Which of the following assessment findings is most consistent with early-stage congestive heart failure?

D) Elevated capillary blood glucose

Based on the patient's initial assessment findings, which nursing intervention is most appropriate to address his exertional shortness of breath?

A) Encourage the patient to increase his physical activity gradually, with rest periods as needed.

B) Advise the patient to avoid any physical activity to prevent worsening symptoms.

C) Increase the patient's fluid intake to help reduce ankle swelling.

D) Suggest the patient use over-the-counter diuretics to manage fluid retention.

What is the significance of an ejection fraction of 55% in a patient with congestive heart failure?

B) It signifies normal heart pumping function.

A) It indicates severe heart failure.

B) It signifies normal heart pumping function.

C) It reflects poor glucose control.

D) It suggests renal impairment.

Based on the diagnostic results, which finding indicates that the patient's heart is compensating for increased workload?

B) Mild left ventricular hypertrophy

In managing a patient who reports mild ankle edema, which of the following interventions is most appropriate to recommend as part of the patient's self-care routine?

B) Elevate the legs during rest periods

A) Increase fluid intake significantly

B) Elevate the legs during rest periods

C) Limit physical activity to prevent swelling

D) Apply heat to the affected area

A patient on a health management plan reports mild ankle edema and fatigue in the afternoons. Which initial nursing intervention is most appropriate to help manage the patient's edema?

B) Advise the patient to elevate his legs during rest periods

A) Encourage the patient to reduce fluid intake significantly

B) Advise the patient to elevate his legs during rest periods

C) Suggest the patient increase his salt intake

D) Instruct the patient to perform vigorous exercise to improve circulation

What is the primary reason for advising the patient to take short breaks during work to rest and elevate his legs?

A) To improve respiratory function

B) To enhance blood glucose control

What is the most appropriate nursing intervention to address the patient's report of increased fatigue in the late afternoons?

B) Suggest the patient take short breaks to rest and elevate his legs.

A) Encourage the patient to increase fluid intake during work.

B) Suggest the patient take short breaks to rest and elevate his legs.

C) Advise the patient to start a new exercise regimen to boost energy levels.

D) Recommend the patient decrease diuretic dosage to reduce fatigue.

Which dietary change is most important for the patient to implement to help manage his blood pressure and fluid status?

A) Increase dietary fiber intake

A patient with mild, persistent fatigue and occasional dizziness reports frequent ankle swelling that subsides with leg elevation. Which dietary modification should the nurse prioritize to help reduce these symptoms?

B) Decrease sodium intake to manage fluid retention

A) Increase protein intake to improve energy levels

B) Decrease sodium intake to manage fluid retention

C) Increase carbohydrate intake for better glucose management

D) Decrease fat intake to lower cholesterol levels

Congestive heart failure, Diabetes type 2 - Nursing Case Study

Pathophysiology

Congestive Heart Failure (CHF):

• Primary mechanism: Reduced cardiac output - The heart's pumping ability weakens, leading to insufficient blood flow to meet the body's needs, often due to damage from conditions like hypertension or coronary artery disease.

• Secondary mechanism: Fluid overload - The kidneys compensate for reduced blood flow by retaining salt and water, causing fluid buildup in tissues and lungs, leading to symptoms like swelling and shortness of breath.

• Key complication: Pulmonary congestion - Fluid accumulation in the lungs impairs gas exchange, worsening breathing difficulties and reducing oxygen supply to vital organs.

Diabetes Type 2:

• Primary mechanism: Insulin resistance - Body cells become less responsive to insulin, leading to elevated blood glucose levels as glucose uptake by cells is impaired.

