Congestive Heart Failure Tests: Case Study

Congestive Heart Failure 

Congestive heart failure (CHF) is when the heart is not able to pump effectively or does not meet the body’s metabolic demands. Because of this lack of performance, the heart is not able to supply oxygen and nutrients throughout the body. As a result of the impaired pump, blood and other fluids back up into areas like an individual’s lungs and legs, causing congestion. Other cardiovascular conditions may increase an individual’s chance of developing CHF, such as coronary artery disease or high blood pressure (Mayo Clinic, 2017). This essay will be analyzing Mrs. S a recently diagnosed CHF patient who was admitted to the hospital. Additionally, it will be defining the clear connection between Mrs. S’ objective and subjective data in correlation to CHF.

Tests to Confirm Presence of CHF (1) 

CHF which formerly known as heart failure is specifically described by Macon and Cherney (2018) as inadequate supply of blood pumped by the heart due to buildup of fluid.

Diagnostic tests carried out to confirm heart failure or more specifically, CHF are the same and have the aim of finding what the underlying cause is. Although the signs and symptoms Mrs. S is experiencing are that of CHF, they are not specific to only this condition which makes diagnosing hard (Lewis et al., 2019).  According to Taylor, Rutten, Brouwer, & Hobbs (2017), Mrs. S’ myocardial infarction (MI) that occurred last year, makes the presence of CHF more probable.

The first step of confirming the presence of CHF is a physical examination of the patient with a cardiac focus. This will entail listening to her heart to determine any abnormalities with the heart rhythms which will indicate if something is wrong. Mrs. S complained of “fluttering feeling with her heartbeat” which is a symptom of atrial flutter or tachycardia. To ensure an accurate reading, a continuous ambulatory ECG such as Holter monitoring will be done. The recordings will be interpreted and if the symptom Mrs. S complains of is related to an atrial flutter; the ECG results will confirm its presence. (Lewis et al., 2019)

Cardiac markers such as BNP and N-terminal pro-BNP (NT-proBNP) are measured to further confirm accurately that Mrs. S has CHF through blood tests that would be ordered. Aguanno (2017) explained that natriuretic peptides will show if the wall of the heart muscle has been stressed hemodynamically. Lewis et al (2019) found that these cardiac markers which are a type of Natriuretic Peptide (NP) will help to differentiate Mrs. S dyspnea to determine if it is “caused by HF [or] from other causes of dyspnea” (p. 851). B-type Natriuretic peptide (BNP), a hormone released by the heart elevates in presence of heart failure. It is produced by the myocardium and is elevated in response to the stretching of the left ventricle.

Other procedures that may be ordered include a chest X-ray, echocardiography, computerized tomography (CT) scans and magnetic resonance imaging (MRI). An echocardiography will look at the action, size, shape, position of the heart’s internal structures (valves, walls, aorta), the behavior of heart wall and other abnormalities relating to the function and structure of the heart. Taylor et al (2017) advised that “if there is a history of myocardial infarction… [individual is referred] directly to echocardiography…” (“Investigations,” para. 4).

With Mrs. S MI from last year, it may be best for her to be taken for an echocardiography with Doppler technology and color enhancement which would help in the initial assessment but a transesophageal echocardiography (TEE) would lend for an enhanced assessment that would produce detailed results (Inamdar & Inamdar, 2016).

The Chest X-ray will show if there is any abnormality in shape and size of the heart, cardiac contours, heart enlargements that occur which would be related to heart failure. The presence of pleural effusion would be more specifically related to CHF which would be a good indicator in Mrs. S’ case.

Carrying out an MRI, more specifically a cardiovascular magnetic resonance imaging (CMRI) provides the images of the heart in multiple planes and will show if there has been any damage done to the heart. The high-resolution images provided will give further information that will help identify the underlying cause of the CHF through data about blood flow through heart muscle and scarring. This could help healthcare professionals in projecting how and what the course of the CHF could look like. (Inamdar & Inamdar, 2016)

Respiratory Manifestations of CHF (2) 

A nurse performing a respiratory assessment on an individual with congestive heart failure would expect the presence of pulmonary edema, dyspnea and fatigue, and paroxysmal nocturnal dyspnea. When the left ventricle is weak, it causes blood to back flow into the pulmonary veins. Pulmonary edema is when fluid backs up into the lungs, making it difficult for the lungs to perform gas exchange. Mrs. S specified that she has an occasional productive wet cough for pink frothy sputum. When body attempts to removes blood from the respiratory tract and forces the person to cough, this is known as hemoptysis. (Phillips & Zieve, 2019). Furthermore, the nurse would hear crackles in the patient’s lungs, indicating the movement of air through fluid. Additionally, as a result of blood preventing adequate gas exchange, Mrs. S. suffers from shortness of breath, followed with fatigue. That being said, the nurse would notice the patient struggling to take full deep breathes. Lastly, Mrs. S has been unable to lie flat in bed and has added three pillows to allow her to sit up higher to sleep. Lewis et al. (2019) mentioned paroxysmal nocturnal dyspnea is another symptom of CHF; It is when an individual cannot breathe, especially at night when lying down for long periods of time. This is due to the pressure put on the chest when lying flat from the blood back up.

