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Acute Heart Failure with A-fib (RVR)

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↓ Cardiac output → fluid overload → pulmonary edema → hypoxia (NHLBI, 2022; AHA, 2024)

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↓ Cardiac output → fluid overload → pulmonary edema → hypoxia (NHLBI, 2022; AHA, 2024)

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Chronic inflammation → ↓ gas exchange → ↑ infection risk (CDC, 2023)

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Chronic inflammation → ↓ gas exchange → ↑ infection risk (CDC, 2023)

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Insulin resistance → hyperglycemia → delayed wound healing, infection risk (ADA, 2023)

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Insulin resistance → hyperglycemia → delayed wound healing, infection risk (ADA, 2023)

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Venous stasis → clot formation → ↑ embolism risk (CDC, 2023)

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Venous stasis → clot formation → ↑ embolism risk (CDC, 2023)

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 Atherosclerosis → ↓ perfusion → non-STEMI (AHA, 2024)

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 Atherosclerosis → ↓ perfusion → non-STEMI (AHA, 2024)

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↑ LDL → plaque buildup → worsens CAD (Lexicomp, 2025)

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↑ LDL → plaque buildup → worsens CAD (Lexicomp, 2025)

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↑ vascular resistance → worsens heart failure (NHLBI, 2022)

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↑ vascular resistance → worsens heart failure (NHLBI, 2022)

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24–36 hrs pre-discharge

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 Ongoing respiratory care: trach collar care, O₂ support, position upright

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 Ongoing respiratory care: trach collar care, O₂ support, position upright

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Cardiac monitoring: NSR maintained → monitor for arrhythmias

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Cardiac monitoring: NSR maintained → monitor for arrhythmias

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Physical therapy: mobility support before discharge to rehab

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Physical therapy: mobility support before discharge to rehab

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Blood glucose checks, Lantus + sliding scale insulin

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Blood glucose checks, Lantus + sliding scale insulin

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Heparin transitioned to Warfarin: monitor bleeding and INR

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Heparin transitioned to Warfarin: monitor bleeding and INR

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Tube feedings at goal, ensure tolerability and aspiration precautions

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Tube feedings at goal, ensure tolerability and aspiration precautions

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Furosemide – Purpose: Diuretic. Teaching: Monitor K⁺, daily weights, avoid late doses

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Furosemide – Purpose: Diuretic. Teaching: Monitor K⁺, daily weights, avoid late doses

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Amiodarone – Purpose: A-fib rhythm control. Teaching: Monitor lungs, thyroid, liver

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Amiodarone – Purpose: A-fib rhythm control. Teaching: Monitor lungs, thyroid, liver

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Warfarin – Purpose: Anticoagulant. Teaching: Bleeding risk, INR checks, vitamin K diet

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Warfarin – Purpose: Anticoagulant. Teaching: Bleeding risk, INR checks, vitamin K diet

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Metformin/Sitagliptin -Purpose: Glucose control.                           Teaching: Take with food, avoid hypoglycemia

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Metformin/Sitagliptin -Purpose: Glucose control.                           Teaching: Take with food, avoid hypoglycemia

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Empagliflozin – Purpose: Glucose control. Teaching: Stay hydrated, report UTI symptoms

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Empagliflozin – Purpose: Glucose control. Teaching: Stay hydrated, report UTI symptoms

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Atorvastatin – Purpose: Lower cholesterol. Teaching: Take at night, report muscle pain

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Atorvastatin – Purpose: Lower cholesterol. Teaching: Take at night, report muscle pain

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Valsartan – Purpose: HF and BP control. Teaching: Monitor BP and potassium

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Valsartan – Purpose: HF and BP control. Teaching: Monitor BP and potassium

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Heart failure: Daily weights, low-sodium diet, fluid restriction

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Heart failure: Daily weights, low-sodium diet, fluid restriction

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Diabetes: Home glucose monitoring, insulin admin, signs of hypo/hyperglycemia

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Diabetes: Home glucose monitoring, insulin admin, signs of hypo/hyperglycemia

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DVT/Warfarin: Bleeding precautions, INR testing, notify provider for leg swelling or SOB

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DVT/Warfarin: Bleeding precautions, INR testing, notify provider for leg swelling or SOB

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COPD: Smoking cessation, inhaler technique (Advair), infection signs