• Secondary mechanism: Beta-cell dysfunction - Over time, pancreatic beta cells fail to produce enough insulin due to chronic high blood glucose, exacerbating hype

Patient Profile

Demographics:

62-year-old male, retired school teacher

History:

• Key past medical history: Diagnosed with early-stage congestive heart failure and type 2 diabetes 2 years ago

• Current medications: Metformin 500 mg twice daily, Lisinopril 10 mg daily, Furosemide 20 mg daily

• Allergies: None known

Current Presentation:

• Chief complaint: Mild shortness of breath during exertion

• Key symptoms: Occasional fatigue, slight swelling in ankles, stable blood glucose levels

• Vital signs: Blood pressure 128/82 mmHg, heart rate 72 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F, oxygen saturation 96% on room air

Section 1

Initial Assessment Findings:

During the initial nursing assessment, the patient appears alert and oriented, displaying no acute distress. He reports mild shortness of breath during exertion, such as walking up a flight of stairs, but denies any chest pain or palpitations. The patient's skin is warm and dry, with no cyanosis or clubbing noted. Peripheral pulses are palpable and equal bilaterally. Slight pitting edema is observed in both ankles, a common sign of fluid retention associated with early-stage congestive heart failure. Auscultation of the lungs reveals clear breath sounds bilaterally, with no crackles or wheezes detected, suggesting that pulmonary congestion is not currently present.

The patient's capillary blood glucose level is checked and found to be 112 mg/dL, indicating stable glucose control with his current treatment regimen. A review of his dietary habits confirms adherence to a balanced diet low in refined sugars and saturated fats, consistent with managing type 2 diabetes. The patient expresses a good understanding of his dietary needs but admits to occasional difficulty maintaining regular exercise due to fatigue.

Overall, the assessment indicates that the patient's conditions are being managed effectively with his current medication and lifestyle interventions. However, ongoing monitoring of his symptoms, particularly the ankle swelling and exertional breathlessness, is necessary to prevent potential progression. The nursing team plans to continue close observation and reinforce education on medication adherence, dietary management, and safe physical activity levels to support his health stability.

Section 2

New Diagnostic Results:

Following the initial assessment, the healthcare team decides to conduct a series of diagnostic tests to gather more detailed information about the patient's condition. The echocardiogram reveals an ejection fraction of 55%, which is within the normal range, indicating that the heart's pumping function is currently preserved. This finding supports the assessment that the patient's congestive heart failure is in its early stages and is being managed effectively. However, the team notes mild left ventricular hypertrophy, a potential sign of the heart beginning to compensate for increased workload.

Laboratory results show a B-type natriuretic peptide (BNP) level of 120 pg/mL, slightly elevated but not alarming, suggesting mild cardiac stress. Renal function tests indicate a creatinine level of 1.1 mg/dL, within normal limits, and an estimated glomerular filtration rate (eGFR) of 78 mL/min/1.73m², indicating stable kidney function. These results reinforce the importance of ongoing monitoring and management to prevent further complications.

The patient's HbA1c level is found to be 6.4%, reflecting good long-term glucose control. This aligns with the capillary blood glucose readings and dietary adherence noted in the initial assessment, confirming that the patient's type 2 diabetes is well-managed. Based on these diagnostic results, the healthcare team decides to maintain the current treatment regimen, while emphasizing the importance of regular follow-ups to monitor any changes in cardiac function or glucose levels. The patient is advised to continue his balanced diet and is encouraged to engage in gentle, regular physical activity to improve endurance and cardiovascular health, taking care to avoid activities that exacerbate his symptoms.

Section 3

Change in Patient Status:

Over the next few weeks, the patient adheres diligently to the prescribed health management plan, including dietary guidelines and a moderate exercise routine. At a routine follow-up appointment, the patient reports feeling slightly more fatigued than usual, particularly in the afternoons, but denies experiencing any chest pain, palpitations, or significant shortness of breath. He also mentions occasional mild swelling in his ankles, which he attributes to standing for extended periods during his part-time job. These symptoms prompt the healthcare team to perform a thorough reassessment to ensure that the patient's conditions remain under control.

