# data[].attributes.body
Admitting diagnosis: CHF and Severe Aortic Stenosis

Date admitted: Jan 27, 2025

Allergies: NKDA

Code Status: R1

Past medical Hx: CHF, Severe aortic stenosis, Hypertension, Type I diabetes, Cardiomyopathy, Peripheral vascular disease, Hypothyroidism, Bicuspid Aortic Valve, Mild Pulmonary Hypertension, End-Stage Renal Disease

# data[].attributes.body
Decreased cardiac output r/t severe aortic stenosis and CHF exacerbation

Cues: SOB, orthopnea, LVEF 20-25%, pitting edema, CAD, severe AS, hypertension, urea: 9.1 (high) creatinine 94 (high)

Interventions:

1. Monitor VS (BP, HR, RR , SPO2) q4h: To detect early signs of worsening CHF. Decreased cardiac output can cause hypotension, tachycardia, and hypoxia

2. Administer Lasix as prescribed: Reduces fluid overload and pulmonary congestion, improving cardiac output and decreasing symptoms like SOB and edema

3. Monitor daily weights and intake/output: Sudden weight gain could indicate fluid retention and worsening HF. Tracking ins and outs will help me assess her fluid balance.

4. Educate patient on fluid and sodium restrictions: Excessive sodium and fluid intake can lead her to retain more fluid, which will increase cardiac workload and exacerbate her CHF

5. Maintain oxygen >90% as per chart: this is to ensure adequate oxygenation to compensate for decreased perfusing and prevent hypoxia

6. Monitor ECG for dysrhythmias: CHF and electrolyte imbalances could increase her risk for arrhythmias, further reducing cardiac output.

# data[].attributes.body
Impaired gas exchange r/t fluid overload and pulmonary hypertension

Cues: SOB, orthopnea, SpO2 92%, worsening CHF symptoms, crackles, pitting edema

Interventions:

1. Monitor respiratory status (RR, WOB, lungs sounds, ABGs - if she gets them tested): This will help me to detect any signs of respiratory distress, pulmonary edema, or worsening gas exchange impairment

2. Administer supplemental oxygen if SpO2 drops below 90%: This is to improve oxygenation and to reduce dyspnea associated with fluid retention and pulmonary hypertension

3. Encourage patient to sit in semi-fowlers position: this will help her lungs expand and decrease pulmonary congestion

4. Assess for signs of pulmonary edema (crackles, pink frothy sputum): This will help avoid further CHF complications and also assess if her current treatment is working (Lasix)

5. Coordinate with nephrology for dialysis management: Dialysis removes excess fluid, reducing pulmonary congestion and improving respiratory function. Patient gets this done in hospital

6. Encourage pursed-lip breathing and activity pacing: To help reduce dyspnea by preventing airway collapse and optimize gas exchange. She may need some education as to why this is important/helpful

# data[].attributes.body
Fluid volume Excess r/t end-stage renal disease and CHF

Cues: Pitting edema, weight gain, elevated urea (18.2), creatinine (335) low eGFR (11), hemodialysis

Interventions:

1. Monitor intake and output: This is to help assess fluid retention and guide fluid restriction management.

2. Monitor blood pressure closely: fluid overload can elevate blood pressure, and dialysis can lower blood pressure.

3. Ensure pt gets hemodialysis: this will help remove excess fluids and toxins

4. Assess for electrolyte imbalances: electrolytes imbalances can be common in CHF and CKD

5. Educate patient on how she can prevent further fluid overload: ensuring she understands why low sodium and fluid restriction is important will ensure she takes preventative measures when she is discharged home. She has been back and fourth a lot from the hospital so I think this educational piece is really important.

6. Take daily weights and the same time each morning before breakfast: early detection of fluid overload can allow us to intervene and prevent further decompensation

# data[].attributes.body
Ineffective tissue perfusion r/t CAD and severe aortic stenosis

Cues: LVEF 20-25%, awaiting TAVI, hypertension, 50-85% stenosis

Interventions:

1. Monitor for signs of myocardial ischemia (chest pain, ECG changes, troponin) CAD and aortic stenosis increase risk of MI

2. Administer antihypertensive (Metoprolol) as prescribed: Beta blocker will reduce cardiac workload and prevent excessive afterload in CHF

3. Encourage activity pacing: This it to prevent exertion-induced angina and reduce cardiac strain

4. Prepare for potential TAVI procedure: aortic stenosis significantly impacts cardiac output, and TAVI may improve long-term perfusion

5. Monitor hemoglobin levels for anemia: currently her hgb is 91. Low hgb can contribute to decreased oxygen delivery and increased cardiac workload