Other Abnormal Data (3) 

Apart from abnormalities from the respiratory assessment, there are other abnormalities that would be present in Mrs. S. relating to CHF such as altered serum electrolytes such as high sodium levels with the presence of edema, increased heart chamber and lower oxygen saturation.

Regarding her “suffering from fatigue,” this is a normal clinical manifestation that is found in CHF and is said to be one of the symptoms first found with individuals showing signs of CHF. With the inadequate blood supply from the heart, there would be a decreased cardiac output resulting in low blood flow as well as less oxygen carried to tissues and vital organs.

Mrs. S’ complains of a “fluttering feeling with [my] heartbeat” could be a symptom of atrial flutter but could also be a manifestation of tachycardia. Similarly, tachycardia is one of the earliest symptoms of CHF which was what got her admitted into the cardiac rehabilitation center. Her body will use a compensatory mechanism by increasing her heartrate which could be a result of an impaired ventricle. With the heart unable to pump blood efficiently, there will be less cardiac output causing the SNS to be activated causing an increase in heart rate.

The presence of edema is highly likely in Mrs. S. who has gained “2.27kg (5lbs.) in the past week”. This abnormality is commonly found in individuals developing CHF or a worse condition of CHF. (Lewis et al., 2019). Macon and Cherney (2018) found that the development of cough especially from a congested lung indicates that the CHF is exacerbating. This could suggest that Mrs. S with a recent diagnosis of CHF, the “occasional productive wet cough for pink frothy sputum” coming from her lungs could suggest her CHF is worsening.

Macon and Cherney (2018) noted that the feeling of needing to urinate frequently at night is an early sign of CHF. Lewis et al. (2019) confirmed this by saying that with nocturia, the individual will void more through the night due to fluid movement in the interstitial space and a reduced cardiac workload as PNS is stimulated more at night. Mrs. S who isn’t used to getting up at night to void but recently having an increased need to urinate at night, asserted the findings above. She found that she was needing to void “2-3 times each night” which started this past month.

If a blood test was done and assessed, there would be an elevated level of BNP and NT-pro-BNP. Specific levels for these natriuretic peptides were shown in the book ‘Medical-Surgical Nursing in Canada’ by Lewis et al (2019). They found that patients age 50 -75 such as Mrs. S who is 63, a NT-pro-BNP level of “[greater than] 1800pg/ml” will show CHF to be highly probable. Elevated levels of BNP “[greater than] 500pg/mol indicates CHF.” (Lewis et al’, 2019, Table 37-5).

Health Failure Clinic Test (4) 

Initial physical exam and medical history would be obtained from patients to treat the underlying cause and for a formal diagnosis of heart failure. Clinical tests include chest x-ray imaging which may show presence of pulmonary congestion and cardiomegaly (Rahko , P. S. 2014). ECG may be associated with decompensation with a significant volume overload, infiltration cardiomyopathy and used to detect causes and reaction of Heart Failure. ECG changes include sinus tachycardia and example of clinical manifestations related are, reduced stroke volume and reduced cardiac output or high output demand state. BNP, serum chemistry; Liver function, thyroid function are parts of heart failure diagnostic tests. (Inamdar & Inamdar 2016) Cardiac catheterization and coronary angiography are necessary tests in a patient with new onset heart failure and angina. (Inamdar & Inamdar, 2016) BNP is a neuro- hormone, an activated form of proBNP. The 108- amino acid polypeptide precursor is stored as secretory granules in the ventricles and to a lesser extent in the atria. Elevated BNP (Brian Natriuretic peptide levels) is associated with pulmonary edema and renal failure; It is used to assess patients with labored breathing for heart failure. (King. M, et al. 2012) BNP levels increase with age and are higher in women. (Inamdar, A. A., & Inamdar, A. C 2016) Cardiac CT will show an accurate assessment of cardiac structure and function including the coronary arteries. According to (Merck 2018) radionuclide imaging can assess systolic and diastolic function, previous MI and inducible ischemia.

