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Group 3 - CHF Pathopysiology.pdf - Congestive Heart Failure...

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Unformatted text preview: Congestive Heart Failure Group presentation by: Group 3 Contents 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Case scenario Diagram Medical Diagnosis Etiology Anatomy and physiology Pathophysiology Clinical Manifestation Lab diagnostics test Medical management treatment/ Surgical Management Drug study Nursing care plan Discharge planning Case Scenario Name of Patient: Sex: Age: Nationality: Religion: Patient L Female 60 years old Filipino Roman Catholic Date of Admission: Time: Chief Complaint: Admitting Diagnosis: August 2, 2020 11:30 PM Shortness of breath CHF 1 The Patient is a 60 year-old female presenting to the emergency department with acute onset shortness of breath. Symptoms began approximately 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago with an acute, chronic obstructive pulmonary disease (COPD) exacerbation requiring hospitalization. She uses BiPAP ventilatory due to shortness of breath and wanting to sleep. She denies fever, chills, cough, wheezing, sputum production, chest pain, palpitations, pressure, abdominal pain, abdominal distention, nausea, vomiting, and diarrhea. She does report difficulty breathing at rest, forgetfulness, mild fatigue, feeling chilled requiring blankets, increased urinary frequency, incontinence, and swelling in her bilateral lower extremities that is new onset and worsening. Subsequently, she has not ambulated from bed for several days except to use the restroom due to feeling weak, fatigued, and short of breath. There are no known ill contacts at home. Her family history includes significant heart disease and prostate malignancy in her father. Social history is positive for smoking tobacco use at 30 pack years. She quit smoking 2 years ago due to increasing shortness of breath. She denies all alcohol and illegal drug use. There are no known foods, drugs, or environmental allergies. Past Medical History Past medical history is significant for coronary artery disease, myocardial infarction, COPD, hypertension, hyperlipidemia, hypothyroidism, diabetes mellitus, peripheral vascular disease, tobacco usage, and obesity.Past surgical history is significant for an appendectomy, cardiac catheterization with stent placement, hysterectomy, and nephrectomy. Her current medications include Breo Ellipta 100-25 mcg inhaled daily, hydralazine 50 mg by mouth, 3 times per day, hydrochlorothiazide 25 mg by mouth daily, Duo-Neb inhaled q4 hr PRN, levothyroxine 175 mcg by mouth daily, metformin 500 mg by mouth twice per day, nebivolol 5 mg by mouth daily, aspirin 81 mg by mouth daily, vitamin D3 1000 units by mouth daily, clopidogrel 75 mg by mouth daily, isosorbide mononitrate 60 mg by mouth daily, and rosuvastatin 40 mg by mouth daily. Family History (+) HPN (+) Diabetes (-) Asthma (-) Cancer Physical Examination Initial physical exam reveals temperature 97.3 F, heart rate 74 bpm, respiratory rate 24, BP 104/54, BMI 40.2, and O2 saturation 90% on room air. Constitutional: Extremely obese, acutely ill-appearing female. Well-developed and well-nourished with BiPAP in place. Lying on a hospital stretcher under 3 blankets. HEENT Head:Normocephalic and atraumatic Mouth:Moist mucous membranes, Macroglossia Eyes:Conjunctiva and EOM are normal. Pupils are equal, round, and reactive to light. No scleral icterus.Bilateral periorbital edema present. Neck:Neck supple. No JVD present. No masses or surgical scarring. Throat: Patent and moist Cardiovascular: Normal rate, regular rhythm, and normal heart sound with no murmur. 