6. Assess for Metoprolol side effects (especially bradycardia): to make sure beta blocker is optmizing perfusion without causing this adverse effect

# data[].attributes.body
Acute pain r/t CHF exacerbation

Cues: midline burning chest pain upon admission, CAD with stenosis, awaiting TAVI

Interventions:

1. Assess pain using PQRSTUV: This will help me determine cardiac-related pain that requires intervention. I will notify primary RN ASAP if pt complains of CP

2. Administer analgesics as prescribed (acetaminophen): to provide symptom relief without affecting cardiac function

3. Monitor for signs of worsening ischemia (chest pain, ECG changes, troponin): Ensures early detection of myocardial infarction

4. Educate the pt on pain management techniques such as deep breathing: breathing effectively could help the pt get oxygen to heart, which would decrease CP

5. Educate pt about importance of resting between activites: This will reduce oxygen demand and minimize ischemic pain. I want to make sure she understands this before discharged home to avoid coming back to hospital.

6. Ask patient to make a note of what she is doing at the time of chest pain: if we can identify some triggers together we can figure out what is causing the chest pain

# data[].attributes.body
Unstable blood glucose r/t type I diabetes

cues: insulin dependent, fluctuating glucose (13.13 and 8.0 Jan 30) CKD can alter the reabsorbing of insulin which might be contributing to her glucose impairment

Interventions:

1. Monitor blood glucose every 4 hours: End stage renal disease alters insulin clearance, increasing risk for fluctuations

2. Administer basal (Tresiba) and correctional insulin (Apidra) as prescribed: to maintain glucose control while preventing excessive drops in glucose

3. implement hypoglycemia protocol if needed (glucose tabs, juice, dextrose): prevents complications like seizures, coma

4. Educate pt on recognizing hypo or hyperglycemia symptoms: If she is aware of the early signs, she can help prevent complications related to impaired glucose levels

5. Monitor renal function: End stage renal disease affects insulin metabolism and glucose homeostasis

6. Adjust correction insulin based on BGM readings: to prevent flucuations

# data[].attributes.body
CHF is a chronic progressive condition where the heart struggles to pump effectively. In this patient, the weakened heart function has led to fluid overload, resulting in her symptoms of SOB, orthopnea, lower extremity edema, and fatigue. The patient also reports paroxysmal nocturnal dyspnea (waking up breathless at night) which is a common sign of HF. Her echocardiogram revealed reduced ejection fraction of 20-25%., indicating systolic dysfunction where the heart is unable to pump blood out effectively.

Due to the fluid retention, the patient has experienced weight gain and significant lower extremity swelling. The lungs have crackles bilaterally, suggesting pulmonary edena which could explain the persistent dyspnea and hypoxia.

Additionally, the patient's chronic kidney disease further complicated fluid management, as the kidneys are struggling to excrete excess sodium and water. Her history of diabetes and hypertension also contributes to left ventricular remodelling and worsening heart failure.

# data[].attributes.body
Medications:

Metoprolol, ASA, Calcium carbonate, Furosemide, Heparin, Apidra (correction), Tresiba (basal), Epoetin alfa, renal vitamin tablet, Levothyrozine, Acetaminophen, Laxaday

# data[].attributes.body
References:

Gologorsky, Rebecca C, and Shuvo Roy. “Ultrafiltration for Management of Fluid Overload in Patients with Heart Failure.” Artificial organs 44.2 (2020): 129–139. Web.

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2021). Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. Elsevier.

Miller, Wayne L. “Fluid Volume Overload and Congestion in Heart Failure: Time to Reconsider Pathophysiology and How Volume Is Assessed.” Circulation. Heart failure 9.8 (2016): e002922–e002922. Web.

Pellicori, Pierpaolo et al. “Chronic Kidney Disease (CKD) and CKD‐ism in Heart Failure – What a Mess.” European journal of heart failure 24.11 (2022): 2196–2198. Web.

# data[].attributes.body
Relevant labs:

Creatinine 335 -> end-stage renal disease. Dialysis required for waste removal

eGFR 11 -> End stage renal disease

Urea: 18.2 -> kidney failure and inability to excrete waste

Sodium: 132 -> low likely due to fluid overload diluting blood

Potassium: 4.8 -> WNL

Chloride: 92 -> low

RBC: 3.12 -> anemia related symptoms can be common in ESRD due to decreased erythropoietin

Hematocrit: 0.285 -> low (anemia? not mentioned in chart)

These labs confirm worsening CHF and severe renal impairment