heart failure - Nursing Case Study

Pathophysiology

• Primary mechanism: Heart failure occurs when your heart muscle doesn't pump blood as well as it should. This is often due to conditions that damage the heart, such as coronary artery disease or high blood pressure. Over time, the heart can't keep up with the body's demand for blood, leading to the symptoms of heart failure.

• Secondary mechanism: As heart failure progresses, the heart's pumping action grows weaker. The body responds by releasing hormones that increase blood volume and constrict blood vessels, which helps to maintain blood flow. However, these compensatory mechanisms also increase the workload on the heart and can further weaken the heart muscle.

• Key complication: Fluid buildup is a common complication of heart failure. When the heart can't pump enough blood, fluid can build up in the lungs, liver, gastrointestinal tract, and the arms and legs. This can cause shortness of breath, swelling (edema), and other symptoms.

Patient Profile

Demographics:

67, Male, Retired School Teacher

History:

• Managed hypertension for 10 years, mild osteoarthritis

• Metoprolol 50mg daily for hypertension, occasional paracetamol for osteoarthritis pain

• No known allergies

Current Presentation:

• Chief complaint: Progressive shortness of breath for 2 weeks

• Key symptoms: Mild fatigue, occasional palpitations, slight swelling in ankles by end of day

• Vital signs: Blood pressure 130/80 mmHg, pulse 78 beats per minute, respiratory rate 16 per minute, oxygen saturation 98% on room air, body temperature 98.6°F.

Section 1

Initial Assessment Findings:

During the physical examination, the patient exhibits mild ankle edema, predominantly on the right side, and his weight has increased by 3 pounds since his last visit two months ago. Auscultation of the heart reveals a regular rhythm, but there's a third heart sound (S3 gallop) indicative of fluid overload. His lungs are clear to auscultation bilaterally, suggesting that fluid accumulation has not yet reached the lungs. His jugular veins are not distended, indicating right heart failure is not pronounced at this stage.

Given his progressive shortness of breath, mild fatigue, occasional palpitations, and slight swelling in ankles, the nurse suspects that the patient’s heart failure may be worsening. His increased weight could be due to fluid retention, a common symptom in heart failure. The presence of the S3 gallop typically signifies an increase in left ventricular filling pressures, or in other words, fluid overload. The nurse recognizes these symptoms as early signs of heart failure exacerbation and understands the need for further diagnostic tests and therapeutic interventions.

Section 2

New Diagnostic Results:

To further investigate the patient's condition, the nurse orders a series of diagnostic tests. The patient's blood work shows an elevated B-type natriuretic peptide (BNP) level of 450 pg/mL, which is indicative of heart failure, given that normal values are generally under 100 pg/mL. His kidney function tests reveal a slightly elevated creatinine level of 1.3 mg/dL, suggesting that his kidneys may be under strain due to the heart failure. His complete blood count is within normal limits, indicating that he is not anemic or suffering from a concurrent infection.

The nurse also reviews the results of the patient's echocardiogram, which shows an ejection fraction of 45%. This is slightly below the normal range of 50-70%, indicating that the patient's heart isn't pumping blood as efficiently as it should. Combined with the physical examination findings and the patient's symptoms, these results confirm the nurse's suspicion of early stage heart failure. The nurse knows that it is crucial to manage the patient's condition properly to prevent it from progressing to a more severe stage. The appropriate course of action involves initiating lifestyle modifications, monitoring the patient's response to new medications, and educating the patient about his condition.

Section 3

Change in Patient Status:

After a week of treatment and lifestyle modifications, the patient returns to the clinic for a follow-up appointment. The nurse takes the patient's vital signs and notes that his blood pressure has decreased to 130/80 mmHg from 150/90 mmHg a week ago. His resting heart rate has also improved, now averaging at 78 beats per minute compared to 92 beats per minute during his previous visit. The patient also reports an improvement in his symptoms, stating that he no longer feels as breathless as he used to be, especially during physical activities.

However, the patient also reports a new symptom: he has been experiencing bouts of dizziness, especially when standing up from a seated or lying position. The nurse recognizes this as orthostatic hypotension, a common side effect of some heart medications and a potential complication of heart failure. This new development, although minor, necessitates a review of the patient's current medications and possible adjustment of dosages. The nurse makes a note to discuss this with the physician and educate the patient about safety measures to prevent falls and injuries due to dizziness.

Section 4

Change in Patient Status:

During the patient's follow-up visit, the nurse conducts a thorough physical assessment and records any changes. The patient's weight has dropped two pounds since his last visit, which could indicate improved fluid balance. His breath sounds are clearer, with no signs of fluid accumulation in the lungs. The nurse also performs a quick cognitive assessment and notes that the patient is alert and oriented to time, place, and person.

However, the nurse does observe orthostatic changes in the patient's blood pressure. Upon standing, the patient's blood pressure drops to 110/70 mmHg from his resting measure of 130/80 mmHg, and his heart rate increases to 85 beats per minute. The patient reports feeling dizzy during this change in position. The nurse concludes that this is likely due to orthostatic hypotension caused by the patient's medication regime, which is a common occurrence in early-stage heart failure patients. The nurse decides to relay these findings to the physician to consider dose adjustments and monitors the patient closely to prevent potential falls or injuries. This new development marks a minor but important change in the patient's status. It also necessitates the nurse to educate the patient about orthostatic hypotension, its possible causes, and ways to manage it safely at home.

Section 5

New Diagnostic Results:

The physician orders a set of labs to further evaluate the patient's condition. The blood test results reveal slightly elevated B-type natriuretic peptide (BNP) levels at 120 pg/mL, a common marker for heart failure. This increased level suggests that the patient's heart is working harder to pump blood. The patient's electrolyte panel shows a slightly low sodium level at 133 mEq/L, which may be a result of the prescribed diuretics. His kidney function is normal, with a creatinine level of 0.9 mg/dL, indicating that his kidneys are adequately filtering waste products.

The physician also orders an echocardiogram to assess the patient's heart function. The results show a slightly reduced ejection fraction of 50%, indicating that the heart isn't pumping as efficiently as it should. However, the patient's heart structures appear normal, with no signs of valve abnormalities or wall thickening.

These new diagnostic results confirm the early stage of heart failure and the minor complications associated with it. The findings also highlight the need for ongoing monitoring and possible adjustment of the patient's medication regimen to manage his symptoms and prevent further progression of the disease. The nurse uses these results to further educate the patient about his condition and the importance of adhering to his prescribed treatment plan.