heart failure - Nursing Case Study

Pathophysiology

• Primary mechanism: Heart failure begins when the heart muscle weakens, reducing its ability to pump blood efficiently. This is often due to damage from a heart attack or conditions that overwork the heart, such as hypertension, coronary artery disease, or faulty heart valves. This leads to the heart enlarging and the pumping action to weaken.

• Secondary mechanism: As the heart's pumping ability declines, the kidneys respond by retaining fluid and salt. This fluid buildup causes congestion in body tissues, resulting in edema and shortness of breath, characterizing what's called congestive heart failure.

• Key complication: Over time, chronic heart failure can lead to a condition called cardiac cachexia, a severe muscle-wasting and weight loss condition. This occurs due to the body's chronic inflammatory response to heart failure, which can lead to decreased appetite and metabolic changes.

Patient Profile

Demographics:

62-year-old male, retired construction worker

History:

• Key past medical history: Hypertension, Type 2 diabetes, previous myocardial infarction 3 years ago

• Current medications: Metformin, Lisinopril, Aspirin, Metoprolol

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Shortness of breath, fatigue, swelling in legs

• Key symptoms: Difficulty performing daily activities, increased breathlessness especially at night, persistent cough with frothy sputum, loss of appetite, rapid weight gain from fluid retention

• Vital signs: Blood pressure 140/90 mm Hg, heart rate irregular at 110 beats per minute, respiratory rate 22 breaths per minute, oxygen saturation 90% on room air, temperature 98.6 F.

Section 1

Response to Interventions:

The healthcare team immediately initiated treatment based on the patient’s symptoms and medical history. The patient was placed on supplemental oxygen to improve his oxygen saturation, which subsequently increased to 94%. Lasix was administered to help reduce fluid retention and decrease the workload on his heart. After medication administration, the patient reported a slight relief in his shortness of breath and his respiratory rate decreased to 18 breaths per minute. However, his blood pressure remained high at 140/90 mm Hg and his heart rate continued to be irregular at 104 beats per minute.

The patient's blood sugar was also monitored due to his history of Type 2 diabetes. His blood glucose level was found to be 200 mg/dl, which is above the target range for individuals with diabetes. This elevated blood glucose level could be a contributing factor to his heart failure, as high blood glucose levels can damage blood vessels and nerves that control the heart. The healthcare team decided to closely monitor his blood glucose levels and adjust his Metformin dosage as necessary.

These interventions provided some relief to the patient, but also revealed the need for ongoing management of his heart failure and comorbid conditions. The patient’s persistent high blood pressure and irregular heart rate, as well as his elevated blood glucose level, indicate the need for further diagnostic testing and treatment adjustments.

Section 2

New Diagnostic Results:

To further understand the patient's cardiac condition, an echocardiogram was performed. The results showed a decreased ejection fraction of 35%, indicating a reduction in the heart’s ability to pump out blood effectively. This finding is consistent with systolic heart failure and it also explains the patient's symptoms of fatigue and shortness of breath. In addition, an EKG revealed atrial fibrillation (AFib), a type of irregular heart rhythm. This could explain the patient's persistent tachycardia and may also contribute to his heart failure, as AFib can lead to an increased workload on the heart and impaired cardiac output.

To understand the reason for the persistently high blood pressure, the healthcare team ordered a renal function test. The results showed elevated creatinine levels of 1.8 mg/dL and decreased glomerular filtration rate (GFR) of 45 mL/min/1.73 m2, indicating that the patient also had chronic kidney disease (CKD) stage 3. This is a common complication in patients with heart failure and hypertension, and it could be contributing to his fluid retention and further stressing his heart.

These new findings indicated that the patient's heart failure was more complex than initially thought. The combination of reduced ejection fraction, AFib, and CKD suggested the need for a more comprehensive and aggressive treatment strategy that addresses all these interrelated conditions.

Section 3

Change in Patient Status:

Over the next several days, the patient's condition continued to worsen. He became increasingly lethargic and his shortness of breath worsened even with minimal exertion. His oxygen saturation levels dipped to 90% on room air, further indicating poor oxygenation due to decreased cardiac output. His blood pressure remained uncontrolled, averaging 150/90 mmHg, and his heart rate continued to fluctuate between 100-130 bpm due to the AFib.

Additionally, the patient began complaining of increased lower extremity edema and a 2 kg weight gain was noted over a 48-hour period, suggesting worsening fluid retention likely due to his CKD and heart failure. His daily urine output had also significantly decreased to 400 ml/day. The worsening edema, weight gain, and decreased urine output all pointed towards a worsening renal function, likely exacerbating his heart failure. This decline in status underscored the need for urgent intervention to manage his overlapping cardiac and renal conditions.

Section 4

New Diagnostic Results:

Laboratory values returned from the lab indicated a rise in the patient's B-type natriuretic peptide (BNP) levels to 1200 pg/mL, well above the normal range of less than 100 pg/mL, indicating increased cardiac stress from the worsening heart failure. Additionally, his serum creatinine levels increased from 1.3 to 1.9 mg/dL, along with an elevated blood urea nitrogen (BUN) level of 40 mg/dL, both indicative of deteriorating renal function.

An echocardiogram showed a decrease in ejection fraction from 45% to 35%, reflecting a worsening left ventricular function. His chest X-ray also showed increased pulmonary congestion and cardiomegaly, further confirming the exacerbation of heart failure. These results prompted an urgent consultation with both cardiology and nephrology teams to address the interrelated problems of the patient's worsening heart failure and renal function. The patient's condition is now more critical, requiring a reassessment of current management strategies and consideration of more aggressive and invasive interventions.

Section 5

Change in Patient Status:

Over the next 24 hours, the patient's condition deteriorated further. His oxygen saturation levels dropped to 88% on room air, and he developed an increased respiratory rate of 28 breaths per minute, indicative of worsening pulmonary congestion. On auscultation, there were bilateral crackles in the lower lung fields, and he started to cough up pink, frothy sputum. His blood pressure fluctuated, with readings ranging from 100/60 to 130/85 mmHg. He became increasingly fatigued with minimal exertion, and reported increased difficulty in lying flat due to worsening orthopnea.

The patient's urine output significantly decreased to less than 0.5 mL/kg/hr over the last 6 hours, suggesting possible acute kidney injury on top of his chronic kidney disease. This was accompanied by swelling in his lower extremities and an increase of 3 kg in his body weight within two days, likely due to fluid retention. The patient also complained of new onset, persistent abdominal discomfort, which could indicate hepatic congestion or gastrointestinal issues secondary to decreased perfusion. This significant deterioration in the patient's respiratory, cardiovascular and renal status necessitates immediate intervention and reevaluation of his current treatment plan.