A patient with worsening heart failure presents with increased shortness of breath, bilateral crackles, and peripheral edema despite diuretic therapy. Which intervention should the nurse prioritize to address the patient's current condition?

C) Administer supplemental oxygen and monitor respiratory status.

A) Increase the dose of the current diuretic medication.

B) Encourage the patient to walk more to improve circulation.

C) Administer supplemental oxygen and monitor respiratory status.

D) Prepare the patient for immediate cardiac catheterization.

A patient with worsening heart failure presents with increased shortness of breath, orthopnea, bilateral crackles, moderate peripheral edema, elevated blood pressure, tachycardia, and decreased oxygen saturation. Which nursing intervention should be prioritized to address his current condition?

B) Administer the prescribed diuretic and monitor the patient's weight and urine output.

A) Increase the patient's oral fluid intake to improve kidney perfusion.

B) Administer the prescribed diuretic and monitor the patient's weight and urine output.

C) Encourage the patient to ambulate to decrease peripheral edema.

D) Withhold the patient's antihypertensive medication due to elevated blood pressure.

A patient with advanced coronary artery disease and heart failure is being treated with intravenous furosemide and spironolactone, but continues to exhibit signs of fluid overload. Which nursing intervention is most appropriate to address the patient's ongoing heart failure symptoms while managing renal function?

B) Educate the patient on fluid restriction and monitor daily fluid intake and output.

A) Increase the frequency of vital signs monitoring to every 15 minutes.

B) Educate the patient on fluid restriction and monitor daily fluid intake and output.

C) Encourage the patient to ambulate frequently to reduce peripheral edema.

D) Initiate a high-protein diet to support renal function improvement.

A patient with heart failure is receiving intravenous furosemide and spironolactone to manage fluid overload. The patient exhibits slight improvement in symptoms but continues to have elevated creatinine levels and significant coronary artery stenosis. What is the most appropriate nursing intervention to prioritize in managing this patient's condition?

B) Monitor renal function closely and report any further elevation in creatinine levels.

A) Increase the rate of furosemide infusion to enhance diuresis.

B) Monitor renal function closely and report any further elevation in creatinine levels.

C) Encourage the patient to ambulate to improve cardiac perfusion.

D) Administer additional oxygen to maintain saturation above 95%.

A patient with a history of coronary artery disease and heart failure presents with increased respiratory distress, confusion, and declining renal function. Based on the clinical presentation, which of the following interventions should the nurse prioritize to address the patient's acute condition?

B) Prepare for non-invasive ventilation to improve oxygenation

A) Initiate a fluid restriction to manage fluid overload

B) Prepare for non-invasive ventilation to improve oxygenation

C) Administer additional diuretics to enhance fluid excretion

D) Increase oxygen flow rate to maintain adequate saturation

A patient with acute decompensated heart failure is experiencing increasing respiratory distress and confusion. Which of the following actions should the nurse take first to address the patient's respiratory status?

D) Position the patient in a high Fowler's position.

A) Increase the flow rate of supplemental oxygen.

B) Administer a prescribed dose of intravenous diuretics.

C) Prepare for intubation and mechanical ventilation.

D) Position the patient in a high Fowler's position.

A patient with acute respiratory distress is being managed with BiPAP therapy, showing improved oxygen saturation and respiratory rate. However, the patient remains confused and intermittently agitated. Which of the following nursing interventions is most appropriate to address the ongoing neurological concerns?

C) Monitor and maintain mean arterial pressure (MAP) above 65 mmHg.

A) Increase the BiPAP settings to improve oxygen delivery.

B) Administer a sedative to manage agitation and promote rest.

C) Monitor and maintain mean arterial pressure (MAP) above 65 mmHg.

D) Discontinue BiPAP therapy to prevent further neurological impairment.

A patient receiving BiPAP therapy for acute respiratory distress begins to show signs of confusion and agitation. What should the nurse prioritize to address this change in neurological status?

C) Assess and adjust blood pressure medications to optimize cerebral perfusion.

A) Increase the BiPAP pressure settings to improve oxygenation.

B) Stop BiPAP therapy and switch to high-flow nasal cannula.

C) Assess and adjust blood pressure medications to optimize cerebral perfusion.

D) Administer a sedative to manage the patient's agitation.

A patient with worsening heart failure and multi-vessel coronary artery disease is being considered for percutaneous coronary intervention (PCI). The patient has a serum creatinine level of 2.3 mg/dL, indicating renal impairment. Which of the following interventions should the nurse prioritize to reduce the risk of contrast-induced nephropathy during the procedure?

B) Ensure adequate pre-procedural hydration with isotonic fluids

A) Administer furosemide to increase urine output before the procedure

B) Ensure adequate pre-procedural hydration with isotonic fluids

C) Withhold all nephrotoxic medications 24 hours prior to the procedure

D) Increase dietary protein to support renal function

A patient with an acute exacerbation of heart failure has a decreased left ventricular ejection fraction of 25% and renal impairment with a serum creatinine level of 2.3 mg/dL. The healthcare team is considering percutaneous coronary intervention (PCI) to address significant coronary artery stenosis. What is the priority nursing action to prevent contrast-induced nephropathy in this patient?

