NR 526 Week 5 Case Study Assignment: Congestive Heart Failure
Case Study Assignment
Chamberlain College of Nursing
NR 526 Advanced Pathophysiology,
... [Show More] Health Assessment, and Pharmacology for Nurses
Case Study Topic (health condition related to your case study): Congestive Heart Failure
Objectives:
1. At the end of this simulation the student will state the physiological basis for the clinical manifestations of heart failure.
2. At the end of this simulation the student will describe expected clinical assessment findings for patients with heart failure.
3. At the end of this simulation the student will discuss the standard pharmacological therapies for chronic heart failure.
4. At the end of this simulation the student will explain nonpharmacological therapies for management of heart failure.
5. At the end of this simulation the student will describe expected outcomes for therapeutic management of patients with heart failure.
Case Study:
Mr. Connors has arrived at the Emergency Department at his local hospital. He is a 69-year-old male whose chief complaint is shortness of breath. He is alert and oriented. Past medical history includes myocardial infarction, congenital heart disease, and hypertension. Mr. Connors is an every day smoker and has been for the past 40 years. When asked about his diet he does not follow a cardiac healthy diet. Mr. Connors states he has noticed an increase in his shortness of breath of the past week. He has also noticed increased swelling in both of his lower extremities. Mr. Connors denies any recent cold but has noticed a cough that produces white or pink blood-tinged mucus. He also complains of a tired feeling all the time and difficulty with everyday activities. He denies any chest pain. Crackles can be auscultated to right and left lower lobes. Patient is short of breath with minimal activity. Vital signs read a blood pressure of 179/82, pulse 88, respirations 22, O2 saturation of 94%. +2 pitting edema noted to bilateral lower extremities. Heart rate is regular. When asked about a support system at home patient states he lives at home with his wife and that his sons stop by often to help him with up keep of the house. Mr. Connors states he is very social with his family and often hosts large family cookouts on Sundays. Denies any anxiety or thoughts of self-harm.
Current Patient Medications
Metoprolol Tartrate 25mg PO BID
Aspirin 81 mg PO Daily
Multivitamin 1 Tab PO Daily
Fish Oil 500 mg PO Daily
Dr. Coor the attending ER physician has ordered a one time dose of Lasix 20 mg IV push, an EKG, echocardiogram, chest xray, blood work for a BNP, CBC, BMP, and strict intake and output monitoring.
Results
EKG – Regular sinus rhythm with notable PACS.
Echocardiogram – Thickening of the left ventricle, ejection fraction of 40%.
Chest X-Ray – Noted cardiomegaly, alveolar edema, and haziness of vascular margins.
BNP - 900 pg.mL
Nursing Interventions
Monitor strict intake and output of patient. Respiratory assessments including changes in lungs sounds and increasing shortness of breath. Will maintain patient o2 saturation level >90%. Minimal activity as tolerated. Monitor increase or decrease in peripheral edema. Administer Lasix as ordered. Monitor vital signs report any abnormal readings to MD. Educate patient to elevate lower extremities. Educate patient on cardiac healthy diet.
Risk Factors Non-modifiable
Past myocardial infarction, congenital heart defect
Risk Factors Modifiable
Hypertension, every day smoker, poor diet
Signs and Symptoms
Peripheral edema, shortness of breath, increase in fatigue from performing everyday activities
Psychosocial Factors
Patient seems it have a good support system at home. However large family gatherings could promote poor dietary choices.
Priority Interventions
Reduce excess systemic fluid load with diuretic, stabilize blood pressure
Questions Referenced Rationale
Pharmacology
Medications are an important component in the long-term treatment of heart failure. Which of the medications list below would be routinely prescribed for Mr. Connors in the treatment of heart failure?
A. Lisinopril
B. Eliquis
C. Seroquel
D. Lipitor
Correct Answer – A
Rationale
Lisinopril is an ace inhibitor. “ACE inhibitors are among the first-line drugs for patients with HF, especially those with impaired left ventricular systolic dysfunction (Caple & Uribe, 2016).” Many studies have confirmed the benefits of the use of ace inhibitors in heart failure patients in improving mortality, reducing hospitalizations and emergency department visits, and reducing HF symptoms (Caple, 2016).
Medication is an important component of the long-term management of heart failure. Therefore, knowing the first line drugs in the treatment of heart failure is an essential piece in the heart failure patient.
Pathophysiology
How does uncontrolled hypertension increase the patient’s heart failure risk?
When caring for any patient it is important that the student have knowledge of the patients diagnosis in order to provide high quality care and aid in developing a plan of care. Knowledge of the pathophysiology of heart failure will aid the student in recognizing patient risk factors and developing a plan to reduce modifiable risk factors.
In the case of Mr. Connors one of his most important risk factors is his poorly controlled hypertension despite taking his prescribed Metoprolol. Poorly controlled hypertension can increase left ventricular afterload and left ventricular diastolic pressures which can result in reduced stroke volume. These effects are estimated to increase the risk of HF 3-fold compared with normotensive patients. Therefore, hypertension may be a prognostic indicator of the development of heart failure before clinical manifestations occur in a patient. (Gheorghiu & Barkley, 2017).
Physical Assessment
Upon assessing Mr. Connors it was noted that he had +2 pitting edema to bilateral lower extremities. Is this a common sign of heart failure?
As a nurse it is important to interpret findings in the physical assessment and what they mean regarding the patient’s current health status.
Peripheral edema can occur due to decreased cardiac output. As blood flow out of the heart slows, blood returning to the heart through the veins backs up, causing fluid to build up in the tissues. The kidneys are less able to dispose of sodium and water, also causing fluid retention in the tissues.
“Of the signs and symptoms associated with fluid accumulation, lower limb edema is the most accurate clinical parameter for a reproducible assessment of peripheral congestion as it occurs in about 60% of patients with ADHF and in 20% with chronic heart failure” (Massari et al., 2016).
References
Caple, C. M., & Uribe, L. M. (2016). Heart Failure: Treatment with ACE Inhibitors. CINAHL
Nursing Guide,
Gheorghiu, V., & Barkley Jr, T. W. (2017). Identification and Prevention of Secondary Heart
Failure: A Case Study. Critical Care Nurse, 37(4), 29-35. doi:10.4037/ccn2017478
Massari, F., Iacoviello, M., Scicchitano, P., Mastropasqua, F., Guida, P., Riccioni, G., & Di Somma,
S. (2016). Care of Patients with Heart Failure: Accuracy of bioimpedance vector analysis
and brain natriuretic peptide in detection of peripheral edema in acute and chronic
heart failure. Heart & Lung - The Journal of Acute And Critical Care, 45319-326.
doi:10.1016/j.hrtlng.2016.03.008 [Show Less]