Running head: PATIENTS PLAN: CHF 1

Patients Plan: CHF

Lauren Neff

Brigham Young University Idaho

Nursing 322 Section: 01

Sister Jamison

February 23, 2017

PATIENTS PLAN: CHF 2

Lauren Neff, M.D.

4560 NE Dianna Way
Camas, WA 98607

February 23, 2017

Mr. and Mrs. Ward

4533 NW Hunch Dr.
Vancouver, WA 98660

Dear Mr. Ward:

I hope that you are doing well. My name is Dr. Lauren Neff, and I am your physician that has
helped you work through your diagnosis of Congestive Heart Failure (CHF). I understand that
you are experiencing exacerbated symptoms of your CHF and are trying to better control your
condition and gain relief from the symptoms you are experiencing. I hope this letter can help
educate you on your diagnosis as well as address your concerns and help you on the road to
better health.

To put simply, congestive heart failure is the inability of your heart to pump sufficient blood to
the rest of your body. You have left-sided heart failure which is the inability of the left ventricle
to empty or fill adequately. Thus, fluid has been building up in your lungs. There are several
different causes for this including coronary artery disease (CAD), high blood pressure, rheumatic
heart disease, myocarditis, hyperthyroidism, and cardiomyopathy. The two main culprits tend to
be CAD and high blood pressure. Some risk factors include diabetes, metabolic syndrome,
tobacco use, and vascular disease (Lewis, 2017).

Unfortunately, congestive heart failure is very prevalent in the U.S. today. If you visit to
emoryhealthcare.org, you can find a number of statistics discussing the incidences of CHF.
There are currently 5 million Americans living with CHF and each year another 500,000 are
diagnosed. With that, I think you should also be aware that there are around 290,000 deaths a
year due to CHF and, therefore, your diagnosis should not be taken lightly (Emory, 2017).

With this being said, I stress to you the effects it is having on both yourself and your family.
If this disease isnt taken care of properly, the chances of you passing is a real risk. You
mentioned feeling short of breath during physical activity. We have also seen that your
respiratory rate is 24 with inspiratory crackles in both lung bases and an oxygen saturation of
89.3%. During your chest x-ray we also found cardiomegaly (heart enlargement; increasing your
hearts load causes increased muscle build up which increases your heart size) and lower-lobe
infiltrates. These lower lobe infiltrates show us that there is indeed fluid built up in your lungs.
The effect of pulmonary edema on the body is stated well in book Medical-Surgical Nursing:
Assessment and Management of Clinical Problems. It says, As pulmonary edema progresses, it
inhibits O2 and CO2 exchange at the alveolar-capillary interface (Lewis, 2017). This
PATIENTS PLAN: CHF 3

essentially means your lungs are filling with fluid (due to left-sided heart failure) which inhibits
the normal exchange of the oxygen and carbon monoxide. This in turn effects your entire body
by decreasing oxygen supply. We will discuss ways to improve this later but know that it will
effect your day to day living as you have already experienced and will continue to worsen if
actions arent taken.

Ambulatory/Home Care Environment:

You have mentioned feeling dyspnea upon exertion. Another symptom that may arise is called
paroxysmal nocturnal dyspnea (PND). This is a symptom that occurs during your sleep. You
may wake up, in a panic and [have] feelings of suffocation and a strong desire to sit or stand to
aid breathing (Lewis, 2017). This causes impaired gas exchange by fluid accumulating in the
alveoli (air sacs) of the lungs. To help these symptoms, try raising your head while lying down
or sleeping with pillows.

Making sure that you are safe at home also means sticking with your medication regime. There
is a lot more room for error when medications are taken at home versus a health care setting.
Education tailored to your medication will be given and we will make sure that you feel
comfortable with them before going home (Ellenbecker, 2007).

Plan of Care for Health Promotion and Treatment Options:

As we have seen, you have a high blood pressure of 165/95 which would be put into the category
of Stage 2 hypertension. This is the highest category in the spectrum and aggressive treatment
should take place (Mayo, 2015). I am going to start you on some antihypertensive medications
including a diuretic. This will help with not only your heart failure, but youre your pulmonary
edema. Lets have a goal of reaching a blood pressure of around 120/80 within the next six
months. At or below this number means that you are at a normal blood pressure (Mayo, 2017).
If you control you blood pressure you can also expect to have your cold feet symptoms
disappear. I believe that your hypertension is causing poor circulation resulting in cold feet.

