iHuman Case Study: 60-Year-Old Female Patient with Shortness of Breath (CHF Exacerbation), Exams of Nursing

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o Aggravating Factors: Physical activity, lying flat (orthopnea) o Relieving Factors: Sitting upright, using extra pillows at night o Associated Symptoms: Fatigue, mild ankle swelling, occasional dry cough, mild chest tightness o Denies: Fever, chills, hemoptysis, recent travel, or sick contacts

• Past Medical History (PMH): o Hypertension (HTN), Type 2 Diabetes Mellitus (T2DM), Hyperlipidemia o No known COPD or asthma
• Medications: o Lisinopril 10 mg PO daily o Metformin 1000 mg PO BID o Atorvastatin 20 mg PO at bedtime
• Allergies: NKDA
• Family History: Mother had congestive heart failure (CHF), father had a myocardial infarction (MI)
• Social History: o Former smoker (quit 10 years ago, 20 pack-year history) o No alcohol or illicit drug use

• Review of Systems (ROS): o General: Fatigue, recent mild weight gain o Respiratory: SOB, no wheezing, no hemoptysis o Cardiovascular: Mild chest tightness, no palpitations o Gastrointestinal: No nausea, vomiting, or abdominal pain o Neurological: No dizziness, confusion, or syncope O – Objective Vital Signs:

BP: 145/85 mmHg HR: 92 bpm RR: 22 breaths/min Temp: 98.7°F O₂ Sat: 92% on room air Physical Exam Findings:

• General: Appears fatigued, mild respiratory distress
• Respiratory: o Crackles at bilateral lung bases

1. Diagnostic Testing:
   • • • • • • • BNP (Brain Natriuretic Peptide): Elevated in CHF Chest X-ray (CXR): Check for cardiomegaly, pulmonary congestion Electrocardiogram (EKG): Evaluate for arrhythmia or ischemia Echocardiogram: Assess ejection fraction (EF) and cardiac function Basic Metabolic Panel (BMP): Check kidney function, electrolytes CBC: Rule out anemia ABG (if needed): Evaluate hypoxia severity

2. Treatment & Management:

   • Oxygen Therapy: Nasal cannula at 2- L/min as needed for O₂ saturation >94% Diuretics: Furosemide 20 mg IV to reduce fluid overload Beta-Blocker (if tolerated): Consider metoprolol for rate control and CHF management Low-Sodium Diet Education: Limit sodium to <2g/day

• Fluid Restriction: <1.5L/day if severe volume overload Daily Weight Monitoring: Report weight gain of >2 lbs in 24 hours Cardiology Consultation: If severe CHF or worsening symptoms Nursing Care Plan Nursing Diagnosis 1: Ineffective Breathing Pattern

Goal: Improve oxygenation and reduce dyspnea Interventions: o Monitor oxygen saturation and respiratory rate frequently o Position patient in high Fowler’s position to ease breathing o Administer oxygen therapy as prescribed o Encourage pursed-lip breathing and slow, deep breaths Nursing Diagnosis 2: Fluid Volume Excess

• Goal: Reduce fluid retention and improve cardiac function

• Reports improvement in SOB but still fatigued No new chest pain or dizziness Denies significant weight gain Objective:

Vitals: BP 138/80, HR 78, O₂ Sat 95% on room air Respiratory: Crackles diminished Cardiac: No new murmurs, edema reduced to trace level Assessment: CHF Improving with diuretics and lifestyle modifications Plan:

Continue diuretics, beta-blocker, low- sodium diet Increase activity gradually as tolerated Follow up in 2 weeks for further evaluation Patient Handout – Managing CHF at Home What is CHF?

CHF occurs when the heart cannot pump blood effectively, leading to fluid buildup in the lungs and body. Key Symptoms to Monitor: Shortness of breath, especially when lying down Swelling in legs, feet, or abdomen Sudden weight gain (more than 2 lbs in 24 hours) Fatigue or dizziness Self-Care Tips: Weigh yourself daily and report weight gain > lbs Follow a low-sodium diet (<2g/day) Take medications exactly as prescribed Monitor fluid intake (if restricted by doctor) Avoid alcohol and smoking Emergency Warning Signs : Sudden severe SOB or chest pain Confusion or extreme fatigue Rapid weight gain (>5 lbs in 3 days)

o Less likely due to no history of chronic cough or wheezing 2.Pneumonia o No fever, no purulent sputum 3.Pulmonary Embolism (PE) o No acute pleuritic chest pain, no recent immobilization 4.Anemia o Possible, but would require confirmation with CBC Diagnostic Workup for CHF Exacerbation A thorough diagnostic evaluation is essential to confirm congestive heart failure (CHF) exacerbation, assess severity, and rule out other potential causes of shortness of breath (SOB).

