Case Study on Heart Failure

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Requirement

Need to answwr the questions based on case study which is related to one patient with medical hostory like h increasing shortness of breath, swollen ankles, mild nausea and dizziness.

Solution

Causes, Incidence & Risk Factors 

Congestive heart failure or heart failure occurs when the heart muscles do not pump blood in the same efficiency as it used to (Scott & Winters, 2015). The typical causes associated with such heart failure develop from conditions which have weakened or damaged the heart. However, heart failure can occur if the heart becomes weak, and also if stiffness occurs in the heart muscles. The conditions which can weaken the heart and initiate the heart failure are – diseases pertaining to coronary arteries, hypertension or high blood pressure, faulty operation of heart valves, cardio-myopathy, arrhythmias and other diseases namely, hyper and hypothyroidism, diabetes, hemochromatosis etc (Lord, Hansson, Kvart, & Häggström, 2010). 
 As per 2015 findings, 43,602 deaths occurred in Australia due to heart ailments. Of all Australians aged 75 – 84, 26.0% reported to be having heart issues (Heart Foundation, 2015). 

The behavioural risk factors include smoking, wrong diet, physical activities, alcohol abuse and the medical risk factors are – high blood pressure, disease of coronary artery, diabetes, certain diabetes medications, medications like NSAIDs (Non Steroidal Anti-Inflammatory Drugs), obesity and weight issues, mental health problems etc. Further complications can arise from the risk factors like, advanced age, damage of the kidneys, problems in the heart valve, damage of the liver etc (O’Brien & Davis, 2013). 
The prevalence and incidence of heart failures have increased by manifold in the last few decades, and though treatment and early detection techniques have markedly improved, the patients still suffer from the impact of the problem and have high rates of mortality (Smeulders et al., 2009). This disease leaves a physical and psychosocial impact on the patients and their care giving family. As congestive heart failure, typically is associated with frequent re--hospitalizations, this becomes a psychological and physical tiresome burden for both patients and their families (Rustad, Stern, Hebert, & Musselman, 2013). The chances of congestive heart failure increases with advanced age, and deprivation and this gradual shift in the demographics leave a challenge for the health service. The patients typically have a number of health complications, very strict medical regimens to be followed, disabling conditions, unpredictable worsening of situations and need critical and accurate care. Therefore, this leaves a great mental burden on the patient families, and their mental health along with making the patient fatigued, irritable and breathless (Wall, Ballard, Troped, Njike, & Katz, 2010). Hence, the mental and physical health of both the patients and their families get impacted and hence, proper treatment and helpful guidance must be offered to both the patients and their caregivers. 

Signs & Symptoms of Congestive Heart Failure 

• 1.    Exertional Dyspnea which can be accompanied by dyspnea at rest is a symptom (O’Brien & Davis, 2013). Mrs McKenzie has been suffering from shortness of breath and she complained that such shortness worsens every time she tries to do gardening or goes on a walk. This depicts that she has Exertional Dyspnea, and this acts as the first sign and symptom of Congestive Cardiac / Heart Failure. The patho-physiology of associated to this symptom, is the feeling of not getting enough air in your lungs and always feeling like being slightly “out of breath”. 

• 2.    Orthopnea – This is another key symptom of a congestive heart failure, and depicts a condition where the patient feels shorteness of breath which occurs even when the patient is lying at rest and is in the flat posture (Kantharia, 2010). This causes the patient to sleep either sitting in a chair or propped up on the bed. Though Mrs. McKenzie still did not depict this condition, it is one of the most key symptoms of CHF. The patho-physiology of this is the patient feels the need for more air when lying in the flat posture, and therefore needs to be propped up. 

• 3.    Acute pulmonary edema is another key symptom of CHF and this depicts the filling up of airspaces in the lung with fluid (Scott & Winters, 2015). Mrs. McKenzie has been identified having lower lobe infiltrate, which is a sign of pulmonary edema. The pathophysiology associated is the feeling of breathlessness and short of breath, and also the time taken for the skin to get back to normal when pinched upon is slower than normal conditions, as is depicted in the case of Mrs. McKenzie. 

