0700: The client is a 72-year-old male who presents to the emergency department with increasing shortness of breath over the past two days that gets worse when he is lying flat in bed at night. He states, “I feel like I can’t catch my breath,” and he had to sleep in a recliner. He reports a 4 lb weight gain over the last week and increasing fatigue. The client is alert and oriented but is using his accessory muscles to breathe. He reports feeling short of breath, orthopnea, and paroxysmal nocturnal dyspnea. He has bilateral pedal edema (+2), bilateral crackles heard upon auscultation, and jugular vein distension noted on his assessment. The client has a medical history of hypertension, coronary artery disease, and a prior myocardial infarction. He was diagnosed with heart failure with reduced ejection fraction (HFrEF) two years ago. Current home medications include lisinopril, metoprolol succinate, furosemide, and atorvastatin.

0730: Blood samples collected for laboratory tests. Client transported to radiology for imaging as ordered.

0715

• Complete Blood Count (CBC)
• Basic Metabolic Panel (BMP)
• Brain Natiuretic Peptide (BNP)
• Chest X Ray
• Echocardiogram



0800

Chest X-Ray

Indication: Shortness of breath, history of heart failure

Findings:

• Cardiomegaly is present.
• Pulmonary vascular congestion noted with prominence of the upper lobe vasculature.
• Bilateral perihilar interstitial infiltrates consistent with pulmonary edema.
• Mild bilateral pleural effusions are noted.
• No evidence of focal consolidation or pneumothorax.

Impression:

Findings consistent with congestive heart failure with evidence of pulmonary edema and cardiomegaly.

Echocardiogram

Indication: Worsening dyspnea and edema

Findings:

• Left ventricular ejection fraction estimated at 35%.
• Global hypokinesis of the left ventricle.
• Mild left atrial enlargement.
• Trace mitral regurgitation noted.
• Right ventricular size and function are within normal limits.
• No pericardial effusion observed.

Impression:

Left ventricular systolic dysfunction with reduced ejection fraction (HFrEF); findings consistent with worsening heart failure.

0900: The client is a 72-year-old male with a known history of heart failure with reduced ejection fraction (HFrEF), hypertension, and prior myocardial infarction. He presents with increasing dyspnea, orthopnea, paroxysmal nocturnal dyspnea, weight gain, bilateral lower extremity edema, and evidence of pulmonary congestion on exam. Physical assessment reveals bilateral crackles, jugular vein distension, and accessory muscle use with respiration. Chest X-ray shows cardiomegaly and pulmonary vascular congestion, and echocardiogram confirms reduced ejection fraction. Based on clinical presentation and diagnostic findings, the client is experiencing an acute exacerbation of heart failure.

1000

• Administer spirolactone 25 mg PO daily
• Administer metoprolol succinate 25 mg PO daily
• Strict intake and ouput
• Daily weights
• Nutritional services consultation
• Schedule a follow-up with cardiology within 7 days