Nursing Case Study Heart Failure

Nursing Case Study Heart Failure

The term “heart failure” can be scary but it doesn’t mean the heart has stopped working.  Rather, it means the heart doesn’t pump as well as it should. Heart failure is a major health problem affecting many people and is the leading cause of hospitalization in people older than 65 in US. There is need to let people with heart failure know that they can enjoy better health and quality of life if they take good care of themselves. This nursing case study heart study heart failure answers explores cases of heart failure and answers related questions.

 

J.S. is a 78-year-old male patient who is experiencing congestive heart failure after abdominal surgery. He has received digoxin for the past 4 days and has been progressing favorably. J.S. is usually very alert and entertaining. He is a sports fanatic, and he especially loves football. When the nurse enters the room, the patient is watching a football game on the television. The patient asks, “Why are those guys hitting each other and falling on the ground?” The patient is also confused as to the date and his location.

What does the nurse suspect is the cause of the sudden onset of confusion?

Decreased cerebral circulations and poor gas exchange: Deceased CO caused decreased cerebral circulation and poor gas exchange.

Digoxin Toxicity: too much intracellular toxicity. Common side effects are confusion, dizziness, drowsiness & trouble seeing

  1. What laboratory test does the nurse expect to be ordered? What outcome does the nurse expect?

Digoxin Test

BNP B-type natriuretic peptide (the higher the level, the worse the heart level) (other reasons pulmonary embolism, renal failure, and acute coronary failure)

Other tests:

Kidney function tests

Liver tests

CBC

Urine Analysis

A higher level of BNP suggests worse heart failure.

  1. What treatment option does the nurse expect to administer?

Diuretics/ Fluid restictions

ACE-inhibitors

Angiotensin II Receptor Blockers

Aldosterone Antagonists

Vasodilators

Oxygen

Digoxin immune fab (digibind)- antidote to digoxin

ACE- inhibitors (name suffix, mech of action)

Med name end in “pril” (e.g. benazepril, captopril, lisinopril, ect)

Mech of Action

Angiotensin-converting enzyme inhibitors (ACE inhibitors) are medications that slow (inhibit) the activity of the enzyme ACE, which decreases the production of angiotensin II. As a result, blood vessels enlarge or dilate, and blood pressure is reduced. This lower blood pressure makes it easier for the heart to pump blood and can improve the function of a failing heart

Digoxin Test Value

Therapeutic Range: 0.5-0.8

What signs/symptoms should you immediately evaluate in the E.D.?

Consciousness, signs of deliium, patient airway, spontaneous breathing, chest motion, breath sounds, pulse, chest movement symmetry, B.P., and temp.

*Mainly look for symptoms of RDS, shock, and mental impairment.

 

What therapeutic equipment should be ready for emergency treatment in the E.D.?

O2 therapy, intubation equipment, resuscitation bag and mask, O2 reservoirs, fluids, and drugs.

What are the possible causes of RDS? (both cardiac and respiratory)

Pulmonary edema, left ventricular failure, exacerbations of COPD, myocardial infarction, or pulmonary infection.

How does a left ventricular failure affect lung function?

LV failure induces pulmonary hypertension. It increases lung water, WOB, and airway resistance. Causes alveolar edema, V/Q mismatch, diffusion defect, hypoxemia, and ventilatory failure. While reducing pulmonary compliance.

What are the signs and symptoms of heart failure?

Rapid onset of dyspnea, anxiety, tachycardia, low B.P., inspiratory crackles, JVD, skin cool to touch, pedal edema, and poor peripheral circulation.

What will diagnostic tests help determine the cause of RDS?

ABG, chest x-ray, ECG, B.P., blood count, oxyhemoglobin saturation, and assessment of cardiac enzymes.

How do cardiac arrhythmias contribute to C.F.?

The out of porition rate with B.P. contributes to acute H.F.

Interpret these findings and relate them to H.F.:

Temp.- 37.5 C

R.R.- 31

H.R.- 160

BP- 100/70

Capillary Refill- 5 secs

Inspiratory crackles are bilateral bases, dim expansion, accessory muscles, JVD, pedal edema, calm, clammy skin, and digital cyanosis.

R.R., use of accessory muscles, and dim expansion indicate dyspnea

H.R. shows tachycardia

Cap. Refill time of 5 secs indicates poor circulation related to edema, cool and clammy skin, and digital cyanosis.