The clinical evaluation reveals stable vital signs with a blood pressure of 128/78 mmHg and a heart rate of 72 beats per minute. Respiratory rate is at 16 breaths per minute with an oxygen saturation level of 96% on room air. Physical examination confirms mild bilateral ankle edema, but no jugular venous distention or pulmonary crackles are noted. Capillary blood glucose readings remain within target range, and a repeat laboratory panel shows a BNP level of 130 pg/mL, slightly higher than before but still relatively low. The patient's HbA1c is steady at 6.5%, indicating continued effective diabetes management. Based on these findings, the healthcare team decides to adjust the patient's diuretic dosage slightly to help manage the edema, while continuing to monitor his cardiac status closely.

The patient is counseled on the importance of elevating his legs during rest periods to reduce swelling and is encouraged to maintain regular follow-up visits to track any changes in symptoms or laboratory values. The team emphasizes the need for ongoing communication about any new or worsening symptoms, ensuring that the patient understands the significance of reporting these promptly. By addressing the mild edema and observing for any further developments, the healthcare team aims to prevent potential complications and support the patient's journey towards optimal health.

Section 4

Several weeks later, the patient returns for a scheduled follow-up appointment. He reports an improvement in the ankle swelling since the diuretic dosage adjustment, noting that the edema is now only occasional and resolves more quickly with leg elevation. However, he mentions experiencing increased fatigue in the late afternoons, which he attributes to his part-time work schedule. He continues to deny any chest pain, palpitations, or significant shortness of breath, and reports no new symptoms.

During the clinical evaluation, the patient's vital signs remain stable, with a blood pressure of 126/80 mmHg and a heart rate of 74 beats per minute. His respiratory rate is 16 breaths per minute, and his oxygen saturation is steady at 97% on room air. A physical examination reveals no signs of pulmonary congestion, and auscultation of the heart and lungs remains normal. The mild bilateral ankle edema is noted as improved from previous visits. A capillary blood glucose test shows a reading of 110 mg/dL, consistent with his usual range. A repeat laboratory panel demonstrates a BNP level of 125 pg/mL, slightly decreased since the last visit, and his HbA1c remains stable at 6.6%.

The healthcare team is encouraged by these findings and discusses the importance of maintaining the current management plan. They emphasize lifestyle modifications, such as implementing short breaks during work to rest and elevate his legs, which may help alleviate fatigue and prevent further swelling. Additionally, the patient is advised to monitor his symptoms closely and report any changes promptly. The team schedules the next follow-up appointment to continue their vigilant monitoring and to ensure that his conditions remain well-controlled, aiming to prevent any future complications.

Section 5

Two months after the follow-up appointment, the patient experiences a minor change in his status. He reports to the clinic with mild, persistent fatigue and occasional dizziness, particularly when standing up too quickly. He continues to work part-time and adheres to his prescribed medication regimen, but admits to occasional lapses in his dietary plan, particularly with high-sodium foods. While he denies any significant shortness of breath, chest pain, or palpitations, he notes that his ankle swelling has become more frequent, though it still subsides with leg elevation.

During the clinical evaluation, the patient's vital signs show a slight increase in blood pressure, now measuring 134/82 mmHg, while his heart rate remains stable at 76 beats per minute. His respiratory rate is unchanged at 16 breaths per minute, and oxygen saturation is steady at 96% on room air. Physical examination reveals mild bilateral ankle edema, similar to previous visits. However, there are no new findings of pulmonary congestion or abnormal heart sounds. A capillary blood glucose test shows a slightly elevated reading of 128 mg/dL, indicating a need for more rigorous dietary adherence. Repeat laboratory tests demonstrate a BNP level of 130 pg/mL, slightly increased from the last visit, and an HbA1c of 6.8%, suggesting a minor decline in glycemic control.

The healthcare team reviews these findings and discusses potential adjustments to the patient's management plan. They emphasize the importance of dietary adherence, particularly reducing sodium intake, to help manage his blood pressure and fluid status. Additionally, they consider a slight modification in his diuretic dosage to better control edema and discuss strategies to improve his energy levels, such as incorporating regular, light exercise tailored to his capacity. The patient is encouraged to continue monitoring his symptoms and to maintain detailed records of his dietary intake and activity levels. A follow-up appointment is scheduled in six weeks to reassess his progress and ensure that his conditions remain under control.