CASE STUDY: CONGESTIVE HEART FAILURE

BY: DANIEL ANGELO E. ARANGO

SUBMITTED TO: GASPAR M. SANTOS, RN, MN

CASE VIGNETTE
Mr. Cee, a 75-year-old male widower, born in Bulan, Sorsogon and residing Sorsogon City was
admitted to the hospital in October 2022 due to Congestive heart failure. The patient was referred 1 year
before to SPH with a history of progressive dyspnea triggered by less than ordinary activities, and lower-
extremity edema. The patient was a previous smoker and had stopped smoking at the age of 37 years. He
was also an alcoholic and reported drinking alcohol for the last time 1 year before. He was referred to
ISPH for treatment of heart failure. The patient reported daily use of furosemide 20 mg, and digoxin
0.125 mg.
On October 2022, his physical examination showed a weight of 55 kg, height of 1.75 m, body mass index
(BMI) of 18 kg/m2, heart rate of 60 bpm, blood pressure of 90 X 50 mm Hg, and the presence of a
hepatojugular reflux.

INTRODUCTION
Congestive heart failure, according to Mayo Clinic occurs when the heart muscle doesn't pump
blood as well as it should. When this happens, blood often backs up and fluid can build up in the lungs,
causing shortness of breath. Furthermore, Certain heart conditions, such as narrowed arteries in the heart
(coronary artery disease) or high blood pressure, gradually leave the heart too weak or stiff to fill and
pump blood properly. Heart failure often develops after other conditions have damaged or weakened the
heart. However, heart failure can also occur if the heart becomes too stiff.
Signs and Symptoms
Signs and symptoms of congestive heart failure may include breathlessness during activity (most
commonly), at rest, or while sleeping, which may come on suddenly and wake you up, fatigue and
weakness, swelling in the legs, ankles and feet, rapid or irregular heartbeat , reduced ability to exercise
persistent cough or wheezing with white or pink blood-tinged mucus, swelling of the belly area
(abdomen), very rapid weight gain from fluid buildup, nausea and lack of appetite, difficulty
concentrating or decreased alertness, chest pain if heart failure is caused by a heart attack.
Causes
Heart failure can start suddenly after a medical condition or injury damages your heart muscle.
But in most cases, heart failure develops slowly from long-term medical conditions.
Conditions that can cause heart failure include:

 Arrhythmia (a problem with the rate or rhythm of your heartbeat)