Along with JVD and crackles

*All signs/symptoms of H.F.

What X-ray findings are consistent with cardiogenic pulmonary edema?

Cardiomegaly, bilateral vascular engorge, interstitial and alveolar edema, atelectasis, and Kerley B lines

Interpret the ABG:

7.24/51/44/22

(on a simple mask at 9Lpm)

Hematocrit- 45%

Hemoglobin- 15 g/dl

RBC- 5.2×106

Platelets- 262,000

Respiratory Acidosis with moderate hypoxemia

Normal blood count with slight WBC elevation, possibly due to infection

What respiratory and cardiac treatment is typical in H.F.?

Respiratory: CPAP, BiPAP, Vent., Intubation, bronchodilator.

Cardiac: ECG, B.P., IV, drug therapy, electro cardioversion, fluid retention with diuretics, vasodilators

 

How does increased urine output increase oxygenation?

Reduces pulmonary edema

What is the intended outcome of cardioversion?

Cardioversion uses shock to stop all electrical activity in the heart to get it back to normal rhythm and rate.

Interpret and recommend treatment for this ABG:

7.26/51/49/24 with a SaO2 of 79%

PaO2/FiO2 ratio- 49

P9A-a)02- 660 mmHg

Acute Respiratory Acidosis with moderate hypoxemia

Give masked CPAP or BiPAP and bronchodilators to lower WOB

Right-sided heart failure

The heart cannot move blood from the body to the lungs effectively.

Blood staying in the body effects

Since the blood stays in the body, it causes systemic edema and for the organs to swell, such as hepatosplenomegaly, congestion of G.I. (nausea & G.I. problems), distended jugular veins

Not enough blood going to the lungs

Less blood going to the lungs causes activity intolerance, fatigue, weakness and confusion, and angine (pain in the heart) because the blood is not receiving oxygenated air.

Tricuspid Regurgitation

The tricuspid valve is not closing properly, causing blood to leak/flow backward. Because the tricuspid is supposed to close during systole, you will hear the murmur as the blood flows back up to the atria, causing atrium overload.

Stretches out because its walls are thin. The stretched atrium will then release the hormone atrial natriuretic peptide (ANP), making the person pee out salt & water, causing the blood volume to decrease and decreasing ejection fraction.

 

INCREASE HEART RATE

When your cardiac output is low, your SNS turns on, causing your adrenal glands to release more norepinephrine (adrenaline), which travels in the bloodstream and stimulates your heart to beat faster)

INCREASE PERIPHERAL VASCULAR RESISTANCE

When there is reduced blood flow, the RAAS releases renin & angiotensin II, which act as a potent vasoconstrictor that increases peripheral vascular resistance.

Adaptations to keep cardiac output the same

Myocardial hypertrophy

The heart increases in size because the cardiac muscle cells don’t have an oxygenated blood supply, which weakens them.

This means they have to grow larger to do the same work as normal cells.

They need more oxygen and perform less efficiently, so they are prone to heart failure and may suffer sudden death during exertion.

Atrium overload #2

If blood is sitting in the atrium, it forms mural thrombi clots. Mural thrombi could get loose and be washed into the blood, which then turns into emboli and blocks smaller arteries

When the artery is blocked, it causes myocardial infarction (dead tissue because its blood supply was cut off)

Warfarin is prescribed as a blood thinner to reduce the formation of blood clots in the veins and arteries.

If warfarin is not taken, the arteries that contain the mural thrombus could cause myocardial infarction of the arteries leading to Atherosclerosis.

Atherosclerosis

The myocardial infarction (damaged artery) begins to accumulate with fatty deposits (plaques) made of cholesterol and other cell waste products.

 

If the surface of the plaque ruptures, platelets will clump @ the site to try to repair it, causing even more blockage in the artery leading to a heart attack.

LDL

LDLs deposit in injured areas of the blood vessel wall. In the wall, they begin to oxidize.

This attracts monocytes.

Monocytes migrate into the tissues and become macrophages.

They eat the oxidized lipids.

Now the macrophages full of lipid are called ‘foam cells.’

Foam cells secrete inflammatory mediators, causing a chronic inflammatory state leading to unstable plaques that will eventually rupture and cause a clot to form that blocks the artery, which leads to myocardial infarction.

