Your client, Mr. Black, is a 72-year-old man who called his TeleNurse Line from home and, based on the symptoms he described, was advised to go directly to the Emergency Department at his local hospital. His admitting diagnosis is exacerbation of heart failure (HF). His Ht is: 5’9”, Wt. 235 lbs. He states that his usual weight is about 220. Upon admission, his symptoms are: extreme shortness of breath; unable to tolerate lying flat; heavy, aching feeling in his chest; respirations labored @ 32/min.; radial pulse 108 and regular; BP 150/78; color dusky and O2 Sat is 82% on room air; slight diaphoresis; peripheral edema is 3+ pitting, ankle to knee bilaterally and sacral edema is also present. Bilateral BS present with coarse crackles in both lower lobes. He appears frightened and anxious; he states, “This is the worst it has ever been – please don’t leave me alone.”
Past Medical/Social History: Coronary Artery Disease (CAD), hypertension, cor pulmonale, emphysema-moderate stage. He smoked 2 packs per day for 35 years, and quit 5 years ago. Hospitalized 3 times previously for HF; the most recent hospitalization was 6 months ago. He is a retired insurance salesperson; married and lives with his wife in a condominium. Sedentary life-style; plays golf occasionally. He skipped his diuretics over the weekend because he was golfing.
1. Which stage of the NYHA classification system and the ACC/AHA staging system would Mr. B’s symptoms best fit within? Why?
I think his NYHA classification would be Class II. He has Coronary Artery disease and ordinary activity causes fatigue for him Mr. B’s ACC/AHA stage is Stage D. He has been hospitalized 3 times previously for HF.
2.Discuss the differences between right and left heart failure, consider the pathophysiology, physiological progression, and signs and symptoms.
-The most common
-Results from left ventricular dysfunction. This prevents normal forward blood flow causing blood to back up into the left atrium and pulmonary veins. Increased pulmonary pressure causes fluid leakage from pulmonary capillary bed into the interstitial and then the alveoli -Manifests as pulmonary congestion and edema
-occurs when right ventricle fails to contract effectively. -Causes a backup of blood into the right atrium and venous circulation. -Venous congestion in the systemic circulation results in jugular venous distention, hepatomegaly, splenomegaly, vascular congestion of the GI tract, and peripheral edema
-May also result from an acute condition such as right ventricular infarction or pulmonary embolism -Core Pulmonale can also cause right sided HF
-Its primary cause is Left sided HF. Left sided HF results in pulmonary congestion and increased pressure in the blood vessels of the lungs. Eventually chronic pulmonary hypertension results in right sided hypertrophy and HF
3. Mr. Black’s orders include: a bedside chest x-ray, ECG, echocardiogram, and the following labs: Troponin I, CK-MB, CBC with differential, BNP, Digoxin level, Electrolytes, Mg++, ABG’s, BUN and creatinine. What is the rationale for performing each of these diagnostics tests? How will the findings/information obtained from the tests be useful in managing Mr. Black’s care?
Bedside chest x-ray:
Troponin I: present in MIs
BNP: High in patients with HF
Mr. Black is stabilized and transferred to the Cardiac Telemetry unit with the following orders:
Oxygen at 2-4 liters per nasal cannula to keep O2 Sat > 90%
Complete bed rest with HOB elevated 60-90 degrees, legs dependent
Saline Lock IVFurosemide (Lasix) 80 mg I.V. push Stat
I&OFurosemide (Lasix) 80 mg I.V. push every 8 hr.