Lasix Information (5)   

Lasix also known as furosemide, is a loop diuretic and an antihypertensive drug; Used to treat edema associated with renal disease, and acute pulmonary edema by increasing the excreation of water, and sodium chloride (Saunder, 2019). It can be contraindicated in persons who have a hypersensitivity reaction. Excessive Lasix can lead to electrolyte and water loss, resulting in  dehydration, hypokalemia, hyponatremia. Blood pressure and pulse should be checked before administration. In the case of Mrs.S Lasix would be administered to treat pulmonary edema. IV will be the first route to administer the drug, because it is fast acting because it goes directly into the bloodstream. Delivering the medication by IV should be at a rate 20-40 mg per minute, and should not exceed 4mg per minutes, if given as a short-term intermittent infusion (Saunder, 2019). Oral Lasix may be given with or without food and it has a slower absorption rate, which is the reason why it was prescribed to Mrs.S. after the initial IV administration. Lasix will lessen congestive heart failure symptoms such as shortness of breath and swelling in extremities. Some side effect includes nausea, abdominal cramps, and electrolyte disturbance (Saunders, 2019).

Teaching about Diuretics (6) 

Lasix is used to manage symptoms relating to fluid retention; and causes diuresis, which is an increase in urine (Saunder, 2019). Thus, patients who are on Lasix should expect an increase in urine production and frequency. Due to the movement of fluids and the body adjusting to the medication, an individual may experience some dizziness, lightheadedness, headache and/or blurred vision (Saunder, 2019). These are things the nurse should inform Mrs. S about taking her diuretic medication.

Other Lifestyle Changes to Control Signs & Symptoms (7) 

In addition to regular exercise, other lifestyle changes such weight management and dietary changes are essential to implement for control. Before Mrs. S is discharged, it is imperative that a dietician does an assessment of what her diet normally entails of. This will enable the dietician to make a detailed plan on what Mr. S can have. Social and financial influence should be accommodated into the detailed plan to ensure it is individualized and the patient feels involved. The diet should include fruits and vegetables as well as whole grains.

Mrs. S needs to be taught about the importance of reducing her sodium intake. Water is attracted to sodium so with a high sodium intake, there will be an increase in water retention. Lewis et al (2019) states that “2-g/day sodium diet” is recommended for mild HF while “1.5-g/day sodium” is recommended for those with severe HF. It would benefit Mrs. S if she is taught about food labels, adding salt while preparing food and having food with lower salt content. (Mayo Clinic Staff, 2017)

Stress can exacerbate heart failure. Mrs. S should be taught techniques on reducing stress levels and stress causes an increase in heartrate. This is detrimental for the heart as it is already inefficient in meeting the body’s demands for blood supply.

It may be hard for Mrs. S to know how to change or adhere to lifestyle changes to help control her heart failure. However, nurses and other healthcare professionals need to work together to devise a detailed yet individualized plan for Mrs. S that she can comply with.

Captopril Drug Classification (8) 

Captopril is an Angiotensin Converting Enzyme (ACE) Inhibitor. The usual dosage given to patients is within the range 12.5- 50mg twice a day (Porter et, al. 2018). The drug prevents the conversion of angiotensin I to angiotensin II. It subdues the renin-angiotensin-aldosterone system. It does this by decreasing plasma angiotensin II, increasing plasma renin activity, and decreasing aldosterone secretion. Captopril is used as treatment of chronic diseases such as Heart Failure (HF), hypertension, diabetic nephropathy, and post myocadiac infarction for prevention of ventricular failure (Saunders, 2019). According to the Merck Manual (2018), the side effects of the drug are rashes, pruritus, dysgeusia, headache, Insomnia, cough, dizziness, fatigue, paresthesia (abnormal skin sensation), malaise (a slight pain that the cause is difficult to find), nausea, diarrhea or constipation, dry mouth, and tachycardia. Saunders (2019) states that the adverse effects of the captopril are angioedema, hyperkalemia, agranulocytosis, and renal impairment (p. 187).

Baseline assessment is done to ensure that the patient does not experience preventable adverse effects. For example, obtaining blood pressure and being alert to fluctuation before administering each dose. In patients with prior renal disease, test urine for protein by dipstick with first urine of the day and periodically thereafter. In patients with renal impairment, autoimmune disease or taking drugs that affect the leukocytes or immune response obtain CBC before administration every 2 weeks for 3 months (Saunders, 2019). Discontinue medication and contact physician if angioedema occurs. Nursing assessment that could be done are observing skin for rash or pruritus; monitoring urinalysis for proteinuria (high levels of protein in the urine); monitoring serum potassium levels in patients on diuretic ongoing therapy; monitor B/P, serum BUN, Creatinine, CBC.

Mrs. S is administered oral Captopril as a treatment for her congestive heart failure. Since CHF is a progressive disease that involves the inability of the heart muscles to meet up with the body’s demand or pump blood accurately, Captopril stops the production of the ACE which allows the vasodilation of the heart vessels which helps to decrease blood pressure and lowers the reoccurrence of a MI in Mrs. S. This greatly decreases the workload that Mrs. S’ heart must do.

