A patient with a history of hypertension and recently exacerbated heart failure presents with bilateral crackles, significant pitting edema, and orthopnea. Which nursing intervention should be prioritized to address the patient's current symptoms effectively?

C) Administer the prescribed diuretic and monitor for effectiveness.

A) Encourage the patient to drink more fluids to prevent dehydration.

B) Elevate the patient's legs to reduce edema.

C) Administer the prescribed diuretic and monitor for effectiveness.

D) Teach the patient pursed-lip breathing to reduce dyspnea.

A patient presents with symptoms of heart failure exacerbation, including bilateral crackles, pitting edema, and orthopnea. The laboratory tests reveal elevated BNP and mild hyponatremia. The healthcare team is considering adjusting the diuretic regimen. Which nursing intervention is most appropriate to prioritize in this situation?

B) Monitor the patient's urine output and electrolyte levels closely after diuretic adjustment

A) Encourage the patient to increase oral fluid intake to manage hyponatremia

B) Monitor the patient's urine output and electrolyte levels closely after diuretic adjustment

C) Advise the patient to avoid using pillows at night to improve breathing

D) Discontinue all diuretics to prevent further renal impairment

A patient with heart failure is experiencing increasing fatigue and generalized weakness despite adjustments in their diuretic therapy. Recent echocardiogram results show a decreased ejection fraction. What is the most appropriate nursing intervention to address the patient's current symptoms and support cardiac function?

B) Educate the patient on the importance of daily weights and monitoring for signs of fluid overload.

A) Encourage increased oral fluid intake to combat fatigue.

B) Educate the patient on the importance of daily weights and monitoring for signs of fluid overload.

C) Suggest a diet high in sodium to improve energy levels.

D) Increase the frequency of physical activity to improve cardiac output.

A patient with heart failure is being treated with furosemide and a thiazide diuretic to manage fluid overload. Despite improvements in edema and lung sounds, the patient continues to experience orthopnea and paroxysmal nocturnal dyspnea. The clinical team has initiated a low-dose beta-blocker. The patient's recent echocardiogram shows a decreased ejection fraction, suggesting systolic dysfunction. Which nursing intervention is most appropriate to address the patient's ongoing symptoms and support cardiac function?

B) Educate the patient on the importance of daily weights and fluid restriction

A) Encourage the patient to increase salt intake to manage hyponatremia

B) Educate the patient on the importance of daily weights and fluid restriction

C) Advise the patient to engage in moderate-intensity exercise to improve cardiac output

D) Recommend the patient avoid all physical activity to prevent fatigue

A patient with ischemic heart disease and atrial fibrillation is being evaluated for changes in their heart failure management plan. Which nursing intervention is most appropriate to prioritize when considering the current diagnostic findings?

B) Monitor for signs of bleeding due to potential anticoagulation therapy.

A) Educate the patient on sodium restriction to address hyponatremia.

B) Monitor for signs of bleeding due to potential anticoagulation therapy.

C) Assess the patient's understanding of lifestyle modifications for heart failure management.

D) Initiate fall precautions due to the risk of dizziness from potential medication adjustments.

A patient with ischemic heart disease and atrial fibrillation is experiencing worsening heart failure symptoms. The healthcare team is considering various management strategies. Which nursing intervention is the most appropriate to prioritize while the medical team evaluates the need for percutaneous coronary intervention?

A) Administer prescribed diuretics to manage fluid overload.

B) Educate the patient on low-sodium diet to prevent further hyponatremia.

C) Monitor liver function tests closely to assess for hepatic congestion.

D) Initiate fall precautions due to potential dizziness from low potassium levels.

A patient post-PCI for significant stenosis in the left anterior descending artery is experiencing persistent fatigue, palpitations, and mild dizziness. Current laboratory results show slight hyponatremia and low potassium. Which intervention should the nurse prioritize to address the patient's current symptoms and laboratory findings?

A) Administer a prescribed potassium supplement to correct hypokalemia

B) Increase the dosage of the low-dose beta-blocker to better control heart rate

C) Educate the patient on dietary modifications to increase sodium intake

D) Hold the anticoagulation therapy until symptoms of dizziness resolve

A patient who recently underwent a successful percutaneous coronary intervention (PCI) is now experiencing mild dizziness and lightheadedness. The patient is on warfarin and a low-dose beta-blocker, with lab tests showing mild hyponatremia (serum sodium at 132 mmol/L) and low potassium (3.4 mmol/L). Which nursing intervention is most appropriate to address these symptoms while considering the patient's current treatment plan?

C) Monitor the patient's blood pressure and heart rate closely, and assess for signs of overmedication.

A) Encourage the patient to increase oral fluid intake to address hyponatremia.

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

C) Monitor the patient's blood pressure and heart rate closely, and assess for signs of overmedication.

D) Recommend discontinuation of beta-blocker therapy to alleviate dizziness.

A patient with worsening heart failure is experiencing increased shortness of breath and peripheral edema. The healthcare provider has increased the dose of furosemide. Which nursing intervention is most important to implement to prevent complications associated with this treatment change?

