing for Remdesivir. Past medical history significant for HTN, HLD, HFrEF, CAD s/p DES, Afib s/p cardioversion, pulmonary HTN, OSA, CVA, and ESRD on dialysis. Patient transferred to Kearsley Rehab for continued medical optimization.
Nursing Interventions:
Medication Management – Metoprolol, Amlodipine, Lipitor, Valsartan, Synthroid, Plavix, Eliquis, Torsemide
Close Monitoring of Vital Signs
Monitoring Dialysis Access Site
In-House Dialysis on Tuesday, Thursday, Saturday schedule
Cardiology Interventions:
Patient was followed closely by our Cardiologist, Dr. Steven Domsky for her history of chronic systolic and diastolic CHF, HTN, Afib, VT s/p AICD. Her cardiac medicine regimen was optimized and she remained stable from a cardiac perspective.
Therapy Interventions:
Upon admission, she required contact guard assistance for bed mobility, transfers and to ambulate 30 feet with RW. She also required contact guard assistance to complete her activities of daily living including bathing, dressing and toileting. An individualized therapy plan was developed consisting of physical and occupational therapy. At the time of discharge, she was Mod I for bed mobility, supervision for transfers, able to ambulate 175 feet with RW and safely ascend/descend > 15 steps. She also advanced to Mod I for toileting and set-up assistance for bathing and dressing.
After 12-day stay at Kearsley Rehab, the patient was discharged home with support from family and Penn Medicine at Home. She will continue to follow with her PCP, Dorothy Alveranga, CRNP and receive dialysis at DaVita Waverly in the community.
Pulmonary / ENT Surgery Case Study
62-year-old female admitted to Kearsley Rehabilitation and Healthcare Center from Hospital of the University of Pennsylvania after extensive ENT surgery. Patient with history of oral cavity lesions with a recent biopsy that showed squamous cell carcinoma of the soft tissue of the mandible and right lower mandible. Patient s/p right segmental mandibulectomy, right neck dissection, right fibular free flap reconstruction, s/p #8 cuffed Portex tracheostomy and DHT placement. Patient with extensive past medical history including sarcoidosis s/p bilateral lung transplant on immunosuppression, CMV, pulmonary HTN, CKD, multiple thyroid nodules and recent COVID-19 infection.
Nursing Interventions:
Medication Management – Azithromycin, Bactrim DS, Valganciclovir, Levothyroxine Sodium, Tacrolimus, Prednisone, Metoprolol
Maintain Adequate Nutrition – Dietitian following; patient weaned from enteral tube feeds to tolerating pureed diet with thin liquids and Glucerna TID – Goal Met
Monitor Facial Incision and Flap
Respiratory Interventions:
Maintain Adequate Oxygenation – Wean as tolerated – Goal Met
Maintain Patent Airway – Wean as tolerated, Patient was decannulated! – Goal Met
Under the leadership of our in-house Respiratory Therapist, the team managed this fragile
patient’s stay. During her 17-day LOS at Kearsley, the patient was decannulated, her diet was advanced to puree with thin liquids, and she became independent with her ADLs. Upon discharge, the patient returned home with support of family and our partners at Penn Medicine at Home. She will continue to be followed by her PCP, Dr. McFillin-Petrongolo; ENT, Dr. Brody; and Pulmonologist, Dr. Ahya in the community.
Renal Heart Failure Case Study
ON-SITE HEMODIALYSIS ACCOMMODATIONS
58-year-old male admitted to Kearsley Rehabilitation and Healthcare Center after a prolonged (~1 year) hospitalization at Thomas Jefferson University Hospital with an admitting diagnosis of HFrEF (EF 15%) secondary to NICM s/p HM3 LVAD placement, as a bridge to heart and kidney transplant. Hospital course complicated by ESRD on dialysis, cardiogenic shock, acute on chronic respiratory failure s/p trach placement and subsequent decannulation, sternal wound infection s/p multiple debridement with a prolonged course of antibiotics, left parietal infarct, HTN, and HIV on HAART.
Nursing Interventions:
Medication Management – Amiodarone, Midodrine, Coumadin, Biktarvy, Plavix, completed 4-week course of vancomycin
Wound Management – Stage 3 pressure injury resolved at time of discharge.
Monitor Vitals, Labs & Diagnostics – Potassium, BUN, Creatinine, Sodium, INR, HGB
Therapy Interventions:
Patient actively participated in physical and occupational therapy 5 days per week. Upon admission, patient was Max A for bed mobility and dependent for bed to chair transfers. After a successful stay at Kearsley, the patient was discharged home at an independent for bed mobility, ambulating Min A 13 feet, as well as being able to ascend/descend 1 step x4 at a Min A level.
