Case Study Mijares

CONGESTIVE HEART FAILURE A Case Presentation

Introduction Cardiac failure is the pathophysiological state in which the heart is unable to pump blood at a rate commensurate with the requirements of the metabolizing tissues or can do so only from an elevated filling pressure.” Eugene Braunwald “

Congestive heart failure (CHF) represents a complex clinical syndrome characterized by abnormalities of left ventricular function and neurohormonal regulation, which are accompanied by effort intolerance, fluid retention, and reduced longevity” Milton Packer

Heart Failure: Epidemiology  Burden of CHF is staggering  5 million in US (1.5% of all adults)  500,000 cases annually In the elderly 6-10% prevalence  80% hospitalized with HF  250,000 death/year attributable to CHF

Diagnostic Work-up In all cases •History, exam, ekg •Echocardiogram Etiology • Labs •TSH, ferritin, Na, Cr •Exercise testing

• Assessment of CAD One of few reversible causes •In selected cases Labs Catheterization CAD Hemodynamics •Endomyocardial biopsy If infiltrative disease considered

Heart Failure is a Clinical Diagnosis Major Criteria • Orthopnea/PND • Venous distension • Rales • Cardiomegaly • Acute pulmonary edema

Minor Criteria • Ankle edema • Night cough • Exertional dyspnea • Hepatomegaly • Pleural effusion • Tachycardia (>120) • Decrease VC • Weight loss with CHF tx

Direct Causes • 1- Myocardial abnormalities (CHD!) 2- Hemodynamic overload 3- Ventricular filling abnormalities 4- Ventricular dyssynergy 5- Changes in cardiac rhythm

Aggravating Factors regnancy

•P • Endocarditis

• Obesity •

Arrhythmias (AF)

• Hypertension

Infections

• Physical activity

•

• excess • Dietary Thromboembolism • Hyper/hypothyroidism

Symptoms (involving Involving gravity/exhaus circulation tion of heart Swelling of the ankles, legs, and hands Orthopnea, or the shortness of breath when lying flat Shortness of breath during exertion

Involving congestion

Cyanosis, or a Unexplained or bluish color that is unintentional seen in the lips and weight gain fingernails from a Chronic cough lack of oxygen Increased urination Fatigue or Distended neck weakness veins Rapid or irregular Loss of appetite or heart beat indigestion Changes of behavior such as restlessness, confusion, and decreased attention

The Donkey Analogy • Ventricular dysfunction limits a patient's ability to perform the routine activities of daily living

Patient’s Profile • Name : Patient X : Linuk, Bauyan, Lanao del Sur • Address : 58 years old • Age : Female • Sex • Birth date : January 18, 1950 • Occupation : housewife • Religion : Islam

Nursing Health History • Chief Complaint: Dyspnea • History of Present Illness 7 days PTA patient suffered difficulty in breathing associated with cough and fever. Cough and fever usually occurred during waking up in the morning when patient usually feels like her chest was slightly compressed.

Patient’s blood pressure was also high, 170/90 mmHg. She complained of difficulty in breathing every time she lies down flat on bed. She sought medical attention in a local health center and was prescribed with medications which only gave temporary relief. The problem gradually worsened thus the patient was advised for

Past History Childhood illnesses  chicken pox at age 7  streptococcal infection at ages 9 and 12 Childhood immunization status  unrecalled

Allergies  no known allergies to food, drugs, animals and other environmental agents Accidents and injuries  no accidents and injuries recalled except for minor cuts, scalds and bruises Past hospitalization  patient is admitted for the first time

Family History Patient had positive heredofamilial history for cardiac disease as her father died of an unrecalled cardiac illness eventually leading to cardiac arrest. She cannot recall if there is a member of the family who had cancer. Most of her relatives from ages 40 above have problems on blood sugar level.

• Hypertension runs common among her siblings and relatives. Evidence of obesity in their family is not recognized. Her parents had complained of osteoarthritis past 60's. No family member, both paternal and maternal side, was diagnosed of tuberculosis. Likewise, no family member suffered from any mental illness

Social Data • Though patient does not eat pork, her cholesterol level is high this is because the patient loves to eat especially chicken. Patient is also a smoker for 30 years. • Patient’s highest educational attainment is high school. • Since she was married, she never took any job and concentrated on taking care of her family.

• Patient’s medical care is shouldered by the spouse. • She live in a typical rural neighbourhood where people usually rely on natural resources they have in the area.

