CASE STUDY

CONGESTIVE HEART FAILURE: A CLOSER LOOK

PATIENT PROFILE
Name: Mr. J
Gender: Male
Age: 69 years old
Occupation: Retired Banker
Nationality: Saudi
Marital Status: Married
Religion: Islam
HISTORY OF PRESENT CONDITION AND FOCUSED REVIEW OF SYSTEMS
Mr. J, a 69 year old male, presents to the Emergency Department on March 5, 2021 at 0300H with a complaint
of general fatigue for 4 days, shortness of breathing and abdominal discomfort. He has visited his doctor 5 days
ago before the symptoms occurred for his annual medical checkup. Mr. J, has medical history of hypertension
and coronary artery disease (CAD). He had a previous 90% LAD blockage and 50% RCA blockage with stent
placements in both. He is conscious, coherent and oriented to time, place, person spoken to with GCS of 15/15.
However, upon further assessment, the patient has crackles bilaterally and tachycardia. Chest Xray was
immediately conducted and showed cardiomegaly and pulmonary edema. An Urgent ECG also revealed atrial
fibrillation. His vital signs were as follows:
BP – 150/72 mmhg
HR – 103 bpm and irregular
RR – 32 cpm
Temperature – 37.3
Mr. Jones was admitted to the Coronary Care Unit for hemodynamic monitoring and aggressive therapy. About
three hours after admission to CCU, Mr. J’s skin becomes cool and clammy. His respirations are labored and he
is complaining of abdominal pain. Upon physical examination, he is diaphoretic and gasping for air, with
distention of the jugular vein, bilateral crackles and an expiratory wheeze.
PAST MEDICAL AND SURGICAL HISTORY AND FAMILY HISTORY
Mr. J, as previously mentioned, has history of hypertension and coronary artery disease. He has been
hypertensive since he was 40 years old, and is diagnosed with CAD when he was 65 years old. He had coronary
stenting procedure 4 years ago. He was a smoker when he was younger, but stopped approximately 10 years
already. He has a familial history of Diabetes, Hypertension and Heart Diseases both in his maternal and
paternal side.
FUNCTIONAL HEALTH PATTERN ASSESSMENT
Health Perception and Management Pattern

