CHF case study

A Case Presentation of Congestive Heart Failure secondary to Coronary

Artery Disease

Objectives

At the end of this case study, the learner should be able to:

Understand Congestive Heart Failure

Recognize its clinical signs and symptoms

Identify causative factors of the Heart Failure

Learn the medical and surgical management

Know perioperative care in meeting patient’s needs

Congestive Heart Failure Is the insufficiency of the cardiac output to supply the metabolic

needs of the peripheral tissue caused by insufficient pump.

The most common reason for hospitalization in adults >65 years old.

Complications of CHF are Kidney damage or failure, Heart valve problems, Liver damage and Stroke

Management of CHF: Increase Cardiac Contractility – DigitalisReduce Preload – Diuretics and Rotating torniquet Reduce Afterload – Vasodilators and Rest

Classifications of Heart FailureClassification Symptoms

Stage A High risk of heart failure but no structural heart disease or symptoms of heart failure

Stage B Structural heart disease but no symptoms of heart failure

Stage C Structural heart disease and symptoms of heart failure

Stage D Refractory heart failure requiring specialized interventions

2 Types of problems in congestive heart failure:

1. Systolic dysfunction occurs when the heart can't pump enough blood to supply all the body's needs.

2. Diastolic dysfunction occurs when the heart cannot accept all the blood being sent to it.

Etiology

o Damage to muscular wall (M.I)

o Cardiomyopathy

o Hypertesion

o Coronary Artery Disease

o Valvular Defects

o Infections

Signs and Symptoms:

Signs and Symptoms:

Anatomy and Physiology

Pathophysiology

Patients Profile

Name: R.M.G

Ward Rm: SMW (Special Monitoring Ward) Bed #4

Age: 61 y/o

Sex: Male

Civil status: Married

Birth place: Valenzuela city

Nationality: Filipino

Religion: Catholic

Adm. Date and Time: 9/5/14

Type of admission: SPECIAL MONITORING WARD BED#4

Physician’s Diagnosis: COGENITAL HEART FAILURE SECONDARY TO CORONARY ARTERY DISEASE.

Physical Examination

VITAL SIGNS: BP 130/80 PR :89 RR: 24 TEMP: 36

SKIN: (-) Rashes

HEENT: conjuctival erythema, + puffy eyelids

CHEST: SCE

HEART: dynamic precordium, AB 5th intercostal

LUNGS: (-) rales

ABDOMEN: globular, soft, everted umbilicus

GENITALIA: + swelling

RECTUM: N/A

EXTREMITIES: grade 2-3 bipedal edema

NEUROGICAL: GCS 15

ADMITTING DX: Congestive Heart Failure Secondary to Coronary artery disease.

Patient’s HistoryChief Complain: Edema

History of Present illness:

3 Months PTA, patient noted on and off SOB, 2 week PTA noted bipedal edema. 1 week PTA noted puffy eyelids 2 days PTA consulted VMC, CXR ECG done.

Past Medical/Surgical History:

(-) HPN / Edema

Family History

NONE

Personal Social History:

Smoker

Alcohol drinker

Diagnostic Tests

TEST RESULT UNIT REFERENCES NORMAL VALUE

BUN 14.57 mmol/L high 2.50 – 6.50

CREATININE

154.2 mmol/L high 58.0 -127

SODIUM 131.60 mmol/L low 135.0 – 148.0

POTASSIUM 4.83 mmol/L 3.50 -5.30

CHLORIDE 98.10 mmol/L 98.00 – 107.00

Serum TestSeptember 9, 2014

Diagnostic Tests: Abnormal FindingsTEST NAME RESULT UNIT REFERENCES NORMAL VALUES

BUN 14.57 mmol/L high 2.50 – 6.50

CREATININE 154.2 mmol/L high 58.0 -127

SODIUM 131.60 mmol/L low 135.0 – 148.0

HEMOGLOBIN 162 g/L high 125-160

HEMATOCRIT 0.518 g/L high 0.380-0.500

GLUCOSE 3.68 mmol/L low 5.05-6.45

HDL 0.5 mmol/L low 0.90-1.50

TOTAL PROTEIN 61.6 g/L low 62.0-85.0

URINE: BACTERIA few

UTZ Minimal bilateral effusion. ascites

Gordon’s 11 Functional Health Pattern

1.Health perception /health management

Patient is a 62-year-old, male, married. Diagnose with congestive heart failure secondary to coronary artery disease. He cannot describe thoroughly about his condition due to unconsciousness.