Physical Assessment SYSTEM PROCEDU OBJECTIV SUBJECTIV PROBLE RE E E M IDENTIFI ED General Assess for Conscious, Pt. Fatigue Appearanc LOC signs coherent, verbalized Anxiety e of distress fatigued, “Dili ko Altered anxious makatulog Sleeping ug tarong Pattern tungod kay nabalaka ko sa akong sakit, ug kapoy akong pamati sako lawas,

Head, Face and Neck

Head – Normocepha “Pt. NONE inspect for lic verbalized size, shape, No “Wala man and tenderness nagsakit tenderness Ears: (-) akong ulo, Ears – hearing loss makakita whisper, Eyes: ug Weber and PERRLA, makadung Rhine’s test anecteric og rapud Peripheral – sclerae ko ug ayo” 6 cardinal Eyebrows: PERRLA – Present use of bilaterally, penlight move External eye symmetricall – shape, y with facial symmetry, changes conjunctiva, sclera

IntegumentaryAssess for color, lesions, temp. turgor, texture and mobility

Nose

Mouth

Macular – area, patency, size and symmetry

Cold clammy Pt. verbalized Impaired skin T= 36.5 “Dili man Skin No lesions katol akong Integrity Bruises on lawas” “Naay left arm and lagom sa ako wrist kamot tungod sa tambal”

Symmetric Patent No discharges No deformities Symmetry, Symmetric swelling, No Swelling size and Pale lips placement Dry mucus of tongue, membrane color of lips, Tongue is

Pt. verbalized NONE “Ok raman, wala ko gisipon”

Pt. verbalized Altered “Dili man ko Mucus maglisod ug Membrane kaon”

Gordon’s Functional Health Pattern

Functional Pattern Health Describes Pattern

Patient’s Data

Health Perception/ Health Management

Client's perceived pattern of health and well-being and how health is managed

Patient is compliant with medication treatment regimen and annual checkups.

NutritionalMetabolic

Pattern of food and fluid consumption relative to metabolic need and pattern; indicators of local nutrient supply

patient eats 3x a day with snacks, is properly groomed but slightly heavy for height

Elimination

Patterns of excretory function (bowel, bladder, and skin) includes client's perception of normal" function.

Patient has regular daily elimination and normal urination pattern

Activity Exercise

Patterns of exercise, activity, leisure, and recreation.

Patient’s ADLs include household chores ; walking to market is the

Cognitive- SensoryNo evidence of Perceptual perceptual and memory loss or cognitive sensory patterns. impairment was observed. Sleep-Rest Patterns of sleep, Patient sleeps 8 rest, and hours and has rest relaxation. periods during the day. SelfClient's selfPerception concept pattern / and perceptions Self of self. Concept

Patient is somewhat insecure of her weight but feels comfortable in interacting with the interviewer.

RoleClient's pattern of Patient has good Relationshi role engagements perception of current p and relationships. major roles and responsibilities (e.g., father, husband, and salesman); satisfied with family, work, or social relationships. Sexuality- Patterns of Patient has 7 histories of Reproductiv satisfaction and pregnancy and 6 e dissatisfaction with childbirths; she has no sexuality pattern; difficulties with sexual reproductive pattern. functioning and is satisfied with sexual relationship. Coping / Stress Tolerance

General coping Patient has usual manner pattern and effective of handling stress, has of the pattern in available support terms of stress systems, can perceive tolerance. ability to control or

Value - Belief Patterns of values, beliefs (including spiritual), and goals that guide client's choices or decisions.

Active with religious affiliation. She perceives value-belief conflicts related to health, special religious practices are important in life .

Normal Anatomy • The heart is a muscular organ in all vertebrates responsible for pumping blood through the blood vessels by repeated, rhythmic contractions. The term cardiac means "related to the heart" and comes from the Greek καρδία, kardia, for "heart."

Physiology

• The heart has four separate compartments or chambers. The upper chamber on each side of the heart, which is called an atrium, receives and collects the blood coming to the heart. The atrium then delivers blood to the powerful lower chamber, called a ventricle, which pumps blood away from the heart through powerful, rhythmic contractions.

• The human heart is actually two pumps in one. The right side receives oxygen-poor blood from the various regions of the body and delivers it to the lungs. In the lungs, oxygen is absorbed in the blood. The left side of the heartreceives the oxygen-rich blood from the lungs and delivers it to the rest of the body.

Blood circulation flow

Schematic Diagram Predisposing Factors • age • gender

Precipitating Factors • • • • • •

diet high in sodium,fats diet high in cholesterol sedentary lifestyle smoking alcohol intake overweight

hypertension coronary artery disease congenital heart disease dilated cardiomyopathy lung disease heart tumor

right-sided heart failure

left-sided heart failure

Comparative Chart Classical Clinical Rationale Manifestations Manifestatio ns Left-sided Heart Failure Dyspnea on exertion

manifested

Exertion gives congested lungs additional workload thus making patient dyspneic

orthopnea

manifested

Lying flat compresses the lungs making the patient orthopneic

Pulmonary crackles

manifested

Fluid-filled lungs cause these noises upon expiration due to

Right -sided Heart Failure

tachycardia

manifested Heart pumps faster to meet body’s requirements for oxygen

Cool extremitiesmanifested Warm blood only reaches peripheral vessels in small amount due to poor pumping action fatigue

manifested Fatigue is due to less oxygen- carrying blood circulating around the body

