heart failure, early stage - Nursing Case Study

Pathophysiology

• Primary mechanism: Cardiac output reduction - In early-stage heart failure, the heart's ability to pump blood effectively declines due to damage to the heart muscle (myocardium). This can result from conditions such as hypertension, coronary artery disease, or previous heart attack. Reduced output leads to insufficient blood supply to the body's organs and tissues.

• Secondary mechanism: Compensatory mechanisms - As output falls, the body attempts to compensate. The heart may enlarge (hypertrophy), pump faster (tachycardia), or retain more fluid and salt (to increase blood volume). These mechanisms, while initially beneficial, can further strain the heart and exacerbate heart failure over time.

• Key complication: Fluid overload - As heart failure progresses, the kidneys, due to lower blood flow, may not efficiently excrete sodium and water, causing fluid to accumulate in the lungs, liver, and lower body (edema). This can lead to breathlessness, fatigue, and swollen ankles/legs which

Patient Profile

Demographics:

67-year-old male, retired engineer

History:

• Key past medical history: Hypertension, Type II Diabetes, High Cholesterol

• Current medications: Metformin, Lisinopril, Atorvastatin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Shortness of breath after mild exertion

• Key symptoms: Mild fatigue, occasional palpitations

• Vital signs: Blood Pressure 130/80 mmHg, Pulse 75 bpm, Respiratory Rate 16 breaths per minute, Temperature 98.6°F, Oxygen Saturation 96% on room air

Section 1

Change in Patient Status:

Over the course of the next few days, the patient reported increasing fatigue and difficulty in performing his daily activities due to breathlessness, especially after mild exertion. The patient also mentioned that his ankles appeared to be more swollen than usual, even in the mornings. On physical examination, his blood pressure was recorded as 140/90 mmHg, a slight increase from his previous readings, and his pulse rate was 80 bpm, also slightly elevated. On auscultation, there were crackles noted at the bases of both lungs, indicating possible fluid accumulation. His oxygen saturation was 94% on room air, a slight decrease from his previous readings.

These findings indicate that the patient's heart failure may be progressing, despite the compensatory mechanisms. The increased blood pressure and pulse rate suggest that the heart is working harder to pump blood, while the crackles in the lungs and the swollen ankles suggest fluid overload. This could be due to the kidneys' inability to excrete sodium and water efficiently due to the reduced blood flow from the heart. These changes in the patient's status require close monitoring and might need adjustments in his treatment plan.

Section 2

Response to Interventions:

The nursing team immediately communicated the change in the patient’s condition to the physician. Based on the reported symptoms and physical findings, the physician ordered a diuretic to help reduce the fluid overload. The patient was started on furosemide 20 mg orally, once daily. A low sodium diet was also recommended to help decrease fluid retention.

After two days of the new intervention, the patient reported a slight decrease in his fatigue level and breathlessness. His weight had also decreased by 1.5 kg, indicating a reduction in fluid retention. His blood pressure and pulse rate returned to previous levels, at 130/80 mmHg and 72 bpm respectively. His oxygen saturation was at 96% on room air. However, the crackles at the bases of the lungs were still present, though reduced. The patient's ankles remained slightly swollen, but less than before. These improvements suggest that the interventions were effective, but continuous monitoring and further adjustments to the treatment plan may be required to manage the patient's heart failure optimally.

Section 3

New Diagnostic Results:

Following the initial interventions, the physician ordered an echocardiogram to further evaluate the patient's heart function. The results showed a slightly decreased ejection fraction at 50%, indicating the heart was not pumping as efficiently as it should. There were no signs of valvular disease or other structural abnormalities. The B-type natriuretic peptide (BNP) levels were also checked, which were slightly elevated at 150 pg/mL, further supporting the diagnosis of heart failure.

The nurse explained these findings to the patient, emphasizing the importance of adhering to the prescribed medications and dietary restrictions. The patient expressed understanding and willingness to comply. The nurse scheduled a follow-up appointment for the patient in two weeks to monitor progress and make any necessary adjustments to his treatment plan. The patient was also advised to monitor his weight daily and to report any significant changes or increase in symptoms. The nurse also provided education about the symptoms of worsening heart failure such as increased shortness of breath, sudden weight gain, and swelling in the ankles or feet. The patient was advised to seek immediate medical attention if these symptoms occur. The patient's understanding was confirmed through teach-back method.

This additional diagnostic information and continued patient education is crucial in managing the patient's heart failure, aiming to slow down the progression of the disease and improve the patient's quality of life.

Section 4

Two weeks later, the patient returned for his scheduled follow-up appointment. He reported that he had been following the prescribed medication regimen and dietary restrictions. He mentioned noticing some slight improvements in his shortness of breath and was able to do some light activities without becoming too fatigued. However, he also noted a 2 pound weight gain over the past week, which had him slightly concerned.

The nurse reassessed the patient's vitals and found his blood pressure to be 130/85 mmHg, heart rate of 75 bpm, respiratory rate of 18 breaths per minute, and oxygen saturation of 98% on room air. The nurse also noted slight peripheral edema in the patient's ankles. The patient's weight was confirmed to have increased by 2 pounds since his last visit. Based on these findings, the nurse contacted the physician to discuss the observed weight gain and ankle edema, which could be indicative of fluid accumulation, a common complication in heart failure patients. The physician ordered a repeat BNP test and a diuretic adjustment to manage this potential complication. The nurse reinforced the importance of daily weight monitoring and dietary compliance, especially sodium restriction, in managing his heart failure. The patient was scheduled for another follow-up visit in a week's time to assess the effectiveness of the adjusted medications.

Section 5

At the subsequent follow-up visit, the patient reported a decrease in ankle swelling and no additional weight gain since the last visit. The nurse took the patient's vitals which showed a blood pressure of 128/80 mmHg, a heart rate of 70 bpm, a respiratory rate of 16 breaths per minute, and an oxygen saturation of 98% on room air. The patient's weight was unchanged from the previous week. The nurse also performed a physical examination and confirmed the reduction in peripheral edema.

The results of the repeat BNP test showed a slight decrease from the previous level, indicating a reduction in cardiac strain. These findings suggest that the adjusted diuretic regimen was effective in managing the patient's fluid accumulation. Despite these improvements, the nurse emphasized the importance of continuing with the prescribed medication regimen, dietary restrictions, and daily weight monitoring. The patient was also reminded to report any changes in symptoms immediately. The nurse scheduled a follow-up appointment for the patient in a month's time to continue monitoring his heart failure.