2. Nutritional metabolic

Before

Patient has complete meals ( breakfast, lunch and dinner) and has usually fluid intake of 8-12 glasses /day.

Now

He’s on a diet of low fat, low salt. And limits fluids 1L/day. With all needs attended. With PNSS inserted.

3. Elimination

BLADDER:

Before

He can void 4-5x a day without any pain felt.

Now

He wears a diaper that is soaked weighing 800 gms (800ml) at the end of the shift.

4. Activity/ exercise

Before

He has no work due to his age. And always stay at their house and make fun to his family and to his grandson/granddaughter.

Now

He is on bed over a long period of time.

5. Cognitive- perception

Before

He is a college graduate of a school they did not mention. According to the significant others, he has no deficit to his sensory perception (hearing and sight)and he’s able to read and write.

Now

He is experiencing difficulty of breathing due to his condition. And he cannot talk since he was admitted because he is stroke. And he is still unconscious

6. Sleep- Rest

Before

He has a good sleep- wake cycle. He usually sleeps at 9 pm and awakes at 6-7 am to help her family in their house work.

Now

He has sleep disturbance due to always experiencing difficulty of breathing.\

7. Self perception/ Self concept

According to the significant others, the patient is a good father and husband to his wife. He is very dedicated to his work before when he is still strong. He sometimes smoke and drink alcohol but not all the time.

8. Role-Relationship

Communication:

Before

According to significant others, before his speech is clear. And he can speak Tagalog and English.

Now

He cannot communicate due to his condition. He just nod when nurse’s, doctor’s and his relatives talk to him.

9. Sexuality –reproductive

According to the significant others, he has a wife with 6 siblings.

10. Coping /stress tolerance

According to the significant others, that whenever he has a problem, he shares it to his family member in order to solve it.

11 .Value –Belief

According to the significant others, patient is a Catholic since birth. He did not change into any religion.

Course in the Ward

• Doctor’s Notes Nurse’s Notes

• Admit to SMW• Monitor VS q2• LSLF diet• Limit fluid 1L a day• Heplock• Labs: CXR – ECG • CBC- BUN – CREA – PT, PTT –

HGT – TPAG – FBS – • Furosemide 20mg IV q6 BP

>110/70• Spironolactone 50g 1tab OD• Rosuvastatin 20g 1tab OD• Trimetazidine 35g 1tab BID• Clopidogrel75g 1 Tab OD• I & O every shift

• Admitted 62 - year-old male diagnose with congestive heart failure

• received patient from ER accompanied by relative and nurse on duty

• With heplock intact• With foley cath connected to

urine bag with o2 support via nasal cannula

• Elevated blood pressure• Labs requested • Meds given• Place a low salt low fat diet • Limit fluids 1L/day• BP : 130/80

September 5, 2014

Doctor’s Notes Nurse’s Notes

• Decrease furosemide to q8• Decrease VS every 4 hour•

• Fluid volume excess• On bed with heplock • With o2 support via nasal

cannula• With foley cath connected to

urine bag • Ordered to limit fluid to 1L

per day • Diuretic given with BP• VS taken • Advise significant other to

assist with ADL•

September 6, 2014


• Increase Furosemide 20 mg q6

• Whole abdominal utz

• Fluid volume excess• On bed with heplock • With o2 support via nasal

cannula• With foley cath connected to

urine bag • Ordered to limit fluid to 1L

per day • Diuretic given with BP• VS taken • Advise significant other to

assist with ADL

September 7, 2014


• Repeat CXR• Ceftriaxone 2g IV q12 (-)ANST

• To continuity of care• On bed conscious, with

heplock• Checked safety and

comfortability • O2 inhalation via nasal

cannula • Seen and examined by Dra.

