Case Study - Heart Failure PDF

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This essay was based on a simulation patient (not a real life scenario) who had heart failure. This essay discusses the pathophysiology of heart failure, etiology, risk factors, clinical manifestations, diagnostic testing, laboratory work, and nursing considerations. It also includes a thorough nurs...

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Running head: CASE STUDY ASSIGNMENT

Case Study Assignment: Heart Failure in Nursing Care Kaytlin Ketchabaw Northern College NS2144 Mireille Walsh February 27th, 2017

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Case Study Assignment: Heart Failure in Nursing Care The client I was assigned to for my NS2144 case study assignment is a 70-year-old male of Pacific Islander ethnicity, who identifies as Catholic, and is married with three adult children. He arrived to the hospital via ambulance after an appointment in his health care provider’s office, with a chief diagnosis of a heart failure exacerbation as manifested by shortness of breath, including dyspnea at rest. He was admitted to the medical-surgical unit on Monday at 0700 for medication adjustment, heart failure monitoring, and cardiac rehabilitation, and my care began at 0900 on that same day. When I left at the end of my shift, my patient was stable, but still admitted for further cardiac monitoring and rehabilitation. This assignment will begin with the clustering of data using a focused systems assessment framework to gather all pertinent information regarding my client’s clinical presentation and other relevant health information, followed by a thorough analysis of all the data obtained regarding my client’s health state. I will then formulate three nursing diagnoses that are applicable to my client and develop a plan of care regarding the prioritized nursing diagnosis. The plan of care will entail client goals, nursing interventions supported with rationales, and an evaluation of the effectiveness of the care plan and whether the outcomes were met or not. The assessment phase is the foundation of the nursing process and is an absolute requirement in order to proceed with the diagnosis, planning, and intervention phases (Lewis, Dirkson, Heitkemper, Bucher & Camera, 2014). I have collected objective and subjective data through the initial assessment with my client shortly after he was admitted to the floor, and organized it by clustering related findings together using a focused systems assessment framework. Refer to appendix A.

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While at his primary care provider’s office, my patient verbally reported a chief complaint of “heart failure complications” which he described as a history of dyspnea with exercise over the past few months that has worsened over the past week, as well as orthopnea. His primary care provider added digoxin to the medication regimen three days ago, but he reported continued worsening dyspnea, which prompted his care provider to order direct admission to the medical-surgical unit with heart failure exacerbation. The purpose of the admission was to monitor his heart failure, adjust his medication regimen, and enroll him in cardiac rehabilitation. Heart failure occurs when the heart is unable to create proper cardiac output, resulting in insufficient tissue perfusion, increased diastolic filling pressure of the left or right ventricles, or both (Huether & McCance, 2017). My client is diagnosed with left sided heart failure, frequently referred to as congestive heart failure (CHF), meaning that left ventricular pumping is inadequate (Huether & McCance, 2017). The clinical manifestations that could arise from CHF emerge from pulmonary vascular congestion and inadequate perfusion of systemic circulation, and include: dyspnea, orthopnea, cough of frothy sputum, fatigue, decreased urinary output, edema, changes in blood pressure, an S3 gallop, and pulmonary edema (Huether & McCance, 2017). Upon physical assessment, the major abnormal findings included: dyspnea on exertion, orthopnea, crackles and diminished breath sounds, fatigue, +1 pitting peripheral edema on the lower extremities, an S3 heart sound, nocturia, and decreased oxygen saturation at 93%. Dyspnea is one of the most prominent manifestations of heart failure exacerbations, which is caused by pulmonary edema (Lewis et al., 2016). Pulmonary edema in my patient is demonstrated by the fine crackles noted upon auscultation, and is an excess accumulation of fluid in the interstitial spaces of the lungs, which inhibits oxygen and carbon dioxide exchange at the alveolar level, and