Before Hospitalization: “Well I already had the procedure for my heart so everything is definitely well”
During Hospitalization: “I hope to breathe normally after I am given the treatment I need”
Interpretation: Mr. J had this perception that because he had the surgery for his condition before, it means that
everything is well and there is nothing to be afraid of. He has missed to perceive that though surgery has been
done, it is of utmost importance that he has to take care of his health more.
 CASE STUDY
Nutritional-Metabolic Pattern
Before Hospitalization: “I usually eat tea and bread for breakfast, Kabsa for lunch and Kabsa for dinner. I eat
normally and I love what my wife prepares for me”
During Hospitalization: “I do not have the appetite to eat now. I cannot breathe properly and I have gained some
weight. I want to be normal again so I can eat properly”
Interpretation: It is unfortunate that Mr. J has been consuming food that is high in salt and oil content. Food that
is not allowed or should be minimized because of his health condition. He has to eat balanced food such as
vegetables and fruits for him to regain his health”
Elimination Pattern
Before Hospitalization: “I don’t have problem with this until recently, I noticed my urine got more and darker.”
During Hospitalization: “I am afraid of my urine. It has changed in color. I also pass urine more. sI can defecate
normally but the straining gives me pain and difficulty breathing”
Interpretation: Mr. J has been experiencing the signs and symptoms of Heart Failure, which include frequently
passing urine, urgency and urge incontinence.
Activity and Exercise Pattern
Before Hospitalization: “I usually sit in esteraha with my friends and drink tea.”
During Hospitalization: “My legs grew bigger than usual.”
Interpretation: Sedentary lifestyle has always been one of the predisposing factors for any heart disease. As
observed, Mr. J has frequently sits and seldomly performs physical activities.
Sleep and Rest Pattern
Before Hospitalization: “I usually sleep from 3 am to 11 am. That’s roughly 8 hours. That is normal right?”
During Hospitalization: “I cannot sleep comfortably here; I cannot breathe properly and I am scared”
Interpretation: The sleeping pattern of the patient before hospitalization is considered to be unhealthy. Sleep
must be encouraged to 8 hours per day, however, sleeping at 3 am can have effects on the health on an
individual. He has not slept properly since admission because of his SOB and the unfamiliarity of the place.
Cognitive and Perceptual Pattern
Before Hospitalization: “I don’t have any problems before even though I had surgery, I always feel so healthy.”
During Hospitalization: “I keep on thinking about my heart and if I will die.”
Interpretation: The patient has no sensory problems. He is fully oriented with his current condition.
Self-Perception and Self-Concept Pattern
Before Hospitalization: “I know I have cardiac problems but Alhamdullilah I feel Okay.”
During Hospitalization: “I have to improve and change my lifestyle. Cardiac problems are of no joke. I don’t
want to be hospitalized again.”
Interpretation: The patient is very positive with his current condition. He is aware that he has to change his
lifestyle to improve his condition and prevent future re admissions/hospitalizations.
Role and Relationship Pattern
Before Hospitalization: “My children are living with me in the same building. We often visit our village
whenever we have time”
During Hospitalization: “My children and wife are very worried of me. They wanted to stay here for me but of
course It is not allowed”
Interpretation: The patient has a strong familial relationship being the head of the family.
Coping Stress and Tolerance Pattern
 CASE STUDY
Before Hospitalization: “If I have problems, I will pray and talk to my wife and children”
During Hospitalization: “I am always positive and happy person.”
Interpretation: Mr. J is a happy person and knows how to cope with problems.
Values and Belief Pattern
Before Hospitalization: “I pray 5 times a day. It is a must”
During Hospitalization: “This is the Qadr of Allah”
Interpretation: The patient has a strong religious belief; He feels that he can go through with everything because
of Allah.
COMPLETE FOCUSED PHYSICAL EXAM
Body Parts Actual Findings and Assessment Method
Inspection – Hair is un evenly distributed; hair is white in color; in some areas that are noted
Hair
baldness; no other unusualities
Palpation – Normocephalic, no masses, tenderness; No abnormal enlargement
Skull
Inspection – No lesions, wounds, cuts or other unusualities noted
Inspection - symmetrical facial features. With mustache and beard. No noted edema or
Face hollowness; No facial drop or any unusualities, has scattered mole on the face
Palpation – no masses, tenderness or lumps noted