C) Assess the patient's blood pressure and pulse regularly.

A) Monitor the patient's blood glucose levels closely.

B) Encourage the patient to consume foods high in sodium.

C) Assess the patient's blood pressure and pulse regularly.

D) Advise the patient to decrease fluid intake drastically.

A patient with worsening heart failure is being managed with an increased dose of furosemide and potassium supplementation. Which of the following assessments is most crucial to perform regularly to prevent complications associated with this treatment regimen?

C) Evaluate electrocardiogram (ECG) for changes indicating hypokalemia.

A) Monitor blood pressure for signs of hypotension.

B) Assess for signs of dehydration, such as dry mucous membranes.

C) Evaluate electrocardiogram (ECG) for changes indicating hypokalemia.

D) Inspect skin for signs of rash or allergic reaction.

heart failure - Nursing Case Study

Pathophysiology

• Primary mechanism: Reduced cardiac output due to impaired ventricular function. This occurs when the heart muscle weakens (systolic dysfunction) or stiffens (diastolic dysfunction), leading to insufficient blood flow to meet the body's needs, causing fatigue and exercise intolerance.

• Secondary mechanism: Neurohormonal activation, particularly the renin-angiotensin-aldosterone system (RAAS) and sympathetic nervous system. This compensatory response initially helps maintain perfusion but eventually contributes to fluid overload, vasoconstriction, and further cardiac stress.

• Key complication: Fluid retention due to increased hydrostatic pressure from venous congestion leads to edema and pulmonary congestion, exacerbating symptoms like shortness of breath and swelling.

Patient Profile

Demographics:

67-year-old female, retired school teacher

History:

• Key past medical history: Hypertension, Type 2 Diabetes, Hyperlipidemia

• Current medications: Lisinopril, Metformin, Atorvastatin, Furosemide

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing shortness of breath and fatigue

• Key symptoms: Peripheral edema, orthopnea, paroxysmal nocturnal dyspnea, decreased exercise tolerance

• Vital signs: Blood pressure 150/90 mmHg, heart rate 96 bpm, respiratory rate 24 breaths per minute, oxygen saturation 92% on room air, temperature 98.4°F

Section 1

Initial assessment findings reveal further insights into the patient's condition. Upon physical examination, the nurse notes bilateral crackles in the lung bases, indicating pulmonary congestion, and significant pitting edema in the lower extremities. The jugular venous pressure is elevated, suggesting increased central venous pressure. The patient reports increased difficulty in breathing while lying flat, requiring two pillows at night for relief, a classic sign of orthopnea. The patient also describes episodes of waking up gasping for air, consistent with paroxysmal nocturnal dyspnea.

Laboratory tests show an elevated B-type natriuretic peptide (BNP) level, reinforcing the suspicion of heart failure exacerbation. The serum creatinine is slightly increased, hinting at potential renal impairment due to decreased renal perfusion and possibly aggravated by diuretic use. Electrolyte analysis reveals mild hyponatremia, which is often associated with fluid overload and neurohormonal activation in heart failure. An echocardiogram is ordered to assess the ejection fraction and further evaluate cardiac function, but the preliminary findings suggest a potential diastolic dysfunction given the patient's history of hypertension and preserved systolic function on previous assessments.

The findings prompt a reassessment of the current management plan, particularly concerning volume status and medication adjustments. The presence of worsening edema and pulmonary symptoms indicates that the current diuretic regimen may need optimization. The clinical team considers increasing the dose of furosemide or adding a thiazide diuretic for synergistic effects to better manage the fluid overload. Additionally, they contemplate the potential need for heart rate control with a beta-blocker, given the elevated heart rate, to improve cardiac output and reduce myocardial workload. These steps aim to alleviate symptoms and prevent further complications while monitoring kidney function closely to avoid exacerbating renal issues.

Section 2

Following the adjustment in the patient's management plan, the clinical team increases the dose of furosemide and adds a thiazide diuretic to address the persistent fluid overload. Over the next 48 hours, the patient demonstrates some improvement in symptoms; the bilateral crackles in the lung bases are less pronounced, and there is a noticeable reduction in the pitting edema of the lower extremities. Despite these positive changes, the patient's respiratory status remains a concern. The patient continues to experience orthopnea and reports two more episodes of paroxysmal nocturnal dyspnea, albeit less severe than before.

Vital signs are closely monitored, revealing a blood pressure of 140/85 mmHg and a heart rate of 95 beats per minute. Although the heart rate is still elevated, the clinical team decides to initiate a low-dose beta-blocker to help control the rate and reduce myocardial workload. The team remains cautious, considering the potential impact on cardiac output and monitoring for any signs of bradycardia or hypotension. Repeat laboratory tests show a slight improvement in serum creatinine levels, suggesting stabilization of renal function, but the mild hyponatremia persists.

As the patient continues to be monitored, new complications arise. Despite the fluid management adjustments, the patient begins to experience increasing fatigue and generalized weakness. A follow-up echocardiogram reveals a decreased ejection fraction compared to previous evaluations, indicating a possible progression to systolic dysfunction. This unexpected finding prompts further investigation into potential reversible causes and reassessment of the patient's overall treatment strategy. The clinical team considers the possibility of ischemic heart disease or arrhythmias contributing to the decline in cardiac function, guiding the next steps in diagnostic and therapeutic interventions.