Daily weight Albuterol Inhaler 2 puffs twice per day
Pulse oximetry – continuousK-Dur 10 mg. p.o. daily
Foley catheterASA 81 mg p.o. daily
TelemetryMetoprolol 100 mg p.o. twice daily
Diet: 2 Gm Na Lisinopril 10 mg p.o. daily
Fluid restriction of 1000 mL/dayHCTZ 50 mg p.o. daily
Code status: Full codeDigoxin 0.25 mg p.o. daily; Hold for HR < 60 bpm
Lovenox 60mg SQ every 12 hrsDucosate sodium 100 mg p.o. daily
4. Discuss the rationale for each of the orders above
Patients with HF typically have oxygenation problems
Furosemide is a loop diuretic
Daily Weight- water retention
Pulse ox- monitor O2
Foley Catheter: monitor output and on bed rest
Metoprolol: beta blocker that treats high BP
Lisinopril: ACE inhibitor for HTN
Lovenox: Prevents and treats clots
Fluid Restriction: Excess fluid strains the heart
Digoxin: Treats rhythmic problems
Ducosate: Stool Softener
5. Identify 3 priority nursing diagnoses to include in the nursing care plan for Mr. Black.
Excess fluid volume
Decreased cardiac output
Impaired gas exchange
6. What changes/assessment findings would alert the nurse that Mr. Black’s condition is worsening?
Fatigue and dyspnea continue to worsen, weight continues to increase, edema and chest pain worsens, pleural effusion and dysrhythmias begin to develop, hepatomegaly, and renal failure begins to occur
Mr. Black responds well to the treatment plan and his acute symptoms resolve within 3 days. His weight returns to 220 lbs. and he is able to perform his ADL’s with minimal SOB and able to sleep comfortably with 2 pillows. Discharge plans are finalized.
7. Which state of the NYHA Classification system and the ACC/AHA staging system
Would Mr. Black’s symptoms now fit?
NYHA- Class II
ACCF/AHA- Stage C
8. Select 2 discharge topics (your choice) to focus on. Discuss what should be included in the discharge teaching plan for Mr. B. (and his wife) for each topic.
Activity and rest: exercise training can improve symptoms of HF, however Mr. B needs to understand that he will need lots of rest during and after exercise and that he shouldn’t overexert himself. Teach Mr. B’s wife to monitor his exercise and encourage him to take breaks when needed
Drug therapy: Teach Mr. B and his wife the expected action of all his medication and how to recognize drug toxicity. Also teach him and his wife how to take a pulse rate and what range the pulse rate should be in. Teach them the symptoms of hypokalemia and hyperkalemia if diuretics are order. Self BP monitoring may also be appropriate in Mr. B’s situation.
New York Heart Association Classification
American College of Cardiology/American Heart Association Guidelines Treatment Recommendations
Stage A. People at high risk of developing heart failure (HF) but without structural heart disease or symptoms of HF
-Treat hypertension, lipid disorders, diabetes.
-Encourage patient to stop smoking and to exercise regularly.
-Discourage use of alcohol, illicit drugs.
-ACE inhibitor if indicated
Class I. Patients with cardiac disease without limitations of physical activity. Ordinary physical activity doesn’t cause undue fatigue, palpitations, dyspnea, or anginal pain. Stage B. People who have structural heart disease but no symptoms of HF.
-All stage A therapies
-ACE inhibitor unless contraindicated
-Beta-blocker unless contraindicated
Class II. Patients with cardiac disease who have slight limitations of physical activity. They’re comfortable at rest. Ordinary physical activity results in fatigue, palpitations, dyspnea, or anginal pain.
Class III. Patients with cardiac disease who have marked limitation of physical activity. They’re comfortable at rest. Less than ordinary physical activity causes fatigue, palpitations, dyspnea, or anginal pain.
Stage C. People who have structural heart disease with current or prior symptoms of heart failure. -All stage A & B therapies
-Avoid or withdraw antiarrhythmic agents, most calcium channel blockers, and nonsteroidal anti- inflammatory drugs.
-Consider aldosterone antagonists, angiotensin receptor blockers, hydralazine, and nitrates. Class IV. Patients with cardiac disease who can’t carry out any physical activity without discomfort. Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. Any physical activity increases discomfort. Stage D. People with refractory heart failure that requires specialized interventions.
-All therapies for A, B, and C
-Mechanical assist device, such as biventricular pacemaker or left ventricular assist device
-Continuous inotropic therapy
Caboral, M. & Mitchell J. (2003). New guidelines for heart failure focus on prevention. The Nurse Practitioner, 28, 22.
Evaluation of Edema
Four-point scale 1+ to 4+:
1+ – pitting barely detectable
4+ – pitting persistent and deep (1” or 2.54 cm.)