A patient with a history of hypertension and recent diagnosis of early-stage heart failure with reduced ejection fraction (HFrEF) presents with worsening symptoms, including increased shortness of breath and bilateral ankle edema. Which nursing intervention is most important to implement first to address the patient's current condition?

D) Administer prescribed diuretics and monitor for effectiveness.

A) Educate the patient on reducing sodium intake.

B) Monitor daily weight and report significant changes.

C) Encourage the patient to increase physical activity.

D) Administer prescribed diuretics and monitor for effectiveness.

A patient with hypertension and early-stage heart failure with reduced ejection fraction (HFrEF) is experiencing increased symptoms despite adherence to prescribed medications. Which adjustment in the patient's treatment plan should the nurse anticipate as a priority to address fluid overload and improve cardiac function?

B) Add a diuretic to manage fluid retention

A) Increase the dose of Lisinopril

B) Add a diuretic to manage fluid retention

C) Initiate a calcium channel blocker

D) Discontinue current antihypertensive therapy

A patient on Lisinopril, a diuretic, and a beta-blocker reports a new onset of a persistent dry cough and has elevated potassium levels. What is the most appropriate nursing intervention?

B) Educate the patient to avoid foods high in potassium and notify the provider about the cough.

A) Advise the patient to increase fluid intake to dilute potassium levels.

B) Educate the patient to avoid foods high in potassium and notify the provider about the cough.

C) Suggest the patient switch from Lisinopril to another ACE inhibitor to alleviate the cough.

D) Instruct the patient to discontinue all medications until a follow-up appointment.

A patient with heart failure and hypertension has recently had their medication regimen adjusted to include an increased dose of Lisinopril, a diuretic, and a beta-blocker. During a follow-up visit, the patient reports a new onset of a persistent dry cough and lab results indicate hyperkalemia. Which action should the nurse anticipate as a priority in managing this patient’s treatment plan?

B) Substitute Lisinopril with an angiotensin receptor blocker (ARB).

A) Increase the dose of the diuretic to manage fluid overload.

B) Substitute Lisinopril with an angiotensin receptor blocker (ARB).

C) Introduce a potassium supplement to balance the electrolyte levels.

D) Discontinue the beta-blocker due to concerns of bradycardia.

A patient with heart failure has been switched from Lisinopril to an angiotensin receptor blocker (ARB) and started on a potassium-sparing diuretic. The patient now reports occasional palpitations and increased fatigue. Which action should the nurse prioritize to address the patient's symptoms and ensure safety?

C) Educate the patient to monitor for signs of hyperkalemia, such as muscle weakness.

A) Advise the patient to increase fluid intake to manage fluid retention.

B) Review the patient's current medication list for potential interactions.

C) Educate the patient to monitor for signs of hyperkalemia, such as muscle weakness.

D) Recommend the patient engage in light exercise to improve cardiovascular health.

A patient with heart failure has been switched from Lisinopril to an ARB and is on a potassium-sparing diuretic. The patient reports palpitations, fatigue, and continues to have crackles at the lung bases. Recent labs show stable potassium levels but a rise in creatinine. Which nursing intervention is most appropriate to address the patient's current symptoms and lab findings?

C) Collaborate with the healthcare provider to consider adding a loop diuretic

A) Increase the dosage of the potassium-sparing diuretic to enhance fluid removal

B) Educate the patient on reducing dietary potassium intake to prevent hyperkalemia

C) Collaborate with the healthcare provider to consider adding a loop diuretic

D) Advise the patient to decrease physical activity to reduce the risk of fatigue

A patient with heart failure is experiencing weight gain and mild pulmonary congestion despite stable potassium levels on a potassium-sparing diuretic. What is the most appropriate nursing intervention to address the fluid overload while monitoring renal function and electrolyte balance?

B) Initiate a loop diuretic and schedule regular monitoring of renal and electrolyte levels.

A) Increase the dosage of the potassium-sparing diuretic.

B) Initiate a loop diuretic and schedule regular monitoring of renal and electrolyte levels.

C) Suggest a decrease in fluid intake to less than 1 liter per day.

D) Recommend a high-potassium diet to counteract potential diuretic effects.

A patient with worsening heart failure and a recent increase in baseline weight is being considered for a loop diuretic addition to his treatment plan. Which nursing intervention is most appropriate to prioritize for this patient to ensure effective management of his condition?

B) Monitor the patient's blood pressure and pulse rate before and after administering the loop diuretic.

A) Encourage the patient to drink 8-10 glasses of water daily to promote kidney function.

B) Monitor the patient's blood pressure and pulse rate before and after administering the loop diuretic.

C) Advise the patient to avoid all physical activity until his condition stabilizes.

D) Instruct the patient to limit dietary potassium intake to prevent hyperkalemia.

A patient on a loop diuretic reports dizziness and has an increased creatinine level. Which nursing intervention should the nurse prioritize to address the patient's symptoms while ensuring renal protection?

C) Encourage the patient to rise slowly from sitting or lying positions to manage dizziness.

A) Increase the patient's fluid intake to enhance renal perfusion.

