NSN724 Acute Care: Congestive Heart Failure Case Study Analysis

This case study examines the therapeutic management of a 74-year-old female patient with Congestive Heart Failure (CHF) following a coronary artery bypass graft (CABG). The assignment delves into the patient's medical history, current medications, and presenting symptoms, including abdominal pain, shortness of breath, and other complications. It provides a comprehensive patient assessment and discusses various non-pharmacologic, pharmacologic, and intrusive strategies for managing CHF, including the use of beta-blockers, ACEIs/ARBs, aldosterone antagonists, and CRT. The study highlights the importance of considering age-related physiological variations and comorbidities in elderly patients. Furthermore, it offers recommendations for improved nursing practice, emphasizing optimization of care transitions, enhanced patient education, provision of equitable care, and the recruitment of specialists to guide CHF care across disciplines, and also stimulation of research into different treatments. The case study stresses the significance of palliative care in end-stage CHF, focusing on symptom regulation and emotional support.

Running head: CONGESTIVE HEART FAILURE
Case Study on Congestive Heart Failure
Student’s Name
Affiliate Institution

CONGESTIVE HEART FAILURE 2
Introduction
Congestive Heart Failure (CHF) happens when one’s heart muscle fails to pump blood as
proper as it should (Grady, 2017). Particular illnesses such as high blood pressure or constricted
arteries in an individual's heart (coronary heart condition), progressively leave one's heart very
weak or hard to fill and pump properly. Not every condition that results in CHF could be
retreated; however, treatments may enhance the symptoms and signs of CHF to assist an
individual in living longer. Lifestyle alterations such as lowering one's sodium intake, cutting
weight, exercising, and coping with stress could enhance an individual's quality of life. One
technique of inhibiting CHF is to hinder and regulate illnesses that lead to heart failures, such as
obesity, hypertension, diabetes or coronary heart condition. CHF could be fatal; therefore if an
individual is suspected of having it, speedy medical treatment should be sought.
According to Centrella and Nigro (2016), CHF is a universal epidemic affecting at best
27 million persons globally, and it is escalating in prevalence. Approximately 5.9 million
individuals in the U.S. alone have been diagnosed with CHF. An epidemic may reveal escalated
incidence, escalated survival resulting in an increased rate or both aspects combined. It is an
overwhelming medical and public health concern, linked to considerable deaths, illness, and
healthcare expenses, specifically amongst older individuals aged 65 and above. There is an
increasing rate of cases presenting with conserved discharge for which there is no definite
treatment. In spite of the advancement in lowering deaths related to CHF, hospitalisations for
CHF stand very common and proportions of readmissions are still rising.

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Case Study
The presented case study is of an old female aged 74 who had a coronary artery bypass
graft (CABG) surgery six weeks before admission to the facility. Her chief complaint includes
abdominal pain, breath shortness, general sickness for three or four days, blurry vision, fevers,
and recent inception of headaches. Her history of present disease comprises abdominal pain and
oliguria, breath shortness, inability to carry out recommended therapy activities, and general
malaise for three or four days. The patient is currently on medications which include Enalapril
20mg BD, Tramadol 100mg BD, Metoprolol 50mg BD, Jurnista 16mg daily, Lasix 40mg daily,
Endone 5mg prn, Span K 600mg daily, Lipitor 20mg daily, Metformin 500mg daily, Rantidine
150mg BD, Novorapid 20 units TDS, Coloxyl with senna 2 tablets daily, Lantus 30 units BD,
Movicol 1 sachet PRN, and Panadol Osteo ii TDS. She has no identified allergies.
The patient’s past medical history asserts that she is obese weighing 115kg, she has had
hypertension for 25 years, hyperlipidemia and type 2 diabetes for ten years, protracted back pain
for 12 years, gastric ulcer for five years, osteoarthritis of limbs/spine, CABG (× 4 grafts) six
weeks ago. Additionally, she drinks a litre of cask wine daily, has anxiety but does not take
suppositories, persistent obstructive pulmonary disorder with slight exercise easiness, petulant
bowel pattern with regular constipation, fresh inception protracted renal failure and non-
compliant with fluid 1.5 litre fluid retention and renal dialysis, peritoneal dialysis 4 times in a
week but takes on once in a week.
There is no account of her mother; however, her father died of bowel cancer at 68. Two
of her siblings were diagnosed with heart disorders; one of them has undergone a heart surgical
procedure. The patient is a widow with two sons and two daughters, all of whom are married. All

