# A 55-year-old patient with chronic heart failure is admitted to the medical unit with acute exacerbation. The patient presents with severe dyspnea, bilateral lower extremity edema, and jugular venous distension. Vital signs: BP 160/95 mmHg, HR 110 bpm, RR 28/min, O2 sat 88% on room air. Laboratory results show BNP 2,400 pg/mL (normal

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## 문제

A 55-year-old patient with chronic heart failure is admitted to the medical unit with acute exacerbation. The patient presents with severe dyspnea, bilateral lower extremity edema, and jugular venous distension. Vital signs: BP 160/95 mmHg, HR 110 bpm, RR 28/min, O2 sat 88% on room air. Laboratory results show BNP 2,400 pg/mL (normal

## 보기

1. Monitor blood pressure and heart rate every 15 minutes.
2. Assess for signs of digitalis toxicity.
3. Evaluate peripheral pulse strength and capillary refill.
4. Auscultate lung sounds and assess respiratory effort. **✔ 정답**

**정답: 4**

## 해설

In acute heart failure exacerbation, respiratory assessment (auscultating lung sounds) is priority due to risk of pulmonary edema and respiratory failure, as indicated by severe dyspnea and low O2 sat. Other assessments (vital signs, digitalis toxicity, peripheral perfusion) are important but secondary to immediate respiratory status evaluation.

## 심화 해설

Correct Answer: 4. Auscultate lung sounds and assess respiratory effort.

The patient is presenting with an acute exacerbation of chronic heart failure (CHF), evidenced by severe dyspnea, bilateral lower extremity edema, jugular venous distension, hypertension, tachycardia, tachypnea, and critically low oxygen saturation (O2 sat 88% on room air). The markedly elevated BNP of 2,400 pg/mL provides strong biochemical confirmation of acutely decompensated heart failure. In this clinical scenario, the immediate nursing priority is to assess the patient's respiratory status to determine the severity of pulmonary congestion and guide urgent interventions.

Why Auscultation and Respiratory Assessment is the Priority

In acute decompensated heart failure, elevated left ventricular filling pressures cause a backward transmission of pressure into the pulmonary vasculature, leading to hydrostatic pulmonary edema. Fluid shifts from the pulmonary capillaries into the interstitial space and alveoli, impairing gas exchange. This is the direct pathophysiological mechanism behind the patient's severe dyspnea and hypoxemia. Auscultating lung sounds allows the nurse to immediately detect the presence and extent of this fluid. The expected findings would be crackles (rales) at the lung bases, which may progress upward as the condition worsens, and possibly wheezes (often termed "cardiac asthma"). Assessing respiratory effort—including the use of accessory muscles, respiratory rate, and depth—provides real-time data on the work of breathing and the patient's ability to compensate. This assessment directly informs the need for and titration of life-saving interventions such as supplemental oxygen, non-invasive positive pressure ventilation, or intravenous diuretics. The critical nature of pulmonary function assessment in cardiac patients is underscored by research focusing on interventions to improve it, such as the study by Akıncı and Eren, which investigated the effects of combined breathing exercises on postoperative pulmonary function after mitral valve replacement, highlighting that maintaining and assessing pulmonary integrity is a central concern in cardiac care .

Analysis of Other Options

1. Monitor blood pressure and heart rate every 15 minutes.

While continuous cardiovascular monitoring is essential in acute heart failure, this action is a component of ongoing assessment, not the single most critical priority upon initial presentation with severe respiratory distress. The patient's hypertension and tachycardia are compensatory sympathetic responses to decreased cardiac output and pulmonary congestion. The immediate threat to life is the hypoxemia from pulmonary edema, which must be assessed and managed first. Monitoring frequency is an intervention that follows the primary assessment.

2. Assess for signs of digitalis toxicity.

This is an important safety consideration for patients with chronic heart failure who may be on a digitalis preparation like digoxin. However, the question does not state the patient is taking digoxin. Furthermore, the acute presentation is classic for fluid volume overload and pulmonary edema, not a primary cardiac dysrhythmia or toxicity symptom. Assessing for toxicity (e.g., visual disturbances, nausea, bradycardia) is a secondary assessment that does not address the immediate, life-threatening respiratory compromise.

3. Evaluate peripheral pulse strength and capillary refill.

This assessment evaluates peripheral perfusion, which can be diminished in acute heart failure due to low cardiac output and vasoconstriction. The patient's elevated diastolic pressure and edema already suggest significant fluid overload. While a thorough cardiovascular assessment includes peripheral perfusion, it is a lower priority than evaluating the patient's airway and breathing. The patient's primary distress is dyspnea and hypoxemia, making the respiratory system the focal point of the initial assessment. The development of a specialized nursing program for cardiac catheterization patients, as outlined by Shan et al., emphasizes structured, comprehensive assessment protocols, but in an acute decompensation, the ABCs (Airway, Breathing, Circulation) framework dictates that breathing assessment takes precedence .

## 임상 시나리오

Acute Decompensated Heart Failure: Initial AssessmentPrioritizing Respiratory Status in Pulmonary Edema
In acute exacerbation, elevated left ventricular filling pressure transmits backward, causing hydrostatic pulmonary edema. Fluid in alveoli impairs gas exchange, leading to the critical symptoms of dyspnea and hypoxemia.

The immediate nursing priority is auscultating lung sounds to detect crackles (often bibasilar, ascending with severity) and assessing respiratory effort (rate, depth, accessory muscle use). This directly evaluates the life-threatening physiological problem.

CautionA BNP level of 2,400 pg/mL is a strong biochemical marker of acutely decompensated heart failure. Do not delay respiratory assessment for other tasks; oxygen saturation of 88% on room air indicates severe hypoxemia requiring immediate intervention.

## 핵심 개념

- **BNP** — Brain Natriuretic Peptide, a hormone released by ventricles in response to stretching; levels >100 pg/mL suggest heart failure, and >400 pg/mL indicate acute decompensation.
- **Pulmonary Edema** — Abnormal accumulation of fluid in the interstitial spaces and alveoli of the lungs, commonly due to increased hydrostatic pressure from left-sided heart failure.
- **Jugular Venous Distension (JVD)** — Visible bulging of the jugular veins in the neck, indicating increased central venous pressure often associated with right-sided heart failure or volume overload.

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