Section 3

New Diagnostic Results

Following the concerning findings from the echocardiogram, the clinical team decides to conduct further diagnostic tests to identify the underlying causes of the patient's decreasing ejection fraction. A coronary angiography is performed, revealing significant stenosis in the left anterior descending artery, suggesting that ischemic heart disease is likely contributing to the patient's declining cardiac function. Additionally, a 24-hour Holter monitor is employed to assess for arrhythmias, which uncovers intermittent episodes of atrial fibrillation with rapid ventricular response, correlating with the patient's ongoing fatigue and weakness.

Laboratory tests further complicate the situation. The patient's brain natriuretic peptide (BNP) levels are markedly elevated, indicating worsening heart failure. The mild hyponatremia persists with a serum sodium level of 133 mmol/L, and potassium levels are at the lower end of normal at 3.5 mmol/L, raising concerns about the risk of arrhythmias. Liver function tests reveal mild elevations in transaminases, suggesting possible hepatic congestion secondary to heart failure. The combination of these findings necessitates an urgent multidisciplinary approach to address both the ischemic and arrhythmic components of the patient's condition, requiring adjustments in both pharmacologic and possibly interventional strategies.

The clinical team must now weigh the benefits and risks of more aggressive management options, such as percutaneous coronary intervention to alleviate the coronary stenosis, alongside optimizing the patient's current heart failure medications. The potential addition of an antiarrhythmic agent or anticoagulation therapy is also considered to manage the atrial fibrillation effectively. Continuous monitoring and regular reassessment will be crucial to ensure that these interventions stabilize the patient's condition and improve overall cardiac function, setting the stage for the next phase of the patient's heart failure management.

Section 4

Change in Patient Status

Following the initiation of the revised management plan, the patient undergoes a percutaneous coronary intervention (PCI) to address the significant stenosis in the left anterior descending artery. The procedure is successful, with improved blood flow noted in the previously narrowed artery. In the days following the intervention, the patient's vital signs show initial signs of stabilization; blood pressure is maintained at a more consistent 120/80 mmHg, and heart rate has decreased to a controlled 78 beats per minute, aided by the adjusted medication regimen. However, despite these improvements, the patient reports persistent fatigue and occasional palpitations, indicating that further issues may still be impacting overall cardiac function.

A repeat echocardiogram is conducted, revealing a slight improvement in ejection fraction, now at 35%, but still within a concerning range. The patient's episodes of atrial fibrillation continue intermittently, prompting the clinical team to initiate anticoagulation therapy with warfarin to reduce the risk of thromboembolic events. Additionally, a low-dose beta-blocker is prescribed to manage the ventricular rate during atrial fibrillation episodes. Despite these interventions, the patient experiences mild dizziness and lightheadedness, which raises concerns about potential side effects or drug interactions.

Laboratory tests conducted the following week show a slight improvement in BNP levels, now at 450 pg/mL, suggesting some degree of response to the treatment. However, the mild hyponatremia persists, with serum sodium at 132 mmol/L, and potassium remains at 3.4 mmol/L, prompting the team to consider electrolyte supplementation. Liver function tests show stable transaminase levels, indicating no further hepatic congestion at this time. The team is now tasked with carefully balancing the patient's medication regimen while monitoring for adverse effects, ensuring that the patient remains stable and progresses towards improved cardiac function.

Section 5

Over the following week, the patient presents with new symptoms of increasing shortness of breath and a productive cough, raising the suspicion of developing pulmonary congestion. On physical examination, bilateral crackles are auscultated in the lower lung fields, and mild peripheral edema is observed in the ankles. The patient’s oxygen saturation, previously stable at 96% on room air, has decreased to 90%, necessitating supplemental oxygen at 2 liters per minute via nasal cannula. These findings indicate possible worsening heart failure or fluid overload, prompting further investigation.

A chest X-ray is ordered and reveals mild pulmonary edema, with increased vascular markings and mild pleural effusion, confirming the clinical suspicion. In response, the clinical team decides to adjust the patient's diuretic regimen, increasing the dose of furosemide to enhance fluid removal and reduce cardiac workload. Concurrently, the patient’s electrolyte levels are closely monitored, given the increased risk of hypokalemia with intensified diuretic therapy. The potassium supplement is adjusted to maintain potassium within a target range of 4.0 to 4.5 mmol/L to prevent arrhythmias.

As the patient’s management plan is modified, the team remains vigilant for signs of further complications, such as renal impairment or worsening electrolyte imbalances. Lab tests are scheduled to assess renal function and electrolyte levels every other day, ensuring prompt identification and correction of any adverse trends. The patient is educated on recognizing early signs of fluid retention and instructed to report any abrupt weight gain or worsening dyspnea. This integrated approach aims to stabilize the patient’s condition while minimizing the risk of exacerbations, setting the stage for the next phase of the patient’s recovery and rehabilitation.