Comprehensive Simulation Scenario for Nurse Training: Congestive Heart Failure (CHF) Case History and Initial Assessment
Scenario Title: Structured Interview, Vital Signs Monitoring, and Diagnostic Preparation for Congestive Heart Failure
Setting: Internal Medicine Unit / Emergency Department
Characters:
- Nurse (RN) – Responsible for the comprehensive assessment of the patient
- Mr. Jaeho Park (Patient) – 69-year-old male with worsening CHF symptoms
Phase 1: Patient Identification and Introduction
Nurse: Good morning, Mr. Park. I’m the nurse assisting you today. Could you please confirm your full name and date of birth?
Patient: Good morning. My name is Jaeho Park, and my date of birth is April 15, 1955.
Nurse: Thank you, Mr. Park. I’d like to ask you a few questions to understand your current condition better. Please feel free to let me know if you feel uncomfortable at any time. All the information you provide will be kept confidential.
Phase 2: Chief Complaint (CC)
Nurse: What brings you to the hospital today?
Patient: I’ve been having trouble breathing, especially when I lie down.
Nurse: Is there any other symptom bothering you?
Patient: Yes, my legs and ankles have been very swollen lately.
Phase 3: History of Present Illness (HPI)
Nurse: When did you first start feeling short of breath?
Patient: About a week ago.
Nurse: On a scale from 0 to 10, with 10 being the most severe, how would you rate your shortness of breath?
Patient: I’d say it’s about an 8, especially when I’m trying to sleep at night.
Nurse: Did your symptoms appear suddenly or develop gradually?
Patient: They gradually got worse over the past week.
Nurse: Is your shortness of breath present throughout the day, or is it worse at particular times?
Patient: It’s definitely worse at night when I lie flat.
Nurse: Does anything help ease your breathing?
Patient: Sitting upright helps. Lying down makes it harder to breathe.
Nurse: Besides swelling in your legs and shortness of breath, have you noticed any other symptoms such as fatigue, reduced appetite, or weight gain?
Patient: I feel very tired all the time, and I think I’ve gained a few pounds recently.
Phase 4: Past Medical History (PMH)
Nurse: Have you previously been diagnosed with any heart-related conditions, such as heart failure or coronary artery disease?
Patient: Yes, I was diagnosed with heart failure three years ago.
Nurse: Have you undergone any cardiac procedures or surgeries?
Patient: I had a coronary stent placed about five years ago.
Nurse: Have you been hospitalized for heart failure or fluid overload in the past?
Patient: Yes, I was admitted once last year for similar symptoms.
Nurse: Do you monitor your weight and blood pressure at home?
Patient: I check my blood pressure sometimes, but I haven’t been checking my weight regularly.
Phase 5: Family History (FH)
Nurse: Do any of your family members have a history of heart disease or heart failure?
Patient: Yes, my father had heart failure, and my older brother had a heart attack a few years ago.
Phase 6: Social History (SH)
Nurse: Do you currently smoke or drink alcohol?
Patient: I quit smoking 10 years ago, but I still drink occasionally—maybe once a week.
Nurse: Are you currently working, or are you retired?
Patient: I’m retired now. My previous job was very stressful.
Nurse: Do you participate in any regular physical activity?
Patient: Not really. I try to walk, but my breathing makes it difficult.
Nurse: How is your diet? Do you follow any dietary restrictions?
Patient: I try to avoid salty foods, but I’m not strict about it.
Phase 7: Medication History and Allergies
Nurse: What medications are you currently taking?
Patient: I take a diuretic and a medication for high blood pressure.
Nurse: Are you taking your medications as prescribed?
Patient: Yes, I take them every day.
Nurse: Have you noticed any side effects or had any recent changes in your prescriptions?
Patient: No side effects, and I haven’t changed any medications recently.
Nurse: Do you take any over-the-counter supplements or herbal products?
Patient: No, just the prescribed ones.
Nurse: Do you have any known allergies to medications, foods, or environmental substances?
Patient: No, I don’t have any known allergies.
Phase 8: Vital Signs Assessment
Nurse: Mr. Park, I’m going to take your vital signs now. Please let me know if anything feels uncomfortable.
8.1 Temperature
Nurse: I’ll begin by taking your temperature using an ear thermometer.
(Nurse performs hand hygiene, uses a probe cover, and gently places the thermometer.)
Nurse: Your temperature is 37.2°C, which is within the normal range.
8.2 Blood Pressure
Nurse: Next, I’ll take your blood pressure. Please rest your arm here at heart level.
(Nurse wraps the cuff, inflates it, and auscultates for accurate reading.)
Nurse: Your blood pressure is 140/95 mmHg. That’s slightly elevated and could be contributing to your symptoms.
8.3 Pulse
Nurse: I’ll now check your pulse.
(Nurse counts the radial pulse for one full minute.)
Nurse: Your heart rate is 110 beats per minute. That’s high and could be due to fluid overload or cardiac stress.
8.4 Respiratory Rate
Nurse: Lastly, I’ll observe your breathing.
(Counts chest movements discreetly for one minute.)
Nurse: Your respiratory rate is 24 breaths per minute, which is elevated and aligns with your breathing complaints.
Phase 9: Clinical Summary and Immediate Actions
Nurse: Based on your symptoms and vital signs:
- Normal temperature indicates no active infection.
- Elevated blood pressure suggests possible fluid retention.
- Tachycardia (110 bpm) and tachypnea (24 breaths/min) are consistent with decompensated heart failure.
To understand the severity of your condition and plan treatment, we’ll proceed with the following tests:
- Echocardiogram – To evaluate heart structure and function (30–45 minutes).
- Electrocardiogram (ECG) – To monitor electrical activity and detect arrhythmias.
- Chest X-ray – To check for pulmonary congestion or cardiomegaly.
- Blood Tests – Including BNP (B-type natriuretic peptide), kidney function, electrolytes.
- Urinalysis – To monitor fluid balance and renal impact.
Phase 10: Patient Education and Support
Nurse: These tests are mostly non-invasive and straightforward. If you feel any discomfort during the process, please let us know immediately.
While we wait for test results:
- Avoid lying flat if it worsens your breathing. Use pillows to stay propped up.
- Limit fluid and sodium intake until the doctor advises further.
- Notify staff if your breathing worsens, or if you experience chest pain, dizziness, or confusion.
Patient: Will I need to be hospitalized?
Nurse: That will depend on the results. If there’s significant fluid overload or cardiac dysfunction, the doctor may recommend admission for close monitoring, IV medication, and oxygen therapy.
Patient: Thank you for explaining.
Nurse: You’re welcome, Mr. Park. Let’s start with the echocardiogram. Please take it slow when you get up, and let me know if you need help.
Learning Objectives for Nurse Trainees
- Conduct a structured CHF case history including symptom severity, fluid status, and functional impact
- Evaluate CHF risk factors (past events, medications, lifestyle)
- Identify clinical signs of decompensation and correlate with vitals
- Prepare and educate the patient on diagnostic tests and monitoring
- Provide comfort measures and reinforce adherence to care plan
End of Scenario
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