Heart FailureCase Study

What is Heart Failure?Heart Failure is a condition that causes the muscle in the heart wall to slowly weaken and enlarge, which prevents the heart from pumping enough blood to your body.

Incidence and prevalence

• One of the most common reasons that people age 65 and older go to the hospital.

• HF affects about 5.1 million Americans

• One in NINE deaths in 2009 included HF as a contributing cause

Incidence and prevalence

• Men more likely to die than women from HF (over age of 55)

• 71% Men died over a 15 year period from HF

• 39% Women died over a 15 year period from HF

Healthcare Cost

• HF costs the nation $32 BILLION each year. Includes health care costs, medications and missed days of work.

Genetics?

• Genes for cardiomyopathies

• Genes for myocyte contractility

• Neurohumoral receptors

Heart Failure Video• http://www.youtube.com/watch?v=GnpLm9fzYxU

Heart Failure BINGO• Cross off “HEART” Bingo squares as you hear the HF signs or

symptoms

• FREE box in the middle HEART FAILURE

• When you get a row (up, down, across or horizontally) you have to stand up and say “I have Heart Failure”

• You must then tell everyone your signs and symptoms of HF

• Questions?

Patient’s Name: J.M.

Age: 70 years old

Chief Complaint: Very tired, SOB last

2 days, swelling of ankles to ‘the

size of tree trunks’

Case Study Internal Care

Clinic

Medical History: J.M. has been

coming to the clinic for several

years for management of CAD.

Pt. also has hypertension and

anemia.

Assessment:

- SOB when pt climbs stairs at

home. Becomes exhausted and

has to put feet up.

- Irritating, non productive cough.

- In last 2 days as eaten Chick-fil-

a, a bag of salted peanuts and

ham sandwich.

- Denies palpitations

- Patient states that he feels

dizzy.

Case Study Internal Care

Clinic

Assessment:

- Pt suffers from orthostatic

hypotension

- Pt’s shoulder has been ‘killing’

him the last few months. Hard

to get comfortable.

- Decreased exercise tolerance

- 2 pillow orthopnea

Case Study Internal Care

Clinic

Vitals- BP 142/83

- 18 BPM- Temp 97.9

- Pulse 105

Case Study Internal Care

Clinic

Heart History:

- 02/01/2013

- Cardiac Cath showed 50%

stenosis of circumflex

coronary artery

Case Study Internal Care

Clinic

Heart History:

- 01/10/14- X ray showed cardiomegaly

Case Study Internal Care

Clinic

NORMAL HEART XRAY J.M.’S XRAY

Heart History:

- 01/10/14- X ray showed cardiomegaly

- 12 lead ECG - LBBB

Case Study Internal Care

Clinic

J.M.’s Lab resultsPatient Normal results

Na: 136 mmol/L 135 - 148

K: 5.2 mmol/L 3.5 – 5

BUN: 15 mg/dl 7 – 18

Creatinine: 1.8 mg/dl 0.7 – 1.3

Glucose: 82 mg/dl 70 - 110

CI: 95 mmol/L 98 – 106

WBC: 4.4 thou/cmm 5 – 10

Hgb: 10.5 g/dl 13.5 – 17.5

Hct: 31.4% 40 – 54%

Platelets: 229 thou/cmm 150 - 350

Case Study Internal Care Clinic

Lab Value Note…The hemoglobin and hematocrit levels might be falsely decreased because of hemodilution of HF.

Physical Heart+Circulation:

- Slow peripheral capillary refill

- Edema, non pitting on both

ankles- Cool damp skin surrounding

ankle edema

- Tachycardia

- Arrhythmia

- Murmurs

Case Study Internal Care

Clinic

Physical Lungs:

- Bilateral crackles

Case Study Internal Care

Clinic

Lasix 40mg by mouth twice a day

What other classes of meds could be prescribed?