 Cardiomyopathy
 Congenital heart defects or other types of heart diseases that you are born with
 Coronary artery disease
 Endocarditis
 Heart attack
 Heart valve diseases
 High blood pressure
 A blood clot in your lung
 Diabetes
  Certain severe lung diseases, such as COPD (chronic obstructive pulmonary disease)
 Obesity
Risk factors
Risk factors for heart failure include:
 Coronary artery disease. Narrowed arteries may limit your heart's supply of oxygen-rich blood,
resulting in weakened heart muscle.
 Heart attack. A heart attack is a form of coronary artery disease that occurs suddenly. Damage
to your heart muscle from a heart attack may mean your heart can no longer pump as well as it
should.
 Heart valve disease. Having a heart valve that doesn't work properly raises the risk of heart
failure.
 High blood pressure. Your heart works harder than it has to if your blood pressure is high.
 Irregular heartbeats. These abnormal rhythms, especially if they are very frequent and fast, can
weaken the heart muscle and cause heart failure.
 Congenital heart disease. Some people who develop heart failure were born with problems that
affect the structure or function of their heart.
 Diabetes. Having diabetes increases your risk of high blood pressure and coronary artery disease.
Don't stop taking any medications on your own. Ask your doctor whether you should make
changes.
 Some diabetes medications. The diabetes drugs rosiglitazone (Avandia) and pioglitazone
(Actos) have been found to increase the risk of heart failure in some people. Don't stop taking
these medications on your own, though. If you're taking them, ask your doctor if you need to
make any changes.
 Certain other medications. Some medications may lead to heart failure or heart problems. They
include nonsteroidal anti-inflammatory drugs (NSAIDs); certain anesthesia medications; and
certain medications used to treat high blood pressure, cancer, blood conditions, irregular or
abnormal heartbeats, nervous system diseases, mental health conditions, lung and urinary
problems, inflammatory diseases, and infections.
 Alcohol use. Drinking too much alcohol can weaken the heart muscle and lead to heart failure.
 Sleep apnea. The inability to breathe properly while you sleep results in low blood-oxygen levels
and an increased risk of irregular heartbeats. Both of these problems can weaken the heart.
 Smoking or using tobacco. If you smoke, quit. Using tobacco increases your risk of heart
disease and heart failure.
 Obesity. People who have obesity have a higher risk of developing heart failure.
 Viruses. Certain viral infections can cause damage to the heart muscle.
ANATOMY
Heart failure often develops after other conditions have damaged or weakened the heart.
However, heart failure can also occur if the heart becomes too stiff. In heart failure, the main pumping
chambers of the heart (the ventricles) may become stiff and not fill properly between beats. In some
people, the heart muscle may become damaged and weakened. The ventricles may stretch to the point that
the heart can't pump enough blood through the body. Over time, the heart can no longer keep up with the
typical demands placed on it to pump blood to the rest of the body. Ejection fraction is used to help
classify heart failure and guide treatment. In a healthy heart, the ejection fraction is 50% or higher —
meaning that more than half of the blood that fills the ventricle is pumped out with each beat.
But heart failure can occur even with a normal ejection fraction. This happens if the heart muscle
becomes stiff from conditions such as high blood pressure.
Heart failure can involve the left side (left ventricle), right side (right ventricle) or both sides of your
heart. Generally, heart failure begins with the left side, specifically the left ventricle — your heart's main
pumping chamber.

Type of heart failure Description

Left-sided heart failure Fluid may back up in the lungs, causing

shortness of breath.

Right-sided heart failure Fluid may back up into the abdomen, legs and
feet, causing swelling.

Systolic heart failure (also called heart failure The left ventricle can't contract vigorously,
with reduced ejection fraction) indicating a pumping problem.

Heart failure with preserved ejection fraction The left ventricle can't relax or fill fully,
indicating a filling problem.

PATHOPHYSIOLOGY
Congestive heart failure is a syndrome that can be caused by a variety of abnormalities, including
pressure and volume overload, loss of muscle, primary muscle disease or excessive peripheral demands
such as high output failure. In the usual form of heart failure, the heart muscle has reduced contractility.
This produces a reduction in cardiac output, which then becomes inadequate to meet the peripheral
demands of the body. The 4 primary determinants of left ventricular (LV) performance are generally
altered as follows: (1) There is an intrinsic decrease in muscle contractility. (2) Preload or left atrial filling
pressure is increased, resulting in pulmonary congestion and dyspnea. (3) Although systemic blood
 pressure is often reduced, there is an increase in systemic vascular resistance (afterload), which can
further reduce cardiac output. (4) Heart rate is generally increased as part of a compensatory mechanism
associated with an increase in sympathetic tone and circulating catecholamines. In patients with coronary
disease, there is often an imbalance between myocardial oxygen supply and demand. An increase in heart
size may be particularly deleterious by increasing wall tension because of the Laplace relation and
increasing myocardial oxygen consumption.
TREATMENT OPTIONS
Heart failure is a chronic disease needing lifelong management. However, with treatment, signs and
symptoms of heart failure can improve, and the heart sometimes becomes stronger.
Doctors sometimes can correct heart failure by treating the underlying cause. For example, repairing a
heart valve or controlling a fast heart rhythm may reverse heart failure. But for most people, treatment of
heart failure involves a balance of the right medications and, sometimes, use of devices that help the heart
beat and contract properly.
MEDICAL INTERVENTION
Medical Intervention

