heart failure - Nursing Case Study

Pathophysiology

• Primary Mechanism: Reduced Cardiac Output - Heart failure occurs when the heart muscle cannot pump enough blood to meet the body's needs. This may be due to weakened heart muscles or stiff heart chambers that do not fill properly, leading to decreased stroke volume and cardiac output.

• Secondary Mechanism: Neurohormonal Activation - In response to reduced cardiac output, the body increases sympathetic nervous system activity and releases hormones like renin and aldosterone. While initially compensatory, chronic activation can cause harmful effects like fluid retention and further weakening of the heart muscle.

• Key Complication: Fluid Overload - The reduced pumping capacity and hormonal changes lead to fluid build-up in the body. This results in swelling (edema), most often in the legs, and fluid accumulation in the lungs, causing breathlessness.

Patient Profile

Demographics:

68, Female, Retired School Teacher

History:

• Mild hypertension for the past 5 years

• Lisinopril 10mg daily, baby aspirin 81mg daily

• No known allergies

Current Presentation:

• Shortness of breath during routine household chores

• Mild fatigue, occasional palpitations, shortness of breath

• Blood pressure: 135/85 mmHg, Pulse: 78 bpm, Temperature: 98.6°F, Respiratory rate: 16 breaths per minute, Oxygen saturation: 97% on room air.

Section 1

Initial Assessment Findings:

On physical examination, the patient appeared slightly anxious, had mild bilateral pitting edema in the lower extremities, and mild jugular venous distention. On auscultation, an S3 heart sound was noted, which is often heard in heart failure patients. Breath sounds were clear bilaterally. She did not present any chest pain, but she mentioned she feels more comfortable while sitting. Her body mass index (BMI) was 28 indicating she is overweight, which could be contributing to her hypertension and heart failure. Her EKG showed normal sinus rhythm with no signs of ischemia or infarction.

The nurse conducted a thorough review of the patient's medications and noted that she has been taking Lisinopril and baby aspirin as prescribed. The nurse educated the patient about the importance of medication adherence in managing her heart failure and hypertension. She was also advised to monitor her weight daily and to report any sudden weight gain which may indicate worsening heart failure. The patient verbalized understanding of the instructions given. She was scheduled for an echocardiogram to assess her heart's function and structure.

Section 2

New Diagnostic Results:

The patient's echocardiogram results showed a mild decrease in left ventricular ejection fraction (LVEF) of 50%, which is slightly lower than the normal range. This finding is consistent with early stage heart failure, suggesting a slightly impaired ability of the heart to pump blood efficiently. Her B-type natriuretic peptide (BNP) level was also elevated at 350 pg/mL, which is higher than the normal level of less than 100 pg/mL. This is another sign that heart failure might be present, as BNP is a hormone that the heart and blood vessels produce to help maintain blood pressure and fluid balance. When the heart is working harder than usual, levels of BNP rise.

In response to these findings, the nurse discussed with the patient the importance of lifestyle modifications including low sodium diet to manage fluid volume, regular exercise, and weight control to reduce the strain on her heart. The nurse also reinforced the importance of medication adherence and scheduled a follow-up appointment to monitor the patient's progress and response to the interventions. The patient expressed understanding and agreed to make the necessary changes.

Section 3

Change in Patient Status:

At the follow-up appointment, the patient reported that she had been adhering to the low sodium diet and engaging in regular, moderate exercise. She also noted a two-pound weight loss since the previous visit. Her vital signs were stable with a blood pressure of 120/80 mmHg, heart rate of 72 bpm, and oxygen saturation of 96% on room air. The patient, however, expressed concerns about intermittent episodes of shortness of breath, especially when climbing stairs or carrying groceries.

On auscultation, the nurse noted a slight, non-persistent crackle in the lower lobes of her lungs, suggesting a possible increase in fluid accumulation. The nurse discussed the significance of these findings with the patient and advised her to continue with the lifestyle changes, but also to monitor for any potential increase in symptoms. The nurse also scheduled additional diagnostic tests to assess whether the patient's heart failure was progressing or if there were any other underlying issues contributing to her symptoms. This new development provided an opportunity for the nurse to reinforce the importance of the patient's active role in managing her condition and monitoring for changes.

Section 4

New Diagnostic Results:

The patient returned to the clinic within a week for her scheduled diagnostic tests, which included a chest x-ray and an echocardiogram. The chest x-ray showed slight congestion in the lower lobes of her lungs, in line with the nurse's previous auscultation findings. The echocardiogram revealed that the patient's ejection fraction was 50%, which was lower than expected for her age and physical condition, indicating mild heart dysfunction. The nurse also noticed a slight increase in the patient's B-type natriuretic peptide (BNP) levels from the routine blood work, a marker often associated with heart failure.

These results confirmed that there was indeed a mild progression in the patient's heart failure, although it was still in the early stages. The nurse explained the results to the patient, assuring her that her condition was still manageable with the right interventions and self-care. This new information served as an opportunity for the nurse to highlight the critical importance of the patient's adherence to medications, dietary restrictions, and exercise routines to prevent further deterioration of her heart function. The nurse also emphasized the importance of regular check-ups and monitoring of symptoms to promptly address any potential complications.

Section 5

Change in Patient Status:

In the following weeks, the patient was diligent in adhering to the prescribed medications and lifestyle modifications. During her next visit to the clinic, she reported a noticeable improvement in her symptoms. She no longer experienced shortness of breath during mild physical activities, and the edema in her lower extremities had significantly reduced. The patient also reported having a more regular sleep pattern, which she attributed to less nighttime urination, a symptom often linked with heart failure.

During the physical examination, the nurse found the patient's blood pressure to be 130/80 mmHg, and her heart rate was steady at 70 beats per minute. Her BNP levels were slightly lowered, indicating a decrease in cardiac strain. However, the nurse noted that her ejection fraction remained at 50%, suggesting that the heart's pumping ability had not improved despite the patient's subjective reporting of symptom relief. The nurse reminded the patient that while the symptomatic improvement was a positive sign, it was crucial to continue the interventions as heart failure is a chronic condition and requires ongoing management. The nurse's objective was to prevent further progression, reduce hospitalization risk, and improve the patient's quality of life.