A nurse is caring for a patient with severe aortic stenosis and heart failure. The patient is experiencing increased dyspnea and fatigue. Which intervention should the nurse prioritize to address the patient's current symptoms?

B) Administer the prescribed diuretic to reduce fluid overload.

A) Encourage the patient to perform moderate exercise to improve cardiac function.

B) Administer the prescribed diuretic to reduce fluid overload.

C) Position the patient flat in bed to promote rest.

D) Withhold all medications until further evaluation by the physician.

A patient with severe aortic stenosis and heart failure exhibits symptoms of increased fatigue, dyspnea on exertion, and peripheral edema. The recent diagnostic evaluation shows left ventricular hypertrophy and a reduced ejection fraction. Which nursing intervention is most appropriate to address the patient's symptoms while awaiting further surgical evaluation?

C) Educate the patient about the importance of adhering to a low-sodium diet to manage fluid retention.

A) Encourage the patient to increase fluid intake to prevent dehydration.

B) Instruct the patient to engage in daily vigorous exercise to improve cardiac function.

C) Educate the patient about the importance of adhering to a low-sodium diet to manage fluid retention.

D) Advise the patient to sleep in a supine position to enhance breathing and circulation.

A patient with severe aortic stenosis and heart failure has developed atrial fibrillation with a rapid ventricular response. Which nursing intervention is the priority to address the patient's acute decompensation?

B) Initiate intravenous beta-blocker therapy to control heart rate

A) Administer intravenous diuretics to reduce pulmonary edema

B) Initiate intravenous beta-blocker therapy to control heart rate

C) Prepare the patient for emergency cardioversion

D) Administer supplemental oxygen and position the patient upright

A patient with atrial fibrillation and rapid ventricular response is being managed with an intravenous beta-blocker and supplemental oxygen. Despite these interventions, the patient remains diaphoretic and exhibits labored breathing, with laboratory findings indicating respiratory acidosis and renal hypoperfusion. What is the priority nursing action at this time?

B) Prepare the patient for possible electrical cardioversion.

A) Increase the rate of the intravenous beta-blocker.

B) Prepare the patient for possible electrical cardioversion.

C) Administer a diuretic to reduce fluid overload.

D) Initiate a fluid bolus to improve renal perfusion.

A patient with atrial fibrillation and rapid ventricular response is receiving an intravenous beta-blocker. Despite a reduction in heart rate, the patient remains diaphoretic and has labored breathing. Which nursing intervention should be prioritized to address the patient's current condition?

D) Reposition the patient to a high Fowler's position to facilitate breathing.

A) Increase the flow rate of the non-rebreather mask to maximize oxygen delivery.

B) Prepare for potential electrical cardioversion as discussed with the healthcare team.

C) Administer an additional dose of the beta-blocker to further reduce heart rate.

D) Reposition the patient to a high Fowler's position to facilitate breathing.

A patient with severe aortic stenosis is experiencing worsening respiratory distress, hypotension, and confusion. Which immediate nursing intervention is most appropriate to prioritize the patient's respiratory status?

B) Prepare the patient for intubation and mechanical ventilation

A) Administer a prescribed dose of diuretics to decrease pulmonary congestion

B) Prepare the patient for intubation and mechanical ventilation

C) Increase the rate of intravenous fluids to improve blood pressure

D) Reassess the patient's mental status every 30 minutes

A patient with severe aortic stenosis is experiencing worsening respiratory distress, hypotension, and altered mental status. Which nursing intervention is most appropriate to prioritize at this time?

D) Collaborate with the respiratory therapist to initiate non-invasive positive pressure ventilation.

A) Administer a high-flow oxygen therapy to improve oxygenation.

B) Prepare for immediate surgical intervention to address aortic stenosis.

C) Initiate dopamine infusion to increase blood pressure and cardiac output.

D) Collaborate with the respiratory therapist to initiate non-invasive positive pressure ventilation.

A patient with severe aortic stenosis is experiencing respiratory acidosis and hypotension despite non-invasive ventilation support. What is the nurse's priority intervention to stabilize the patient before surgery?

B) Prepare for intubation and mechanical ventilation

A) Administer a diuretic to reduce pulmonary congestion

B) Prepare for intubation and mechanical ventilation

C) Increase the infusion rate of intravenous fluids

D) Administer a bolus of intravenous vasopressors

A patient with severe aortic stenosis requires intubation and mechanical ventilation due to persistent respiratory acidosis and hemodynamic instability. Which of the following nursing interventions is most important immediately after intubation?

B) Ensure proper endotracheal tube placement by auscultating bilateral breath sounds.

A) Administer a bronchodilator to improve airway patency.

B) Ensure proper endotracheal tube placement by auscultating bilateral breath sounds.

C) Increase the ventilator's tidal volume to maximize lung expansion.

