CONGESTIVEHEARTFAILURE
LEARNING OBJECTIVESAt the end of this case study, the learner should be able to: Describe Congestive Heart Failure Recognize its clinical signs and symptoms Identify causative factors of heart failure Identify diagnostic procedures used to determine heart failure Know the medical and surgical management
I. INTRODUCTIONCongestive heart failure is defined as the state in which the heart is unable to pump blood at a rate adequate for satisfying the requirements of the tissues with function parameters remaining within normal limits usually accompanied by effort intolerance, fluid retention, and reduced longevity. Currently, congestive heart failure or heart failure continues to be a major public health problem worldwide. It is the leading cause of morbidity and mortality in most developed countries. According to the American Heart Association, approximately 5 million patients have heart failure and nearly 550,000 new patients are diagnosed each year. In addition, nearly 300,000 patients die from heart failure yearly.In the Philippines, cardiovascular diseases are the most common causes of mortality. According to the Department of Health, about 77,060 in a 100,000 populations have died in the Philippines due to diseases of the heart. The aging of the population and the emerging pandemic of cardiovascular diseases in the developing nations of the world signal a rise in the incidence and prevalence of heart failure globally and magnify the importance of its prevention. The prevention of heart failure is an urgent public health need with national and global implications.CHF is usually the result of other health problems. This may include hypertension, Myocardial Infarction, Diabetes, cardiomyopathy, arrhythmias, valve defects, infections, certain kidney conditions, and Coronary Artery Disease. The most common cause of CAD is atherosclerosis, in which waxy substances called plaque (plak) build up inside the coronary arteries. It is a disease where there is impaired blood flow in the arteries that supply oxygen-rich blood to the heart muscle. The particular symptoms that an individual experiences are determined by which side of the heart is involved in the heart failure. For example, the left atrium receives oxygenated blood from the lungs and passes it onto the left ventricle, which pumps it to the rest of the body. When the left side isnt pumping efficiently, blood backs up in the vessels of the lungs, and sometimes fluid is forced out of the lung vessels and into the breathing spaces themselves. This pulmonary congestion causes shortness of breath. The other major symptoms of left-sided heart failure are fatigue, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and the sputum production that comes from pulmonary congestion. Right-sided failure occurs when there is resistance to the flow of blood from the right heart structures (right atrium, right ventricle, pulmonary or lung artery) into the lungs or when the tricuspid valve, which separates the right atrium from the right ventricle, fails to work properly. This results in a backup of fluid and pressure in the veins that empty into the right side of the heart. Pressure then builds up in the liver and the veins in the legs. The liver enlarges and may become painful. The major symptoms of right-sided heart failure are edema and nocturia. The different types of edema possible are dependent edema, edema that results in enlargement or swelling of the liver, ascites, and edema of the skin or soft tissuesComplications of CHF include Kidney damage or failure, Heart valve problems, Liver damage, and Stroke. Heart failure can reduce the blood flow to your kidneys, which can eventually cause kidney failure if left untreated. The valves of your heart may not function properly if your heart is enlarged, or if the pressure in your heart is very high. HF can also lead to a buildup of fluid that puts too much pressure on the liver. This fluid backup can lead to scarring. And because blood flow through the heart is slower than in a normal heart, it's more likely you'll develop blood clots, which can increase your risk of having a stroke.This paper is a case report about N.E., a 59 year old female, Filipino, hypertensive, nondiabetic, with bronchial asthma and is currently diagnosed with Congestive Heart Failure secondary to Acute Coronary Syndrome. Its purpose is to review the Case of a patient with Congestive Heart Failure, know its pathophysiology, preanalytical factors, and treatment and identify possible recommendations for future nursing care.