2+ pitting edema bilateral lower extremities and strong pulses in all four extremities. Pulmonary/Chest: No respiratory status distress at this time, tachypnea present, (+) wheezing noted, bilateral rhonchi, decreased air movement bilaterally. Patient barely able to finish a full sentence due to shortness of breath. Abdominal: Soft.Obese. Bowel sounds are normal. No distension and no tenderness Skin: skin is very dry Neurologic: Alert, awake, able to protect her airway. Moving all extremities. No sensation losses. Admission order Initial evaluation to elucidate the source of dyspnea was performed and included CBC to establish if an infectious or anemic source was present, CMP to review electrolyte balance and review renal function,and arterial blood gas to determine the P02 for hypoxia and any major acid-base derangement, creatinine kinase and troponin I to evaluate presence of myocardial infarct or rhabdomyolysis, brain natriuretic peptide, ECG, and chest x-ray. Considering that it is winter and influenza is endemic in the community , a rapid influenza assay was obtained as well. CBC: largely unremarkable and non-contributory to establish a diagnosis CMP: Showed creatinine elevation above baseline from 1.08 base to 1.81 indicating possible acute injury. EGFR at 28 is consistent with the chronic renal disease. Calcium was elevated to 10.2. However, when corrected for albumin this corrected to 9.8 mg/dL. Mild transaminitis present as seen in Alkaline Phosphatase, AST, and ALT measurements which could be due to liver congestion from volume overload. Initial arterial blood gas with pH 7.491, PCO2 27.6, PO2 53.6, HCO3 20.6, and O2 saturation 90% on room air indicating respiratory alkalosis with hypoxic respiratory features Creatinine Kinase was elevated along with serial elevated troponin I studies. In the setting of her known chronic renal failure, and in the setting of acute injury indicated by tge above creatinine value, a differential of rhabdomyolysis is set. Influenza A and B: Negative ECG Normal sinus rhythm with non-specific ST changes in inferior leads. Decreased voltage in leads I,III, aVR, aVL, aVF. Chest X-Ray Findings: Bibasilar airspace disease that may represent alveolar edema. Cardiomegaly noted. Prominent interstitial markings noted. small bilateral pleural effusions Radiologist Impression: Radiographic changes of congestive failure with bilateral pleural effusions greater on the left compared to the right. 2nd Day of Admission the second day of the admission patient’s shortness of breath was not improved, and she was more confused with difficulty arousing on conversation and examination. To further elucidate the etiology of her shortness of breath and confusion further history was obtained via the patient’s husband. He revealed that she is poorly compliant with taking her medications. He reports that she “doesn’t see the need to take so many pills”. Testing was performed to include TSH, Free T4, BNP, repeated arterial blood gas, CT scan of the chest, and echocardiogram. TSH and free T4 evaluate hypothyroidism. BNP evaluates fluid load status and possible congestive heart failure. CT scan of the chest will look for anatomical abnormalities. An echocardiogram is used to evaluate for left ventricular ejection fraction, right ventricular function, pulmonary artery pressure, valvular function, pericardial effusion and any hypokinetic area. ● TSH: 112.717 (H) ● Free T4: 0.56 (L) ● TSH and Free T4 values indicate severe primary hypothyroidism ● BNP: 187 BNP can be falsely low in obese patients due to the increased surface area. Additionally, adipose tissue has BNP receptors which augment the true BNP value. Also, african american patients more excretion may have falsely low values secondary to greater excretion of BNP. This test is not that helpful in renal future due to the chronic nature of fluid overload. This allows for desensitization of the cardiac tissues with a subsequent decrease in BNP release. Repeat arterial blood gas on BiPAP ventilaion shows pH 7.397, PC02 35.3, PO2 72.4, HC03 21.2, and oxygen saturation 90% on 2L supplemental oxygen. CT Chest without contrast was mainly obtain to evaluate left hemithorax especially retrocardiac area. Radiologist impression: Tiny bilateral pleural effusions. Pericardial effusion. Coronary artery calcification. some left lung