Pitting edema

Not Edema primarily occurs manifested because of the body’s retention of too much salt which causes body to retain water

Weight gain

manifestedWater leaks into the interstitial spaces, where it appears as edema, thus harder to excrete making the weight increase

oliguria

manifestedPatient has less urine output due to decreased volume of fluid circulating the body

Diagnostic Results   2D echo /Doppler

Interventricular septal hypertrophy Segmental hypokinesia Mild mitral regurgitation Mild pulmonary hypertension Mild pericardial effusion

Chest X-ray (PA View)

Right basal pneumonia with suggestive minimal pleural effusion Moderate Cardiomegaly with pulmonary congestion and hypertension

Complete Blood Count Compone nts Hemoglobi n Hematocrit

Normal Value

Result

120-170

120

0.37-0.54

0.36

WBC neutrophils

4.5-10 .5-.7

8 0.73

Lymphocyt es

.20-.40

0.26

Lipid Profile Component s Cholesterol Triglycerides HDL LDL Glucose Creatinine

Normal Value 220 200 30-85 60-180 70-107 .7-15

Result 247.96 97.88 35.77 192.61 115.4 1.4

NURSING CARE PLANS I. Problem Subjective data Objective data

: difficulty in breathing : “ Maglisod ko ginhawa, labin na kung maghigda,” as verbalized by patient : dyspnea orthopnea RR 74 CXR film: cardiomegaly with pulmonary congestion and hypertension

Nursing Diagnosis : Ineffective breathing pattern r/t lung congestion as evidenced by verbalized complaint of dyspnea and orthopnea Plan : After 5 days of holistic nursing care, the patient will be able to achieve effective breathing pattern evidenced by: a.respiratory rate, rhythm and depth in normal parameters b.b. absence of dyspnea and orthopnea

Intervention Measures to :

Rationale

1. assess respiratory rate1. Assessment provides a and pattern and report baseline for evaluating for any increase in rate, changes. Increases in RR, retractions or retractions, nasal flaring and development of nasal grunting indicate respiratory grunting or flaring distress. 2. position pt on his side 2. Proper positioning with his head slightly facilitates drainage of lower than the rest of his secretions from airway body 3. monitor patient’s 3. Exposure to cold increases temperature and keep the metabolic rate, increasing him warm via radiant need for oxygen thus warmer or wrap closely in increasing RR

Health Teaching Plan Objective

Time Allotmen t

At the end 20-30 of the minutes health teaching, the patient will be able to gain adequate knowledge, skills and attitude towards achieving control of hypertensio n

Content Outline

Materials Teaching Needed Strategie s

Control of Hypertension 1.Healthy eating 2. Reducing sodium in diet 3.Maintaining healthy weight 4.Engaging in appropriate physical activity 5.Quitting smoking 6.Curtailing drinking of alcoholic beverages

Textbook Discussio with n pictures Q&A Diagrams Pamphlet s

Drug Record I. Generic name : Furosemide Trade name : Lasix General classification : Diuretic Route, dose, frequency : 10 mg IVTT q 6 hrs Mechanism of Action : stops reabsorption of sodium and chloride in the proximal tubule and loop of Henle; : decreases cardiac preload by increasing venous capacity causing quick diuresis

Indications Side effects

Nursing Consideration s

Edema due to cardiac, hepatic & renal disease, burns; mild to moderate hypertension, hypertensive crisis, acute heart failure, chronic renal failure, nephrotic

Check BP first before administering     Contraindicated in patient hypersensitive to drug

hypotension, dry mouth, hypochloremia, hypokalemia, hyponatremia, hypercalcemia, hyperglycemia, and ECG change secondary to electrolyte disturbances.

EVALUATION, RECOMMENDATION, PROGNOSIS Heart failure is a serious disorder that carries a reduced life expectancy. Many forms of heart failure can be controlled with medication, lifestyle change, and correction of any underlying disorder. Heart failure is usually a chronic illness, and it may worsen with infection or other physical stressors. The patient having CHF has poor prognosis which gets even poorer if she won’t adhere to recommendations. There is 5-year survival around 50% and about 20% survive longer than 8-12 years for patients who have Congestive Heart Failure. •

Patient is recommended to her strict treatment regimen to improve her condition and alleviate the symptoms brought about by the presence of her disease. The patient should also cease smoking because smoking cessation reduces morbidity and mortality in all populations - those with heart failure as well as other health conditions. And lastly patient should be educated on her activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen, because Heart failure is a chronic health condition.

Special thanks to Ms. Christian Bulos