• 4.    Fatigue and dizziness, acts as another key symptom of Congestive Cardiac Failure (Goodlin, 2009), and the patient feels week, nauseas and dizzy as has been the case of Mrs. McKenzie. 

• 5.    Fluids build up and swelling in the ankles depict that fluid accumulation is occurring in the body, and this can act as a symptom and sign of worsening of a heart failure (Albert, 2012). The patient feels bloated, and discomfort as a result. 

2 common genre drug to treat this & psychological effect 

The two common genre drugs used to treat Congestive Cardiac Failure are Beta Blockers and ACE Inhibitors.

Beta Blockers

Beta blockers are also known as blocking agents of beta-adrenergic drugs which block the adrenaline and norepinephirine from the action of binding of beta receptors on the nerve (Akhtar & Barash, 2002). These epinephrine and norepinephrine are produced by nerved all around the body along with the adrenal gland and these serve as neurotransmitters. These beta blockers are traditionally used as the treatment for congestive cardiac failure, as they slow down the laboured breathing (Wiysonge, Bradley, Volmink, Mayosi, & Opie, 2017). 
A number of side effects of beta blockers exist namely, diarrhoea, cramps in the stomach, vomiting, nausea, blurred vision, insomnia, muscle cramps. However, the psychological impact beta blockers have on the patient is also significant. Along with fatigue and weakness, beta blockers are known to impact the mood of the patients. As per a paper by Head et al, beta blockers lead to making the patients more anxious and negatively impacted on the overall mood (Head, Kendall, Ferner, & Eagles, 1996). Beta blocker medicines are also associated with depression in patients (van Melle et al., 2006) but certain studies have also negated this association (Hoogwegt, Kupper, Theuns, Jordaens, & Pedersen, 2012). 

ACE Inhibitors

ACE Inhibitors are used for treating congestive cardiac failure problems as these medicines help in the reduction in the production of the Angiotensin II and the blood vessels as a result dilate and get enlarged and this results in the lowering of the blood pressure (Hemels et al., 2003). 
These are well tolerated amongst majority of patients but still can cause side effects namely, dizziness, headaches, weakness, salty or metallic taste in the mouth, chronic cough, heightened sensitivity to the sun etc (Kumar, Kumar, Sharma, & Baruwa, 2010). The psychological impact of ACE inhibitors can be the sensation of weakness, fatigue, mental confusion and also can lead to a change in the manner patients usually speak. Along with this, a discouraging attitude, lower libido, nausea, nervousness, insomnia etc are specific psychological aspects which also leave a negative impact on the psyche of the patients (Hanif, Bid, & Konwar, 2010). 

Nursing Care Strategies – 24 hours post ED Admission 

Primarily, the focus would be on reducing her blood pressure and bringing normality in the bradycardiac stage her present status is in. As the immediate nursing interventions three strategies would be initially focused upon on the first 24 hours after her Emergency admission- Bringing normalcy in her cardiac output and reducing the breathlessness and activity intolerance and managing the fluid presence in her body. 
For bringing normalcy in her cardiac output in the first 24 hours, the following interventions can be taken and their rationale are also mentioned as follows; 

1. -    The heart rates will be accessed, her heart rhythm monitored and the abnormality if any will have to be monitored. 

2. -    Heart sounds should have to be measured effectively, and murmurs if any can present valvular incompetency

3. -    Palpation of the peripheral pulses have to be done and if abnormality observed will have to be monitored and noted 

4. -    BP has to be monitored and it might be elevated due to the presence of SVR. 