base atelectasis with minimal airspace disease. Echocardiogram The left ventricular systolic function is normal. The left ventricular cavity is borderline dilated. The pericardial fluid is collected primarily posteriorly, laterally but not apically. There appeared to be a subtle, early hemodynamic effect of the pericardial fluid on the right-sided chambers by way of an early diastolic collapse of the RA/RV and delayed RV expansion until late diastole. Dedicated tamponade study was not performed. Estimated ejection fraction appears to be in the range of 66% to 70%. The left ventricular cavity is borderline dilated. The aortic valve is abnormal in structure and exhibits sclerosis The mitral valve is abnormal in structure. Mild mitral annular calcification is present. There is bilateral thickening present. Trace mitral valve regurgitation is present. Diagram 2 2 MEDICAL DIAGNOSIS CONGESTIVE HEART FAILURE a serious condition in which the heart doesn’t pump blood as efficiently as it should, the heart muscle has become less able to contract over time or has a mechanical problem that limits its ability to fill with blood. As a result, it can’t keep up with the body’s demand, and blood returns to the heart faster than it can be pumped out—it becomes congested, or backed up. This pumping problem means that not enough oxygen-rich blood can get to the body’s other organs. Etiology Heart failure is caused by several disorders, including diseases affecting the pericardium, myocardium, endocardium, cardiac valves, vasculature, or metabolism ● ● ● ● idiopathic dilated cardiomyopathy (DCM) coronary heart disease (ischemic) hypertension valvular disease. Anatomy & Physiology of the Heart NOVELAS 3 Pathophysiology 4 Clinical Manifestations Patient L has; ● acute shortness of breath ● weak & fatigue ● confusion ● swelling (+2 pitting edema) ● incontinence(increase urinary frequency) Clinical Manifestations The American College of Cardiology/American Heart Association has advocated a staging system for HF (A, B, C, or D) to highlight the need for HF prevention. ● A: High risk of HF but no structural or functional cardiac abnormalities or symptoms ● B: Structural or functional cardiac abnormalities but no symptoms of HF ● C: Structural heart disease with symptoms of HF ● D: Refractory HF requiring advanced therapies (eg, mechanical circulatory support, cardiac transplantation) or palliative care Severe LV failure may cause pulmonary edema or cardiogenic shock . Laboratory and Diagnostic Procedure HOW IS CONGESTIVE HEART FAILURE DIAGNOSED? (a) Comprehensive Assessment of the Heart Muscle (b) Medical history is taken to reveal symptoms. (c) Physical Examination is done. 5 Laboratory and Diagnostic Procedures COMPREHENSIVE METABOLIC PANEL (CMP) Laboratory Test Normal Values Result/Findings Analysis Significance/Interpretation Creatinine 0.59 to 1.04 mg/dL 1. 81 mg/dL High = Possible acute injury and impaired kidney function. BUN (Blood Urea Nitrogen) 6 to 24 mg/dL 28 mg/dL Elevated = Indicative of damaged kidneys EGFR (Estimated Glomerular Filtration Rate) > 60 mL/min 28 mL/min Low = A very low EGFR may indicate chronic kidney disease. 44 – 147 IU/L 148 IU/L Mildly Elevated 8 – 33 U/L 98 U/L High 4 – 36 U/L 46 U/L High 8.6-10.1 mg/dL 10.2 mg/dL Elevated Liver Function Tests ● ALP (Alkaline Phosphatase ● AST (Aspartate Aminotransaminase) ● ALT (Alanine aminotransferase) Calcium = Patient’s liver is not working effectively. = increased risk of developing coronary artery disease and heart attack 5 Laboratory and Diagnostic Procedures INITIAL ARTERIAL BLOOD GAS (ABG) Laboratory Test ● ● ● ● ● pH pCO2 pO2 HCO3 O2 Sat Creatinine Kinase Troponin I Normal Values Result/Findings Analysis Significance/Interpretation 7.35 – 7.45 35 – 45 mmHg 75 – 100 mmHg 22 – 26 meq/L 95% - 100% 7.49 27.6 53.6 20.6 90% Elevated Low Low Low Low = metabolic acidosis = respiratory alkalosis = decreased o2 delivery = metabolic acidosis = inability of the heart to receive oxygenated blood from the lungs, indicative of