• Inotrope (digoxin) - to increase cardiac contractility and CO

• Vasodilator (ACE inhibitor) – to increase organ perfusion and coronary artery perfusion

• Beta Blockers – Help open up BV and slow down HR

• ARB – Prevents vasoconstriction from Angiotensin II keeping the BP from rising

Banana vs. K SupplementTo get the same amount of K from a banana that the supplement provides, he would have to eat a banana that is 4 feet long!

4 feet!The supplement also comes in a drink form.

Lifestyle Modifications• Gradually increase exercise• Minimize stress• Learn to take pulse• Avoid very hot or very cold environments• Report 2-5lb weight gain over 1-4 days• Take medications faithfully• Carefully monitor salt intake

BAD salty foods

A Registered DieticianJ.M. needs to be educated on the foods that are high in sodium. He obviously does not understand that some foods are high in sodium even without adding salt.

A RD can provide information and teach J.M. how to read food labels, and make low-sodium food modifications.

Nursing DiagnosesActivity Intolerance r/t fatigue, generalized weakness, lack of adequate oxygenation aeb client’s SOB climbing the stairs to his bedroom and his need to lie down and rest (“put his feet up”) at least an hour twice a day.

Activity Intolerance Interventions• When appropriate, gradually increase activity.

• Monitor the client and report the client’s ability to tolerate activity: note pulse rate, blood pressure, monitor pattern, dyspnea, use of accessory muscles, and skin color before, during, and after the activity.

• Encourage routine low-level exercise periods such as a daily short walk or chair exercises.

• Refer to medical social services as necessary to assist the family in adjusting to major changes in pattern of living because of activity intolerance.

Nursing DiagnosesDecreased Cardiac Output r/t impaired cardiac function and altered heart rate aeb tachycardia, (pulse of 105), orthopnea, prolonged capillary refill, edema, and fatigue.

Decreased CO Interventions• Monitor and report presence and degree of symptoms including dyspnea at rest

or with reduced exercise capacity, orthopnea, paroxysmal nocturnal dyspnea, nocturnal cough, distended abdomen, fatigue, or weakness.

• Place client in semi-fowler’s or high fowler’s position with legs down or in a position of comfort.

• Check blood pressure, pulse, and condition before administering cardiac medications such as ACE inhibitors, ARBs, digoxin, and beta blockers.

• Encourage small, frequent, sodium-restricted, low saturated fat meals.

Nursing DiagnosesExcess fluid volume r/t compromised regulatory mechanism (weakened heart, ventricles, decreased CO) aeb SOB, orthopnea, increased pulmonary congestion, peripheral edema.

Excess FV Interventions• Monitor daily weight for sudden increases; use same scale and type of clothing at

same time each day, preferably before breakfast.

• Administer prescribed diuretics as appropriate; check blood pressure before administration to ensure it is adequate. If IV administration of a diuretic, note and record the blood pressure and urine output following the dose.

• Teach about signs and symptoms of both excess and deficient fluid volume such as darker urine and when to call the physician.

Community resources• Caregiver Support-http://www.heart.org/HEARTORG/Conditions/HeartFailure/PreventionTreatmentofHeartFailure/For-Heart-Failure-Caregivers_UCM_306366_Article.jsp

• St. Vincent’s Mobile Health Outreach Mobile health unit that delivers care to rural and indigent areas (serves Clay, Duval, Nassau, Putnam, St. Johns and Volusia counties)

Community resourcesOnline Support Groups

Mended Hearts-Heart Disease- http://mendedhearts.org/

Daily Strength-Heart Failurehttp://www.dailystrength.org/c/Heart-Failure/support-group

Heart Failure Mattershttp://www.heartfailurematters.org/EN/What-can-you-do/Support-groups

NCLEX Question time!An elderly client is being monitored for evidence of congestive heart failure. To detect early signs of heart failure, the nurse would instruct the certified nursing attendant (CNA) to do which of the following during care of the patient?

a. Observe electrocardiogram readings and report deviations to the nurse.b. Assist the client with ambulation three times during the shift.c. Monitor vital signs every 15 minutes and report each reading to the nurse. d. Accurately weigh the patient, and report and record the readings.