Inspection - Hair evenly distributed with skin intact. Symmetrically aligned with equal
Eyes -
movement. Evenly distributed hair Skin intact Lids close symmetrically; Pupils equally round
Eyebrows
and reactive to light and accommodation; however patient is using reading glasses
Inspection - Pupils equally round and reactive to light and accommodation (PERRLA); Pupils
Internal Eye
at 3mm both reactive; no cataract noted; Sclera white in color, Conjunctiva pale in color noted;
Structure
no signs of infection or other unusualities noted.
Inspection - Color same as facial skin Symmetrical and aligned with outer canthus in eye. No
difficulty in hearing. Can hear whispered voices during the Rinne and Weber’s Test; No signs
Ears-
of infection, visible wound or lesions; no abnormal discharges noted; Earwax noted; no pressure
Auricles
injury noted on the ears
Palpation – no palpable mass or tenderness
Inspection – Symmetrical and straight, nose bridge normal; Noted nasal flaring; no masses and
Nose and
lumps
Sinuses
Palpation – nasal septum normal upon palpation
Inspection – Teeth is incomplete; has noted dental carries, yellow to brown in color; no
Teeth and
difficulty distinguishing taste; tongue does not have lumps, lesions or mass; gingiva is pale in
Gums
color; no oral thrush noted
Inspection - Neck muscle equal in size and head centered, Trachea in central of neck; distented
jugular veins noted
Neck
Palpation – No palpable masses, tenderness or lumps; no tracheal deviation upon palpation;
Palpable carotid arteries
Inspection - Symmetric, Chest wall intact. Respiratory rate is 32 cycles per minute; Shortness
and difficulty breathing noted; Saturation is 89% without oxygen; started on oxygen 4L/min via
Thorax and nasal cannula and spo2 increased to 96%; patient is gasping for air
Lungs Auscultation – Bibasilar posterior crackles noted; crepitus also noted; wheezes on expiration
noted
Palpation – no masses, lumps and other unusualities noted
Heart Inspection – no discoloration in the chest area not visible enlargements; HR is 103 beats per
 CASE STUDY
minute and is irregular and weak; BP is 150/72 mmHg; tachycardia noted; CVP is 19 mmHg;
Cardiac Output is 4.5 L/min; Cardiac Index is 2.3 L/min/m2
Palpation – Pulses are palpable but are irregular and weak
Auscultation – S1 and S2 diminished; Aortic sound diminished, Pulmonic sound diminished,
Mitral diminished
Inspection - Skin is intact and uniform in color, no bruising
Auscultation - with active bowel sounds in all quadrants
Abdomen
Palpation - abdominal pain noted. No masses, lumps, lesions upon palpation
Percussion – Normal internal organ border sounds
Inspection – patient has been inserted an Indwelling Foley’s Catheter for monitoring of urine
Genitourinary
output; Output is 20ml/hr since admission
Tract
Palpation – No masses, lumps nor other unusualities
Inspection – visible edema on the lower extremities; diaphoretic
Extremities Palpation – skin cool to touch; Pitting edema grade 2 noted on both lower extremities; Pulses
diminished.
PROCEDURES Nursing Considerations and Rationale
 Ensure that consent has been taken as it is an invasive
procedure.
 Check the central line every day and ensure that dressings are
changed appropriately to prevent infection.
Insertion of Central Venous  If connected to transducer monitoring system, ensure that the
Catheter for monitoring of lines are zeroed and no kinks or disconnection is noted to ensure
Central Venous Pressure appropriateness of reading.
 Ensure aseptic technique is followed in handling the central line
to prevent cross contamination.
 DO NOT USE the CVC immediately after insertion unless an
XRAY has confirmed the placement.
 Check if the patient is on anticoagulation medication and inform
the physician to prevent the patient for bleeding during the
procedure.
 Ensure that consent has been taken as this is an invasive high
risk procedure.
Angioplasty or Percutaneous  Check the vital signs, GCS and the general condition of the
Coronary Intervention ( PCI) patient to serve as baseline data.
 Assess the insertion site for any signs of bleeding or pain to
prevent further complications.
 Perform neurovascular checks as frequent as possible.
 Ensure that ECG, Echocardiogram and Xray has been done
before and after.
Coronary Artery Bypass Graft  Ensure that a consent has been taken.
 For pre-operative phase, ensure that medications has been given
and anticoagulation discontinued to prevent bleeding.
 Pre-operative teaching must be performed to the patient and the
family to allay anxiety and provide relevant information.
 Pulmonary care during the post operative procedure is necessary
 CASE STUDY
to ensure that it is maintained.
 Monitor the hemodynamic parameters of the patient and inform
the physician for any changes in patient’s condition.
 Regularly check the vital signs.
 Administer pain medications.