B) Ensure adequate pre-procedural hydration

A) Administer a diuretic before the procedure

B) Ensure adequate pre-procedural hydration

C) Delay the procedure until renal function improves

D) Increase the dose of inotropic agents before PCI

Heart Failure and coronary artery disease - Nursing Case Study

Pathophysiology

• Primary mechanism (Heart Failure): Reduced cardiac output due to impaired myocardial contractility or structural heart changes, leading to inadequate tissue perfusion and fluid overload.

• Secondary mechanism (Heart Failure): Neurohormonal activation, including increased sympathetic nervous system activity and renin-angiotensin-aldosterone system (RAAS) activation, exacerbates heart stress and fluid retention.

• Primary mechanism (Coronary Artery Disease): Atherosclerosis, characterized by plaque buildup in coronary arteries, reduces blood flow and oxygen delivery to the myocardium, potentially causing ischemia.

• Secondary mechanism (Coronary Artery Disease): Plaque rupture and thrombosis can lead to acute coronary syndromes, including myocardial infarction.

• Key complication: Both conditions can lead to chronic heart failure, arrhythmias, and increased mortality, emphasizing the importance of early intervention and management.

Patient Profile

Demographics:

67-year-old male, retired construction worker

History:

• Key past medical history: Diagnosed with coronary artery disease five years ago; history of hypertension and type 2 diabetes

• Current medications: Lisinopril, Metoprolol, Atorvastatin, Aspirin, Furosemide, Metformin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing shortness of breath and fatigue

• Key symptoms: Dyspnea on exertion, orthopnea, mild peripheral edema, occasional chest discomfort

• Vital signs: Blood pressure 145/90 mmHg, heart rate 110 bpm, respiratory rate 22 breaths per minute, oxygen saturation 92% on room air, temperature 98.6°F

Section 1

Change in Patient Status:

During the hospital stay, the patient's condition began to deteriorate. Notably, his shortness of breath intensified, making it difficult to speak full sentences without pausing for breath. He also reported increased orthopnea, requiring more pillows to sleep comfortably at night. On physical examination, bilateral crackles were auscultated in the lower lung fields, suggesting pulmonary congestion. His peripheral edema had progressed from mild to moderate, extending from his ankles to his mid-calf. Despite the diuretic therapy, his weight had increased by 4 pounds over the last three days, indicating fluid retention.

The patient's vital signs revealed further instability: his blood pressure had risen to 160/95 mmHg, and his heart rate was now elevated at 120 bpm, indicating potential worsening of heart failure and increased sympathetic nervous system activity. His respiratory rate remained elevated at 24 breaths per minute, and his oxygen saturation had decreased to 88% on room air, necessitating supplemental oxygen. Blood tests showed elevated B-type natriuretic peptide (BNP) levels, confirming increased cardiac stress, and worsening kidney function with elevated creatinine, suggesting renal impairment due to poor perfusion and ongoing fluid overload.

These findings necessitated a reassessment of the current treatment regimen, focusing on optimizing heart failure management and addressing the potential complications of renal insufficiency. The healthcare team considered advancing diuretic therapy and possibly introducing other medications like spironolactone to address RAAS activation. Additionally, further cardiac imaging and possibly a stress test were planned to evaluate the coronary artery disease's current impact on myocardial perfusion, seeking to prevent further ischemic events and stabilize the patient's condition.

Section 2

Response to Interventions:

Following the reassessment, the healthcare team decided to intensify the diuretic regimen by transitioning from oral to intravenous furosemide, aiming for more effective diuresis and rapid fluid removal. Spironolactone was also initiated to counteract the effects of aldosterone and provide additional diuretic benefit. Over the next 48 hours, the patient experienced some relief in symptoms; his shortness of breath slightly improved, and he reported being able to lie slightly more flat with fewer pillows. His peripheral edema reduced marginally, now localized predominantly to the ankles. However, his weight remained stable, reflecting ongoing fluid overload challenges.

The patient's vital signs showed modest improvement; his blood pressure decreased to 145/90 mmHg, and his heart rate settled at 110 bpm, though still elevated. Oxygen saturation improved to 92% with supplemental oxygen, indicating better oxygenation but ongoing respiratory compromise. Repeat blood tests revealed a slight decrease in BNP levels, suggesting a reduction in cardiac stress. However, renal function showed no significant improvement, with creatinine levels remaining elevated, highlighting persistent renal insufficiency. These findings prompted a multidisciplinary discussion on the next steps, potentially involving nephrology consultation to manage the renal component of his condition effectively.