Aguilla with order made and come out needs attached for whole abdomen Ultrasound (UTZ) On 9/9/14 at 1 p.m

• Maintained and encouraged deep breathing and relaxation technique.

• Noted still within episode of difficulty of breathing endorsed to next shift.

September 8, 2014


• Decrease furosemide 20 gram IV every 8 hours x 1 day, then reassess

• On bed, conscious, slightly dyspnic, with o2 support via nasal cannula at 2pm.

• Promote rest and maintained on high back rest, encourage deep breathing exercise.

• Still with o2 support via nasal cannula.

• Reported of difficulty of breathing mild to moderate to next shift.


• Paracetamol 1 ampule every 4 hours ANST(-) Temp: 38.5 C

• Paracetamol TIV 1 tab every 4 hour ,T: 37.8 C

• Ineffective breathing pattern• On bed , tachypnic concerns.• Vital sign taken • Kept at o2 support, Temp. 38.6

September 9, 2014

September 10, 2014


• Continue Furosemide 20mg IV q8

• Refer labs once available

• On bed, conscious, with heplock inserted, not to distress.

• Checked safety and comfortability

• Oral meds recorded

September 11, 2014


• Shift IV Furosemide to 40mg tab BID

• VS every shift• Cefixime 200mf cap BID• Bladder training x 2 cycles

• Continuing of care• Vital signs taken, oral meds

given• Put side rails up for the

patients safety

September 12, 2014


• Shift Furosemide IV to 40 mg tabs BID

• Decrease VS to every shift• Shift ceftriaxone to cefixime

200 mg caps

• On bed with body weakness, with o2 support via nasal cannula

• Vital sign taken, kept patients comfortable

• Medication given, encouraged in deep breathing exercise

September 13, 2014


• MGH• Follow up check-up after 1

week

• Rounds made by Dr. Aguilla with may go home ordered

• Meds given & instructed• Advise follow – up check- up

after 1 week

September 14, 2014

Drug Study

DRUG CLASS ACTION INDICATION CONTRAINDICATIONADVERSE EFFECT

NURSING INTERVENTION

PARACETAMOL(Antipyretic, Nonopiod)

Acts directly on heat-regulating center to cause vasodilation and sweating

Temporary reduction of fever, back and muscle aches

Allergy to acetaminophen u/c impaired hepatic, chronic alcoholism

Headache, Dyspnea, hepatic toxicity and failure

Shake well before use give drug with food DC if hypersensitivity occurs

Ceftriazone3rd generation cephalosporin

Inhibits synthesis of bacterial cellwall causing celldeath.

Intra-abdominal infections caused by E.coli, Klebsiella pneumoniae

Contraindicated with allergy to cephalosporins or penicillins. Use cautiously with renal failure, lactation, pregnancy

PainIndurationPhlebitisRashDiarrheaThrombocytosisLeucopeniaGlossitisRespiratory superinfections

Assess patient for signs and symptoms of infection before and during the treatment

AldactoneSpironolactonePotassium-sparingdiuretic

Completely blocks the effects of aldosterone in the renal tubule, causing loss of sodium and water and retention of potassium

Primary hyperaldosteronism, adjunctive therapy in the therapy in the treatment of edema associated with CHF, nephritic syndrome, hepatic cirrhosis, treatment of hypokalemia

Acute renal insufficiency, progressive renal failure, hyperkalemia, and anuria. Clients receiving potassium supplements, amiloride or triamterene

Dizziness, headache, drowsiness, rash, cramping, diarrhea, hyperkalemia, hirsutism, gynecomastia, deepening of the voice, irregular menses

Instruct client not to drive/operate machinery until drug effects are realized may cause drowsiness or uneasy gait.