CONGESTIVE HEART FAILURE 4
her children have requested her to stay with them due to her poor urine release, blurred vision,
loss of memory, and current headaches but she has refused because she does not want to be an
encumbrance.
Comprehensive Patient Assessment
Medical treatment for CHF comprises several non-pharmacologic, pharmacologic, and
intrusive strategies to regulate and reverse its appearances (Journal of Continuing Education in
Nursing, 2018). Basing on the seriousness of the disease, non-pharmacologic treatments consist
of dietetic fluid and sodium restraints, somatic action as suitable, and mindfulness to weight
addition. Pharmacologic treatments comprise the use of vasodilators, diuretics, beta-blockers,
digoxin, anticoagulants, and inotropic agents. Intrusive procedures for CHF consist of electro-
physiologic intrusion like pacemakers, implantable cardioverter-defibrillators (ICDs), and
cardiac resynchronisation therapy (CRT); valve replacement or repair; ventricular restoration;
and revascularisation procedures like percutaneous coronary intervention (PCI) and coronary
artery bypass grafting (CABG). However, the PCI and CABG are not routine procedures. PCI
may be used to intervene and stop a heart attack when a patient is actively having a heart attack
by opening up the blocked or narrow artery. On the other hand CABG is used as a treatment
option in severe CHF if heart failure is caused by coronary artery condition. In this procedure,
the physician uses veins or arteries taken from other body (referred to as grafts), and redirects the
flow of blood around one or more obstructed heart arteries.
Various aspects should be regarded in CHF elderly patients going through
pharmacological therapy. First, such patients suffer from numerous chronic illnesses, which
escalates the possibility of adverse medication reactions (electrolytic disturbances kidney

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dysfunction, and hypertension) and frequently inhibit the optimum prescribed treatment. This is
the case with chronic severe obstructive pulmonary disease and beta-blockers. Similarly, patients
with CHF take many medicines, which further escalate the risk of contrary drug-drug interaction
and medication occurrences. Furthermore, drugs pharmacodynamics and pharmacokinetics are
affected by age-linked physiological variations of capacity distribution. These features, in
addition to the lessening in drug clearance, might change to a specific range the drug plasma
concentration at stable-condition, escalating the danger of drug buildup and its undesirable
impacts. Ultimately, the therapeutic plan could be affected by the age-linked mental damage,
besides economic and social aspects, which damage the observance to the medication routine.
Owing to the reasons above, various findings suggested that elderly patients with CHF had
reduced instruction based clinical therapy prescription proportions at discharge likened to
younger patients.
Dornelas and Sears (2018) assert that beta-blockers are front-row therapy in the treatment
of CHF. The efficiency of beta-blockers in elderly patients is well-recorded. Research results
exhibit a 15% comparative danger lessening in the complex threat of all-cause death, or
cardiovascular hospice admission likened to placebo. Studies suggest that the effect of nebivolol
is comparable in patients with persistent renal failure. To stop the main frequent undesirable
impacts like hypotension or bradycardia, beta-blocker treatment ought to be commenced with the
least prescribed dosage and increased at recesses of at least two weeks towards the objective
dosage.
Elderly patients with no history of allergies to Angiotensin-converting enzyme (ACEIs)
ought to be treated, initiating with reduced dosages. On the contrary, Angiotensin-receptor

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blockers (ARBs) should be regarded only in patients who are allergic to ACEIs owing to rash,
angioedema, or cough (Yin, Ding, Hua, and Zhang, 2017). A recent paradigm-CHF trial showed
a new category of pharmacological treatment, which puts together the ARB valsartan with the
neprilysin inhibitor sacubitril thereby reducing hospitalisation and heart disease deaths, besides
all-cause deaths likened to enalapril alone.
Brawn et al. (2016) propose that aldosterone antagonists’ treatment should be
administered with closer patient observation to inhibit opposing occurrences such as
hypotension, renal dysfunction, and hyperkalemia, particularly in elderly patients. Ivabradine
may be safely recommended to elderly patients. However, incidents of contrary effects like
phosphenes, asymptomatic bradycardia, and symptomatic bradycardia are likely to be observed.
The DIG test indicated that digoxin lowers the possibility of hospitalisation with a more
significant threat of withdrawals and toxic effect in the elderly.
Empagliflozin, a sodium-glucose cotransporter 2 (SGTL2) inhibitor, considerably lowers
the possibility of CHF hospitalisation. While numerous aspects may account for the effects of
empagliflozin on CHF comprising sodium retention, osmotic diuresis, and lessening of plasma
volume, the renal mechanism is unclear. Empagliflozin has demonstrated an excellent safety
summary. However, an increased possibility of volume deletion-linked opposing occurrences
and urinary infections might be likely in elderly patients.
Cardiac resynchronisation therapy (CRT) has been shown to lower all-cause deaths and
CHF hospitalisation while escalating left ventricular ejection fraction, lessening left ventricular
capacities, improving quality of life, and highest oxygen consumption. Additionally, echo-
graphic and medical reaction to CRT appears to lower unclustered and clustered ventricular

