Congestive Heart Failure Case Study: Assessment, Diagnosis, and Management

This case study discusses the assessment, diagnosis, and management of congestive heart failure in a 72-year-old male patient. It covers the pathophysiology and physiological findings of heart failure, systematic approach of assessment, intervention and treatment administered, potential complications, and nursing care strategies.

090023, Assessment 3,
Case study

Table of Content.
Table of Content............................................................................................................................2
INTRODUCTION...........................................................................................................................1
MAIN BODY..................................................................................................................................1
Mr John Allan, presentation:.......................................................................................................1
Systematic approach of assessment of Mr John in CCU.............................................................3
Provide rationales for intervention and treatment administered and patient physiological
response and outcome discussion................................................................................................4
Discuss the 2 potential complication of Mr John, during the CCU stay and the consideration
and strategies for nursing care.....................................................................................................6
Discussion on Mr John discharge planning and follow up care, psychological and cultural
needs of patient and family..........................................................................................................7
CONCLUSION................................................................................................................................9
REFERENCES..............................................................................................................................10

INTRODUCTION
The congestive heart failure is known as heart failure. It is occurring in case an individual
heart muscle does not able to pump sufficient blood due to certain condition such as arteries
narrowed. It has been seen that this disease is more common to elderly people. Some of the
common symptoms may include fatigue, shortness of breath, oedema, arrhythmia and many
more. The diagnostic test recommended for congestive heart failure is ECG, chest X-ray,
echocardiography as well as cardiac enzyme level. This project gives brief knowledge about the
case study of 72-year-old male. As he is admitted to the emergency department because of
continuous dry cough. As his symptoms is related the congestive heart failure. The project report
includes John history, assessment as well as their diagnosis. It also includes intervention or
treatment along with the potential health problems. It also discusses the discharge planning
health teaching and lifestyle changes to improve clinical outcome and to reduce hospital
readmissions. As all patient and family should be taught about the prognosis and the risk of
sudden cardiac death and utilising the multi dispensary team support in place, especially in end -
of-life care.
MAIN BODY
Mr John Allan, presentation:
72-year-old elderly, male presented to the ED with a recurrent history of dry cough and
shortness of breath on exertion, orthopnoea and paroxysmal nocturnal dyspnoea. Besides, in the
last weeks, he had a history mild chest discomfort, peripheral oedema, fatigue, anorexia,
sweating, pale, accompanied by insomnia. During the past days, he is having a trouble in ADLS
and at work as well. He is a full – time plumber and lives with his family. He has a long history
as a heavy smoker and quit last year. He has multiple comorbidities such as asthma, atrial
fibrillation, hypertension on medication. Patient exhibited signs of respiratory compromises and
fluid overload managed by oxygen therapy and frusemide 80 mg IV Stat. John was admitted and
transferred to the CCU for further intervention and management for mild heart failure.
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The pathophysiology and physiological findings of heart failure of Mr. John Allan
In normal conditions, heart has a very effective pump with reverse mechanism available to allow
output to meet the changing demands, includes increase the heart rate and cardiac output, dilation
to creative muscle stretch and effective contraction, hypertrophy of myocytes, increased stroke
volume by increased venous return and contractability. There are several terms used in the
process of pathology of heart failure. Backward failure, systemic and pulmonary congestion
result from failure of the ventricular expel its volume. Congestive heart failure develops over
time as a result of the inability of compensatory mechanisms to maintain an adequate cardiac
output to meet the metabolic demands of the body. As this is the same condition happen to Mr.
John to develop heart disease. As Mr. John is unable to breath continuously or sufficiently
because of heart unable to pump sufficiently (Vogelsang & et.al., (2020)).
Pathophysiology of Mr John heart failure:
In the initial stages of congestive heart failure, cardiac physiology attempts to adapt via several
compensatory mechanisms to maintain cardiac output and to meet systemic demands. As in case
of Mr. John heart also try to adapt some other method to pump blood sufficiently by adapting
some mechanism such as Frank-Sterling mechanism, changes in myocyte regeneration,
myocardial hypertrophy, and myocardial hypercontractility. With increased wall stress, the
myocardium attempts to compensate via eccentric remodelling, which further worsens the
loading conditions and wall stress. A decrease in cardiac output stimulates the neuroendocrine
system with a release of epinephrine, norepinephrine, endothelin-1 (ET-1), and vasopressin.