DRUG CLASS ACTION INDICATION CONTRAINDICATION ADVERSE EFFECT

NURSING INTERVENTION

Rosuvastatin calciumCrestor

Lowering high cholesterol and triglycerides in certain patient. It also increases high-density lipoprotein cholesterol levels.

an adjunct to diet in the treatment of elevated total cholesterol, mixed dyslipidemia, atherosclerosis

hypersensitivity, impaired hepatic function, alcoholism, renal impairment, advanced age, hypothyroidism

Nausea, dyspepsia, diarrhea, constipation, vomiting, rhinitis, sinusitis, cough, dyspnea, pneumonia

- Monitor patient closely for signs of muscle injury, especially higher doses - Provide comfort measures to deal with headache, muscle cramps, or nausea

Vastarel MRTrimetazidine dihydrochloride

acts by directly counteracting all the major metabolic disorders occurring within the ischemic cell.

Long treatment of coronary insufficiency, angina pectoris.

Do not take Vastarel MR if you are allergic to any of the constituents.This drug is generally not recommended during breast feeding

Rare cases of GI disorders.

use cautiously in patients with heart failure or hypertension and in elderly patients.

DRUG CLASS ACTION INDICATION CONTRAINDICATION

ADVERSE EFFECT

NSG INTERVENTION

Clopidogrel 75 mg 1 tab PO OD

Anti-platelet agents Platelet aggregation inhibitors

Reduction of atherosclerotic events in patients at risk for such events including recent MI, acute coronary syndrome stroke, or peripheral vascular disease.

Use Cautiously in:Patients at risk for bleeding. History of GI bleeding/ulcer disease Severe hepatic impairment

(CNS) Headache, dizziness, and myasthenia. (GI) N & V and incontinence. ( CV) Hypotension. (SKIN) Flushing pallor sweating and increased perspiration

Assess patient for symptoms of stroke, peripheral vascular disease, or MI periodically during therapy

Betamethasone dipropionate>Corticosteroid(long acting)>Glucocorticoid>Hormone

Betamethasone is a synthetic (man-made) corticosteroid that is used topically (on the skin).

Ulcerative colitis, acute exacerbations of MS, and palliation in some leukemias and lymphomas Trichinosis with neurologic or myocardial involvement

Hypersensitivity Systemic fungal or acute infections

Acne, cracking and stinging of the skin; dryness; excessive hair growth; inflamed hair follicles; itching; skin irritation

Give daily dose before 9 AM to mimic normal peak corticosteroid blood levels. Increase dosage when patient is subject to stress.

ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTIONS

RATIONALE EVALUATION

Subjective:“Nanghihina ako, dalhin niyo na ako sa hospital.” as verbalized by the patient. Objective: Weaknes

s Irregular

rhythm of pulse

Pale conjunctiva and nail beds

Paleness dystrhyth

mia

Decreased cardiac output r/t altered heart rate and rhythm.

After series (2-3 days) of nursing interventions, the patient’s cardiac output will be in its normal limits; BP, peripheral pulses strong and equal with adequate capillary refill time and decrease frequency or absence of dysrhythmias.

1. Review signs of impending failure/shock, nothing vital signs, invasive hemodynamic parameters, breath sounds, heart tones, and urinary output.

2. Assess patient’s skin temperature; evaluate quality and equality of pulses as indicated.

3. Monitor cardiac rhythm continuously.

4. Note response to activity and promote adequate rest by decreasing stimuli, providing quiet environment, schedule activities and assessments.

5. Give oxygen as indicated by patient’s symptoms, oxygen saturation and ABGs.

6. Provide for diet restrictions with frequent small feeding or easily digested meal and provide fluid as indicated. (may need to consider electrolyte replacement)

1. Note presence of pulsus paradoxus, reflecting cardiac tamponade.

2. Decreased cardiac output results in diminished weak/thready pulses. Irregularities suggest dysrhythmias which may require further evaluation or monitoring.

3. To note effectiveness of medication/ devices.

4. To maximize sleep periods. Overexertion increases oxygen consumption/ demand.

5. Increase amount of oxygen available for myocardial uptake, reducing ischemia and resultant cellular irritation/ dysrhythmias.

