Cardiac Nurse Heart Failure Template

Cardiac Nurse Heart Failure Template: Reason for Visit: Patient, a 72-year-old female, presents with progressively worsening shortness of breath and lower extremity swelling over the past two weeks. Symptoms began insidiously and have significantly impacted her ability to perform daily activities. History of Presenting Illness: Two weeks ago, Mrs. Smith noted increased fatigue and mild swelling in her ankles. Over the past week, her shortness of breath has intensified, particularly with exertion (walking short distances, climbing one flight of stairs) and at night, requiring her to sleep on three pillows (orthopnoea). She also reports occasional paroxysmal nocturnal dyspnoea, waking her from sleep gasping for air. The oedema has progressed to her knees and is non-pitting. She denies any recent chest pain, palpitations, or syncope. Her appetite has decreased, and she feels generally weaker. **Symptoms reviewed:** - Shortness of Breath (SOB): Significant dyspnoea on exertion (NYHA Class III), orthopnoea (3 pillows), and occasional PND. Exertional limitations prevent her from walking more than 50 metres without significant breathlessness. - Oedema: Non-pitting oedema extending to both knees, worse at the end of the day. - Fatigue: Profound fatigue impacting all daily activities, requiring frequent rest breaks. - Dizziness: Occasional mild lightheadedness upon standing, but denies any syncope or blackouts. - Chest Pain/Discomfort: Denies current chest pain or discomfort. - Palpitations: Denies palpitations or heart rhythm irregularities. - Weight Changes: Reports a 3 kg weight gain over the last two weeks, consistent with fluid retention. - Other: Decreased appetite and general malaise. Past Medical History: Congestive Heart Failure (diagnosed 5 years ago), Hypertension, Type 2 Diabetes Mellitus, Chronic Kidney Disease (Stage 3), Atrial Fibrillation (managed with anticoagulation). **Cardiac History:** - Heart Failure Aetiology: Ischaemic cardiomyopathy secondary to previous myocardial infarctions. - Ejection Fraction: 30% (documented on 1 May 2024 via echocardiogram). - Hospitalisations for Heart Failure: Admitted twice in the last year for acute decompensated heart failure (latest admission 1 March 2024, due to medication non-adherence and dietary indiscretion). - Interventions: Percutaneous Coronary Intervention (PCI) to LAD 7 years ago (successful stent placement). No valve surgery or device implantation. Medications: Bisoprolol 5mg OD, Ramipril 5mg OD, Furosemide 40mg OD, Spironolactone 25mg OD, Metformin 500mg BD, Warfarin 3mg OD, Atorvastatin 20mg OD. **Medication Reconciliation:** - Bisoprolol 5mg PO daily, for heart rate control and heart failure management. - Ramipril 5mg PO daily, for blood pressure control and heart failure management. - Furosemide 40mg PO daily, for fluid management. - Spironolactone 25mg PO daily, for heart failure management and potassium sparing. - Metformin 500mg PO twice daily, for type 2 diabetes. - Warfarin 3mg PO daily, for atrial fibrillation and stroke prevention (INR last checked at 2.5). - Atorvastatin 20mg PO daily, for hyperlipidaemia. - New Medications: None. - Discontinued Medications: None. **Allergies:** Penicillin (rash). Social History: Lives alone in a second-floor flat. Has an informal support system from her daughter who visits weekly. Former smoker (quit 10 years ago). Occasional social alcohol use (1-2 units per week). Denies illicit drug use. Reports a high-sodium diet, often consuming processed foods. Limited physical activity due to symptoms. Family History: Father had a myocardial infarction at age 65. Mother had hypertension. No known genetic conditions. Review of Systems: Constitutional: General fatigue, decreased energy. Cardiovascular: Worsening dyspnoea, orthopnoea, PND, peripheral oedema (as