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ultimately results in difficulty breathing and a decrease in oxygen saturation (Lewis et al., 2014). This was manifested in my patient as his chief complaint was dyspnea, and his oxygen saturation was at 93%, falling below the acceptable range (Lewis et al., 2014). Fatigue is one of the earliest manifestations of CHF, which is mainly demonstrated by the individuals increased fatigue after engaging in activities that are normally not tiring for that person, mainly caused by decreased carbon dioxide (Lewis et al., 2014). This was exhibited by my patient as he verbally reported a major increase in fatigue, the inability to engage in activities he once participated in regularly, and simply not being as active as he would like to be. An extra heart sound called S3 was noted upon auscultation, which occurs in CHF because of the ventricular wall’s decrease in compliance (Silvestri, 2017). Peripheral edema in CHF results from neurohumoral mechanisms that promote sodium and water reabsorption by the kidneys, which ultimately promotes the leakage of fluid into the interstitial spaces and causes it to buildup (Huether & McCance, 2017). Individuals with decreased cardiac output experience impaired renal perfusion and decreased urinary output throughout the day, but the fluid is more quickly moved back into the circulatory system from the interstitial spaces when the individual lies down, therefore causing an increase in urination at night (Lewis et al., 2014). This is a likely cause of my patient’s nocturia, but it could also be a result of the Lasix he is taking since it is a diuretic, meaning that it excretes excess fluid (Kizior & Hodgson, 2016). It may also be a result of a combination of the two. The orders that were expected to be implemented and maintained throughout my patient’s hospitalization were completed by the provider at 0800, and include: activity as tolerated, regular low-sodium diet, intake and output every shift, vital signs twice daily, oxygen via nasal cannula titrated to maintain oxygen saturation levels greater than 92%, stat digoxin level, complete blood count and basic metabolic panel, basic metabolic panel and digoxin level Monday, Wednesday

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and Friday, daily weight measures, and the medication administration record (MAR). A low sodium diet is strongly encouraged in congestive heart failure patients in order to prevent fluid retention (Lewis et al., 2014). Monitoring intake and output is a crucial component when caring for a CHF patient in order to monitor fluid balance and prevent fluid retention or excess diuresis (Lewis et al., 2014). Being able to track how much fluid is being input and excreted minimizes the likelihood of fluid balance complications occurring (Lewis et al., 2014). This scenario did not provide me with adequate information regarding my patient’s intake and output; I was given information that he had an intake of 120ml of oral fluids at 0800, but nothing to follow up with. It is also important to monitor the weight of congestive heart failure patients on a daily basis because they often experience weight changes from weight gain due to fluid retention, to weight loss from being too sick to eat, ascites, or hepatomegaly (Lewis et al., 2014). My patient weighs 210 pounds and has denied any recent weight gain or loss. Oxygen therapy is initiated to improve gas exchange and pulmonary function (Silvestri, 2017). My patient responded well to the plan of care and had no issues with compliance; however, he did express anxiety that he will not get better and will have to live in long-term care for the rest of his life. He is awaiting physical and occupational therapy consults, as well as cardiac rehabilitation to improve his activities of daily living that are impacted by the heart failure exacerbation. My patient was stable, which was demonstrated by stable vital signs: a temperature of 36.9, blood pressure of 108/72mmHg, pulse of 88 beats per minute, respiratory rate of 20 breaths per minute, and oxygen saturation at 93%. The oxygen saturation is lower than the recommended range, but it is still coherent with the order to keep it above 92%. Health teaching was done regarding the new medications added to the MAR, and the importance of medication compliance. My patient stated that he understood, but that he would have his wife help him when he returns home.

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My patient’s MAR was prepared and ready for implementation on Monday at 0800 and included: furosemide, atenolol, digoxin, and acetaminophen. These meds were ordered to be taken orally, once a day, except for acetaminophen which is ordered every four hours as needed for pain. Prior to the hospitalization, he was already taking furosemide and atenolol as prescribed by his health care provider, and digoxin was added to the regimen three days before he was hospitalized. The overall goals in the management of congestive heart failure are to reduce preload and afterload, which can be achieved through the use of loop diuretics (Huether & McCance, 2017). Furosemide, also known as Lasix, is a loop diuretic given to individuals with congestive heart failure to excrete excess fluid buildup associated with pulmonary edema (Kizior & Hodgson, 2016). Atenolol is a beta1 adrenergic blocker that is used for the treatment of hypertension and/or arrhythmias (Kizior & Hodgson, 2016). Digoxin is a cardiac glycoside used for the treatment of heart failure as well as atrial fibrillation (Kizior & Hodgson, 2016). My client has been taking atenolol and digoxin for the prevention of an irregular heartbeat as it could manifest from heart failure. When the lab results returned at 0915 on Monday morning, the provider’s orders were to hold the digoxin for that day and immediately administer 20mEq of potassium chloride, which was also added to the MAR to be taken once daily. Potassium chloride is an electrolyte given to replenish potassium levels and treat or prevent hypokalemia (Kizior & Hodgson, 2016), and was ordered for my patient as his potassium levels were low. The digoxin was held as the serum digoxin concentration indicated that it was above the therapeutic range, thus it needed to return to an acceptable range, resulting in the temporary halting of the drug. Refer to appendix B. For diagnostic purposes, all the primary health care provided needed was a history and physical assessment to confirm that the manifestations the patient was experiencing were related