They cause vasoconstriction leading to increased afterload. There is an increase in cyclic
adenosine monophosphate (cAMP), which causes an increase in cytosolic calcium in the
myocytes. This increases myocardial contractility and further prevents myocardial relaxation
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(McKenna & Judge (2021)). An increase in afterload and myocardial contractility with impaired
myocardial relaxation leads to increased myocardial oxygen demand. This paradoxical need for
increased cardiac output to meet myocardial demand eventually leads to myocardial cell death
and apoptosis. As apoptosis continues, a decrease in cardiac output with increased demand leads
to a perpetuating cycle of increased neurohumoral stimulation and maladaptive hemodynamic
and myocardial responses. Heart failure resulting from a variety of cardiovascular conditions
including chronic hypertension, coronary artery disease and valvular diseases. When heart failure
occurs, adaptive responses are inhibited by the body to maintain own normal perfusion. The
compensatory mechanism includes SNS response, renin-angiotensin – aldosterone system
(RAAS), Frank – starling response and neuro hormonal response. As in heart failure develops,
body activates neurohormonal compensatory mechanism. Systolic heart failure result reduced
blood volume ejected from the ventricle. Sympathetic nerve system stimulated to release
epinephrine and nor epinephrine. Diminished renal perfusion cause renin release and, then
promote the formation of angiotensin one. Angiotensin one, into angiotensin two, by ACE which
constrict the blood vessels and stimulates aldosterone release that cause sodium and fluid
retention. Reduction in the contractability of heart muscles fibres result in increased workload of
heart. Compensations: The heart compensates the increased workload by increasing the thickness
of the heart muscles causes Mr. John a short breathing problem, fatigue, oedema as well (Rao
&et. al., (2020)).
Systematic approach of assessment of Mr John in CCU.
As per Mr. John presenting problems some primary, secondary and tertiary assessment, A-
G assessment and head to toe assessment is used for treatment. A, Airway assessment revealed
airway compromises, Mr. John had sign of breathlessness and increased respiratory rate and use
of accessory muscles, crackles, mild confusion and Mr, John was experiencing chest discomfort.
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B, breathing, increased work of breathing, he had equal expansion of chest wall noted, abnormal
oxygen saturation reported. C, In the circulation assessment, audible murmur (S3) radial and
carotid pulse palpable, increased jugular venous pressure noted, cold and calmy, pale,
normotensive and sinus tachycardia on telemetry. D, John is alert and oriented but mildly
confused, stated feeling lethargic. E, skin looks dry and fragile, afebrile, peripheral bilateral
swelling noted. F, looks fluid overloded,1.5L FR, daily weight monitoring, fluid balance chart.
G, stable BGL, constipated, abdomen distended, bowel sounds present. Nil allergy (Boyde & et.
al., (2018)).
Potential red flags- Priority is to establish a Mr. John airway and reduce fluid overload. In this
case study due to inadequate respiratory compromise, increased WOB, RR:28/mt, as this
situation can be managed by providing the injection furosemide 80mg IV stat given. As
Furosemide is a loop diuretic which is used to treat fluid build-up due to heart failure. It is
focused on respiratory assessment to maintain adequate gas exchange and perfusion needs and
good diuresis achieved. Chest Xray was attended in ED which showed cardiomegaly and fluid
overload and pulmonary congestion. systematic way assessment along with the pathological and
diagnostic result helped me for clinical decision-making and problem-solving.
Provide rationales for intervention and treatment administered and patient physiological response
and outcome discussion.
The diagnosis of heart failure is consisting of clinical history, physical examination as well
as diagnostic interventions. Hence, in the period of Mr. John admission to the CCU he had to
follow some diagnosis procedure such as electrocardiogram (ECG), it shows left ventricular
hypertrophy. It is also important for identification of acute myocardial infraction or ischemia or
in Mr. John heart condition. The other diagnosis type is chest X- ray, this process helps in
findings the cardiac to thoracic width ratio above rhythm abnormalities, such as atrial fibrillation
which is seen 50% cephalisation of the pulmonary vessels and pleural effusions and pulmonary
oedema, Cardiomegaly Sugumar & et. al., (2019)). As from this, it is found that Mr. John had
oedema so in order to reduce oedema an injection of Furosemide is given to Mr. John. Another
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diagnosis type is cardiac enzyme blood test, it includes cardiac troponin (T or I), complete blood
count, serum electrolyte, blood urea nitrogen, creatinine, liver function test and brain natriuretic
peptide (BNP). The other diagnosis types are Transthoracic echocardiogram, it determines
ventricular function and hemodynamic showed moderately dilated ventricles, EF:45%. Another
diagnosis types are cardiac catheterisation result shows minor coronary artery disease and
nuclear cardiology test. As CTPA result was bilateral pleural effusion, assessment of cardiac
function is done by invasive technique (Ha & et. al., (2018)).