B) Recommend the patient take the diuretic at bedtime to reduce daytime dizziness.

C) Encourage the patient to rise slowly from sitting or lying positions to manage dizziness.

D) Advise the patient to avoid potassium-rich foods to prevent hyperkalemia.

A patient on a loop diuretic reports dizziness when standing and has an increased creatinine level. Which nursing intervention is most appropriate to address these findings while considering the patient's fluid status and renal function?

B) Advise the patient to rise slowly from sitting or lying positions to minimize orthostatic hypotension.

A) Encourage the patient to drink at least 2 liters of fluid daily to prevent dehydration.

B) Advise the patient to rise slowly from sitting or lying positions to minimize orthostatic hypotension.

C) Suggest reducing the diuretic dose to alleviate renal strain and monitor blood pressure closely.

D) Recommend increasing potassium-rich foods to stabilize electrolyte balance.

Hypertension - Nursing Case Study

Pathophysiology

• Primary mechanism: Increased systemic vascular resistance is the main driver of hypertension. This occurs due to the narrowing of blood vessels, often from chronic stress or endothelial dysfunction, leading to higher blood pressure to maintain adequate circulation.

• Secondary mechanism: Overactivation of the renin-angiotensin-aldosterone system (RAAS) plays a crucial role. This system causes vasoconstriction and sodium retention, increasing blood volume and pressure. Excessive angiotensin II also stimulates aldosterone, further raising blood pressure by promoting fluid retention.

• Key complication: Persistent hypertension can lead to target organ damage, such as hypertensive heart disease, where the heart muscle thickens (left ventricular hypertrophy) to cope with increased workload, eventually reducing cardiac efficiency and increasing the risk of heart failure.

Patient Profile

Demographics:

52-year-old male, construction worker

History:

• Key past medical history: Diagnosed with hypertension 5 years ago, borderline Type 2 diabetes

• Current medications: Lisinopril 20 mg daily, Metformin 500 mg twice daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Persistent headaches and dizziness

• Key symptoms: Fatigue, shortness of breath during exertion, occasional chest discomfort

• Vital signs: Blood pressure 160/100 mmHg, heart rate 88 bpm, respiratory rate 20 breaths/min, temperature 98.6°F

Section 1

During a follow-up visit, the patient reports that his headaches and dizziness have intensified, now occurring almost daily. His fatigue has worsened, and he experiences increased shortness of breath even during light activities, such as climbing a single flight of stairs. Upon examination, the patient's blood pressure has risen to 170/105 mmHg, despite adherence to his prescribed medications. A physical assessment reveals mild bilateral ankle edema and jugular venous distention, suggesting possible fluid overload and raising concerns about worsening cardiac function.

To further evaluate the patient's condition, a series of diagnostic tests are ordered. A chest X-ray reveals cardiomegaly, indicating potential left ventricular hypertrophy. An echocardiogram confirms the presence of left ventricular hypertrophy with a reduced ejection fraction of 45%, suggesting the early stages of heart failure with reduced ejection fraction (HFrEF). Blood tests show slightly elevated B-type natriuretic peptide (BNP) levels, corroborating the suspicion of heart failure. Serum electrolytes reveal normal sodium levels but a slight increase in potassium, possibly due to the effects of Lisinopril.

These findings suggest that the patient's hypertension has progressed to hypertensive heart disease, leading to decreased cardiac efficiency and the onset of heart failure symptoms. The clinical team must now consider adjusting his treatment regimen to address both his uncontrolled hypertension and early heart failure. This may involve increasing the dose of Lisinopril, adding a diuretic to manage fluid retention, and considering beta-blockers to reduce the cardiac workload. Close monitoring of his blood pressure, heart function, and potential side effects will be crucial in managing his evolving condition.

Section 2

In the weeks following the adjustment of the patient’s treatment regimen, which now includes an increased dose of Lisinopril, the addition of a diuretic, and the introduction of a beta-blocker, the patient presents for another follow-up visit. During the assessment, the patient reports some improvement in his symptoms; his headaches and dizziness have slightly decreased, and his fatigue is somewhat better managed. However, he continues to experience shortness of breath with minimal exertion, and notes a new onset of a persistent dry cough.

Upon examination, his vital signs reveal a blood pressure of 160/98 mmHg, indicating a partial reduction but still elevated levels. Heart rate is 68 beats per minute, and respiratory rate is 20 breaths per minute. On auscultation, there are crackles at the lung bases, suggesting fluid retention despite the diuretic therapy. Repeat blood tests show stable BNP levels, but a further increase in potassium levels to 5.5 mmol/L, raising concerns about hyperkalemia, likely exacerbated by the combined effects of Lisinopril and the new diuretic regimen.

These findings prompt the clinical team to revisit and refine the treatment plan. The persistence of fluid overload symptoms and the development of hyperkalemia necessitate a careful review of the diuretic choice and dosage, possibly switching to one with potassium-sparing properties. The dry cough may be a side effect of Lisinopril, and an alternative angiotensin receptor blocker (ARB) may be considered. Balancing the need to manage blood pressure and heart failure symptoms with the mitigation of adverse effects will require ongoing clinical reasoning and patient monitoring. The team plans to initiate these adjustments, schedule frequent follow-ups, and educate the patient on recognizing signs of worsening heart failure or electrolyte imbalances.