NCLEX Question time!Which of the following drug classifications should the nurse question if prescribed for a person with congested heart failure (CHF)?

a. Angiotensin-converting enzyme (ACE) inhibitorb. Beta-adrenergic blockerc. Alpha adrenergic antagonistd. Rosiglitazone (Avandia)

NCLEX Question time!A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles and the nurse suspects pulmonary edema. The nurse immediately asks another nurse to contact the physician and prepares to implement which priority inventions? Select all that apply.

a. Administering oxygen.b. Inserting a foley catheterc. Administering furosemide (Lasix)d. Administering morphine sulfate intravenously.e. Transporting the client to the coronary care unit.f. Placing the client in a low fowler’s side-lying position.

NCLEX Question time!One hour after administering IV furosemide (Lasix) to a client with heart failure, a short burst of ventricular tachycardia appears on the cardiac monitor. Which of the following electrolyte imbalances should the nurse suspect?

a. Hypocalcemiab. Hypermadnesemiac. Hypokalemiad. Hypernatremia

NCLEX Question time!Which of the following symptoms is most commonly associated with left-sided heart failure?

a. Hepatic engorgementb. Arrhythmiasc. Cracklesd. Hypotension

NCLEX Question time!Correct answer: D. Accurately weigh the patient, and report and record the readings.

Rationale: Due to fluid accumulation, an expanded blood volume can result when the heart fails. Body weight is a sensitive indicator of water and sodium retention, which will manifest itself with edema, dyspnea –especially nocturnal- and pedal edema. Patients should be instructed about the need to perform daily weights upon discharge to monitor body water. It is not within the role of the CNA to monitor ECG readings, and ambulation is not an assessment. Vital signs every 15 minutes are not necessary for this level of patient care.

NCLEX Question time!Correct answer: D. Rosiglitazone (Avandia)

Rationale: Thiazolidinediones, like rosiglitazone (Avandia), are glucose-reducing drugs that are prescribed for persons with type 2 diabetes mellitus. ACE inhibitors, such as Lisinopril, are first-line drugs used to treat CHF. Propranolol (Inderal), a beta blocker, has remained one of the most widely used beta-blocking drugs. It blocks both beta1 and beta2 receptors in various organs, resulting in reduction of heart rate and force of contraction, and suppresses impulse conduction through the AV node, all of which slows the progression of the disease process. Carvedilol (coreg) is another beta-adrenergic blocker used to treat heart failure.

NCLEX Question time!Correct answer : a, b, c, dAdministering oxygen, inserting a foley catheter, administering furosemide, administering morphine sulfate intravenously.

Rationale: Pulmonary edema is a life-threatening event that can result from severe heart failure. In pulmonary edema, the left ventricle fails to eject sufficient blood, and pressure increases in the lungs because of the accumulated blood. Oxygen is always prescribed, and the client is placed in a high fowler’s position to ease the work of breathing. Furosemide, a rapid acting diuretic, will eliminate accumulated fluid. A foley catheter is inserted to measure output accurately. IV administered morphine sulfate reduces venous return (preload), decreases anxiety, and reduces the work of breathing. Transporting the client to the coronary care unit is not a priority intervention. In fact, this may not be necessary at all if the client’s response to treatment is successful.

NCLEX Question time!Correct answer: c. Hypokalemia

Rationale: furosemide is a potassium-depleting diuretic that can cause hypokalemia. In turn, hypokalemia increases myocardial excitability, leading to ventricular tachycardia

NCLEX Question time!Correct answer : c. Crackles

Rationale: Crackles in the lungs are a classic sign of left-sided heart failure. These sounds are caused by fluid backing up into the pulmonary system. Arrhythmias can be associated with both right and left-sided heart failure. Left-sided heart failure causes hypertension secondary to an increased workload on the system.

The foods that are killing ushttp://www.ted.com/talks/dean_ornish_on_the_world_s_killer_diet.html

Thank you!