Patient Teaching Regarding Captopril (9) 

Ensuring that the patient receives the best care possible, it is important that nurses provide them with information that would minimize the possibility of adverse effects occurring and facilitate the healing process. Patients with renal insufficiency or taking potassium sparing diuretics should refrain from taking this drug as it may cause hyperkalemia (Saunders, 2019, p.187). Patient should be informed that the therapeutic effect of the drug may take several weeks to lower the blood pressure. The nurse will teach the patient when to report to them if they experience swelling in their face, lips and/or tongue. Additionally, the patient should be careful when rising from sitting/fowler’s position. Lastly, the nurse should inform the patient that skipping or stopping the intake of their medication would cause blood pressure increases after stopping the administration of the drug also known as rebound hypertension.

How Would Mrs. S Know if the Medications are Effective (10) 

Mrs. S may observe reduced swelling on her feet, ankles, hands, weight loss, and reduced pulmonary edema. Her breathing will become easier; she may not require 2 or more pillows to sleep at night and she may be able to lie flat. She may observe increased urinary output and frequency and reduced wet cough after taking Lasix. Mrs. S may notice decreased symptoms of congestive heart failure, lowered blood pressure, less fatigued, and reduced heart rate within months of taking captopril.

Conclusion 

Congestive Heart Failure (CHF) is when the heart muscle is unable to perform its function properly. CHF may also cause excessive fluid buildup which leads to edema and cardiac dysfunction. There are several drugs such as Lasix and Captopril that are used as treatment of CHF. This paper explored CHF, its symptoms, treatments, and its effect on patients. It also looks at tests done such as chest x-ray and ECGs that aims to discover the underlying cause of the disease. It linked Mrs. S.’ objective and subjective data to CHF for a better understanding of the chronic illness.

References 

• Aguanno, S. (2017). Diagnosis and management of patients with heart failure. Retrieved October 19, 2019, from https://www.mlo-online.com/continuing-education/article/13009421/diagnosis-and-management-of-patients-with-heart-failure#platformComments
• Hodgson, K. J. (2019). Saunders nursing drug handbook 2019. (R. J. Kizior, Trans.). St. Louis, MO: Elsevier.
• Inamdar, A. A., & Inamdar, A. C. (2016). Heart Failure: Diagnosis, Management and Utilization. Journal of clinical medicine, 5(7), 62. doi:10.3390/jcm5070062
• King, M., Kingery, J. E., & Casey, B. (2012, June 15). Diagnosis and Evaluation of Heart Failure. Retrieved October 19, 2019, from https://www.aafp.org/afp/2012/0615/p1161.html.
• Lewis, S., Bucher, L., Heitkemper, M., Harding, M., Barry, M., Lok, J., Tyerman, J Goldsworthy, S., Kwong, J., Roberts. D. (2019). Medical-surgical nursing In Canada- Assessment and management of clinical problems (4th Canadian ed.). Toronto, ON: Elsevier Canada Inc.
• Macon, L. B., & Cherney, K. (2018). Congestive Heart Failure (CHF). Retrieved October 23, 2019, from https://www.healthline.com/health/congestive-heart-failure
• Mayo Clinic. (2017, December 23). Heart failure. Retrieved October 22, 2019, from https://www.mayoclinic.org/diseases-conditions/heart-failure/symptoms-causes/syc-20373142.
• Porter, R. S., Kaplan, J. L., Lynn, R. B., & Reddy, M. T. (2018). Porter, R. S., Kaplan, J. L., Lynn, R. B., & Reddy, M. T. (2018). The MERCK Manual Of Diagnosis and Therapy (20th ed.). Kenilworth, NJ: Merck Sharp & Dohme Corp., A Subsidiary of Merck & Co, Inc.
• Phillips, M. M., & Zieve, D. (2019, October 3). Coughing up blood: MedlinePlus Medical Encyclopedia. Retrieved October 24, 2019, from https://medlineplus.gov/ency/article/003073.htm.
• Rahko, P. S. (2014). Heart Failure: A Case-Based Approach. New York, NY: Demos Medical. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=nlebk&AN=663990&site=ehost-live&scope=site
• Taylor, C. J., Rutten, F. H., Brouwer, J. R., & Hobbs, F. R. (2017). Practical guidance on heart failure diagnosis and management in primary care: recent EPCCS recommendations. The British journal of general practice: the journal of the Royal College of General Practitioners, 67(660), 326–327. doi:10.3399/bjgp17X691553
• Kizior, R. J., & Hodgson, K. J. (2019). Saunders nursing drug handbook 2019. St. Louis, MO: Elsevier.