II. ANATOMY AND PHYSIOLOGYCoronary Artery blood supply of the heart
Veins are blood vessels that carry blood towards the heart Vena Cava(largest vein) carries blood from the body back to the heartRight Atrium receives deoxygenated blood from the bodyTricuspid Valveprevents the backflow of blood between the RA and the RVRight Ventricle pumps deoxygenated blood into the pulmonary arteryPulmonary Artery carries deoxygenated blood from the RV to the lungsPulmonary Vein takes oxygenated blood from the lungs to the LALeft Atrium receives oxygenated blood from the lungsMitral Valve prevents the backflow of blood between the LA and the LVLeft Ventricle pumps oxygenated blood into the aortaAorta (largest artery) takes oxygenated blood from the LV to the bodyArteries are blood vessels that carry blood away from the heartIII. PATHOPHYSIOLOGY
Precipitating Factors:*Heart Disease*Faulty Diet*Tobacco Use*Sedentary Lifestyle*Increased systemic oxygen demand*Previous Heart Attack
Predisposing Factors:*Elderly age (weakened heart muscle)Decreased systemic blood flow
Cardiac Insult:
Increased workload of the right ventricleIncreased workload of the left ventricle
Right-ventricular hypertrophy as (prolonged)Left-ventricular hypertrophy (prolonged)
Weakening of left ventricular pumpWeakening of left ventricular pump
Backflow of blood to the systemic venous circulationBackflow of blood to the pulmonary circulation
Right-Sided Heart Failure:*Cardiomegaly*Hepatomegaly*Cardiac cirrhosis*Congestion of the gastro-intestinal tract with: nausea, anorexia*Anasarca or systemic edema*Ascites*Jugular vein distentionLeft-Sided Heart Failure:*Crackles*Dyspnea*Orthopnea*Paroxysmal *Nocturnal Dyspnea*Cough*Pink, frothy sputum*Cardiac asthma*Cheyne-stokes *respirations
Decreased blood flow to the left cardiac chambers
Cerebral hypoxiaSystemic hypoxiaSystemic hypoxemiaPallorFatigueBody Malaise
Decreased systemic blood flow
IV. PATIENTS PROFILE
Patients Name: PATIENT SJWard Rm: EMERGENCYAge: 73 y/oSex:MALECivil Status: MarriedNationality: FilipinoReligion: CatholicPhysicians Diagnosis:CHF 2CC:DOB
History of Present Illness:A few hours PTC, patient had DOB allegedly synonymous with an asthma attack. She was brought to Chinese General Hospital where CXR was done with unrecalled results and was nebulized 2x with Salbutamol. She was also given Fluimicil, Salbutamol nebulization and was discharged. A few hours later, patient was able to tolerate food but once again experienced DOB. She was nebulized once more and was given Fluimucil when she was noted by her relatives to be gasping, hence consult to MCU-ER
Past Medical History:(+) Bronchial Asthma, last attack June 2015 (+) HPN() DM() Allergy
Family History:(+) HPN, Mother
Personal and Social History:() Smoker() Alcohol drinker
PHYSICAL EXAMINATIONVITAL SIGNS: BP 220/100PR 139 bpmRR GaspingTEMP: 37.1CSKIN: Good skin turgor, warm to touch, no lesion, no rashesHEENT: Anicteric Sclera, PERRLACHEST/LUNGS: Symmetric chest expansion with supraclavicular retractions,clear breath soundsHEART: Adynamic precordium, tachycardic, regular rhythm, (-) murmursABDOMEN: Flabby abdomen, NABS, soft, non-tenderEXTREMITIES: Full and equal pulse, (-) edemaNEUROGICAL: GCS 15
V. LABORATORY PROCEDURESTESTRATIONALENORMAL VALUESACTUAL RESULTSINTERPRETATION
Urinalysis
Done to screen Patient RM for urinary tract infections and to detect metabolic or systemic diseases unrelated to renal disorderColor: Yellow AmberTransparency: ClearpH: 4.5 8.0Sp. Gravity: 1.010YellowTurbid5.01.025Presence of blood, albumin, ketones, and sugar may be a sign of heart failure
NEG Albumin, Sugar, Ketones, Bilirubin, Blood++ Blood, + Albumin, + Sugar, + Ketones
Prothrombin TimeAPTT To determine how long it takes for blood to clot, help recognize bleeding problems
11 14 sec24 35 sec11.2 27.7 WNL
BUNCreatinineSodiumPotassiumThese are markers of renal sufficiency, balance of Na & K indicates how well the kidneys & heart are functioning2.5 6.5 mmol/L58 127 mmol/L135 148 mmol/L3.5 5.3 mmol/L4.64 67.5 142.60102.60WNL
GlucoseTotal CholesterolTriglycerideHDLLDLTotal ProteinAlbuminGlobulinA/G RatioTo determine blood sugar level is within healthy rangeLipid profile can determine approximate risks for CVDTPAG measures the proteins that help maintain circulatory and immunity functions5.05 6.45 mmol/L0 5.2 mmol/L0.40 2.30 mmol/L0.90 1.56 mmol/L1.70 4.60 mmol/L62 85 g/L35 53 g/L27 32 g/L1.5 2 .5 g/L8.16 HIGH9. 30 HIGHWNLWNL7.34 HIGHWNLWNLWNLWNL
High glucose, cholesterol and LDL level may be an indicator of heart disease since the client si hypertensive.