5. -    Skin colour and texture has to be monitored for pallor, and presence of cyanosis if any as pallor indicates inadequate cardiac input and cyanosis can occur in refractory type of Cardiac Failure (Orr, Boxer, Dolansky, Allen, & Forman, 2016)

6. -    The urine output has to be monitored for any abnormality, and if presence of decreased and concentrated urine, notification should be done

7. -    Encourage the patient for rest, maybe propped on the bed so that flat posture is avoided 

8. -    Care must be taken to note any unusual disorientation, lethargy and anxiety and depression symptoms

9. -    Provision of a quiet environment has to be given so that therapeutic management activities can be ascertained and patient can be in a stress less environment. Efforts can be taken to create an open and communicative relationship (Azzolin et al., 2013)

10. -    Bedside commode must be provided so that patient has to engage in minimal physical activities 

11. -    The legs must be elevated and pressure should be avoided on the knee 

12. -    Calm tenderness should be looked for, and swollen ankles must be noted and interventions provided 

13. -    Supplemental oxygen can be provided as this would combat the effects of hypoxia if any (Albert, 2006)

Along with this, as a nursing strategy, care and interventions must be taken to note the vital signs after each activity to understand the cardiopulmonary responses to such activity. Along with this, since Mrs. McKenzie also complained of swollen ankles and had fluid deposition, care and interventions during the first 24 hours of patient care must involve activities of tackling fluid management as well. The following are the strategies which the nursing care can take;

1. -    Checking the urine output and related detail 

2. -    Keeping the patient on bed rest in the position of semi-Fowler, and keeping the feet in elevated position

3. -    Inspection must be done on the dependent body regions for edema and the general edema 

4. -    Positions must be changed frequently and skin surface must be checked (Jung, Yeh, & Pressler, 2012)

5. -    The breath sounds must be noted carefully for crackles as the presence of fluid can lead to pulmonary congestion. 

6. -    If sudden breathlessness and air hunger is noticed, immediate actions should be taken. 

Reference List

• Akhtar, S., & Barash, P. G. (2002). Significance of beta-blockers in the perioperative period. Current Opinion in Anaesthesiology. https://doi.org/10.1097/00001503-200202000-00005

• Albert, N. M. (2006). Evidence-based Nursing Care for Patients With Heart Failure. AACN Advanced Critical Care, 17(2), 170–184. https://doi.org/10.1097/00044067-200604000-00013

• Albert, N. M. (2012). Fluid management strategies in heart failure. Critical Care Nurse, 32(2), 20–32. https://doi.org/10.4037/ccn2012877

• Azzolin, K., Mussi, C. M., Ruschel, K. B., de Souza, E. N., de Fátima Lucena, A., & Rabelo-Silva, E. R. (2013). Effectiveness of nursing interventions in heart failure patients in home care using NANDA-I, NIC, and NOC. Applied Nursing Research, 26(4), 239–244. https://doi.org/10.1016/j.apnr.2013.08.003

• Goodlin, S. J. (2009). Palliative Care in Congestive Heart Failure. Journal of the American College of Cardiology. https://doi.org/10.1016/j.jacc.2009.02.078

• Hanif, K., Bid, H. K., & Konwar, R. (2010). Reinventing the ACE inhibitors: some old and new implications of ACE inhibition. Hypertension Research?: Official Journal of the Japanese Society of Hypertension, 33(November 2009), 11–21. https://doi.org/10.1038/hr.2009.184

• Head, A., Kendall, M. J., Ferner, R., & Eagles, C. (1996). Acute effects of beta blockade and exercise on mood and anxiety. British Journal of Sports Medicine, 30(3), 238–242. https://doi.org/10.1136/bjsm.30.3.238

• Heart Foundation. (2015). Australian Heart Disease Statistics 2015. Retrieved March 31, 2018, from Heart Foundation: https://www.heartfoundation.org.au/images/uploads/publications/RES-115-Aust_heart_disease_statstics_2015_WEB.PDF

• Hemels, M. E. H., Bennett, H. A., Bonari, L., Han, D., Traverso, M. L., & Einarson, T. R. (2003). HOPE study impact on ACE inhibitors use. Annals of Pharmacotherapy, 37(5), 640–645. https://doi.org/10.1345/aph.1C339