The team also reviewed the cardiac imaging results, which demonstrated significant stenosis in multiple coronary arteries, suggesting advanced coronary artery disease. This finding necessitated consideration of revascularization strategies to improve myocardial perfusion and prevent further ischemic events. The patient's journey now hinged on balancing heart failure management with renal protection while assessing the feasibility of interventional cardiology procedures to address coronary artery disease. The next steps would involve careful monitoring and potential adjustments to his therapeutic regimen to prevent new complications and stabilize his overall condition.

Section 3

New Complications:

Over the next 24 hours, the patient began exhibiting signs of increasing respiratory distress. His shortness of breath worsened, and he found it increasingly difficult to speak in full sentences. His respiratory rate increased to 28 breaths per minute, and auscultation revealed diffuse crackles throughout both lung fields, indicating pulmonary congestion. Despite the intensified diuretic therapy, the patient's weight increased by 1 kg, suggesting a worsening fluid overload. His oxygen saturation dropped to 88% on supplemental oxygen, necessitating an increase in oxygen delivery to maintain adequate saturation. These changes prompted immediate concern for acute decompensated heart failure and potential pulmonary edema.

Concurrent with these respiratory changes, the patient developed new-onset confusion and restlessness, raising concerns about cerebral hypoperfusion or potential hypoxia. Repeat lab tests showed an increase in creatinine to 2.3 mg/dL, further indicating declining renal function, while BNP levels rose again to 2200 pg/mL, reflecting heightened cardiac stress. Electrolyte panels revealed mild hyponatremia, complicating the clinical picture. Given these developments, the healthcare team considered the urgent need for further intervention, such as non-invasive ventilation support or possible escalation to mechanical ventilation. The nephrology team was consulted to reassess renal management, and cardiology was engaged to expedite evaluation for possible revascularization. The focus shifted to stabilizing the patient's respiratory and renal status, while also planning for potential cardiac interventions to address the underlying coronary artery disease.

Section 4

Focus on: Response to interventions

In response to the patient's deteriorating respiratory status, the healthcare team initiated non-invasive positive pressure ventilation (NIPPV) using a bilevel positive airway pressure (BiPAP) machine. This intervention aimed to improve oxygenation, reduce the work of breathing, and alleviate pulmonary congestion. Within the first hour of BiPAP therapy, the patient's oxygen saturation improved to 92%, and his respiratory rate decreased to 22 breaths per minute, indicating a positive initial response. His ability to converse also improved slightly, and he expressed feeling less breathless, suggesting some relief from the acute respiratory distress.

Despite these positive respiratory changes, the patient's neurological status remained concerning. His confusion persisted, and he demonstrated intermittent periods of agitation. The medical team focused on optimizing cerebral perfusion by adjusting his blood pressure medications to maintain a mean arterial pressure (MAP) above 65 mmHg. Additionally, supplemental oxygen was carefully titrated to avoid potential hyperoxia, which could further complicate his neurological condition. Repeat blood gas analysis showed a slight improvement in his pH, suggesting correction of a mild acidosis, but his lactate levels remained elevated, indicating ongoing tissue hypoperfusion.

The nephrology team adjusted the patient's diuretic regimen in light of his rising creatinine levels, opting for a more aggressive yet carefully monitored approach to relieve fluid overload while minimizing further renal insult. Continuous monitoring of urine output and renal function was prioritized. Meanwhile, cardiology evaluated the patient for revascularization options, considering his coronary artery disease as a potential contributor to the acute decompensation. Together, these collaborative efforts aimed to stabilize the patient and pave the way for further cardiac interventions, though the risk of additional complications remained a significant concern.

Section 5

As the healthcare team continued to address the patient's complex needs, new diagnostic results shed light on the evolving clinical picture. A follow-up echocardiogram revealed a significant decrease in left ventricular ejection fraction, now at 25%, indicating worsening cardiac function. This finding corroborated the suspected acute exacerbation of his heart failure and underscored the need for further cardiovascular support. Concurrently, a coronary angiography confirmed multi-vessel coronary artery disease with critical stenosis in the left anterior descending artery, suggesting a high likelihood of ischemic contribution to the patient's current state.

In light of these results, the cardiology team prioritized revascularization as a therapeutic option, considering percutaneous coronary intervention (PCI) to address the significant stenosis and potentially improve myocardial perfusion. However, the decision was complicated by the patient's ongoing renal impairment, as reflected in a serum creatinine level that had risen to 2.3 mg/dL. The nephrology team expressed concerns about the risk of contrast-induced nephropathy, necessitating a delicate balance between urgent cardiac intervention and renal preservation.

In response to the challenges presented by these new findings, the interdisciplinary team engaged in thorough clinical reasoning to weigh the risks and benefits of proceeding with PCI. Strategies to mitigate renal risk, such as pre-procedural hydration and the use of low-osmolar contrast media, were discussed. Meanwhile, additional pharmacological support, including the introduction of inotropic agents, was considered to bolster cardiac output and address the patient's declining hemodynamic status. This collaborative approach aimed to stabilize the patient further and prepare him for potential revascularization, while also closely monitoring for any new complications that could alter the course of his treatment plan.