WBCNeutrophilsEosinophilsBasophilsRBCHemoglobinHematocritMCVMCHCPlateletCBC determines blood oxygen levels, inflammatory response, or presence of infection
5.0 10.0 x 109/L40 60 %1 6 % 0 1 %4.5 5.5 x 109/L125 160 g/L0.38 0.50 L/L80 100 fL320 360 g/dL150 450 x 109/L15.2 HIGH 79.8 HIGH WNLWNLWNLWNLWNLWNLWNLWNLThis signals a response to bacterial infection
VI. NURSING CARE PLANAssessmentNsg. DiagnosisPlanningInterventionRationaleEvaluation
Subjective data:Nahihirapan akong huminga, hindi ko malabas yung plema ko, as verbalized by the pt.
Objective data:-abnormal breath sound-use of accessory muscles-having difficulty in vocalizing- restlessness- RR 42 cpm-O2 sat 92Ineffective airway clearance related to difficulty in breathing as evidenced by presence of abnormal breath sounds, use of accessory muscle, restlessness and difficulty of vocalizingAfter 2 hours of nursing interventions, airway patency of the patient will be maintained and signs of dyspnea will be lessen. Positioned the client to High-fowlers position.
Noted the ability to remove secretions or cough effectively
Moistened the air / oxygen inspiration
Monitored breath sounds from time to time
Closely monitored respiration rate and 02 saturation
Encouraged the client to do deep breathing and coughing exercises.
DependentNebulized the patient with Salbutamol + ipratropium as ordered
Administered Fluimucil as orderedTo promote lung expansion.
Expenditures are difficult when there are thick secretions and sputum
Prevents drying of mucous membranes
To check for the accumulation of secretions or respiratory blisters
To maximize breathing effort
Bronchodilator
Mucolytic, will help with the secretionsAfter 2 hours of nursing interventions, airway patency of the patient has been maintained and signs of dyspnea has been lessened.
AssessmentNsg. DiagnosisPlanningInterventionRationaleEvaluation
Subjective data:Nahihirapan akong kumilos, parang ang bigat ng likod at dibdib ko. as verbalized by the patient
Objective data:-weakness-dyspnea-tiredness-limited ROM- PR 104 bpm- BP 180/90Activity intolerance r/t imbalanced O2 supply and demand AEB: Patients statement, Nahihirapan akong kumilos, parang ang bigat ng likod at dibdib ko.weakness, tiredness,dyspnea, limited ROM and ABN BP/pulse response to activityAfter 8 hours of nursing care, the patient will report measurable increase in activity intolerance with vital signs within normal rangePositioned the client to High-fowlers position.
Provide positive and calm atmosphere
Assist patient in self-care activities
Monitor response of patient to an activity and recognize the signs and symptoms
Encourage patient to have adequate bed rest and sleep
Instruct to avoid straining during defecation
DependentAdminister Oxygen therapy as indicatedTo promote lung expansion.
Helps minimize frustrations, rechanneling energy
To promote comfort
To indicate need to alter activity level
To promote relaxation of the body
Valsalva maneuver may disrupt blood flow
To provide sufficient oxygenation of tissuesAfter 2 hours of nursing interventions, airway patency of the patient has been maintained and signs of dyspnea has been lessened.