hypoxia 22 to 198 U/L 202 U/L Elevated = injury or stress to muscle tissue, heart, or brain 0 and 0.04 ng/mL 0.7 ng/mL Elevated = ongoing myocardial injury with an underlying ischemic or non-ischemic mechanism 5 Laboratory and Diagnostic Procedures ELECTROCARDIOGRAM (ECG) > Is a non-invasive investigation that is recommended in the initial evaluation of patients with heart failure. > Sound waves are used to produce images of the heart in motion. This test shows the size and structure of the heart and heart valves and blood flow through the heart. > Sensors attached to the skin are used to detect the electrical signals produced by the heart each time it beats. FINDINGS: Normal sinus rhythm with non-specific ST changes in inferior leads. Decreased voltage in leads I, III, aVR, aVL, aVF. 5 Laboratory and Diagnostic Procedures CHEST X-RAY > Identifies or rules out other possible causes of shortness of breath and fluid buildup in the lungs, including lung problems such as pneumonia or emphysema. FINDINGS: Bibasilar airspace disease that may represent alveolar edema. Cardiomegaly noted. Prominent interstitial markings noted. Small bilateral pleural effusions. Radiologist Impression: Radiographic changes of congestive failure with bilateral pleural effusions greater on the left compared to the right Normal CHF 5 Laboratory and Diagnostic Procedures THYROID FUNCTION TESTS Laboratory Test Normal Values Result/Findings Analysis Significance/Interpretation TSH 0.5 to 5.0 mIU/L 112.17 High = Indicative of hypothyroidism FREE T4 0.7 to 1.9 ng/dL 0.56 mg/dL Low = Indicative of hypothyroidism B-TYPE NATRIURETIC PEPTIDE (BNP) Laboratory Test BNP Normal Values Result/Findings Analysis Significance/Interpretation < 100 pg/mL 187 pg/mL High = cardiac myocytes are strained and may suggest heart failure 5 Laboratory and Diagnostic Procedures CT SCAN of the CHEST > It uses X-ray and computer technology to make detailed pictures of the organs and structures inside the chest. > These images are more detailed than regular X-rays. They can give more information about injuries or diseases of the chest organs. Radiologist Impression: Tiny bilateral pleural effusions. Pericardial effusion. Coronary artery calcification. Some left lung base atelectasis with minimal airspace disease. Normal CHF 5 Laboratory and Diagnostic Procedures ECHOCARDIOGRAM > This test helps in the assessment of left ventricular size, mass and function. > Two-dimensional echocardiography is recommended as an initial part of the evaluation of patients with known or suspected congestive heart failure. Ventricular function may be evaluated, and both primary and secondary valvular abnormalities may be accurately assessed. FINDINGS: The left ventricular systolic function is normal. The left ventricular cavity is borderline dilated. The pericardial fluid is collected primarily posteriorly, laterally but not apically. There appeared to be a subtle, early hemodynamic effect of the pericardial fluid on the right-sided chambers by way of an early diastolic collapse of the RA/RV and delayed RV expansion until late diastole. Dedicated tamponade study was not performed. Estimated ejection fraction appears to be in the range of 66% to 70%. The left ventricular cavity is borderline dilated. The aortic valve is abnormal in structure and exhibits sclerosis. The mitral valve is abnormal in structure. Mild mitral annular calcification is present. There is bilateral thickening present. Trace mitral valve regurgitation is present. 