Congestive Heart Failure Case Study: Assessment, Diagnosis, and Management
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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.
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090023, Assessment 3, Case study
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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 dischargeplanning 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 ā 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. 1
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)). PathophysiologyofMrJohnheartfailure: 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 somemechanismsuchasFrank-Sterlingmechanism,changesinmyocyteregeneration, 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 2
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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 compensatorymechanismincludesSNSresponse,renin-angiotensināaldosteronesystem (RAAS), Frank ā 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 problemssome 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 hadsign of breathlessness and increased respiratory rate and use of accessory muscles, crackles, mild confusion andMr, Johnwas experiencing chest discomfort. 3
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 carotidpulsepalpable,increasedjugularvenouspressurenoted,coldandcalmy,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 bemanaged 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 aboverhythm abnormalities, such as atrial fibrillation which is seen 50% cephalisation of the pulmonary vessels and pleural effusions and pulmonary oedema, CardiomegalySugumar & 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 4
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 āpharmacologic pillarsā of heartfailuremanagementarediuretics,beta-blockers,angiotensin-convertingenzyme 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 patientcomfort.Treatmentsincludeseducationandlifestylechanges,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 5
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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 vesselās 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,itisapotassiumsparingdiuretics.secondproblemwasmanagedduringthe 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 6
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 7
treatmentasitreducesthechanceofadverseactionsandprovidepatientwithenhace 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)). 8
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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 withheartfailure. 9
REFERENCES Ariyaratnam, J. P., Lau, D. H., Sanders, P., & Kalman, J. M. (2021). Atrial fibrillation and heart failure:epidemiology,pathophysiology,prognosis,andmanagement.Cardiac 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).Theeffectsoftelemonitoringonpatientcompliancewithself-management recommendations and outcomes of the innovative telemonitoring enhanced care program forchronicheartfailure:randomizedcontrolledtrial.JournalofmedicalInternet research,22(7), e17559. Ha, F. J., Hare, D. L., Cameron, J. D., & Toukhsati, S. R. (2018). Heart failure and exercise: a narrative review of the role of self-efficacy. Heart, Lung and Circulation, 27(1), 22-27. Heraganahally, S. S., Silva, S. A., Howarth, T. P., Kangaharan, N., & Majoni, S. W. (2022). Comparison of clinical manifestation among Australian Indigenous and nonāIndigenous patients presenting with pleural effusion.Internal Medicine Journal,52(7), 1232-1241. Javanparast, S., Naqvi, S. K. A., & Mwanri, L. (2020). Health service access and utilisation amongst culturally and linguistically diverse populations in regional South Australia: a qualitative study.Rural and Remote Health,20(4). Lores, T., Goess, C., Mikocka-Walus, A., Collins, K. L., Burke, A. L., Chur-Hansen, A., ... & Andrews, J. M. (2021). Integrated psychological care reduces health care costs at a hospital-basedinflammatoryboweldiseaseservice.ClinicalGastroenterologyand Hepatology,19(1), 96-103 McKenna, W. J., & Judge, D. P. (2021). Epidemiology of the inherited cardiomyopathies. Nature Reviews Cardiology, 18(1), 22-36. Rao, A., Zecchin, R., Newton, P. J., Phillips, J. L., DiGiacomo, M., Denniss, A. R., & Hickman, L.D.(2020).Theprevalenceandimpactofdepressionandanxietyincardiac rehabilitation: A longitudinal cohort study. European Journal of Preventive Cardiology, 27(5), 478-489. Sugumar, H., Nanayakkara, S., Prabhu, S., Voskoboinik, A., Kaye, D. M., Ling, L. H., & Kistler, P.M.(2019).Pathophysiologyofatrialfibrillationandheartfailure: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 noncardiacsurgerybyaprocess-orientedscore:Aprospectivesingle-centrestudy. European Journal of Anaesthesiology| EJA, 37(8), 629-635. 10