Introduction
The patient is a 67-year-old male who came to the outpatient clinic with difficulty breathing. After an examination and a series of tests, he was diagnosed with congestive heart failure (CHF). CHFally is a result of the heart muscle become weakening and no longer pump in good as well as normally through the body. Consequently, the lungs and the rest of the body will get a hindrance to breathing as fluid accumulates. This is the reason this patient needs medical attention since fluid buildup is believed to lead to breathing problems that need remedy. About this case patient, based on my role as a nurse, the primary focus is checking the patient’s symptoms and implementing clinically proven approaches to control the volume of the patient’s fluid intake. CHF exacerbations can lead to death, so my priority would be to make sure he gets the best medical management to put him in a stable condition. This encompasses repeated weight checks daily to monitor fluid status, reminders of their medications and proper diet intake, and teaching patients about symptom recognition and treatment. Physicians need to take steps toward fixing his respiratory distress and alleviate the burden of fluid accumulation to prevent more damage as a result of his heart failure.
Pathophysiology
Congestive heart failure is due to structural or functional issues with the heart muscle that prevent it from functioning normally and thus reduce the capacity of the heart to pump blood effectively. The left ventricle of the heart in this patient has become weak and, therefore, less contractile. As a result, cardiac output is reduced. As a result, blood congestion in the pulmonary and systemic veins leads to edema in the lungs (pulmonary congestion) and other tissues. The common symptoms of CHF involve increased effort in everyday activities due to shortness of breath, wheezing or coughing, fatigue, swelling in ankles and legs, and irregular movement of the heart (Johansson et al., 2021). The lung fluid building up blocks the passage of oxygenated blood to the other areas of the body, forcing the heart to work harder to supply the tissues demanding greater levels of oxygen, leading to the worsening of the condition if the disease condition was not properly controlled.
History
This patient had a history of hypertension and type 2 diabetes, which are the risk factors that potentially led him to progress to heart failure. Ten years since, he had a heart attack, and was born again through this Triple Coronary Artery Bypass Graft Surgery. Since then, he has been diagnosed and put on several medications to manage his conditions including among others, lisinopril, metoprolol, atorvastatin, and metformin. Unfortunately, even his compliance with the medical prescriptions had not been enough to prevent the last two hospitalizations from happening the last twelve months for the purpose of dealing with CHF exacerbations which was accompanied by worsening edema and breathing difficulty. His present symptoms mirror that his heart failure is decompensating again, which indicates that if treatment of this disease improves, he will have reduced likelihood of deteriorating wellbeing without immediate and prolonged attention (Pandya et al., 2013).
Nursing Physical Assessment
On the primary analysis, the patient’s vital signs were prominently found to be increased blood pressure off 160/90 mmHg, heart rate of 110 beats per minute, resonant rate of 24 respirations per minute, and oxygen saturation of 88% on room air. On physical examination, he had distended jugular veins to 45 degrees angle and I listened to his percussion at the base of both lungs and could hear the crackles there. The client’s feet and calves had 3+ pitting edema all the way to the knees. A cardiac exam showed irregular and irregular rhythm as well as a prominent S3 gallop. The abdominal sounds were hypoactive in all four quadrants. On being questioned, the patient said that he had gained five pounds over the last week and the paroxysmal nocturnal dyspnea which had occurred to him the last two nights forced him to sleep in a recliner. On six-minute walk test, he managed to move 250 feet before he could no longer continue due to breathlessness. His clinical presentation was established as acute respiratory failure due to decompensated heart failure requiring admission to ICU and invasive treatment with inotropes and diuretics for relief of congestion.
Nursing Physical Assessment
In addition to the physical examination, it appeared that the patient had swelling in the abdomen. His ascites showed grade 2 fluctuations, with shift dullness present at umbilicus. The bowel sounds were still hypokinetic, with only three high-pitched sounds in each quadrant over a period of 5 minutes of auscultation. The renal arteries on both sides were audible with an abdominal bruit, this was a concerning fact as this might be indicative of elevated renal pressures from congestion. A neurological assessment revealed sensitivity to light touch lower extremities less than the upper extremities, which reflect the first sign of peripheral edema. Pulmonary examination confirmed the crackles that were one third of the way up from the bases during inspiratory breaths. The oxygen saturation of his blood was 88% while at rest on room air but decreased to 84% during his walk to the bedside commode. In view of his marked clinical deterioration, there was need of initiating intravenous furosemide on him and a prompt adjustment of his weight, office signs, and fluid balance, through input output assessment, to achieve his symptomatic relief.