• Hoogwegt, M. T., Kupper, N., Theuns, D. a M. J., Jordaens, L., & Pedersen, S. S. (2012). Beta-blocker therapy is not associated with symptoms of depression and anxiety in patients receiving an implantable cardioverter-defibrillator. Europace?: European Pacing, Arrhythmias, and Cardiac Electrophysiology?: Journal of the Working Groups on Cardiac Pacing, Arrhythmias, and Cardiac Cellular Electrophysiology of the European Society of Cardiology, 14(1), 74–80. https://doi.org/10.1093/europace/eur295

• Jung, M., Yeh, A.-Y., & Pressler, S. J. (2012). Heart failure and skilled nursing facilities: review of the literature. Journal of Cardiac Failure, 18(11), 854–871. https://doi.org/10.1016/j.cardfail.2012.09.006

• Kantharia, B. K. (2010). Cardiac arrhythmias in congestive heart failure. Expert Review of Cardiovascular Therapy, 8(2), 137–140. https://doi.org/10.1586/erc.09.185

• Kumar, R., Kumar, A., Sharma, R., & Baruwa, A. (2010). Pharmacological review on Natural ACE inhibitors. Scholarsresearchlibrary.Com, 2(2), 273–293. Retrieved from http://scholarsresearchlibrary.com/DPL-vol2-iss2/DPL-2010-2-2-273-293.pdf

• Lord, P., Hansson, K., Kvart, C., & Häggström, J. (2010). Rate of change of heart size before congestive heart failure in dogs with mitral regurgitation. Journal of Small Animal Practice, 51(4), 210–218. https://doi.org/10.1111/j.1748-5827.2010.00910.x

• O’Brien, T. X., & Davis, C. P. (2013). Congestive Heart Failure Causes, Symptoms, Treatment - Congestive Heart Failure Stages. Medicine Health, 5. Retrieved from http://www.emedicinehealth.com/congestive_heart_failure/page5_em.htm

• Orr, N. M., Boxer, R. S., Dolansky, M. A., Allen, L. A., & Forman, D. E. (2016). Skilled Nursing Facility Care for Patients With Heart Failure: Can We Make It “Heart Failure Ready?” Journal of Cardiac Failure. https://doi.org/10.1016/j.cardfail.2016.10.009

• Rustad, J. K., Stern, T. a, Hebert, K. a, & Musselman, D. L. (2013). Diagnosis and treatment of depression in patients with congestive heart failure: a review of the literature. The Primary Care Companion for CNS Disorders, 15(4), 1–38. https://doi.org/10.4088/PCC.13r01511

• Scott, M. C., & Winters, M. E. (2015). Congestive Heart Failure. Emergency Medicine Clinics of North America. https://doi.org/10.1016/j.emc.2015.04.006

• Smeulders, E. S. T. F., Van Haastregt, J. C. M., Ambergen, T., Janssen-Boyne, J. J. J., Van Eijk, J. T. M., & Kempen, G. I. J. M. (2009). The impact of a self-management group programme on health behaviour and healthcare utilization among congestive heart failure patients. European Journal of Heart Failure, 11(6), 609–616. https://doi.org/10.1093/eurjhf/hfp047

• van Melle, J. P., Verbeek, D. E. P., van den Berg, M. P., Ormel, J., van der Linde, M. R., & de Jonge, P. (2006). Beta-Blockers and Depression After Myocardial Infarction. A Multicenter Prospective Study. Journal of the American College of Cardiology, 48(11), 2209–2214. https://doi.org/10.1016/j.jacc.2006.07.056

• Wall, H. K., Ballard, J., Troped, P., Njike, V. Y., & Katz, D. L. (2010). Impact of home-based, supervised exercise on congestive heart failure. International Journal of Cardiology. https://doi.org/10.1016/j.ijcard.2009.09.478

• Wiysonge, C. S., Bradley, H. A., Volmink, J., Mayosi, B. M., & Opie, L. H. (2017). Beta-blockers for hypertension. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD002003.pub5