Echocardiogram (Transthoracic)  Place the patient in supine position, removing articles that can
cause artifacts such as jewelry, clothing to ensure correctness of
the results.
 Explain the procedure to the patient to allay anxiety.
 Encourage the patient to cooperate and decrease motions or
movement.
 Encourage the patient to empty bladder before the procedure.
 Remove and wipe the gel used during the procedure.
TEST/PROCEDURE Results Nursing Considerations and Rationale
COMPLETE BLOOD COUNT
Hemoglobin 11.8 g/dl  Ensure correct identification of patient is
Hematocrit 36.2% done and consent taken.
Red Blood Cells 4.16  Explain procedure to allay anxiety.
White Blood Cells 18.0  Position the patient appropriately.
Pro BNP 843pg/ml  Gather all necessary equipment.
Creatinine 1.2 mg/dl  Puncture the vein and monitor for any
BUN 17 mg/dl complications.
Potassium 3.3 mg/dl  Ensure that pressure is applied to the
Sodium 160 mg/dl punctured site to prevent hematoma.
LDH 705 U/L

Cardiomegaly  Ensure safety and proper use of equipment

and Bilateral in transferring patient to avoid further
Chest X-ray
Pulmonary injury
Edema  Remove all metallic objects.

Cardiac Output 4.5 L/min

 Taken with Echo

Cardiac Index 2.3 L/min

Ejection Fraction 55%

ECG Atrial Fibrillation  Remove objects that cause artifacts such as

jewelry.
 Encourage patient to decrease motion.
 Position patient appropriately.
 CASE STUDY
 Explain the procedure to allay anxiety.

PRESCRIBED MEDICATIONS
Generic Name
Trade Name/
(Dosage, Route, Adverse Reactions Nursing Responsibilities
Classification
Frequency)
o Assess patient’s fluid
status.
Blurred vision, o Monitor BP and HR
dizziness, headache, o Monitor Serum
o Lasix vertigo, electrolytes
Injection Furosemide 80
hypotension, o Caution patient to
mg IV STAT o Loop Diuretics
hypokalemia, change position
hyponatremia, carefully and slowly
hypovolemia to minimize
orthostatic
hypotension.
o Monitor apical pulse
for 1 full minute
o Monitor blood
pressure
Fatigue, headache, periodically.
weakness, blurred o Monitor ECG during
o Lanoxin vision, bradycardia
administration and 6
Injection Digoxin 0.5 mg and ECG changes,
o Antiarrhythmics hours after.
IV STAT nausea and
and inotropic o Monitor intake and
vomiting,
electrolyte output.
imbalances o Check serum
electrolytes and
therapeutic levels
o Monitor for signs of
toxicity
o Monitor BP and
pulse frequently.
Headache,
o Notify health care
dizziness, lower
o Coversyl provider for any
Tablet Perindopril 8 mg extremity pain,
significant change in
PO Once Daily o ACE Inhibitor Abnormal ECG,
patient’s condition.
Palpitations, Chest
o Assess patient for
pain and Edema
signs of edema,
facial swelling.
Tablet Bisoprolol 5 mg o Monocor Fatigue, weakness, o Monitor BP, ECG
PO Once daily o Beta Blocker anxiety, depression, and pulse frequently.
drowsiness,
 CASE STUDY
o Assess for
pulmonary function
such as dyspnea,
insomnia, memory rales and crackles
loss, blurred vision, o May cause increase
bradycardia, BUN, monitor
hypotension kidney function.
o Take apical pulse
first before
administration
ASSESSMENT
Subjective Data Objective Data
 Difficulty breathing noted
 Shortness of breathing noted
 Gasping for air
“I cannot breathe. I feel an impending doom”
 Crackles noted
 Wheezes noted
 Crepitus noted
 Pain score abdomen 6/10 via Numerical Rating
Scale
“I have pain the chest and abdomen”  Pain score on the chest 8/10 via Numerical
Rating Scale
 Guarding behavior noted
 Pitting Edema noted on both extremities grade
“Look at my legs, they are big” 2 noted
 Skin warm to touch; ashen skin noted
 Irregular, diminished peripheral pulses noted
NURSING DIAGNOSIS AND COLLABORATIVE PROBLEM
Ineffective Breathing Pattern related to fatigue and decreased lung expansion and pulmonary congestion
secondary to disease process
Acute Pain as manifested by chest and abdominal pain
Decreased Cardiac Output related to altered myocardial contractility secondary to disease process
PLANS
At the end of 3 hours, patient will have an improved breathing pattern within the patient’s capacity.