Under the Leadership of our In-House Cardiologist’s, Dr. Droogan and Dr. Domsky, the team managed this fragile patient’s stay. He was able to regain strength and endurance needed to return to home with his family. Patient was set up with Christiana Outpatient Dialysis and Bayada for continued services within the community. Patient will continue to be followed by the Jefferson Hospital LVAD team and his PCP, Dr. Chaudhary.
Cardiac Rehab Case Study
56 years old female (S.W.) admitted to Kearsley Healthcare and Rehabilitation Center from Penn Hospital with admitting diagnosis of Ischemic Cardiomyopathy- EF of 5-10% and CHF on Continuous Milrinone Infusion.
Nursing Interventions
Medication Management– Continuous Milrinone Infusion at 5.7 ml/hour, Lasix 80mg daily and Eliquis
Monitor Fluid Balance– Daily Weight, 1000 ml Fluid Restriction, Dietician educated on good food choices; NAS regular and thin liquid diet.
Family Education– Daily CADD Pump Cassette Change and Priming of Tubing
Maintain Safety– History of Falls
Maintain Infection Free– Right Upper Arm PICC
Monitor Labs
Wound Healing– Sacral Wound treated with Meplix
Weekly Collaboration between our In-House Cardiologists, Dr. Droogan and Domsky; with Community Cardiologist, Dr. Rubin to ensure Appropriate Dosing of IV Milrinone.
Therapy
Upon admission, Patient required moderate assistance with all self-care tasks and was able to ambulate 40 feet with moderate assistance. She was receiving occupational and physical therapy for 5 times a week for 2 weeks. Upon discharge from Skilled Stay, Patient was independent with all self-care tasks, able to ambulate 300 feet with a rolling walker and ascend/descend 12 stairs w Supervision.
After a 20-day Short Term Rehab Stay, Patient returns home with Mother and supportive sister. Milrinone Infusion Management continues in the community by Penn Palliative Home Care and Penn Medicine Home Infusion. She will continue to be followed by Cardiologist, Dr. Sharon Rubin as well as The Heart Failure Clinic of Philadelphia.
Pulmonary Rehab Case Study
79-year-old female (MG) admitted after a 50 day stay at HUP with diagnosis of Acute Respiratory Failure secondary to Covid-19 infection and ARDS. Patient has a past medical history of CHF, SVT, and PPM placement. EF of 55-60%.
Nursing and Respiratory Interventions
Treat Infection– Continue Doxycycline for Sepsis Pneumonia
Maintain Patent Airway/Wean Airway as Tolerated– PMV trials advanced to Capping Trials which led to Trach Decannulation
Maintain Adequate Oxygenation– Trach collar at 5 lpm on admit; Room Air on Discharge
Cardiology Led Oversight
: By Dr. Drogan and Domsky (Assessed weekly in the center)
Medication Management– Lasix 40 mg BID, Metroprolol, Coumdin
Monitor Labs– PT/INR for Coumadin levels
Patient was trach weaned on day 20 of her short-term rehab stay. Her stoma healed and she is breathing well on room air.
Therapy
Upon admission, Patient required maximum assistance with all self-care tasks and was She was receiving occupational and physical therapy for 5 times a week for 6 weeks. She made little gains physically throughout her stay. Upon discharge, she is minimal-to moderate assist with bed mobility and non-ambulatory.
Patient returned home with her granddaughter after 51 days LOS in STR. She has home health VNA and her PCP is Dr. James Shepard in the community.
Cardiac Rehab Case Study
58-year-old male (DL) admitted to Kearsley Healthcare and Rehabilitation Center from Penn Medicine with admitting diagnosis of Ischemic Cardiomyopathy- EF of 5-10%, S/P LVAD placement.
Nursing Interventions
LVAD Management– MAP readings, Assess Line site for S/S infection, Dressing change weekly. Patient provided education of self-management in preparation for return to home
Medication Management– Coumadin, Valsartan and Coumadin
Monitor Fluid Balance and Daily Weight Monitoring – Dietician educated on good food choices; NAS regular and thin liquid diet and weight stable throughout stay
Monitor Labs– PT/INR every Tuesday and Friday; Followed by Cardiologist Weekly
Therapy
Upon admission, Patient required moderate assistance with all self-care tasks and was able to ambulate 100 feet with moderate assistance. He was receiving occupational and physical therapy for 5 times a week for 2 weeks. Upon discharge from Skilled Stay, Patient was independent with all self-care tasks, able to ambulate 200 feet with no assistive device and ascend/descend 24 stairs independently.
Patient was followed weekly by Cardiologist, Dr. Droogan and Dr. Domky in the Center.
After a 26 day Short Term Rehab Stay, Patient to discharge to home with his Mother and is followed by Dr. Reza, LVAD coordinator at Penn. Primary Care Provider is Health Clinic on 28th. He is followed by Penn Medicine Cardiology, Todd Hecht.