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to a heart failure exacerbation, which included: dyspnea, orthopnea, peripheral edema, pulmonary edema, S3, and nocturia. Laboratory work was ordered for confirmation, and to assess electrolyte levels and fluid status. When I began my care at 0900 on Monday, the blood work had already been ordered and completed, and the results were ready at 0915. Refer to appendix B for a list of all lab results. Hemoglobin and hematocrit were decreased, which is a common finding in CHF that is indicative of anemia (Silvestri, 2017). Anemia in heart failure is commonly associated with pulmonary congestion and occurs because of reduced oxygen transportation to the tissues (Mozos, 2014). It is frequently associated with cardiovascular mortality, reduced exercise capacity, higher risk for hospitalization, low body mass index, increased level of neurohormones, hypertension, atrial fibrillation, and chronic renal failure (Mozos, 2014). The fact that my patient was experiencing anemia could be a contributing factor to his hospitalization. His platelet counts and white blood cell counts were within acceptable ranges, meaning that he was not experiencing issues with blood clotting or with infection. His calcium, chloride, and sodium levels were all normal, therefore not indicating fluid loss or dehydration, however, his potassium levels were low. Patients with congestive heart failure often experience hypokalemia, so monitoring sodium and potassium levels is very important since decreased potassium can be life-threatening as every body system is affected in some way (Weglicki, Quamme, Tucker, Haigney & Resnick, 2004). Potassium deficit in heart failure is usually caused by diuretics (Silvestri, 2017), which would make sense in my patient’s case as he is taking Lasix. My patient exhibited some manifestations of hypokalemia, including: thread/weak dorsalis pulses, shallow respirations, diminished breath sounds, and muscle weakness (Silvestri, 2017). His blood urea nitrogen (BUN) was elevated; a BUN test measures the nitrogen and urea that is being secreted to determine the kidney’s level of functioning

CASE STUDY ASSIGNMENT (Healthwise Staff, 2012). BUN levels often rise in congestive heart failure due to the decreased renal perfusion, or as a result from a diuretic (Silvestri, 2017). Again, it is likely that my patient is experiencing this elevated as a result of taking Lasix. A digoxin test is used to monitor the levels of the drug digoxin in the blood (Haji & Movahed, 2000). My patient’s digoxin levels were elevated, meaning that he was receiving too much of the drug and needed to stop to return his digoxin levels back to normal. His serum glucose results were normal, therefore not indicative of glucose or endocrine abnormalities. The three nursing diagnoses I have selected that are applicable to my client are impaired gas exchange, excess fluid volume, and decreased cardiac output. According to Ackley & Ladwig (2014), Maslow’s hierarchy of needs is a crucial component to clinical decision making and care planning as understanding each level of human needs and how they are interconnected will assist nurses in providing more holistic care. Impaired gas exchange, excess fluid volume, and decreased cardiac output are all nursing diagnoses that are categorized as physiological needs, meaning that they are the priority and must be met before higher-level, more complex needs can be actualized (Ackley & Ladwig, 2014). Refer to appendix C for further detail about the nursing diagnoses and the rationales for their prioritization. Refer to appendix D for the care plan that has been developed for my patient with the prioritized nursing diagnosis. My patient is a 70-year-old male who presented to the hospital with a heart failure exacerbation, with key complaints of dyspnea and orthopnea. He was admitted to the medicalsurgical floor where he received oxygen therapy, medication changes, dietary changes, health teaching, and was awaiting cardiac rehabilitation. His heart failure was constantly being monitored to assess for any changes in his health state that could signal an emergency. Overall, my patient had a good day and did not experience any major issues.

