• Define heart failure

• Describe types of heart failure

• Identify the etiology, pathophysiology, and clinical manifestations
of heart failure
• Acknowledge of the assessment and diagnostic finding of heart
failure
• Describe medical management of patient with heart failure
• Identify the pharmacologic, nutritional, and additional therapy
• Describe the nursing process for patients with heart
failure(assessment, diagnosis, planing, intervention, and
evaluation)

• History
• Physical exam
• Diagnosis reasoning
• Treatment plan\ Nursing care
• Patient education
• Definition of heart failure
• Types of heart failure
• Etiology of heart failure
• Pathophysiology of heart failure
• Clinical manifestations of heart failure
• Assessment and diagnosis
• Medical management
• Pharmacologic therapy
• Nutritional therapy
• Additional therapy
• Nursing process
Case study
Mr. SB, 60-year-old male is a retiree and was admitted to the hospital
accompanied by his daughter. He is 100kg at a height of 180cm so his
calculated body mass index (BMI) was 30.9 indicating that he was
overweight. When admitted, patient was complained of shortness of breath
for 2 weeks and was worsening on the day of admission. Besides, he also
experienced orthopnea, fatigue, paroxysmal nocturnal dyspnea and leg
swelling up to his thigh. Mr. SB was admitted to the hospital for to the
same problem last year.

History
Mr. SB had known case of heart failure since 3 years ago and he had also
diagnosed with hypertension for 5 years. Before admitted to the hospital,
patient was taking frusemide 40mg, aspirin 150mg, metoprolol 50mg,
amlodipine 10mg, and simvastatin 40mg for his hypertension and heart
failure. Patient is not allergic to any medication and he does not take any
traditional medicines at home. His family history revealed that his father
had died of ischemic heart disease 4 years ago while his brother has
hypertension. As for his social history, he smokes 2-3 cigarettes a day for 35
years and the calculated smoking pack years was 5 pack years. Besides, Mr.
SB also drinks occasionally.

Physical exam
On examination, Mr. SB was found to be alert and conscious but he was
having pedal oedema up to his knee. Besides, the patient was noted with
bibasal crepitations with no rhonchi. His body temperature was normal.
However, his blood pressure was found to be elevated upon admission with
a record of 159/100 mmHg with an irregular pulse rate at 85beats/min. His
echocardiogram showed that he had left ventricle hypertrophy while chest
X-ray was conducted and revealed that the patient had cardiomegaly.

Diagnosis reasoning
Mr. SB was diagnosed with congestive cardiac failure (CCF) with fluid
overload. The patient also suffered from hypertension. The management
plan included intraveneous frusemide 40mg twice daily, aspirin 150mg
once daily, simvastatin 40mg once at night and ramipril 2.5mg once a day.
Besides, patient was asked to restrict his fluid intake to 500ml per day and
oxygen therapy was given to patient at high flow using a face mask when
patient experiencing shortness of breath.

Treatment plan\ Nursing care

First line therapy: ACE inhibitor, beta blocker and diuretic were prescribed.
dose of aspirin 150mg should be reviewed and reduced to 75mg instead
based on the recommendation from British National Formulary. It is also
crucial to monitor Mr. SB’s renal profile and electrolytes in order to detect
or reduced the side effects associated with some of the drug regimen such
as furosemide and beta blockers. The patient should also be counselled on
lifestyle management to reduce the development of fluid overload. These
include reduce the salt intake to 6g per day as well as restrict the fluid
intake. Patient should also be advised to monitor the body weight regularly
and inform GP if weight gain is more than 1.5kg in 2 days.

Patient education
Patient advised on the risk of myopathy.
Patient report any unexplained muscle pain, tenderness or weakness.
Patient educated to Avoid grapefruit juice as it may increased the level of
statin and leads to side effects
Encourage to weigh themself daily.

Definition of heart failure:

is a clinical syndrome caused by structural or functional heart problems that limit
the ventricles' capacity to fill or release blood.
Due to the prevalence of pulmonary or peripheral congestion and edema in HF
patients, the term congestive heart failure (CHF) was frequently used in the past.
HF is now recognized as a clinical condition with features of either insufficient
tissue perfusion or fluid excess. The phrase "heart failure" refers to a cardiac
condition in which pulmonary or systemic congestion may result from inadequate
systolic or diastolic filling of the heart. Depending on the underlying etiology,
some HF cases can be reversed. The majority of the time, heart failure (HF) is a
chronic, deteriorating condition that is controlled with medicine and a change in
lifestyle to avoid bouts of acute decompensated heart failure. The symptoms, CO,
and perfusion are all on the rise during these episodes. Additionally, these
incidents are related to higher hospitalizations, increased health care costs, and
decreased quality of life.

