A Case Study by Jasmine Hunter, Rose Larsen, and Amy Sauls-Crenshaw

Mr. Evans is a 72 year old man who was admitted to the cardiac unit with a diagnosis of heart failure.

Heart Failure may develop after a Heart Attack due to long term hypertension, diabetes, valvular, or inflammatory heart disease. It is the most common diagnosis for hospitalized patients over 65 years old. It usually starts in the left ventricle and if left untreated it progresses to right sided failure. Even though the right side can fail without left side failure.

It is when the body is no longer able to pump the blood it needs to maintain its metabolic needs. It is caused when there is a over release of hormones in the body. (epinephrine and norepinephrine) The release causes a negative effect on the failing heart and the circulatory system.

Decreased Cardiac Output

Fatigue Anginal Anxiety Oliguria Decreased

Pain

Gastrointestinal Motility Pale, Cool Skin Weight Gain Restlessness

Left Ventricular Failure

Dyspnea Cough Frothy,

blood-tinged sputum Orthopnea Paroxysmal nocturnal dyspnea Pulmonary Crackles Radiographic evidence of pulmonary vascular congestion with pleural effusion.

Right Ventricular Failure

Distended Ascites Anorexia

Jugular Veins

Nausea
Abdominal

Distention Liver enlargement with right upper quadrant pain. Edema: feet, ankles, and sacrum. May progress up legs into thighs and external genitalia and lower trunk

Respiratory Distress Number of pillows needed to breathe comfortably when resting. Edema (site, degree of pitting) Abdominal distention secondary to ascites. Weight gain Adventitious breath sounds Abnormal heart sounds Activity intolerance Jugular vein distention Blood flow to the kidneys is diminished, resulting in oliguria. Oxygen deficit in tissues results in cyanosis and general debilitation.

 Shortness

of breath (dyspnea) Fatigue or weakness Swelling in legs, ankle, & feet Persistent cough Sudden weight gain
** Women are more likely than men to have swollen ankles and shortness of breath**

 Kidney

Damage - The kidneys are not functioning in the correct way and the body is retaining fluid instead of eliminating it from the body PVD (tissue damage) - The heart is not functioning properly and the heart is not pumping the blood everywhere it needs to go Pneumonia - Fluid could get into the lungs and cause aspiration

BNP - is a neurohormone secreted by the heart in response to expansion of ventricular and pressure overload < 100 normal > 100 is suggestive of HF Blood chemistry

- will reveal elevated BUN and creatinine resulting from a decreased glomerular filtration

Chest radiograph Reveals pulmonary vascular congestion and pleural effusion ECG Reveals cardiac dysthymias Echocardiogram Done to determine presence of pericardial fluid, heart failure and ejection fraction Pulmonary artery Catheterization Asses right and left ventricular function

Action
Digoxin Increases the force of the heart's contractions, which can be beneficial in heart failure and for irregular heart beats. Used to relieve heart failure symptoms, especially when the patient isn't responding to ACE inhibitors and diuretics. Also slows certain types of irregular heartbeat (arrhythmias), particularly atrial fibrillation. Used to help lower blood pressure. Used to help reduce swelling (edema) from excess buildup of fluid in the body. Causes the body to rid itself of excess fluids and sodium through urination. Helps to relieve the heart's workload. Also decreases the buildup of fluid in the lungs and other parts of the body, such as the ankles and legs. Different diuretics remove fluid at varied rates and through different methods. Potassium supplement. Restores electrolyte loss. Nitroglycerin (nitrates). Used to ease chest pain (angina). Relaxes blood vessels and increases the supply of blood and oxygen to the heart while reducing its workload. Decreases the heart rate and cardiac output, which lowers blood pressure and makes the heart beat more slowly and with less force. Used to lower blood pressure. Used with therapy for cardiac arrhythmias (abnormal heart rhythms) and in treating chest pain (angina). Used to prevent future heart attacks in patients who have had a heart attack. Keeps blood clots from forming by preventing blood platelets from sticking together. Helps prevent clotting in patients who have had a heart attack, unstable angina, ischemic strokes, TIA (transient ischemic attacks, or "little strokes") and other forms of cardiovascular disease. Usually prescribed preventively when plaque buildup is evident but there is not yet a large obstruction in the artery. Used to treat or improve symptoms of cardiovascular conditions including high blood pressure and heart failure. Expands blood vessels and decreases resistance by lowering levels of angiotensin II. Allows blood to flow more easily and makes the heart's work easier or more efficient. Helps to prevent harmful clots from forming in the blood vessels. May prevent the clots from becoming larger and causing more serious problems. Helps to prevent harmful clots from forming in the blood vessels. May prevent the clots from becoming larger and causing more serious problems. Often prescribed to prevent first or recurrent stroke.

Lasix

K-Lyte Cardabid Toprol - XL

Aspirin

Lotensin

Coumadin

 Percutaneous

coronary intervention (PCI) (formerly referred to as angioplasty) Coronary artery bypass Heart transplant Valve replacement Defibrillator implantation Left ventricular assist device (LVAD)

PCI is one type of procedure to reopen blocked vessels. The procedure is usually performed in the cardiac catherization lab. A small tube a catheter with a tiny deflated balloon on the end is inserted through an incision in the groin area and pushed through to the diseased artery. Then the balloon is inflated to push open the artery. The balloon is removed once the artery has been fully opened. A stent may be placed during the procedure to keep the blood vessel open. Although there's a slight risk of damage to the artery during this procedure, PCI usually improves the patient's condition.