Mr John Heart failure management Algorithm: The four “pharmacologic pillars” of
heart failure management are diuretics, beta-blockers, angiotensin-converting enzyme
inhibitors, and Lanoxin. treatment of heart failure is lifelong and multifactorial, requiring a
well-coordinated, multidisciplinary approach. The primary goal of heart failure treatment is to
identify and eliminating the precipitating cause, promote optimal cardiac function, enhance
patient comfort. Treatments includes education and lifestyle changes, pharmacology
management and sometimes implantable device such as CRT, ICDs, IABP support. During the
CCU stay, Mr John was commenced on the gold standard pharmacology for heart failure,
Symptom relief: Diuretics, nitrates, digoxin. Long term management and improved survival.
Angiotensin converting enzyme inhibitors example: captopril and enalapril decrease the systemic
vascular resistance and stopping the angiotensin one conversion to angiotensin two; and decrease
sodium and water retention. Adverse effects are symptomatic hypotension, hyperkalaemia,
unproductive cough, renal failure. Beta -Adrenergic blockers; Bisoprolol, carvedilol, metoprolol.
reduce SVR and HR, adverse effect are hypotension and bronchoconstriction. potassium sparing
diuretics, spironolactone, ARB: Candesartan and Irbesartan and loop diuretics: Frusemide. Good
diuresis achieved with a weight loss of 4kg. Mr John in CCU, Heart failure require frequent
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telemetry monitoring heart rate and rhythm, and oxygen saturations. Daily weight monitoring,
hourly urine output monitoring ,1.5L fluid restriction, teaching regarding dietary salt restrictions
6g/day. monitor the symptoms of hypotension, dizziness, weakness, electrolyte imbalance. The
goals of the treatment help to practise, how to decrease the preload and afterload and to reduce
LVH and prevent complication (Ariyarantam & et. al., (2021)).
Discuss the 2 potential complication of Mr John, during the CCU stay and the consideration and
strategies for nursing care.
Due to heart failure, the patient is high risk of developing the kidney failure and
peripheral heart disease. However, the John is going on with the persistent cough which is
enhancing the risk on the blood vessels. Persistent cough triggers the blood vessels as it creates
pressure on blood vessels which when not analysed on time might damage the blood vessels or
dilate them. Heart failure is symbolised as the condition where heart muscles stop pumping out
or start working weekly. In some cases, this condition led to progression of cyanosis in
individuals. It is condition when due to lack of oxygen in the blood skin turns blue. But the John
has been diagnosed with symptoms like chest discomfort, peripheral oedema, fatigue, shortness
of breath and many more. These symptoms have enhanced the progression of risk for the patient
in rapid form. Heart affects the vessel’s as enriched pressure is provided which also creates
pressure on kidney (Heraganahally & et. al., (2022)). When patient incorporates the kidney
failure, they must also enhanced the chance for development of hyperparathyroidism, bone
disease or fluid build-up in the patients.
Peripheral artery disease is the complication which leads to narrowing of peripheral
arteries which is responsible for supplying blood ot varied parts of the body. Here the fatty
plaque is being formed in body. As per the case study, the john has heart failure which inched the
chance of development of it as pressures is created on vessels due ot weka pumping heart.
Several attempts were made to correct the electrolyte imbalance, later he switched into Spiro
lactone, it is a potassium sparing diuretics. second problem was managed during the
hospitalisation was acute kidney injury, as cardiac function deteriorates, renal blood flow reduces
due to low cardiac output. In addition, renal venous pressure increases, leading to renal venous
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congestion. These changes both result in a reduced eGFR and low urine output. Apart from that,
the effect of nephrotoxic drugs used for HF increase the risk kidney injury.
Management aggregates his problems. Later, he was discharged to home with education
provided to him regarding self-care, medication management and fluid restriction was 1.5; L
/day, daily weight recording and regular, pathology, follow-up and echo 3- 6 monthly. Patient
must be provided with Ace inhibitors for the treatment and nurse need to guide John for some
lifestyle modification that need to be incorporate by them. Patient must be guided to incorporate
the physical activity to enhance their mental and physical well-being. Nurse also need to guide
patient to incorporate the low salt diet while avoid the processed fat or meat (Butler& et. al.,
(2019)).
Discussion on Mr John discharge planning and follow up care, psychological and cultural needs
of patient and family.
