Case Study: A Post-Prosthetic Valve Replacement Patient with Congestive Heart Failure
THEORETICAL BACKGROUNDTheoretical Background.
Heart failure is defined as “the pathophysiologic state inwhich an abnormality of cardiac function is responsible for inadequate systemicfunction” (Woods, et. al, 2010). It is not considered as a disease but a collection of signsand symptoms, the final pathway of a group of diseases, the end-result of mostcardiovascular states.
According to the New York Heart Association (1964), congestiveheart failure may be classified into four functional states. “
Class I (Mild)
are patients withcardiac disease but without resulting limitatios of physical activity. Ordinary physicalactivity does not cause undue fatigue, palpitation, dyspnea (shortness of breath), or anginal pain.
Class II (Mild)
are patients with cardiac disease resulting in slight limitationof physical activity. They are comfortable at rest. Ordinary physical activity results infatigue, palpitation, dyspnea, or anginal pain. On the other hand,
Class III (Moderate)
are patients with cardiac disease resulting in marked limitation of physical activity. They arecomfortable at rest, but less than ordinary activity causes fatigue, palpitation, dyspnea or anginal pain. The last classification is
Class IV (Severe)
are patients with cardiac diseasewherein there is inability to carry out any physical activity without discomfort.Symptoms of cardiac insufficiency or of the anginal syndrome may be present even atrest. If any physical activity is undertaken, discomfort is increased (New York HeartAssociation, 1964).
Nearly 6 million Americans have congestive heart failure (CHF) costing the healthcare system an astonishing $34.4 billion dollars each year. About half of individuals diagnosed with heart failure die within 5 years of diagnosis. Nurse practitioners must be prepared to diagnose and treat CHF as early diagnosis and treatment improves quality of life and increases life expectancy for people with heart failure.
In individuals suffering from heart failure, cardiac output is insufficient to meet the needs of the body. This results in fluid congestion as the heart is not able to output enough blood volume to meet venous return.
A 67 year old female arrives at the emergency department complaining of shortness of breath for the past five days which has gotten progressively worse. Her shortness of breath is worse when lying down and with exertion. She complains of a cough, especially at night. The patient also notes increased swelling in her legs bilaterally and well as mild substernal chest pressure.
The patient has a history of hypertension, diabetes and a prior myocardial infarction. Her vital signs are as follows: BP 210/106, HR 118, RR 26, T 98.2. On exam you note rales in the lung bases bilaterally as well as 1+ pitting edema in the lower extremities bilaterally. The patient is sitting up and in no acute respiratory distress. Her oxygen saturation is 94%.
Suspecting CHF, you order an EKG checking for arrhythmias, ischemia or infarction and coronary artery disease as possible causes. You order the following lab studies:
- Complete Blood Count (CBC)- Shows signs of anemia or infection, potential causes of CHF
- Urinalysis- Proteinuria may be associated with cardiovascular disease
- Electrolyte Levels- May be abnormal related to renal dysfunction or fluid retention
- Liver Function Tests- Heart failure may result in liver dysfunction
- BUN and Creatinine Levels- Indicate decreased renal blood flow
- B-type Natriuretic Peptide (BNP)- Increased in heart failure
A chest X-Ray shows cardiomegaly and mild pulmonary congestion.
Based on lab findings, EKG, X-Ray results and the patient's symptoms and presentation you suspect CHF and plan to order an echocardiogram to confirm your diagnosis to evaluate the patient's heart function.
Management and Outcome
Both nonpharmacologic and pharmacologic therapies are used in treatment of heart failure. Dietary modifications including salt and fluid restriction can help reduce fluid retention in patients with CHF. Restricting sodium to 2-3g/day is recommended.
Many drugs can be used to improve the heart's function and relieve symptoms associated with CHF. Diuretics are commonly prescribed to CHF in order to reduce edema and provide symptomatic relief. ACE inhibitors can improve left ventricular ejection fraction and increase survival. Beta blockers may also be used to control heart rate and prevent arrhythmia. Digoxin, commonly prescribed in CHF, increases cardiac output and improves heart failure symptoms.
Some patients with severe heart failure may require a pacemaker or defibrillator. These devices help maintain the heart in proper rhythm and prevent sudden death. In very severe cases, heart transplant may be considered.
With so many Americans suffering from heart failure, it is important that nurse practitioners be able to diagnose and treat CHF. While severe cases will require a cardiology referral, NP's are often responsible for diagnosing CHF as well as monitoring nonpharmacologic and basic pharmacologic treatment. It is important that CHF be promptly diagnosed and treated as early diagnosis and treatment improves survival and quality of life.
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