1. Laboratory Tests Brain Natriuretic Peptide (BNP) or N- terminal proBNP (NT-proBNP)
   • Expected Finding: Elevated (>400 pg/mL for BNP or >900 pg/mL for NT-proBNP in patients over 50 years old)

• Rationale: BNP is released in response to ventricular stretching due to fluid overload in CHF. Complete Blood Count (CBC)
• Assess for: o Anemia (low hemoglobin/hematocrit) → o Leukocytosis → Suggests infection (e.g., pneumonia) Comprehensive Metabolic Panel (CMP)
• Electrolyte Imbalance: Monitor for hyponatremia, hypokalemia, or hyperkalemia, which can occur due to CHF or diuretic therapy.
• Renal Function (BUN/Creatinine): Impaired kidney function can result from poor cardiac output or nephrotoxic effects of diuretics.
• Liver Function Tests (AST, ALT, ALP, Bilirubin): May be elevated due to hepatic congestion in right-sided heart failure. Arterial Blood Gas (ABG) (if needed)

o Pulmonary congestion or interstitial edema o Kerley B lines (signs of fluid overload) o Pleural effusion (if severe) Echocardiogram (Transthoracic Echocardiography – TTE)

• Gold standard for assessing CHF
• Findings: o Reduced ejection fraction (EF) → Systolic o o heart failure (HFrEF) if EF <40% Diastolic dysfunction → CHF with preserved EF (HFpEF) Wall motion abnormalities (suggestive of ischemic heart disease) o Valvular abnormalities (e.g., mitral regurgitation contributing to CHF) Electrocardiogram (EKG/ECG)
• Assess for: o Ischemic changes (ST depressions, T wave inversions) → Rule out acute coronary syndrome (ACS) o Atrial fibrillation (AFib) → Common arrhythmia in CHF

o Left ventricular hypertrophy (LVH) → Suggests chronic hypertension or heart failure CT Pulmonary Angiography (CTPA) (if PE suspected)

• Rationale: If sudden severe SOB, chest pain, or unexplained hypoxia, rule out pulmonary embolism Right Heart Catheterization (if severe CHF or unclear diagnosis)

Measures pulmonary artery pressure & cardiac output Helps differentiate between pulmonary hypertension and CHF

3. Functional & Stress Testing (If Needed for Further Evaluation) Cardiac Stress Test (if CAD suspected)

• Determines ischemic contribution to CHF

Test Expected Findings ABG Hypoxia or respiratory alkalosis Right Heart Cath (if

Confirms pulmonary

needed) congestion & pressure

changes Treatment Plan for Congestive Heart Failure (CHF) Exacerbation The primary goals of treatment for CHF exacerbation are reducing fluid overload, improving cardiac output, optimizing oxygenation, and preventing further complications.

1. Immediate Stabilization (If Severe Symptoms Present) Oxygen Therapy

• Indication: Hypoxia (O₂ sat < 94%)
• Delivery Methods: o Nasal cannula (2-4 L/min) for mild hypoxia

o Non-rebreather mask (if moderate distress) o Non-invasive positive pressure ventilation (e.g., BiPAP) if severe pulmonary edema

• Monitor: ABG and O₂ saturation to guide therapy Diuretics (First-line Treatment for Volume Overload)
• Furosemide (Lasix) 20-40 mg IV (higher doses if already on home diuretics)
• Goal: Reduce pulmonary congestion, peripheral edema, and dyspnea
• Monitor: o Urine output (target: > mL/hr) o Electrolytes (K+, Na+) o Kidney function (BUN/Cr) Vasodilators (If Blood Pressure Allows)
• Nitroglycerin (IV or sublingual) – Reduces preload and afterload
• Hydralazine or Isosorbide Dinitrate (if unable to tolerate ACE inhibitors)
• Monitor: Blood pressure to avoid hypotension Positioning