Related Treatments
As a result of his decompensated congestive heart failure, the patient undergoes several treatment options, which will facilitate the removal of excess fluid from the body, and will provide relief from cardiac preload and afterload. He is now being administered intravenous furosemide with maintenance Oral Lasix with the goal of enhancing diuresis. There are also two intravenous drugs that he is being treated with for the afterload and preload reduction through vasodilation: nitrates and sodium nitroprusside also advised by Naik et al. (2021). At present, he has started to get supplemental oxygen with a rate of 4L/min through nasal cannula as one of the ways to increase his oxygen saturation. The implementation of a strict regulation on the inputs and outputs will guide the therapy by providing a monitor that will ensure that the diuretics are accurately administered.
Nursing Diagnosis &Patient Goal
According to the patient’s current symptoms and the findings of the examination, the nursing diagnosis is fluid volume excess based on diastolic dysfunction impaired cardiac output, as observed through his weight gain, dyspnea, pitting edema, and fine rales. The primary goal is to decrease symptomatic fluid overload, at the same time protecting the kidney function. This is achieved by having a diuresis that will pass out 2-3 liters of fluid in a one day period as a sign it is successful by looking at the daily test results and the patients symptoms. A baseline goal weight is what will allow the patient to get better and out of breath-like conditions as well as peripheral swelling that is furthering the reduction of the patient’s independence and quality of life. The essence of lessening the congestion via the medicated management that is optimized is unbeatable as a mitigating factor to avoid further decompensation events.
Nursing Interventions
For implementation of the objective, I will seek ideal diuresis through intake and output monitoring by conducting hourly weights and precise recording of all fluid administration and eliminations. Per the standard protocol, IV furosemide will be given every two hours frequently and dose adjustment will be tailored to the hindrance of body weight intermittently and indicators of the clinical response as emphasized by Ouwerkerk et al. (2023). Furthermore, I will also offer patient coaching regarding decreasing sodium intake, increasing activity tolerance, and detecting symptoms of decompensation to support and intensify self-care activities that will be helpful in preventing readmission.
Evaluation
The nursing interventions used resulted in an overall success in meeting the goal of decreased fluid accumulation. Within the first 24 hours, the patient’s weight reduced, and the attending physician recorded an output of about 1.8 L of urine. He also experienced relatively scanty cough, dyspnea, and edema compared to prior readings. After three days’ discharge from the facility, his weight returned to the usual and there were no evident abnormal lung sounds upon auscultation. Sodium levels were constantly stable during his stay. No more IV diuretics were considered before his transferal home with daily dose of oral medicine. The positive outcomes attested holistic nursing services being truly worthwhile endeavors in this specific kind of cases.
Recommendation
In order to sustain recovery as well as limit the potential need for rehospitalization, the patient is required to be regularly adherent to medication regimen and low-sodium diet at home. Encourage him to see his doctor or go to the emergency room for further care as soon as he shows any signs of the symptoms getting worse. The nurse may emphasize the significance of weighing patients daily, drinking no more than 2000ml of fluid per diurnal course, and as tolerated, exercise (Naik et al., 2021). Referring the patient to Cardiac rehabilitation and heart failure education classes may also be helpful in maintaining patient self-care and this will underline the long-term management of his Chronic Congestive heart failure.
References
Johansson, I., Joseph, P., Balasubramanian, K., McMurray, J. J., Lund, L. H., Ezekowitz, J. A., … & G-CHF Investigators. (2021). Health-related quality of life and mortality in heart failure: the global congestive heart failure study of 23 000 patients from 40 countries. Circulation, 143(22), 2129-2142.
Naik, M. S., Pancholi, T. K., & Achary, R. (2021). Prediction of congestive heart failure (chf) ecg data using machine learning. In Intelligent Data Communication Technologies and Internet of Things: Proceedings of ICICI 2020 (pp. 325-333). Springer Singapore.
Ouwerkerk, W., Tromp, J., Cleland, J. G., Angermann, C. E., Dahlstrom, U., Ertl, G., … & Lam, C. S. (2023). Association of time‐to‐intravenous furosemide with mortality in acute heart failure: data from REPORT‐HF. European Journal of Heart Failure, 25(1), 43-51.
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