NGN case study
Heart failure exacerbation after missed diuretic doses
A 66-year-old client with heart failure (ejection fraction 30%) comes to the emergency department reporting increasing shortness of breath and swelling in both legs over 5 days.
Client record
Nurse's Notes
0900: The client says they now sleep on three pillows and wake up at night gasping for breath. They ran out of furosemide 1 week ago and "ate a lot of salty food at a family reunion." Weight 84.4 kg (186 lb); clinic weight 2 weeks ago was 81.2 kg (179 lb). Crackles in both lung bases. 3+ pitting edema in both lower legs. Jugular venous distention at 45 degrees. The client speaks in short sentences.
Vital Signs
| Time | Temp | HR | RR | BP | SpO2 |
|---|---|---|---|---|---|
| 0900 | 36.8°C (98.2°F) | 108/min | 26/min | 162/94 mm Hg | 90% on room air |
Laboratory Results
| Test | Result | Reference range |
|---|---|---|
| BNP | 1,240 pg/mL | Less than 100 pg/mL |
| Potassium | 3.6 mEq/L | 3.5–5.0 mEq/L |
| Sodium | 133 mEq/L | 135–145 mEq/L |
| Creatinine | 1.3 mg/dL | 0.6–1.2 mg/dL |
| Troponin I | Less than 0.04 ng/mL | Less than 0.04 ng/mL |
Orders
- Furosemide 40 mg IV push now
- Oxygen by nasal cannula to keep SpO2 at 92% or higher
- Daily weight; strict intake and output
- 2 g sodium diet; fluid restriction 1.5 L/day
- Basic metabolic panel in the morning
- Chest x-ray
Questions
Question 1 of 6
Recognize cues. Which findings indicate fluid volume excess? Select all that apply.
Answer and rationale
- A. Weight gain of 3.2 kg (7 lb) in 2 weeks
- B. Crackles in both lung bases
- C. Jugular venous distention
- D. 3+ pitting edema in both lower legs
A gain of about 1 kg equals about 1 L of retained fluid. Crackles (pulmonary congestion), JVD and peripheral edema are classic signs of volume overload in heart failure.
Question 2 of 6
Analyze cues. Complete the sentence.
Choose the option that best completes each blank.
The client's symptoms are most likely caused by , leading to .
Answer and rationale
The client's symptoms are most likely caused by missed diuretic doses and high sodium intake, leading to fluid overload with pulmonary congestion.
Non-adherence to medications and diet is one of the most common causes of heart failure exacerbation, and it's a key teaching target.
Question 3 of 6
Prioritize hypotheses. Which complication is the client at greatest risk for right now?
Answer and rationale
A. Acute pulmonary edema
Orthopnea, paroxysmal nocturnal dyspnea, bilateral crackles, SpO2 90% and short-sentence speech suggest worsening pulmonary congestion that can progress to pulmonary edema.
Question 4 of 6
Generate solutions. For each intervention, indicate whether it is indicated or contraindicated for this client.
Choose for each row.
| Item | Indicated | Contraindicated |
|---|---|---|
| Position the client in high Fowler's | ||
| Give furosemide 40 mg IV as prescribed | ||
| Encourage 3 L of oral fluids daily | ||
| Weigh daily at the same time on the same scale | ||
| Give a 1 L bolus of 0.9% sodium chloride | ||
| Teach about reading food labels for sodium |
Answer and rationale
- Position the client in high Fowler's: Indicated
- Give furosemide 40 mg IV as prescribed: Indicated
- Encourage 3 L of oral fluids daily: Contraindicated
- Weigh daily at the same time on the same scale: Indicated
- Give a 1 L bolus of 0.9% sodium chloride: Contraindicated
- Teach about reading food labels for sodium: Indicated
Treatment aims to reduce preload: diuresis, positioning, sodium and fluid restriction, and close monitoring.
Question 5 of 6
Take action. Complete the bowtie: the condition the client is most likely experiencing, 2 actions to take, and 2 parameters to monitor.
Complete the diagram: 1 condition, the actions to take, and the parameters to monitor.
Actions to take
Condition
Parameters to monitor
Answer and rationale
- Condition: Acute decompensated heart failure
- Actions to take: Give IV furosemide as prescribed, Place the client in high Fowler's position
- Parameters to monitor: Daily weight, Breath sounds and SpO2
Decongestion (diuretic, positioning, oxygen) is the immediate action. Daily weight and respiratory status show whether it's working. Serum potassium also matters after diuresis; it's checked with the morning metabolic panel.
Question 6 of 6
Evaluate outcomes. The next morning, which findings indicate treatment has been effective? Select all that apply.
Answer and rationale
- A. Weight 82.6 kg (182 lb)
- B. Crackles only at the right base and diminished
- C. SpO2 95% on 2 L/min
- D. Urine output 2,800 mL over 24 hours
A 1.8 kg drop in weight, less congestion, better oxygenation and brisk diuresis show improvement. Low potassium and orthostatic dizziness are complications to address, not signs of success.