6. To maintain adequate nutrition and fluid balance.

After 2-3 days of nursing interventions, the patient display hemodynamic stability; w/ normal cardiac output, strong and equal peripheral pulses, absence of dysrhythmias and the patient appeared relax.



Subjective:“Hindi ako gaanong makagalaw, parang ang bigat sa pakiramdam.” as verbalized by the patient. Objective: Limited ROM Abnormal

pulse and rhythm

Generalized weakness

(+) DOB

Activity intolerance r/t imbalance oxygen supply and demand as evidenced by limited ROM, generalize weakness and DOB.

After series (2-3 days) of nursing interventions, the patient will report measurable increase in activity intolerance w/ HR and BP within its normal limits, and skin warm, pink and dry.

1. Encourage rest (bed/chair) initially. Thereafter, limit activity on basis of pain/ adverse cardiac response. Provide non-stress divertional activities.

2. Adjust client daily activities and reduce intensity of level. Instruct patient to avoid increasing abdominal pressure. (ex. Straining during defecation) give stool softener as indicated.

3. Review signs and symptoms reflecting intolerance of present activity levels.

4. Provide positive atmosphere, calm and quiet environment, while acknowledging difficulty of the situation for the client.

5. Promote comfort measures and provide for relief of pain.

6. Assist the client in position, elevate head of bed, and encourage changing position slowly.

1. Reduces myocardial workload/ oxygen consumption, reducing risk of complication.

2. Activities that required holding the breath and bearing down (valsalva maneuver) can result in bradycardia (temporarily reduced cardiac output) and rebound tachycardiaw/ elevated blood pressure.

3. Palpitations, pulse irregularities, development of chest pain, or dyspnea may indicate need for changes in exercise regimen or medication.

4. Helps minimize frustration, rechannel energy.

5. To enhance ability to participate in activities.

6. Allows better chest expansion and reduce risk for orthostatic hypotension.

After 2-3 days of nursing interventions, the patient progressive increase in tolerance and participating in activities for his wellness and increase strength of his extremities w/ good color of skin.



Subjective:“Hindi ako makahinga, sumisikip at parang may nakadagan sa dibdib ko.” as verbalized by the patient. Objective: Weaknes

s Productiv

e cough Dyspnea Pursed-

lip breathing

Abnormal pulse rate and rhythm

Pale Difficulty

vocalizing

Ineffective breathing pattern r/t fatigue and decreased lung expansion secondary to CHF

After series (2-3 days) of nursing interventions, the patient’s respiratory pattern will be effective without causing fatigue.

1. Observe breathing pattern for SOB, nasal flaring, pursed-lip breathing or prolonged expiratory phase.

2. Position the patient in optimal body alignment in semi-fowler’s position for breathing.

3. Assess for concomitant pain/ discomfort.

4. Suction airways as needed.

5. Encourage slower/ deeper respirations, used of pursed-lip technique, and so on.

6. Instruct to avoid overeating/ gas-forming foods.

7. Assist patient to use relaxation technique.

8. Encourage client to develop a plan for smoking cessation.

9. Encourage adequate rest periods between activities.

1. Presence of nasal flaring and use of accessory muscles of respirations may occur in response to ineffective ventilation.

2. To open or maintain open airway/ to maximize lung ventilation.

3. That may restrict/limit respiratory effort.

4. To clear secretions.5. To assist client in

“taking control” of the situation.

6. May cause abdominal distension.

7. To reduce stress/ decrease tension level, to enhance sense of well being.

8. To promote wellness

9. To limit fatigue and enhance comfort.

After 2-3 days of nursing interventions, the patient improve his breathing pattern, maximizing respiratory effort with good posture and effective use of accessory muscle without causing fatigue.



Subjective:“bago naming siya dalhin sa hospital, nanlalambot at nanghihina siya at masakit daw ang dibdib nya.” as verbalized by the relative. Objective: (+) chest

pain Pain scale of

7/10 (+) DOB Mouth

breathing Weakness Pale (+) edema

on lower extremities

Ineffective tissue perfusion r/t decreased cardiac output

After series (2-3 days) of nursing interventions, the patient will demonstrate behaviors to improve circulation, increased perfusion as individually appropriate and no pain.