Indication Nursing
Drug Classification Action Dosage
responsibilities
Furosemide Loop diuretics PO: ELDERLY: Inhibits reabsorption 20mg  Check vital
(Lasix) Initially, 20–80 of sodium, and PO signs, esp. B/P,
mg/dose; may chloride in ascending daily pulse, for
increase by 20–40 loop of Henle and hypotension
mg/ dose q6–8h. proximal/distal renal before
May titrate up to tubules. administration.
600 mg/ day in  Assess
severe edematous Therapeutic Effect: baseline renal
states. Increases excretion function, and
of water, sodium, serum
chloride, electrolytes,
magnesium, and esp. serum
calcium. sodium, and
potassium.
 Initiate I & O
monitoring
Digoxin Cardiac PO: ELDERLY: Inhibits 0.125  Assess apical pulse
(Lanoxin) glycoside 0.125–0.25 mg sodium/potassium mg PO before
once daily. ATPase pump in daily administration.
myocardial cells.  Monitor ECG for
Promotes calcium arrhythmias for 1–
influx. Therapeutic 2 hours after
Effect: Increases administration
contractility. (excessive slowing
of the pulse may be
the first clinical
sign of toxicity).
 Assess for GI
 disturbances, and
neurologic
abnormalities
(signs of toxicity).
Monitor serum
potassium,
magnesium,
calcium, and renal
function.

NURSING CARE MANAGEMENT

A. Nursing Care Plan
Cues
Nursing Background Nursing
(Subjective or Goals Rationale Evaluation
Diagnosis Knowledge Interventions
Objective Data)
 Diagnosed stage C Decreased Cardiac output After the conduct  Provi  It is necessary for Hemodynamic
congestive heart cardiac is the quantity of nursing de for the client to parameters are
failure output of blood intervention, the and maximize cardiac in the normal
 Progressive related to pumped by the client will be able encou output; hence, range.
Dyspnea altered heart every to: rage adequate rest is
 Smoker and contractilit minute,  Display adequ needed.
Alcoholic y as shown measured in hemody ate  The patient's oxygen
by liters per namic rest. saturation may be
decreased minute. It is stability  Admi low, requiring
ejection computed by  Shows nister supplementary
fraction multiplying the feeling oxyge oxygen to maintain
stroke volume of n healthy levels.
(the quantity of comfort therap Adequate
blood pumped y as oxygenation is
out of the left prescr required to promote
ventricle ibed. general health and
during each  Admi biological functions.
systolic cardiac nister  As prescribed by the
contraction) by medic physician, the client
the heart rate. ations is to take 0.125 mg
Cardiac output , as digoxin and 20mg
is also appro furosemide PO daily.
regulated by priate, These will help to
three other and improve heart
factors: monit function and
preload, or decrease the patient’s
afterload, and cardia symptoms and
contractility. c cardiac workload.
Decreased respo
cardiac output nses.
is a condition
in which the
heart pumps
insufficient
blood to fulfill
the body's
metabolic
demands.
Conclusion/Implication of the case to students’ learning. How can the case presented contribute to
your learning as a student nurse?
The case that was presented, in particular the client's condition of congestive heart
failure, helped me understand more as a nursing student. Through careful investigation and the
acquisition of knowledge/information, certain terminology, medical jargon, and nursing
treatments were discovered and learned. As a nursing student, I also discovered how crucial it is
to use extreme caution and vigilance when dealing with patients, especially those who are in a
severe state. Basically, as I progress through this course, this assignment encouraged me to
become more and opened up a new body of information and system.
What do you think is its impact on the nursing profession as a whole?
The methodical procedure for choosing and creating a plan of care for a client with
congestive heart failure has a profoundly significant effect. The customer and the nursing
profession both benefit greatly from this step-by-step procedure. It provides an organized
perspective and empirical support for fresh and current knowledge that will be applied further in
the treatment of patients with the same ailment.