We can also discuss corrections to your diet and exercise regime. I am going to have a
wonderful dietitian get in contact with you to discuss the DASH diet plan as well as other tips
and tricks to improving your overall health. This diet plan is focused on reducing sodium
consumption, red meats, sweets, added sugars, and sugar beverages. Living at home with these
types of foods can be the biggest temptations. I suggest going through your pantry with your
wife and eliminating any food that are unhealthy. The DASH eating plan will lower your blood
pressure as well or better as your blood pressure medication would. Additional benefits also
include lowering of low-density lipoprotein (LDL) cholesterol (Lewis, 2017). LDLs are
considered bad cholesterol and significantly increase risk for heart disease. Although this is a
difficult change, I have faith that you can achieve it. Talking with your wife and having her
support can help you in changing your eating habits.

Weight reduction is another big component for you. Right now your BMI is 35. This means that
you are in the obese category and flirting with class 2 obesity. Being this overweight certainly
contributes to your hypertension. I encourage you to take action and reduce your weight. I think
an excellent (but challenging) goal would be a BMI below 25 (Garrow, 2016). The AHA and
American College of Sports Medicine recommend that adults perform moderate-intensity
PATIENTS PLAN: CHF 4

aerobic physical activity for at least 30 minutes most days (i.e., more than 5 days per week)
(Lewis, 2016). I think this is a wonderful goal for you to achieve. Once you begin your
medications and diet plan, exercise wont be so difficult for you to complete. Again, this a very
challenging goal but I believe you have the motivation to succeed. This is something your
dietitian can help you achieve as well.

In your care plan, we also want to develop disease prevention intervention. Engage in regular
exercise, use moderation in alcohol intake, avoid tobacco use, and manage psychosocial risk
factors (Lewis, 2017). Some examples of psychosocial risk factors include work-related stress,
depression, and economic hardship (Rod, 2011). My understanding is that you have all of these
under control. Continue to avoid them because, as you may imagine, they contribute
significantly to CHF.

Management for Acute Episodes:

Finally, if you experience any exacerbated symptoms and oxygen supplementation doesnt
relieve the symptoms, immediately go to the hospital (we will supply you with the appropriate
gear for home oxygen supply). There the staff can provide you with symptomatic relief. This is
usually done through oxygen, morphine, diuretics, ultrafiltration, vasodilators, inotropes, and
vasopressors (Congestive, 2017). It is imperative that you receive the oxygen needed to maintain
organ function. It is also crucial that you are in an environment where emergency care can be
provided if needed.

So, Mr. Ward, heres a better summary of our plan and goals:
Start hypertensive medications including diuretics with a goal to reach a blood pressure
of 120/80 or lower within the next 6 months
Implement the DASH diet immediately
Reduce weight to a BMI below 25 by engaging in moderate-intensity aerobic physical
activity at least 30 min/5 days a week within in the next 2 years
Continue avoiding risk factors (tobacco use, excessive alcohol, etc.)
If you have any exacerbation of symptoms, immediately get professional help

Sincerely,

Lauren Neff, M.D.

4560 NE Dianna Way
Camas, WA 98607
PATIENTS PLAN: CHF 5

Here is an illustration of congestive heart failure. This may help you better visualize what is
occurring in your own body as we discuss symptoms and goals for treatment.
(Kemp, 2011)

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PATIENTS PLAN: CHF 6

References

Congestive heart failure acute exacerbation. (2017). Retrieved February 24, 2017, from

https://online.epocrates.com/diseases/6241/Congestive-heart-failure-acute-

exacerbation/Treatment-Approach

Ellenbecker, C. H. (2007). Patient Safety and Quality in Home Health Care. Retrieved March 05,

2017, from https://www.ncbi.nlm.nih.gov/books/NBK2631

Emory. (2017). Heart & Vascular: Conditions & Treatments. Retrieved February 23, 2017, from

https://www.emoryhealthcare.org/heart-vascular/wellness/heart-failure-statistics.html

Garrow, J., & Webster, J. (2016, June 16). Defining Adult Overweight and Obesity. Retrieved

February 24, 2017, from https://www.cdc.gov/obesity/adult/defining.html

Kemp, C., & Conte, J. (2011, July 11). Pathophysiology. Retrieved February 24, 2017, from

http://heartfailure1.weebly.com/pathophysiology.html

Lewis, S. M. (2017). Medical-surgical nursing: assessment and management of clinical

problems. St. Louis, MO: Elsevier, Inc.

Mayo. (2015, February 21). Blood pressure chart: What your reading means. Retrieved February

23, 2017, from http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-

depth/blood-pressure/art-20050982

Rod, N. H., Andersen, I., & Prescott, E. (2011, August 04). Psychosocial Risk Factors and Heart

Failure Hospitalization: A Prospective Cohort Study. Retrieved February 24, 2017, from

https://academic.oup.com/aje/article/174/6/672/89153/Psychosocial-Risk-Factors-and-

Heart-Failure