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Ackley, B. J. & Ladwig, G. B. (2014). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care (10th ed.). Maryland Heights, MO: Mosby Elsevier. de Souza, V., Zeitoun, S. S., Lopes, C. T., de Oliveira, A. P., de Lima Lopes, J. & de Barros, A. L. (2015). Clinical usefulness of the definitions for defining characteristics of activity intolerance, excess fluid volume, and decreased cardiac output in decompensated heart failure: a descriptive exploratory study. Journal of Clinical Nursing, 24, 2478-2487. doi: 10.1111/jocn.12832 Haji, S. A. & Movahed, A. (2000). Update on Digoxin Therapy in Congestive Heart Failure. American Family Physician, 62(2), 409-416. Retrieved from: http://www.aafp.org/afp/2000/0715/p409.html Healthwise Staff. (2012). Blood Urea Nitrogen. Cardio Smart: American College of Cardiology. Retrieved from: https://www.cardiosmart.org/healthwise/aa36/271/aa36271 Huether, S. E. & McCance, K. L. (2017). Understanding Pathophysiology (6th ed.). St. Louis, MO: Elsevier. Kizior, R. J. & Hodgson, B. B. (2016). Saunders Nursing Drug Handbook 2016. St. Louis, MO: Elsevier. Lewis, S. L. Dirksen, S. R., Heitkemper, M.M., Bucher L. & Camera, I. M. (2014). MedicalSurgical Nursing in Canada: Assessment and Management of Clinical Problems (3rd ed.). Toronto, ON: Mosby Elsevier. Mozos, I. (2014). Mechanisms Linking Red Blood Cell Disorders and Cardiovascular Diseases. BioMed Research International, 2015, 12 pages. http://dx.doi.org/10.1155/2015/682054

CASE STUDY ASSIGNMENT Silvestri, L. A. (2017). Saunders Canadian Comprehensive Review for the NCLEX-RN Examination. Toronto, ON: Elsevier. Weglicki, W., Quamme, G., Tucker, K., Haigney, M. & Resnick, L. (2004). Potassium, Magnesium, and Electrolyte Imbalance and Complications in Disease Management. Clinical and Experimental Hypertension, 1, 95-112. doi: 10.1081/CEH-2000044275

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Appendix A Table 1: Data Clustering: Focused Systems Assessment Body System Neurological

Healthcare Provider’s Office • awake, alert and oriented to person, place and time • experiencing fatigue easily • able to provide accurate information regarding his current health state

Respiratory

• history of dyspnea with exercise over the past several months • experienced worsening dyspnea one week ago, including mild dyspnea even at rest (orthopnea) • reported continued worsening dyspnea, resulting in hospital admission

Cardiovascular

No data provided.

Musculoskeletal

No data provided.

Medical-Surgical Floor 0830 • awake, alert and oriented to person, place and time • able to provide accurate information about his health • denies issues with movement and sensation • denies memory/cognition problems; can recall object name three minutes after mention, place of birth, and year born • tends to tire easily • experiencing minor anxiety related to hospitalization stay and fear o having to stay in long-term care • oriented to his own ability • cooperative • able to control motor movements on command, such as “hold out three fingers” • spontaneously opens eyes, pupils PERRLA • O2 sat 93% via nasal cannula at 2L/min • respiratory rate 20 breaths/min • fine crackles in lower lobes bilaterally • diminished breath sounds throughout all lung lobes • verbal report of dyspnea with exertion and orthopnea • chest x-ray unremarkable • no recent respiratory infections • symmetrical chest expansion • no use of accessory muscles while breathing • respiratory pattern shallow • non-productive cough • trachea midline • has had congestive heart failure for several years now • no history of hypertension • irregular heart rhythm, heart rate 88bpm • blood pressure 108/72 • S1, S2 and S3 heart sounds • +1 pitting edema in lower extremities bilaterally • denies chest pain • cold extremities • thread/weak dorsalis pedis pulses bilaterally, +1 • all other pulses 2+ and expected • capillary refill time in both hands less than 3 seconds • capillary refill time in both feet greater than 3 seconds • cardiac meds: digoxin, furomeside, atenolol • ambulates with assist from wither walker, cane, or crutches • waiting on physical therapy consult • poses medium fall risk • denies back or joint pain • verbal report of weakness related to dyspnea

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Gastrointestinal

No data provided.

Genitourinary

No data provided.

Integumentary

No data provided.

Psychosocial

No data provided.

12 • verbal report of tiring easily and not being as active as he would like to be • weak gait • no history of falls • able to move all extremities independently with full range of motion • range of motion within expected parameters • normocephalic • reports pain at back of head, rates pain as 2 out of 10, describes it as aching but states it is very mild • walks occasionally during day, but for short distances • spends majority of day in bed or chair • weight is 95kg; daily weights ordered • fall precautions: be...