At the end of 3 hours, patient’s pain will be decreased to acceptable limits (abdomen – 3/10; Chest 5/10) within
the patient’s capacity.

At the end of 8 hours, patient will demonstrate adequate cardiac output within acceptable limits and within
patient’s capacity.

NURSING INTERVENTIONS Rationale

1. Monitor and record vital signs. 1. To gain baseline data.
2. Inspect thorax for symmetry of respiratory 2. To determine adequacy of breathing.
 CASE STUDY
movement. 3. To decrease the need for oxygen consumption.
3. Encourage patient to get adequate rest periods. 4. Detects use of hyperventilation as a causative
4. Assess emotional response. factor.
5. Position the patient appropriately to semi-fowlers. 5. To open airway and maximize breathing.
6. Assist patient to use relaxation techniques. 6. Reduces muscle tension, decreases work of
breathing.
1. Administer or assist the administration of 1. The vasodilator nitroglycerin enhances blood
vasodilators as ordered. flow to the myocardium. It reduces the amount
2. Provide comfort measures. of blood returning to the heart, decreasing
3. Establish a quiet environment. preload in which in turn decreases the workload
4. Teach the patient how to distinguish between of the heart.
angina pain and signs and symptoms of myocardial 2. To provide non pharmacological pain
infarction. management.
3. A quiet environment reduces the energy
demands on the patient.
4. The patient needs to understand the differences
in order to seek emergency care in a timely
fashion.

1. Auscultate apical pulse, assess HR, rhythm and 1. Tachycardia is always present to compensate for
note heart sounds. decreased ventricular contractility. In this manner,
2. Monitor urine output, noting decreasing output and baseline data will be established to prevent further
concentrated urine. complications.
3. Give oxygen as indicated. 2. Kidneys respond to reduced cardiac output retaining
4. Implement strategies to treat fluid and electrolyte water and sodium. Monitoring the urine output can
imbalances. give us data on the status of the kidney function.
5. Administer cardiac glycoside agents as ordered and 3. Assisting to alleviate signs of hypoxia.
monitor for toxicity. 4. Decreases the risk for development of cardiac
output due to imbalances.
5. Digitalis has a positive isotropic effect on the
myocardium and strengthens contractility,
improving cardiac output.

EVALUATION
Goal Partially met
At the end of 3 hours, patient’s need for air is still present but saturation rate is 96%.
Goal Fully Met
At the end of 3 hours, Patient verbalized a decreased in pain score, Abdomen 3/10; Chest 5/10
Goal Partially met
At the end of 8 hours, patient has improved cardiac function as manifested by decreased peripheral edema from
grade 2 to grade 1 and improved urine output to 30 ml/hr.
CONCLUSIONS
Why it is important to immediately treat patients with Heart Failure?
Diagnosis and treatment of Heart Failure remain important and challenging and the utilization of available
resources and sound understanding of the pathophysiology of the disease process and the pharmacological
intervention can produce rewarding results to patients. Swedberg, Karl., J., Conclusions on the management of
Heart Failure; October 2020.
 CASE STUDY
What is the best practice for Heart Failure utilized nowadays?
The immediate order of Pro-BNP, immediate referral for patients with ejection fraction of less than 35 % that
persists despite optimal medical therapy; consider cardiac resynchronization therapy for patients with
arrythmias that cannot be corrected with optimal medical therapy.
Heart Failure Treatment: Keeping up with best practices. Darink Brink MD., 2018 January; 67(1): 18-26

How can you reduce the mortality rate and improve morbidity for patients with Congestive Heart
Failure?
Choices of therapies including the dosage and other pharmacologic interventions are necessary as early as
admission to the Emergency Department to prevent unlikely result of the patient’s condition. Service-based
researches must also be conducted to reduce readmissions. Treatments that directly improve the disease
trajectory should also be explored.
Moving from Heart Failure Guidelines to Clinical Practice: Gaps contributing to re-admissions in patients with
multiple comorbidities and older age., David Hare; National Heart Foundation of Australia. 2018
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