Types of heart failure:

• Chronic heart failure
• Acute heart failure
• Systolic heart failure (alteration in ventricular contraction).
• Diastolic heart failure (stiff and noncompliant heart muscle, making it
difficult for the ventricle to fill).

Etiology of heart failure:

can result from a wide range of situations, including coronary artery disease,
hypertension, cardiomyopathy, valvular disorders, and renal dysfunction with
volume overload. Long-term diseases such as diabetes, HIV, an overactive or
underactive thyroid, or a buildup of iron or protein, also may contribute to chronic
heart failure.
Diabetes patients have a higher risk of developing HF. Atherosclerosis of the
coronary arteries is the main cause of HF, The disease results from the buildup of
fatty deposits in the arteries, which reduces blood flow and can lead to heart attack.
and the majority of HF patients have coronary artery disease. Because ischemia
deprives cardiac cells of oxygen and results in cellular damage, it damages the
myocardium.

Clinical manifestation of heart failure:

Ø Left-sided heart failure (left ventricular failure).
pulmonary congestion include:
• dyspnea (shortness of breath)
• dry and nonproductive cough
• pulmonary crackles
• low oxygen saturation levels.
• Decreased brain perfusion causes dizziness, lightheadedness,
confusion, restlessness, and anxiety due to decreased oxygenation
• An extra heart sound, the S3, or “ventricular gallop,” may
• be detected on auscultation
• orthopnea (difficulty breathing) when lying flat.
 • paroxysmal nocturnal dyspnea (PND): Is a sudden attack of dyspnea
at night.
• peripheral pulses become weak.

Ø right-sided heart failure (right ventricular failure).

• Edema of the lower extremities
• hepatomegaly (enlargement of the liver).
• ascites (accumulation of fluid in the peritoneal cavity).
• weight gain due to retention of fluid.
• tenderness in the right upper quadrant of the abdomen.
• Anorexia
• nausea
• abdominal pain

Assessment and Diagnostic Findings:

An important component of the initial diagnostic workup is the evaluation of
ventricular function and Laboratory studies, include serum electrolytes, blood urea
nitrogen (BUN), creatinine, liver function tests, thyroid-stimulating hormone,
complete blood count (CBC), BNP(a key diagnostic indicator of HF), and routine
urinalysis. A chest x-ray and a 12-lead electrocardiogram (ECG) are obtained to
assist in the diagnosis. An echocardiogram is usually performed to determine the
EF. To determine whether myocardial ischemia and coronary artery disease are the
root causes of the HF, cardiac stress testing or cardiac catheterization may be used.

Medical management:
Relieving patient symptoms, enhancing functional status and quality of life, and
extending survival are the goals of HF care. Include:
• heart function is improved with the best pharmacological treatment
• symptoms are reduced, and their functional status is improved.
• weight reduction
• avoidance of smoking
• avoidance of excessive fluid and alcohol intake
• exercise.
• Improvement of patient condition and reduction of hospitalization risk.
• Delay in the development of HF and increased life expectancy.
• encouragement of a heart-healthy lifestyle.
• supplemental oxygen.
 • surgical interventions.
• oral and intravenous (IV) medications.

Pharmacologic therapy:
• Angiotensin-Converting Enzyme Inhibitors
• Angiotensin Receptor Blockers
• Hydralazine and Isosorbide Dinitrate
• Beta-Blockers
• Diuretics
• Digitalis
• Medications for Diastolic Dysfunction
• Intravenous Infusions (milrinone [Primacor], dobutamine [Dobutrex])

Nutritional therapy:
It is typically advised to consume a low-sodium (no more than 2 g/day) diet and to
limit fluid intake, while there is some debate over the efficacy of salt restriction.
Reduced dietary salt decreases fluid retention as well as the signs of pulmonary
and peripheral congestion. The goal of sodium restriction is to lessen the volume of
blood that is circulated, which lessens myocardial effort. It's important to strike a
balance between the patient's capacity for diet compliance and the suggested
dietary restriction. Any dietary changes should take into account both optimal
nutrition and the patient's preferences as well as cultural eating customs. Patient
compliance is crucial since dietary mistakes may induce severe HF exacerbations
that necessitate hospitalization. However, many patients find it challenging to
adjust their behavior in this area.

