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...
View
Full Document