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arrhythmias in a current tendency-tally corresponding study. Even though the rate of elderly
patients with CHF is escalating dramatically in the previous few decades, this subpopulation is
narrowly exemplified in randomised standardised tests, majorly owing to the many intrinsic
problems linked to registration and comorbidities. Thus, direct data on the advantage of CRT in
elderly patients remains narrow (Health and Social Work, 2015).
In a particular trial, CRT lowered the total possibility of mortality and hospitalisation by
13% when likened to optimum clinical treatment alone. Although there is yet no definite reaction
to CRT that is generally recognised, multiple studies have shown that patients aged 74 and above
have similar likelihoods to live up to the suggested eco-graphical and medical standards as their
younger equals. Chen, Pan, Jiayun, and Hongmei (2017) denotes that resynchronisation therapy
provides considerable benefits to the elderly, as it does not need up-titration and is not hindered
by drug interaction or reduced compliance. Nonetheless, it remains underused in regular medical
practice, as it needs appropriate amenities and devoted out-of-hospice aid.
When CHF enters the final stage, patients go through massive physical and spiritual
agony in spite of optimal clinical treatments and usually die of advanced pump failure within a
year. Owing to epidemiological variations, end-stage CHF mostly involves the elderly patients
whose related comorbidities worsen symptoms and escalates the difficulty of management. In
such a clinical situation, there is a normal evolution of physical therapies from life extension to
end of life care with the concentration on symptoms regulation, enhanced life quality, and
emotive support for both the patient and their relatives. To regard these needs, palliative care
comprises both pharmacological (antidepressants, constant intravenous progressive inotrope
support, and opioid treatment) and non-pharmacological methods (functional interventions,

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workout training, and hemofiltration) (Yin, Fan, Guo, Zhu, and Wang, 2017). In line with the
motive of sustaining life quality in the course of dying, when the end of life is forthcoming,
positive removal of conventional treatment and ICD de-activation might similarly be necessary.
Until now, even though the nature and effectiveness of all these methodologies remain not clear,
palliative approaches for patients with final-stage CHF are strongly deliberated and proposed by
all prominent cardiology organisations.
According to Balijepalli, Shirali, Kandaswamy, Ustyugova, Pfaar, et al. (2018),
recommendations for improved nursing practice include the following.
Optimisation of care transitions. Enhanced incorporation of hospice care, societal care, and
emergency provisions will improve patient outcomes and enable more efficient use of resources.
Presently, hospice admission and discharge planning are always poorly coordinated and
incoherently enacted, indicating a necessity for closer interactions amongst all those individuals
involved in patient care.
Improvement of patient education and support- Enhanced knowledge and support for
patients with CHF, and their relatives and caregivers are essential to improve outcomes and
patients' experience of care. Patients often have no awareness, self-confidence, and morale to
take part in their care dynamically, and their observance to guidelines essential for long-standing
health is usually poor.
Provision of an equity of care for every patient- Every patient ought to have a suitable
variety of diagnostic techniques, treatments, and long-standing follow-up care. At the moment,
the quality of care ranges significantly amongst hospitals, and across localities and nations.

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Recruitment of specialists to steer CHF care across disciplines- Multi-Disciplinary
personnel driven by a CHF specialist ought to supervise the care of patients with CHF and the
establishment of guidelines, training, and local assessing to make optimum care the standard
(Habibi, Aroor, Das, Manrique-Acevedo, Johnson, et al. 2019).
Stimulation of research into different treatments- Increased financing is necessary for
investigation into different and more operational procedures, clinical implements, and care
methods for CHF. Various methodologies are immediately needed to cater to unmet needs.
Development and implementation of enhanced criteria of care quality- Performance
criteria founded on strong, evidence-based medical commendations ought to be cultivated and
used to enhance the quality of care for patients with CHF. Present performance criteria are
inconstant and have no evidence base, and their use could have unintentional consequences.
Improvement of the end of life care- Lo et al. (2015) propose that operational methods to
end of life and palliative care, embracing emotive and physical wellbeing, have to be made an
essential part of the care of patients with CHF, both in the hospital and in the society.
Promotion of CHF prevention- Nationwide endeavors to lessen the possible aspects for
CHF, consisting of coronary artery illness and high blood pressure, ought to be stimulated. Once
CHF develops, the advancement of the disease ought to be slowed or stopped by guaranteeing
that proper evidence-based care is enacted immediately.
Patient Experience