VII. DRUG STUDYDRUG/CLASSACTIONINDICATIONCONTRAINDICATIONADVERSE EFFECTSNSG INTERVENTIONS
SPIRONOLACTONE K-sparing diureticBlocks aldosterone, causing loss of sodium and water, and retention of potassiumAdjunctive therapy in the TX of edema assoc w/ HF, hypokalemiaAllergy to aldactone, renal disease, anuria, hyperkalemia
Headache, drowsiness, cramping, diarrhea, hyperkalemia Avoid giving food rich in potassium Advise to change positions slowly Monitor electrolytes
CLOPIDOGREL BISULFATEAnti-platelet Blocks ADP receptors to inhibit platelet aggregation At risk for ischemic events, Tx for acute coronary syndromeAllergy to clopidogrel, PUD, intracranial hemorrhage u/c bleeding d/o, hepatic impairmentHeadache, dizziness, rash, GI bleeding if headache, arrange for analgesics Small frequent meals Monitor for increased bleeding
ATORVASTATINDyslipidaemic AgentsInhibits the enzyme (HMG-CoA) that catalyzes cholesterol synthesis
Reduction of elevated total &LDL cholesterolActive liver disease or elevated serum transaminases >3 times the upper limit of normalHeadache, nausea, cough, HPN, palpitation, liver failure Review lipid profile, TPAG results Give drug at bedtime Provide comfort measures
ACETYLCYSTEINEAcetadote, MucomystReduces the viscosity of pulmonary secretions by splitting disulfide linkages between mucoprotein molecular complexes
Adjunct therapy for abnormal viscid or thickened mucous secretions in patients with pneumoniaUse IV formulation cautiously in patients with asthma or a history of bronchospasmnausea, vomiting, and diarrhea or constipationDrug is physically or chemically incompatible with tetracyclines, erythromycin lactobionate, amphotericin B, and ampicillin sodium.
OMEPRAZOLEProton Pump Inhibitors (PPI)Suppresses gastric acid secretion by inhibiting the H+, K+-ATPase enzyme system [the acid (proton H+) pump] in the parietal cells.Short-term treatment of active duodenal ulcer; First-line therapy in treatment of heartburn or symptoms of gastroesophageal reflux disease
Long-term use for gastroesophageal reflux disease, duodenal ulcers; lactationheadache,dizziness, asthenia,vertigo, insomnia, Monitor urinalysis for hematuria and proteinuria. Periodic liver function tests with prolonged use.
IPRATROPIUM + SALBUTAMOLAnticholinergicAnticholinergic drug which relaxes smooth muscle in the lungBronchodilator for maintenance therapy of bronchospasm.Contraindicated with hypersensitivity to atropine or its derivativesCNS: dizziness, blurred visionGI: nausea, dry mouthTeach the patient pursed-lip breathing, diaphragmatic breathing, and chest splinting
PIPERACILLIN / TAZOBACTAMAnti-pseudomonal penicillin
Interfere with bacterial cell wall synthesis promotes loss of membrane integrity and leads to death of the organismnosocomial or community-acquired pneumonia caused piperacillin-resistant, piperacillin/ tazobactam susceptible
Hypersensitivity to penicillins, cephalosphorins, or other drugsdiarrhea, nausea, constipation, vomiting, pseudomembranous colitisMonitor for hemorrhagic manifestations because high dose may induce coagulation abnormalities
ENOXAPARINAnticoagulant, low molecular weight HeparinPotentiates the actions of an endogenous inhibitor of blood coagulationAcute and extended prophylaxis of deep-vein thrombosisIntramuscular use. Use with prosthetic valves due to possible valve thrombosisHemorrhageAnemiaInjection site hematomaNauseaGive only by deep SC while lying down. Do not mix with other injections/infusions
LOSARTAN
Inhibits vasoconstrictive and aldosterone-secreting action of angiotensin II by blocking angiotensin II receptorHypertension, to reduce risk of CVA in patients with hypertension and left ventricular hypertrophyPatients hypersensitive to drug, breast-feeding is not recommendeddizziness, asthenia, fatigue, headache, insomiaMonitor patients who are also taking diuretics for symptomatic hypotension