D) Administer IV fluids rapidly to improve blood pressure.

aortic valve stenosis - Nursing Case Study

Pathophysiology

• Primary mechanism: Aortic valve stenosis occurs when the valve leaflets become thickened and calcified, leading to a narrowed valve opening. This restricts blood flow from the left ventricle to the aorta, causing increased pressure within the left ventricle.

• Secondary mechanism: To compensate for the increased workload due to the narrow valve, the left ventricular myocardium undergoes hypertrophy. This thickening of the heart muscle maintains cardiac output but reduces ventricular compliance, eventually impairing diastolic filling.

• Key complication: Over time, these changes can lead to left ventricular failure, resulting in symptoms such as dyspnea, angina, and syncope due to reduced cardiac output and increased myocardial oxygen demand.

Patient Profile

Demographics:

68-year-old male, retired construction worker

History:

• Key past medical history: Hypertension, hyperlipidemia, mild chronic obstructive pulmonary disease (COPD)

• Current medications: Lisinopril 20 mg daily, Atorvastatin 40 mg daily, Albuterol inhaler as needed

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing shortness of breath and fatigue

• Key symptoms: Exertional dyspnea, chest pain with activity, lightheadedness, mild ankle swelling

• Vital signs: Blood pressure 140/90 mmHg, heart rate 92 bpm, respiratory rate 22 breaths per minute, oxygen saturation 93% on room air, temperature 98.6°F

Section 1

During the initial assessment, the nurse notes that the patient appears anxious and is experiencing increased difficulty breathing, particularly when lying flat. Auscultation reveals diminished breath sounds in the lower lung fields bilaterally, with a notable systolic ejection murmur best heard at the right second intercostal space, radiating to the carotids. Peripheral pulses are slightly diminished, and there is mild jugular venous distention observed. The patient's ankle swelling has worsened since his last visit, suggesting fluid retention. A quick review of the systems highlights increased fatigue over the past weeks, with the patient needing frequent rest periods after minimal exertion.

The nurse orders a chest X-ray and an echocardiogram to further investigate the underlying cause of these symptoms. The chest X-ray reveals cardiomegaly and pulmonary congestion, indicating possible heart failure. The echocardiogram confirms severe aortic stenosis with a valve area of 0.8 cm² and an increased pressure gradient across the valve. Left ventricular hypertrophy is noted, along with a reduced ejection fraction of 40%, indicating systolic dysfunction. These findings correlate with the patient's symptoms and suggest a significant progression of the aortic stenosis, necessitating a reevaluation of the current management plan.

Given the new diagnostic results, the healthcare team discusses potential interventions, including surgical options such as aortic valve replacement or transcatheter aortic valve implantation (TAVI), considering the patient's age and comorbidities. In the interim, the patient is advised to limit physical activity, and medications are adjusted to optimize heart failure management, including the addition of a diuretic to address fluid overload. The nurse educates the patient and his family about recognizing worsening symptoms and the importance of adhering to the updated treatment regimen. This comprehensive assessment and diagnostic evaluation provide critical insights for the next steps in the patient's care journey.

Section 2

As the treatment plan is implemented, the patient initially shows some improvement with the adjusted heart failure management. The diuretic helps reduce the ankle swelling and jugular venous distention, suggesting effective fluid management. However, a week later, the patient presents to the emergency department with acute changes in his condition. He reports worsening shortness of breath, now occurring even at rest, and an episode of syncope while attempting to stand. These symptoms are accompanied by a rapid, irregular heartbeat.

Upon examination, the patient's vital signs reveal a heart rate of 140 beats per minute with an irregular rhythm, blood pressure of 100/60 mmHg, respiratory rate of 28 breaths per minute, and oxygen saturation of 88% on room air. The nurse notes increased respiratory effort with accessory muscle use and audible crackles in the lung bases, indicating pulmonary edema. A 12-lead ECG confirms the presence of atrial fibrillation with a rapid ventricular response. The patient also exhibits pallor and diaphoresis, suggesting decreased perfusion.

The development of atrial fibrillation in this context of severe aortic stenosis and heart failure poses a significant new complication. The irregular, rapid heart rate exacerbates the patient's hemodynamic instability and contributes to the worsening heart failure symptoms. Immediate clinical reasoning is required to address this acute decompensation. The healthcare team must prioritize rate control and rhythm management to stabilize the patient. Intravenous beta-blockers or calcium channel blockers may be considered to slow the heart rate, while continuous monitoring and supplemental oxygen support are initiated to improve oxygenation and perfusion. This critical juncture underscores the urgency of reassessing surgical intervention options, as the patient's condition now highlights the potential risks of delaying definitive treatment.