5 Medical Management Non- Pharmacological Treatment ● Limit Sodium ● Be active ● Maintain a healthy weight ● Eat healthy diet ● Stop smoking and drinking alcohol Pharmacological Treatment ● Diuretics such as ( Furosemide, Bumetamide, Toresemide ) ● Inotropic agents such as ( Dobutrex, Primacor ) ● Beta - blockers such as ( Bisoprolol, Carvedilol, Metropolol ) ● Digoxin such as ( Crystodigin, Lanoxin ) 6 Surgical Management Coronary Bypass Surrgery Coronary bypass surgery is a procedure that restores blood flow to your heart muscle by diverting the flow of blood around a section of a blocked artery in your heart. Coronary bypass surgery redirects blood around a section of a blocked or partially blocked artery in your heart. Heart Transplant The procedure is also referred to as orthotopic cardiac graft. A heart transplant is performed when congestive heart failure or heart injury can't be treated by any other medical or surgical means. It's reserved for those individuals with a high risk of dying from heart disease within one or two years. Drug Study REYES&TALLEDO Medication Action Indication Contraindication Adverse Effects Nursing Consideration Generic Name: Pharmacodynamics: Produce analgesia and reduce inflammation and fever by inhibiting the production of prostaglandins. Decreases platelet aggregation Inflammatory disorders including: Rheumatoid arthritis, Osteoarthritis. Mild to moderate pain. Fever. Prophylaxis of transient ischemic attacks and MI. Unlabeled Use: Adjunctive treatment of Kawasaki disease Hypersensitivity to aspirin or other salicylates; Cross-sensitivity with other NSAIDs may exist (less with nonaspirin salicylates); Bleeding disorders or thrombocytopenia May increase risk of Reye’s syndrome in children or adolescents with viral infections. EENT: tinnitus. PO: Administer after meals or with food or an antacid to minimize gastric irritation. Food slows but does not alter the total amount absorbed Aspirin Brand Name: Bayer Classification: non-steroidal anti-inflammatory drug (NSAID) Dosage: 81 mg by mouth daily Pharmcokinetics: Well absorbed from the upper small intestine; absorption from enteric-coated preparations may be unreliable; rectal absorption is slow and variable GI: GI BLEEDING, dyspepsia, epigastric distress, nausea, abdominal pain, anorexia, hepatotoxicity, vomiting. Hemat: anemia, hemolysis. Derm: rash, urticaria. Misc: allergic reactions including ANAPHYLAXIS and LARYNGEAL EDEMA Assess pain and limitation of movement; note type, location, and intensity before and at the peak (see Time/Action Profile) after administration. ● Do not crush or chew enteric-coated tablets. Do not take antacids within 1– 2 hr of enteric-coated tablets. Chewable tablets may be chewed, dissolved in liquid, or swallowed whole. Medication Action Indication Contraindication Adverse Effects Nursing Consideration Generic Name: Pharmacodynamics Management of type 2 diabetes mellitus; may be used with diet, insulin, or sulfonylurea oral hypoglycemics Hypersensitivity; Metabolic acidosis (including diabetic ketoacidosis); Severe renalimpairment (CCr 30 mL/min); Iodinated contrast imaging procedure in patients with CCr 30– 60 mL/min, a GI: abdominal bloating, diarrhea, nausea, vomiting, Do not confuse metformin with metronidazole. unpleasant metallic taste. Instruct patient to take metformin at the same time each day, as directed. Take missed doses as soon as possible unless almost time for next dose. Do not double doses Metformin Brand Name: Glucophage, Glucophage XR, Fortamet, Glumetza, and Riomet. Classification: Therapeutic: antidiabetics Pharmacologic: biguanides Dosage: 500 mg by mouth twice per day Decreases hepatic glucose production. Decreases intestinal glucose absorption. Increases sensitivity to insulin Pharmacokinetics Absorption: 50– 60% absorbed after oral administration. Distribution: Enters breast milk in concentrations similar to plasma. history of liver disease, alcoholism or heart failure, in those who will be administered intra-arterial iodinated contrast F and E: LACTIC ACIDOSIS. Misc: decreased vitamin B12 levels Administer metformin with meals to minimize GI effects. Medication Action Indication Contraindication Adverse Effects Nursing Consideration Generic Name: Pharmacodynamics Hypersensitivity; Recent MI; Hyperthyroidism. levothyroxine sodium CNS: headache, insomnia, irritability. CV: angina pectoris, arrhythmias, tachycardia. High Alert: Do not confuse levothyroxine with lamotrigine or La...
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