Atrium overload #3

Rt. Atrium specifically is affected when overloaded & stretched because the pacemaker (S.A. node) is located there and could be damaged, causing arrhythmia & EKG changes with the P wave being altered

Atrial Flutter

occurs and caused by her hypertrophy (tall peaked P waves) & pulmonary embolism from atrium overload

Terms in this set (24)

Which findings indicate that the patient is experiencing RIGHT-sided heart failure?

-fatigue

-dyspnea

-peripheral edema

-tachycardia

-peripheral edema

 

Upon admission to the cardiac care unit, the patient’s dyspnea continues. He reports fatigue but denies chest pain. The nurse implements an oxygen per nasal cannula at 3L/min and a cardiac telemetry monitor. The ECG recording shows no discernible P waves and a rapid, irregularly irregular ventricular response (QRS complexes). This corresponds with his heart rate, which is 136 is irregularly irregular.

 

Which cardiac dysrhythmia is Arnie likely experiencing?

-asystole

-ventricular fibrillation

-sinus tachycardia

-atrial fibrillation

atrial fibrillation

 

Based on the acuity of the pt’s sx, the diagnosis of heart failure, and the diagnosis of A. fib, which action should the nurse implement first?

-call his family to notify them of the hospitalization

-administer a state dose of IV diltiazem

-administer a PO dose of digoxin

-prepare for synchronized cardioversion

-administer a state dose of IV diltiazem

 

Following the dose of IV diltiazem, a calcium channel blocker, the pt’s H.R. slows to 88, but he is still in A. fib. The provider prescribes the following meds:

Digoxin 0.25 mg PO daily (cardiac glycoside)

furosemide 40 mg IV push now and daily (loop diuretic)

captopril 12.5 mg PO 3x per day (ACE inhibitor)

docusate sodium 100 mg P.O. daily (stool softener)

Carvedilol 3.125 mg P.O. twice daily (alpha and beta-adrenergic blocker)

coumadin 5 mg PO (anticoagulant)

Which focused assessment is the priority before the administration of captopril?

-apical pulse

-urine output

-blood pressure

-respiratory rate

blood pressure

 

The nurse should monitor for which expected outcome of digoxin therapy?

-S1 and S2 heart sounds present

-a decrease in the serum potassium level

-slowing of the heart rate

-resolution of the apical-radial pulse deficit

-slowing of the heart rate

 

The nurses collaborate on a plan of care for the patient. Which nursing diagnoses should be included in the pursuit of care? (select all that apply)

-fluid volume deficit

-impaired gas exchange

-ineffective airway clearance

-activity intolerance

-decreased cardiac output

-impaired gas exchange

-activity intolerance

-decreased cardiac output

Which intervention should be implemented based on the diagnosis of activity intolerance?

-encourage regular aerobic exercise

-provide six small meals daily

-provide complete assistance for all activities of daily living

-encourage frequent rest periods

-encourage frequent rest periods

 

The nurse enters the room and finds the pt lying in bed in a supine position. His R.R. is 32. What action should the nurse implement first?

-elevate HOB

-notify the charge R.N.

-notify the R.T.

-assist him in turning on his side

-elevate HOB

 

Which additional intervention will be included in this gentleman’s care plan? (select all that apply):

-elevate legs and monitor them for skin changes

-monitor serum electrolytes and coagulation panel

-monitor VS and SpO2 every shift

-monitor I&O’s

-weekly weights

-fall precautions

-elevate legs and monitor them for skin changes

-monitor serum electrolytes and coagulation panel

-monitor I&O’s

-fall precautions

 

The nurse placed the pt on fall precautions bc of safety concerns r/t several drugs in his medication orders. Which medications have desired effects or S/E that put him at risk for falls? (select all that apply):

-carvedilol

-coumadin

-docusate sodium

-furosemide

-captopril

-furosemide

-captopril

-carvedilol

 

The pt responds well to the plan of care and is anticipating D/C. The nurse reinforces teaching regarding his digoxin therapy. Which instructions should the nurse review w/ him? (select all that apply)

 

-“Report visual changes or nausea and vomiting to your provider.”

-“If your H.R. is less than 60, do not take the dose of digoxin and call your provider.”

-“If a dose of digoxin is missed, you can double the next dose.”

-“Monitor your B.P. before taking your dose of digoxin.”

-“If the prescribed potassium supplements bother your stomach, you can stop taking them.”

-“Report visual changes or nausea and vomiting to your provider.”

-“If your H.R. is less than 60, do not take the dose of digoxin and call your provider.”