Section 3

Response to Interventions

Following the identification of atrial fibrillation with rapid ventricular response, the healthcare team promptly administers an intravenous beta-blocker to manage the patient's heart rate. The goal is to achieve rate control and thereby reduce the cardiac workload and improve hemodynamics. Within the first hour of intervention, the patient's heart rate gradually decreases to 110 beats per minute, although it remains irregular. Concurrently, supplemental oxygen is provided via a non-rebreather mask, improving the patient's oxygen saturation to 92%. Despite these efforts, the patient continues to exhibit labored breathing and remains diaphoretic, indicating persistent hemodynamic compromise.

Laboratory results reveal elevated brain natriuretic peptide (BNP) levels, consistent with exacerbation of heart failure, and a slight elevation in serum creatinine, suggesting renal hypoperfusion. Arterial blood gas analysis shows a pH of 7.32, PaCO2 of 50 mmHg, and PaO2 of 60 mmHg, indicating respiratory acidosis with hypoxemia. These findings confirm the severity of the patient's acute decompensation and the need for ongoing monitoring and potential escalation of care. The healthcare team discusses the potential for electrical cardioversion if pharmacological management fails to adequately control the arrhythmia.

Amidst these interventions, the patient experiences a transient improvement, reporting a slight reduction in dyspnea. However, the persistence of irregular heart rhythm and elevated respiratory rate signals the underlying issue remains unresolved. The multidisciplinary team convenes to consider urgent surgical evaluation for valve replacement, recognizing the unlikelihood of sustained improvement without addressing the stenotic valve. This critical decision point emphasizes the interconnectedness of acute management and long-term treatment strategies for patients with severe aortic stenosis and complex cardiac complications.

Section 4

Change in Patient Status

Despite initial interventions, the patient's condition begins to deteriorate further. Over the next few hours, the patient develops increasing respiratory distress, with a respiratory rate climbing to 32 breaths per minute. Auscultation reveals worsening crackles throughout the lung fields, indicative of pulmonary congestion. The patient's blood pressure remains low, recorded at 88/54 mmHg, despite fluid management efforts. The low blood pressure, combined with the elevated heart rate of 115 beats per minute, suggests ongoing hemodynamic instability.

The patient's mental status changes, becoming confused and lethargic, a possible sign of decreased cerebral perfusion. Repeat arterial blood gas analysis shows a worsening respiratory acidosis, with a pH of 7.28, PaCO2 of 55 mmHg, and PaO2 dropping further to 55 mmHg. This hypoxemia underscores the need for more aggressive respiratory support. The team discusses the potential for intubation and mechanical ventilation to stabilize the patient's respiratory status.

Given these complications, the multidisciplinary team urgently reassesses the treatment plan. The decision is made to expedite surgical consultation for aortic valve replacement, recognizing that medical management alone may not sustain the patient's condition in the face of severe aortic stenosis and its complications. This step aims to address the root cause of the patient's hemodynamic instability and prevent further organ dysfunction. The rapid change in the patient's status highlights the critical need for timely intervention in patients with significant cardiac pathology and underscores the importance of collaborative, decisive care planning.

Section 5

Following the decision to expedite surgical consultation for aortic valve replacement, the patient undergoes a series of pre-operative assessments to evaluate their current status and readiness for surgery. A transesophageal echocardiogram (TEE) is performed to gain a clearer view of the aortic valve's condition. The TEE confirms severe aortic stenosis with a valve area reduced to 0.7 cm² and a mean gradient of 50 mmHg, along with moderate left ventricular hypertrophy. These findings reinforce the critical need for surgical intervention. Additionally, cardiac catheterization is conducted to assess coronary artery status. The results reveal no significant coronary artery disease, allowing the surgical team to focus solely on the valve replacement.

Despite the respiratory support, including the initiation of non-invasive positive pressure ventilation (NIPPV), the patient's respiratory acidosis persists, with repeat ABG showing a pH of 7.25, PaCO2 of 58 mmHg, and PaO2 of 52 mmHg. This suggests that the patient's respiratory efforts are insufficient to overcome the increased cardiac workload and pulmonary congestion caused by the aortic stenosis. The low blood pressure continues to be a concern, now at 85/50 mmHg, indicating that the patient's compensatory mechanisms are failing. This is compounded by the patient's increasing lethargy and confusion, which suggests worsening cerebral hypoperfusion.

In light of these developments, the multidisciplinary team decides to proceed with intubation and mechanical ventilation to stabilize the patient's respiratory and hemodynamic status before surgery. This intervention aims to reduce the work of breathing, improve oxygenation, and optimize hemodynamics by allowing for more controlled fluid and medication management. The surgical team is alerted to the urgency, and plans for the aortic valve replacement are advanced to prevent further deterioration. This strategic shift in the patient's management highlights the integration of clinical reasoning with dynamic decision-making, emphasizing the importance of timely interventions in complex cardiac cases.