1. Assess the response to medication every 5 minutes.

2. Provide quiet, restful atmosphere.

3. Provide oxygen and monitor oxygen saturation via pulse oximetry as ordered.

4. Elevate head of bed.

5. Teach patient relaxation techniques and how to use them.

6. Encourage adequate rest period. Reposition the patient every 2 hours.

7. Encourage client to quit smoking, join stop-smoking programs.

8. Provide for diet restrictions. (ex. Reduction of cholesterol and triglycerides, high or low in protein, small frequent feedings.

1. To know the effectiveness of the medications.

2. Conserves energy/ lowers tissue oxygen demand.

3. Increase amount of oxygen available for myocardial uptake, reducing ischemia and resultant cellular irritation or dysrhythmias.

4. To take advantage of gravity decreasing pressure on the diaphragm and enhancing ventilation to different lung segments.

5. To reduce stress/ decrease tension level, to enhance sense of well being.

6. To prevent fatigue and to enhance comfort.

7. Smoking cause vasoconstriction and May further compromise perfusion.

8. To maintain adequate nutrition and to promote wellness.

After 2-3 days of nursing interventions, the patient circulation was improve with good perfusion, pain scale 7/10 to 0/10 no pain and discomfort, and the patient appeared relax.



Subjective:“Nahihirapan akong huminga, parang may sagabal sa lalamunan ko.” as verbalized by the patient. Objective: (+) DOB Difficulty

vocalizing

Cough Changes

in respiratory rate and rhythm

Pale conjunctiva and nail beds

Ineffective airway clearance r/t retained secretions as evidenced by presence of rales/crackles sounds upon auscultation

After series (2-3 days) of nursing interventions, the patient will be able to establish and improve airway clearance as evidenced by absence of signs of respiratory distress, reduction of congestion w/ breath sounds clear and improved RR.

1. Monitor respirations and breath sounds, noting rate and sounds.

2. Position head midline with flexion appropriate for age or condition.

3. Auscultate breath sounds and assess air movement.

4. Encourage deep breathing and coughing exercises.

5. Elevate head of bed/ change position every 2 hours and PRN.

6. Observe for signs/ symptoms of infection.

7. Instruct patient to have adequate rest periods and limit activities to level of activity intolerance.

8. Support reduction/ cessation of smoking.

9. Administer oxygen therapy and other medication as ordered.

1. Provides a basis for evaluating adequacy of ventilation.

2. To open or maintain open airway in at rest or compromised individual.

3. To ascertain status and note progress.

4. Breathing exercises help maximize ventilation.

5. To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of/ ventilation to different lung segments.

6. To identify infectious process/ promote timely intervention.

7. Prevents/ lessens fatigue.

8. To mobilize secretion.

9. Deliver low to moderate levels of oxygen to relieve hypoxia.

After 2-3 days of nursing interventions, the patient improve his airway clearance w/ absence of rales and crackle sounds, absence of respiratory distress and good RR.

Discharge Planning

MEDICATION

Advice/instruct the client to continue medication that are prescribed by the physician andtheir actions. Instruct the patient or the significant others for any observable alterations on the patient condition.

EXERCISE

Instruct the patient to perform leg exercise as tolerated such as walking to facilitate mobilization on lower extremities.

THERAPY

Instruct the patient to continue medication. Also, activities of daily living and self-caretraining are important to encourage maintenance of hygiene.

HEALTH TEACHING

• Encourage the patient to increase fluid intake

• Encourage the patient to eat foods rich in vitamins and minerals/ nutritious food

• Encourage the patient to avoid salty and fatty foods

• Encourage the patient to have enough rest

OUT-PATIENT CARE

Instruct the client to come back for follow-up check-up as scheduled by the attending physician.

DIET

Advised the patient to a Diet as Tolerated but preferably avoiding saltyand fatty foods

SPIRITUAL/ SEXUAL ADVICE

Encourage the patient learn to accept responsibility for their own physical, emotional,mental, and spiritual healing.

Documents

CHF case study