Coronary artery bypass surgery reroutes the blood supply around a blocked section of the artery. During this procedure, surgeons remove healthy blood vessels from another part of the body, such as a leg or the chest wall. They then surgically attach the vessels to the diseased artery in such a way that the blood can flow around the blocked section.
After a bypass operation, it's especially important for you to watch your diet and reduce the amount of fat and cholesterol you eat, since these substances cause the arteries to clog. Doctors also recommend following a routine of increased physical activity to strengthen the heart muscles.

Some people have severe, progressive heart failure that can't be helped by medications and dietary and lifestyle changes. In such cases a heart transplant may be the only effective treatment option. Surgeons replace the damaged heart with a healthy one taken from a donor who has been declared brain dead. It can take several months to find a donor heart that closely matches the tissues of the person receiving the transplant. But this matching process increases the likelihood that the recipient's body will accept the heart. During a transplant procedure, the surgeon connects the patient to a heart-lung machine, which takes over the functions of the heart and lungs. The surgeon then removes the diseased heart and replaces it with the donor heart. Finally, the major blood vessels are reconnected and the new heart is ready to work.

Heart failure is sometimes caused by a defective or diseased heart valve. Heart valves regulate the flow of blood inside the heart. When they don't work properly, this puts extra strain on the heart and can lead to heart failure. Correcting the problem surgically can often improve or resolve the condition.

A variety of different replacement valves can be used: a mechanical valve made from metal and plastic, one made from human or animal tissue. During the surgery, the patient is connected to a heart-lung machine that supplies blood to the brain and body. The bad valve is removed and replaced.

Some people who have severe heart failure or serious arrhythmias (irregular heartbeats) are candidates for implantable defibrillators. These devices are surgically placed and deliver pacing, or an electric countershock, to the heart when a lifethreatening abnormal rhythm is detected.

A left ventricular assist device (LVAD) is a battery-operated, mechanical pump-type device that's surgically implanted. It helps maintain the pumping ability of a heart that can't effectively work on its own. This device is sometimes called a "bridge to transplant," but is now used in long-term therapy. People awaiting a heart transplant often must wait a long time before a suitable heart becomes available. A common type of LVAD has a tube that pulls blood from the left ventricle into a pump. The pump then sends blood into the aorta (the large blood vessel leaving the left ventricle). This effectively helps the weakened ventricle. The pump is placed in the upper part of the abdomen. Another tube attached to the pump is brought out of the abdominal wall to the outside of the body and attached to the pump's battery and control system.

Decreased Cardiac Output related to impaired contractility and increased preload and afterload Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures Excess Fluid Volume related to sodium and water retention Activity Intolerance related to oxygen supply and demand imbalance

Place patient at physical and emotional rest Rationale: to reduce work of heart. Auscultate heart sounds frequently and monitor cardiac rhythm. Take frequent BP readings Rationale: to detect further complications and attacks Administer pharmacotherapy as directed Rationale: administer medications as ordered to control the signs and symptoms of CHF

Observe for signs and symptoms of reduced peripheral tissue perfusion: cool
temperature of skin, facial pallor, poor capillary refill of nail beds Rationale: to monitor for signs and symptoms of CHF leading to further complications

Raise head of bed 8 to 10 inches (20 to 30 cm)

Rationale: reduces venous return to heart and lungs; alleviates pulmonary

congestion. Auscultate lung fields at least every 4 hours for crackles and wheezes in dependent lung fields

Rationale: to detect fluid accumulates in areas affected by gravity

Encourage deep-breathing exercises every 1 to 2 hours Rationale: to avoid atelectasis Offer small, frequent feedings Rationale: to avoid excessive gastric filling and abdominal distention with subsequent elevation of diaphragm that causes decrease in lung capacity

Administer prescribed diuretic as ordered

Rationale: to eliminate the excess water retained in body tissues

Give diuretic early in the morning nighttime

Rationale: diuresis disturbs sleep

Keep input and output record

Rationale: patient may lose large volume of fluid after a single dose of diuretic

Be alert for signs of hypokalemia

Rationale: may cause weakening of cardiac contractions and may precipitate digoxin toxicity

Increase patients activities gradually and stay within patients limits of his cardiac reserve Rationale: avoid exhaustion but encourage and maintain increases in activity tolerance Assist patient with self-care activities early in the day

Rationale: fatigue sets in as day progresses

Monitor the pulse, symptoms, and behavioral response to increased activity Rationale: to detect signs of exhaustion or complications

Relieve nighttime anxiety and provide for rest and sleep

Rationale: patients with heart failure have a tendency to be restless at night because of cerebral hypoxia with superimposed nitrogen retention

The overall goal of therapy for Mr. Evans is to reduce the signs and symptoms associated with CHF. Therefore this goal would include the following:
Decreasing dyspnea Decreasing adventitious lung sounds Maintain vital signs within acceptable levels Decreasing edema Consistent lab readings within acceptable ranges Adherence to an established nutritional diet Adherence to established medication therapy Avoid alcohol and exercise regularly

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