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COPD: Smoking cessation, inhaler technique (Advair), infection signs

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Med Adherence: Use pill boxes, family support, schedule follow-ups

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Med Adherence: Use pill boxes, family support, schedule follow-ups

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Jessie lives on fixed Social Security income

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Jessie lives on fixed Social Security income

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Case management for financial assistance: Medicare/Medicaid Part D, manufacturer discounts

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Case management for financial assistance: Medicare/Medicaid Part D, manufacturer discounts

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Help with appointment scheduling before discharge

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Help with appointment scheduling before discharge

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Provide info on low-income transportation programs (paratransit, Uber Health)

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Provide info on low-income transportation programs (paratransit, Uber Health)

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Smoking cessation support: NRT + Quitline

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Smoking cessation support: NRT + Quitline

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Involve family in discharge planning with culturally appropriate materials

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Involve family in discharge planning with culturally appropriate materials

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CXR: RUL infiltrate (pneumonia)

15% pneumothorax (Day 3): Iatrogenic or from alveolar rupture in COPD

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WBC 19.8K: Active infection (pneumonia), consistent with CXR

Cr 1.7 / BUN 48: Possible prerenal AKI from hypoperfusion/dehydration

Troponin 2.4 ng/mL: Indicates myocardial strain, possibly demand ischemia

BNP 242 pg/mL: Confirms fluid overload and pressure elevation → HF diagnosis

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pH 7.31, PaCO₂ 52, HCO₃ 19 → Respiratory acidosis with metabolic compensation

Reflects COPD retention of CO₂, worsened by fatigue and poor oxygenation

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RR 38, O2 Sat 76%, PaO₂ 64 mmHg: Hypoxia and increased work of breathing → matches respiratory failure from HF + pneumonia

HR 126, irregular: A-fib with RVR → ↓ preload and CO → worsens systemic perfusion

BP 102/50, MAP 67: Marginal perfusion pressure → puts kidneys and brain at risk

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-Dyspnea (shortness of breath) Stated as: "She was dyspneic" → Even though written in third person, dyspnea is a symptom only the patient can describe → Acceptable as subjective

-Coughing up thick pink mucus Stated in case intro → "Coughing up thick pink mucus" → Commonly reported by patient but also visible → borderline subjective/objective

-Leg pain Day 7: "Jessie complained of right leg pain" → This is a clear subjective statement (patient complaint)

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RR 38, HR 126 irregular, BP 102/50, O₂ Sat 76% Day 1 vitals

Crackles in posterior lungs Lung auscultation findings

CXR: RUL infiltrate, later 15% pneumothorax Imaging

ABG: pH 7.31, PaCO₂ 52, PaO₂ 64 Day 1

WBC 19.8, Troponin 2.4, BNP 242, Glucose 235, Cr 1.7, BUN 48 Lab values

Swollen right leg Day 7 physical exam

Doppler confirms DVT Day 7 diagnostic

Thick pink sputum Observable (could be subjective if reported, but it’s visible here)

Trach collar at 28% FiO₂ Objective respiratory intervention

Tube feeding at goal rate Documented nutrition status

Bed-bound, weak Functional status observation

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CAD: Past non-STEMI + poor coronary perfusion = ↑ myocardial workload

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CAD: Past non-STEMI + poor coronary perfusion = ↑ myocardial workload

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HTN: Contributes to HF by increasing systemic vascular resistance

DVT: Venous stasis from low perfusion and immobility

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Heart failure: Pulmonary congestion worsens hypoxia

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Heart failure: Pulmonary congestion worsens hypoxia

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DM2: Poor glycemic control = ↓ immune response → ↑ pneumonia risk

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DVT: DM is a risk factor for vascular inflammation and clotting

Kidney function: Hyperglycemia can worsen nephropathy (↑ BUN/Cr)

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LDL 196 mg/dL → forms plaques → atherosclerosis

Atherosclerosis → ↓ coronary perfusion → CAD

CAD + A-fib → ↑ risk of demand ischemia and heart failure

Exacerbated during decompensation with hypoxia and arrhythmia

Also onnected to:

HF: CAD worsens heart function

HTN: Works synergistically to increase cardiac stress

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HF (low output), immobility, DM, and A-fib all contribute to clot risk

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HF (low output), immobility, DM, and A-fib all contribute to clot risk