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Optimal transitions may lower the rates of possibly preventable hospitalisations, lessen
the possibility of adverse medical occurrences from other medicines and other inconsistencies,
and uphold patients' fulfillment with care (Schernthaner et al., 2017).
Patient education may substantially lower re-admission proportions for patients with CHF
due to daily weight monitoring and immediate reaction to escalating symptoms. Preferably,
patient education ought to be commenced during hospitalisation. Patient education enables
patients to take responsibility for illness management by intensifying their awareness level,
upholding autonomous decision-making, cultivating observance to therapy guidelines, and
applying methods to inhibit relapses. Lack of awareness of symptoms and poor therapy
observance, especially diet, medicine usage, and weight monitoring are fundamental contributing
aspects in the worsening of CHF necessitating admissions.
Orlowski et al. (2018) denote that provision of the equity of care to all the patients
irrespective of their race, religion, social, and economic background, or social class would result
in patient fulfilment. However, discriminating patients on various grounds would lead to
depression, and further worsen the CHF illness for segregated patients. Equity of care
additionally upholds patience self-confidence and stimulates independent decision-making
among the CHF patients, as al the patients are on kind regard by the medical personnel.
Recruitment of specialists to steer CHF care across disciples may result in prolonged life
spans for patients with CHF. This is the case since; specialists would advise on the optimum care
strategies, precautions and instructions that the CHF patients, nurses, relatives, and caregivers
ought to observe. This would further reduce the rate of hospital re-admissions and prevent the

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illness from advancing. It would similarly lower the price of prompt mortality among patients
with CHF.
Stimulation of research into different treatments would pave the way for advanced
treatment and management strategies of patients with CHF (Gathright, Dolansky, Gunstad,
Redle, Josephson, et al. 2017). Some concerns related to CHF are yet to be addressed due to
insufficient research and investigations. This makes certain CHF patients die in the hands of the
medical personnel who do not know alternative therapy for their particular symptoms. The
additional analysis would, therefore, improve the symptoms of CHF and slow down the
progression of the disease. In return, this would result in a longer life span and consequently,
patient fulfilment.
Development and implementation of enhanced criteria of care quality would improve
patients' outcomes. The use of angiotensin-converting enzyme inhibitors in a patient with left
ventricular systolic dysfunction, evaluation of left ventricular ejection fraction, providing
smoking cessation counselling in current or recent smokers, and providing complete CHF
discharge instructions should be considered in the quality of care provided to CHF patients.
Patients needing specific treatments should be identified and suitable therapy accorded to them.
This would slow down the progression of CHF and lower the risk of untimely death, therefore,
prolonging the life of CHF patients.
Komajda, Anker, Cowie, Flippatos, Mengelle, et al. (2016) asserts that improved end of
life care may substantially enhance the quality of life and fulfilment of the CHF patients. In
regards to symptoms, improvement will be likely with the quality of sleep, dyspnea, anxiety, and
depression. Palliative care interventions are linked to escalated records of the first choice of care

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as shown by numerous investigations. Similarly improved end of life care would result in
increased deaths at home likened to the hospital. Palliative care interventions are likewise
connected to increased persistence rates as research shows that 17% of CHF patients who receive
palliative care had a persistence benefit of 84 days.
Lastly, the endorsement of CHF prevention would significantly lower the incidence of
the disease. A majority of individuals end up developing CHF due to ignorance of its prevention
measures. For instance, encouraging people to lead healthy lifestyles by exercising and eating
right, monitor their weight, avoid stress, seek timely medical attention in case of unusual
symptoms and treat hypertension and coronary artery illness on time would lower the possibility
of developing heart failure by about 44%. Similarly, it is better to prevent CHF from occurring
than having to deal with it long after it has evolved and become severe (Kirklin et al. 2015).
Conclusion
Congestive Heart Failure (CHF) is a complex illness and is majorly an illness of the
elderly, escalating its incidence with the upturning age. Even though elderly patients are scarcely
exemplified in medical trials, all CHF treatments, from medications to implements, are still
prescribed in this populace (Akita, Kohno, Kohsaka, Shiraishi, Nagatomo, et al. 2017).
Nevertheless, the selection of the optimum therapy ought to be customised, regarding more
facets beyond CHF like frailty, comorbidities, economic, and social upbringing and life quality.
Patients with CHF benefit from timely diagnosis, close observation, and management offered by
trained CHF personnel that comprise a CHF nurse expert and a by-cardiology ward nurse with
enough training to uphold safe practice. In contrast to the evidence base to enforce the CHF
nurse in permanent illness management, the nurse's duty in the CHF path is uncertain. Family

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Relations (2018) proposes that we now have to shift our focus to this in-patient period and
reinforce the evidence that upholds the duty, skill, and the number of nurses to strengthen
operational CHF therapy all through the patient journey.

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