Additional therapy:
• Oxygen therapy
• placement of an ICD can prevent sudden cardiac death and extend survival.
• Cardiovascular resynchronization therapy may be beneficial for HF patients
who do not respond to cardiac resynchronization therapy (CRT). A
biventricular pacemaker is used in CRT to address electrical conduction
abnormalities.
• ultrafiltration is an alternate option. It is only used for severe heart failure
patients who are resistant to diuretic treatment. A dual-lumen central IV
catheter is placed, and the patient’s blood is circulated through a small
bedside filtration machine. Liters of excess fluid and plasma are removed
 slowly from the patient’s intravascular circulating volume over a number of
hours.

Nursing process:
Assessment:
• HEALTH HISTORY
The health history focuses on the signs and symptoms of HF.
Nurses must be aware of the many clinical signs and symptoms that could
indicate to worsening HF and must evaluate the patient accordingly. The
nurse evaluates the patient's knowledge of HF, self-management techniques,
capacity to follow through on those techniques, and willingness to do so as
she gathers the patient's medical history.
• PHYSICAL EXAMINATION
Include:
§ observed for restlessness and anxiety
§ The rate and depth of respirations are assessed along with the effort
required for breathing.
§ Measuring blood pressure, pulse rate and Temperature
§ liver may be assessed for hepatojugular reflux.
§ Listening to the heart for murmurs, Crackles and Wheezing or extra heart
sounds.
§ Measuring body weight.
§ measures urinary output

Diagnosis:
• NURSING DIAGNOSES
Major nursing diagnosis may include the following according to assessment
data:
§ Activity intolerance resulting from a drop in CO
§ HF syndrome-related excess fluid volume
§ anxiety relating to HF clinical manifestations
§ Hospitals and chronic illness-related helplessness
§ Management of family health is inefficient
• COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS
§ Hypotension, poor perfusion and cardiac shock
§ Dysrhythmias
 § Thromboembolism
§ Pericardial effusion and cardiac tamponade

Planning and Goals:

Main goals for the patient may include encouraging activity and reducing fatigue,
easing fluid overload symptoms, reducing or improving anxiety, encouraging the
patient to verbalize their ability to make decisions and influence outcomes, and
educating the patient and family about health management.

Nursing Interventions:
• Promoting Activity Tolerance.
• Managing Fluid Volume.
• Minimizing Powerlessness.
• Assisting patient and Family to effectively Manage health
• Monitoring and Managing Potential Complications
• Promoting Home, Community-Based, and Transitional care
• Continuing and Transitional Care.
• End-of-Life Considerations.

Evaluation
Expected patient outcomes may include:
1) demonstrates tolerance for the desired activities
a) Describes adaptable techniques for performing daily tasks.
b) Plans activities to save energy and prevent exhaustion and dyspnea.
c) Maintains heart rate, blood pressure, respiratory rate, and pulse.
d) Maintains oximetry within the desired range.
e) Maintains Fluid balance Exhibits decreased peripheral edema.
f) Verbalizes understanding of fluid intake and diuretic use.

2) Decreased Anxiety
a) Avoids stressful circumstances.
b) sleeps peacefully during the night.
c) reports less stress and anxiety.
d) denies depressive symptoms.

3) Makes Sound decisions regarding care and treatment

a) Demonstrate ability to influence results.
 4) Patients and family members adhere to healthy regimen
a) Performs daily weight checks and records them.
b) Sets a daily sodium intake cap of 2 grams.
c) Administers medication as directed.
d) Describes increasing HF symptoms.
e) Schedules and keeps follow-up appointments.

Reference:
1. Main goals for the patient may include encouraging activity and reducing
fatigue, easing fluid overload symptoms, reducing or improving anxiety,
encouraging the patient to verbalize their ability to make decisions and
influence outcomes, and educating the patient and family about health
management
2. Business Bliss Consultants FZE. (November 2018). Case Study On A
Patient With Heart Failure. Retrieved from https://nursinganswers.net/case-
studies/case-study-on-a-patient-with-heart-failure-nursing-essay.php?vref=1.