 

The pt is D/C’d and goes back home. He lives alone in the home where he and his wife raised their family. His daughter checks on him frequently.

 

The pt returns to the clinic several weeks later for routine lab tests. He complains to the nurse that he is dizzy, has a headache, is “seeing double” and has had 2 diarrhea stool days. He thinks he has the flu and reports that he has been taking aspirin for the headache. The nurse notes that his apical pulse is 60 and irregular.

 

What is the most critical intervention for the nurse to implement?

-instruct him on alternative medications for pain relief

-ask for further information about the diarrhea

-do a complete pain assessment for the headache

-review the results of his lab tests

-review the results of his lab tests

 

The pt has been taking carvedilol 3.125 mg twice daily. What info is most important for the nurse to provide about his meds?

-avoid abrupt transitions from sitting to standing

-the full hypertensive effect will be noted in 1-2 weeks

-take with food, restrict salt and alcohol intake

-this med may increase his sensitivity to cold

-avoid abrupt transitions from sitting to standing

 

He is also taking captopril 12.5 mg twice daily. What is info about this med most important to include in the nurse’s teaching?

-he may develop a cough

-he will need to follow up labs for CBC and renal function

-signs of angioedema

-it may alter his ability to taste

-signs of angioedema

 

The pt currently takes furosemide and is annoyed that he must “go to the bathroom so much.” He wonders how this could help his heart. What info will inform the nurses’ response?

-furosemide decreases atrial constriction

-furosemide improves cardiac conductivity

-furosemide increases venous vasodilation

-furosemide decreases cardiac preload

-furosemide decreases cardiac preload

 

As the nurse reviews his labs, which imbalance places him at the most significant risk of digoxin toxicity and associated dysrhythmias?

-hypokalemia

-leukocytosis

-anemia

-hyponatremia

-hypokalemia

 

The provider admits the patient to the cardiac observation unit to manage his digitalis toxicity. Why is toxicity such a common problem in pts taking digitalis preparations?

-pts with heart failure are older and have decreased renal function

-people who have heart failure are older and have decreased hepatic function

-digoxin interacts with the potassium preparation that these patients often take

-digoxin has a narrow therapeutic index

-digoxin has a narrow therapeutic index

 

Which manifestations are early indications of digitalis toxicity?

-weight gain and fluid retention

-anorexia, nausea, vomiting

-orthostatic hypotension

-hypertension and dizziness

-anorexia, nausea, vomiting

The pt is exhibiting sx of pulmonary edema, a life-threatening complication of heart failure. What pathophysiologic processes are occurring here to result in pulmonary edema? (select all that apply)

-increasing pressure in the left ventricle

-renal insufficiency resulting in fluid volume excess

-rapid atrial fibrillation resulting in decreased cardiac output

-increased venous return to the heart causing fluid to back up in the right ventricle

-fluid leakage across alveolar-capillary membranes

-increasing pressure in the left ventricle

-rapid atrial fibrillation resulting in decreased cardiac output

-fluid leakage across alveolar-capillary membranes

 

What signs and sx of pulmonary edema should the nurse assess for? (select all that apply)

-cool, clammy skin

-crackles in lung bases

-pleural friction rub

-severe dyspnea

-anxiety

-severe dyspnea

-anxiety

-cool, clammy skin

-crackles in lung bases

 

What is the priority nursing diagnosis?

-impaired gas exchange

-fluid volume overload

-decreased activity tolerance

-ineffective airway clearance

-impaired gas exchange

 

The pts condition stabilizes, and is transferred back to the cardiac observation unit. The nurse is reviewing D/C teaching with him and his daughter. What is dietary info most vital for them to understand? (select all that apply)

-force fluids to decrease orthostatic hypotension

-restrict foods that are high in sodium

-eat large portions to increase exercise tolerance

-restrict proteins due to impaired renal function

-eat foods high in potassium

-eat foods high in potassium

-restrict foods that are high in sodium

 

Left-sided heart failure symptoms

-pulmonary congestion: cough, crackles, wheezes, SOB, tachypnea, hemoptysis

-restlessness

-confusion

-orthopnea

-tachycardia

-fatigue

-cyanosis

-exertional dyspnea

-paroxysmal nocturnal dyspnea

-elevated pulmonary capillary wedge pressure

 

Right-sided heart failure symptoms

-peripheral edema

-JVD

-ascites

-enlarged liver and spleen

-weight gain

-anorexia, complaints of G.I. distress

-fatigue

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