Mr John, recovery from critical illness (heart failure) and strategies implement to reduce
the physical and psychosocial, emotional impact of patient and family and services in the
hospital for a long-term recovery and follow up care and appointments in heart failure clinic after
a week of discharge and a repeat echo after 3-6 month. cardiac rehabilitation nurses are the
excellent role models of cardiac care. Health education and health promotion regarding self-
monitoring chronic illness, medication management, compliance, daily weight monitoring,
dietary sodium (2g/day) and water restriction(2L/day), activities and exercise recommendations,
smoking cessation, to improve the clinical outcomes and reduce hospital readmissions. On
discharge his medications were beta-blocker 25 mg BD, Ramipril 2.5 mg OD, spironolactone
12.5 mg daily and furosemide 40 mg mane, telmisartan 40 mg daily. organised through the local
pharmacy (Ding & et. al., (2020)).
Chronic heart failure is a progressive disabling condition significantly impact the patient
quality of life. One of its effects is decreased opportunity to participate in social activities, leads
to reduced social interaction, loneliness, social isolation and lack of social support in his daily
activities. John is diagnosed with heart failure which is also incoperated with wide illness
including the fatigue, anorexia, exerted breathing and many more. To cure the illness patient is
required to be provided with support from the family or friends. It is essential paatient with heart
failure to improve their quality of life. When having the social support the patient wil easily able
to convey the pain or feeling they are gettiing. Patient also requires the sense of safety during the
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treatment as it reduces the chance of adverse actions and provide patient with enhace
satisfaction. Another psychological need of the patient is to create feeling of hope during the
treatment to genenrate the belief that their life are worth living for. It will enhace the john
enaggment in the trreatment provided in care setting. When not incoperated effectviely in care
setting or home in might lead to development of depression or anxirty in them (Javanparast,
Naqvi & Mwanri, (2020)). These symptoms limit the patients daily activities and social activities
and result in poor quality of life and high mortality. This creates the feeling of resentment or
anger in patient which on prolonged manner lead to feeling of lonliness in them. However it also
leads to creation of the emotional distress or irratibiltiy to complete the prescribed medicatinos.
Cultural needs of the patient are their values and communities are need to be respected
by the care provdier when they assist them. Nurse can fulfil the patient cultural needs accurately
by building the effective relationship with the patient to built the effective trust. When the trust is
built the nurse can even interpret the patient needs and provide them emotional support during
the care. To meet patient cultural needs nurse should make sure that patient opinons are being
actively listened by them while avoid forming the assumption or interuptiing in between to
reduce the occurance of language barriers. Nurse need to give patient the effective time to
interpert their cultural belifs and incoperate the treatment in manner in which patient is familiar
to. Nurse need to explain John about their health impact in effective manner to promote their
engament in the treatment (Lores & et. al (2021)).
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CONCLUSION
From the above report the impact of heart failure on patient has been concluded. Report
covers the pathophysiology of heart failure also with its interventions. Report also recount the
complications associated with it and nursing strategies implemented for its management. Report
covers cultural and physiological needs of individuals dealing with heart failure.
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REFERENCES
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Electrophysiology Clinics, 13(1), 47-62.
Boyde, M., Peters, R., New, N., Hwang, R., Ha, T., & Korczyk, D. (2018). Self-care educational
intervention to reduce hospitalisations in heart failure: a randomised controlled trial.
European Journal of Cardiovascular Nursing, 17(2), 178-185.
Butler, J., Yang, M., Manzi, M. A., Hess, G. P., Patel, M. J., Rhodes, T., & Givertz, M. M.
(2019). Clinical course of patients with worsening heart failure with reduced ejection
fraction. Journal of the American College of Cardiology, 73(8), 935-944.
Ding, H., Jayasena, R., Chen, S. H., Maiorana, A., Dowling, A., Layland, J., ... & Edwards, I.
(2020). The effects of telemonitoring on patient compliance with self-management
recommendations and outcomes of the innovative telemonitoring enhanced care program
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Ha, F. J., Hare, D. L., Cameron, J. D., & Toukhsati, S. R. (2018). Heart failure and exercise: a
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Heraganahally, S. S., Silva, S. A., Howarth, T. P., Kangaharan, N., & Majoni, S. W. (2022).
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Rao, A., Zecchin, R., Newton, P. J., Phillips, J. L., DiGiacomo, M., Denniss, A. R., & Hickman,
L. D. (2020). The prevalence and impact of depression and anxiety in cardiac
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Sugumar, H., Nanayakkara, S., Prabhu, S., Voskoboinik, A., Kaye, D. M., Ling, L. H., & Kistler,
P. M. (2019). Pathophysiology of atrial fibrillation and heart failure: dangerous
interactions. Cardiology Clinics, 37(2), 131-138.
Vogelsang, H., Herzog-Niescery, J., Botteck, N. M., Hasse, F., Peszko, A., Weber, T. P., &
Gude, P. (2020). Improvement in pre-operative risk assessment in adults undergoing
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