Case Presentation Daisy Sanchez

case presentation

Daisy SanchezAcute Diastolic Congsestive Heart failure

Index

• Patient teaching

• Patient intrdoction

• Pathophysiology

• Risk preventions

• Timeline

• Reflection

• Manifestations

• Risk factors

• Diagnostic data

• Treatment

• Discharge plan

• NANDA

• Nursing Managment

Patient indroduction

34-year-old male admitted 10/2/25Reasaon for admission: right-sided chest pain (8/10) describes wtih tightness and pressure, SOB with exertion Admmitted with acute diastolic HF History: mitral valve disease, obesity, valve replacement, seizures. Past surgical history of Stenosis of prosthetic mitral valve with regurgitation, Heart valve replacement with bioprosthetic valve Code Status: Full Code Diet: Fluid restriction (1500 mL/day), low sodium

The Failing Relaxation: What’s Happening in Diastolic CHF

• Decreased Ventricular relaxation caused decreased filling which increases pressure in LA and pulmonary veins
• Inadequate relaxation prevents the ventricle from filling up with an adequate amount of blood, which does not ensure proper cardiac output. The ventricle gradually loses compliance, because it requires more force to pump the same volume as a healthy heart. This leads to increased pressure in the left atrium and pulmonary veins, leading to fluid buildup
• In this case the patients history with valve disorders lead to stiffening of the left ventricle
• Secondary disease process was acute bacterial endocarditis, it is a serious infection of the endocardium which is the inner lining of the heart that was infected by another previous/current infection. Additionally, the risk for vegetation can occur on the valves from the pathogens bypassing the body defenses leading to valvular damage, embolic events, and systemic complications

(Ignatavicius et al., 2021)

Timeline

Acute diastoic CHF

Mitral Valve disease

The patient received a surgery for a heart valve replacement with bioprosthetic valve

Current diagnosis

Reguriation of valve

Strep throat

Patient contracts strep throat at age 13, and developed endocarditis

Stenosis of prosthetic mitral valve with regurgitation occured and pt had srugery to fix it

Symptoms & Clinical Picture

Blood backs up into the left atrium and pulmonary veins, leading to increased fluid in the pulmonary space

Fluid accumalting in the air sacs causing shortness of breath

Chest pain: tight, pressureSOB for 2 months, which got worse recently Relieved by rest and semi-Fowler’s position Vital signs were stable, peripheral edema and crackles in lower lobes of the lungs billaterally were present Presented with anxiousness

shortness of breath, paroxysmal nocturnal dyspnea, persistent cough, fatigue, weakness, chest pain or tightness, dizziness, confusion, crackles or rales in the lungs, peripheral edema, weight gain from fluid retention, cool extremities, and (oliguria).

Risk factors

Coronary heart disease, Uncontrolled blood pressure,Diabetes with vascular disease, Left ventricular hypertrophy, Asymptomatic left ventricular dysfunction, Hypertension, smoking, age, family history, genetic disposition, African Americans are more susceptible.

Endocarditis patient had acute bacterial endocarditis 21 years ago, leading to further heart complications, Mitral valve reguritation and valve replacment Cholesterol Patient is at risk for cholesterol due to obesityHispanic makes him more susceptible

Diagnostic data

N-terminal CNT- prohormone BNP: 4,780 pg/mL — indicates severe heart strain.Troponin I: 1.00 ng/mL — to rule out MI (negative). Chest X-ray: Fluid in bilateral lower lobes and size of heart. Echocardiogram: To evaluate ventricular function, valve performance, and size of heart. Electrolytes, BUN, Creatinine: Monitored due to diuretic use CT Echocardiography Extensive stress test Ultrasound: An ultrasound was done on the patients BLE to check for clotting

Treatment

Treatment Lasix (Furosemide 20 mg IV push): Reduces fluid overload, improves breathing, lowers cardiac pressure.Lovenox (0.4 mL SubQ daily): Prevents thrombus formation during limited mobility. Fluid Restriction (1500 mL/day) and Low-Sodium Diet: Minimize preload and prevent retention. Ambulation with PT & Incentive Spirometer: Enhance lung expansion and tolerance. Left ventricular devises

There were no planned surgeries but the doctors wanted to do a angiogram which was not completed

discharge plan

Patient undersatnding

Patient and family demonstrate understanding of medication regimen, diet, and warning signs of heart failure.

Maintence

Oxygen saturation > 95% without supplemental oxygen.Patient maintains stable vital signs (BP and HR within normal limits). Breath sounds are clear with no crackles or signs of respiratory distress.

Monitor

Peripheral edema is reduced and weight remains stable. Extremties arent cool to the touch.

Decreased cardiac output r/t acute diastolic congestive heart failure AEB chest pain and shortness of breath upon exertion

Nursing diagnosis

Nursing management

• Monitor vital signs (BP, HR, RR, SaO₂) every 2–4 hours and report any abnormal trends.
• Assess for signs of decreased cardiac output, such as cool extremities, weak pulses, or changes in mental status.
• Administer Lasix (furosemide) as prescribed to promote fluid removal and reduce cardiac workload.
• Assess for electrolyte imbalances caused by diuretic use.
• Report weight gain >2–3 lbs/day or >5 lbs/week.
• Assess lung sounds every shift and as needed for crackles, wheezing, or diminished breath sounds.
• Encourage the use of an incentive spirometer 10 times per hour while awake to improve alveolar expansion and oxygenation.
• Administer supplemental oxygen as ordered to maintain oxygen saturation >95%.
• Implement a fluid restriction of 1500 mL/day as ordered, and educate the patient on how to measure intake.
• Assess the patient's urine output to document
• Assess for anxiety, depression, or emotional distress related to chronic illness.

Patient teaching

Educate on daily weight monitoring at home

Teach proper precautions such as limiting strenuous activity, elevate legs or avoid extreme temperatures that can cause stress on the heart.

Make sure the patient understands prevention strategies such as following a low sodium diet, taking medications as prescribed, avoiding smoking and limiting alcohol, and getting vaccinations to prevent infections.

Teach them about signs of heart failure, such as SOB with activity or when lying down, swelling edema in the feet, ankles, legs, or abdomen, fatigue, rapid or irregular heartbeat, persistent cough or wheezing with pink frothy sputum, decreased ability to perform daily activities.

Risk Preventions

Fall risk: Ensure patient has sticky socks, proper ambulatory devices, and assistance with ambulation Clot risk: Due to the patient being on bed rest and with increased pressure there is risk for clots, which is being treated with a blood thinner Hypovolemia risk: Due to the patient being on lasix there is a risk for too much fluid being excreted monitoring BUN can help indicate dehydration Seizure risk: Provide padding on the inside of the bed and monitor every 2 hours

REflection

I learned how crucial early detection and routine evaluation are in avoiding complications from caring for this patient with acute diastolic congestive heart failure. I discovered how to link symptoms like crackles, edema, and elevated BNP levels to appropriate nursing interventions like fluid restriction, oxygen therapy, and diuretics. Educating the patient and their family on symptom recognition, sodium restriction, and daily weight monitoring boosted their self esteem and facilitated a safer discharge and improved long term self care.