Section 3

In the weeks following the adjustment to the patient's treatment plan, which involved switching from Lisinopril to an angiotensin receptor blocker (ARB) and altering the diuretic regimen to include a potassium-sparing option, the patient returns for follow-up. During this visit, the patient reports a noticeable reduction in the dry cough, suggesting a positive response to the ARB substitution. However, he continues to experience shortness of breath, and now reports occasional palpitations and a feeling of increased fatigue, which are new developments since the last assessment.

On examination, the patient's vital signs reveal a blood pressure of 150/92 mmHg, showing further improvement but still not reaching target levels. The heart rate has increased to 82 beats per minute, and the respiratory rate remains at 20 breaths per minute. Auscultation of the lungs still reveals crackles at the bases, indicating ongoing fluid retention. The clinical team notes that while the switch in medication has alleviated some side effects, the persistent symptoms may suggest incomplete management of the underlying heart failure.

Recent laboratory results indicate that while potassium levels have stabilized at 5.2 mmol/L, renal function tests now show a slight rise in creatinine, suggesting potential renal impairment. The team recognizes the need for careful titration of the diuretic dosage and possibly incorporating an additional agent to better manage fluid status. Given the complexity of the patient's condition, the team decides to enhance monitoring protocols, including regular home blood pressure and weight tracking, to catch early signs of worsening heart failure or renal compromise. This approach aims to refine the treatment strategy while minimizing risks, setting the stage for a more tailored and responsive management plan.

Section 4

In the following weeks, the patient continues to monitor his blood pressure and weight at home, reporting occasional fluctuations but generally stable readings. However, he notices a steady increase in his baseline weight, raising concerns about fluid retention. During a scheduled follow-up, the clinical team conducts a thorough assessment and discovers that the patient has gained approximately 5 pounds over the past two weeks, which could signify worsening heart failure. His blood pressure at the clinic is recorded at 148/90 mmHg, a slight improvement, but still not optimal. His heart rate remains elevated at 84 beats per minute, and his respiratory rate is now 22 breaths per minute, indicating increased work of breathing.

Given these findings, the team orders a repeat set of laboratory tests and a chest X-ray. The laboratory results reveal a further increase in creatinine levels to 1.8 mg/dL, reinforcing concerns about renal function. Additionally, the chest X-ray shows mild pulmonary congestion, confirming fluid overload. The patient's potassium level remains stable at 5.3 mmol/L, suggesting that while the potassium-sparing diuretic is effective in maintaining electrolyte balance, it may not be adequately addressing fluid status. In response, the clinical team discusses the potential addition of a loop diuretic to enhance diuresis while carefully monitoring renal function and electrolyte balance.

Recognizing the complexity of the situation, the team emphasizes the importance of patient education, reinforcing the significance of adherence to the medication regimen and lifestyle modifications such as dietary sodium restriction and regular physical activity as tolerated. They also decide to increase the frequency of follow-up visits to closely monitor the patient’s response to the adjusted treatment plan and to promptly address any emerging complications. This proactive approach aims to improve clinical outcomes and prevent further deterioration of the patient's condition, setting the stage for ongoing management and potential adjustments in care.

Section 5

A week after initiating the loop diuretic, the patient returns for a follow-up appointment. During this visit, the clinical team conducts a comprehensive assessment to evaluate the effectiveness of the new medication regimen. The patient reports a slight decrease in weight, now down by 2 pounds, suggesting some improvement in fluid status. However, he also mentions experiencing occasional dizziness, particularly when standing up quickly, which raises concerns about potential orthostatic hypotension. Vital signs reveal a blood pressure of 140/88 mmHg, indicating some improvement, but the heart rate has increased to 92 beats per minute, and the respiratory rate remains elevated at 20 breaths per minute. These findings suggest that while the fluid overload is being managed, the cardiovascular system is still under strain.

In addition to the physical assessment, the clinical team reviews the latest laboratory results. The patient's creatinine level has increased slightly to 1.9 mg/dL, indicating that renal function remains a concern, potentially exacerbated by the loop diuretic. Despite this, the potassium level remains stable at 5.1 mmol/L, showing that electrolyte management is currently balanced. Given these findings, the team deliberates the need for further adjustment of the diuretic dosage or the possible introduction of another agent to optimize blood pressure control without compromising renal function. They emphasize the need for the patient to continue monitoring blood pressure and weight daily, reporting any significant changes immediately.

The patient is counseled on strategies to manage dizziness, such as rising slowly from sitting or lying positions, to mitigate the risk of falls. The clinical team also discusses the importance of maintaining adequate hydration without exacerbating fluid retention, suggesting small, frequent sips of water throughout the day. The decision is made to maintain close surveillance of the patient's response to the current treatment plan, with another follow-up scheduled in one week. This ongoing management aims to strike a delicate balance between improving cardiac function and preserving renal health, setting the stage for further adjustments as needed to stabilize the patient's condition.