above). Respiratory: No cough, no wheezing. Gastrointestinal: Decreased appetite, no nausea/vomiting, normal bowel habits. Genitourinary: No dysuria, frequency, or urgency. Musculoskeletal: No joint pain or swelling beyond oedema. Neurological: Occasional lightheadedness, no numbness, tingling, or weakness. Psychological: Reports feeling slightly anxious due to breathlessness, but no formal diagnosis of anxiety or depression. Physical Examination: **Vital Signs:** BP 108/68 mmHg, HR 88 bpm (irregularly irregular), RR 20 bpm, Temp 36.8°C, Weight 78 kg, O2 Sat 92% on room air. **General Appearance:** Appears fatigued and in mild respiratory distress. No obvious cachexia. Mild anasarca noted, particularly in the lower extremities. **Cardiovascular:** S1 and S2 present. S3 gallop audible at the apex. No murmurs or rubs. Jugular venous distension (JVD) to 8 cm at 45 degrees. Weak peripheral pulses bilaterally (dorsalis pedis and posterior tibial). Positive hepatojugular reflux. **Pulmonary:** Bilateral fine crackles heard halfway up the lung fields. No wheezes or rhonchi. Dullness to percussion at lung bases, consistent with pleural effusions. **Abdominal:** Soft, non-tender. Mild hepatomegaly noted, liver edge palpable 3 cm below the costal margin. No ascites or splenomegaly. **Extremities:** 2+ non-pitting oedema extending to both knees. Skin warm, no signs of cellulitis or poor perfusion. Investigations/Labs: NT-Pro BNP: 4500 pg/mL (elevated). Electrolytes: Na 134 mmol/L, K 4.2 mmol/L. Renal function: Creatinine 130 umol/L, eGFR 38 mL/min/1.73m^2. Liver function tests within normal limits. Thyroid function tests within normal limits. Complete blood count: mild anaemia (Hb 11.0 g/dL). ECG: Atrial fibrillation with controlled ventricular response. Echocardiogram (1 May 2024): LVEF 30%, mild mitral regurgitation, moderate tricuspid regurgitation. Assessment: 72-year-old female with chronic heart failure (ischaemic cardiomyopathy, LVEF 30%) presenting with acute decompensation, likely due to fluid overload and possibly dietary non-adherence. NYHA Functional Class III currently. Comorbidities include hypertension, Type 2 Diabetes, CKD Stage 3, and Atrial Fibrillation. Plan: Patient educated on current clinical status and treatment plan. Goals of care discussed, including symptom management and preventing re-hospitalisation. **Medication Management:** - Increase Furosemide to 80mg OD for diuresis to manage fluid overload. - Review Ramipril and Bisoprolol for potential up-titration once euvolaemic and stable, aiming for target doses as per guidelines, with caution due to CKD. **Fluid and Diet Management:** - Reinforce strict fluid restriction of 1.5 litres per day. - Advise on severe sodium restriction (<2g/day) and avoiding processed foods. - Encourage daily weight monitoring and reporting any significant changes (>2kg over 2 days). **Activity and Exercise:** - Encourage light activity as tolerated; avoid strenuous exertion until symptoms improve. - Discuss referral to a cardiac rehabilitation programme once stable. **Monitoring:** - Daily weights at home. - Monitor for worsening SOB, oedema, or dizziness. - Repeat electrolytes and renal function in 3 days post-Furosemide adjustment. **Patient Education:** - Discussed importance of medication adherence and fluid/sodium restrictions. - Reviewed warning signs of worsening heart failure (increased SOB, weight gain, swelling) and when to seek medical attention. - Provided written information on heart failure self-management. **Referrals:** - Refer to Dietitian for comprehensive dietary advice. - Consider referral to Heart Failure Specialist Nurse for ongoing support and education. **Follow-up:** - Follow-up with cardiac nurse in 1 November 2024 for medication review and symptom assessment. - Scheduled follow-up with Dr. Thomas Kelly (Cardiologist) in 3 weeks.