After reviewing this case study, address these questions:
1. Based on the information presented, what do you think the Chest X-ray would show and why? Describe the pathophysiological changes in the heart that occur as a result of heart failure. Can other factors come into play with the development of heart failure?
2. Describe what happens when someone suffers from dilated cardiomyopathy. 3. What current ebp and standards of care are there for heart failure? What would be
appropriate for managing Mrs. Smith’s condition?
4. Heart failure can be a chronic condition. What health promotion practices would you address with Mrs. Smith?
5. What pharmacological interventions would be appropriate for Mrs. Smith? Why? What would influence choice of these interventions in her case?
6. What techniques and medications would you employ in a larger similar population with heart failure?
7. What methods would you use to assess quality improvement in this disease?
Based on the information presented, what do you think the Chest X-ray would show and why? Describe the pathophysiological changes in the heart that occur as a result of heart failure. Can other factors come into play with the development of heart failure?
complain of increased fatigue and shortness of breath, which is most likely related to her
noncompliance of blood pressure medication and overall health promotion activities, putting her at increased risk of cardiovascular alterations and worsening of condition. In addition, the patient also presents with a history of smoking and alcohol drinking, putting her at greater risk of congestive heart failure exacerbation, as noted with her increase in swelling to her lower
extremities. With her extensive history of smoking, the chest x-ray could also reveal chronic lung conditions such as emphysema or cystic fibrosis. The x-ray may also reveal a change in the size and shape of her heart from the underlying diseases process, possibly revealing pericardial effusion and/or cardiomegaly.
In general, many factors can play into the development of heart failure such as obesity, diabetes, renal failure, cardiomyopathies, myocarditis, congenital heart disease, and excessive alcohol use (Brashers, et al, 2014). Anemia, emphysema, atrial fibrillation, thyroid disorders, and other heart arrhythmias are also potential causes. The modifiable risk factors that pertain to the patient in this study include history of smoking, unmanaged high blood pressure, stress, and possible depression.
The pathophysiological changes that occur within the heart as a result of heart failure can be detrimental to cardiac function and result in permanent damage to the structures of the heart that supply essential oxygen to vital organs. For example, the muscle contraction of the heart may weaken due to overloading of the ventricle with blood during diastole. Since the cardiac muscles are too weak, there is a failure of the ventricle to trigger an increase in muscle
order for the heart to pump at this increased rate. Also, stroke volume reduces as the systole or diastole contractions start to fail (Mandal, 2013). In addition to changes in the stroke volume, the cardiac reserve may reduce. Essentially, the heart no longer has the capacity to cope with normal metabolic demands, as well as elevated demands, during exercise or exertion (Mandal, 2013). Over time, the heart begins to hypertrophy leading to the heart muscles becoming stiff, a drop in the blood pressure within the arteries, and reduced blood flow to the kidneys (Mandal, 2013). Describe what happens when someone suffers from dilated cardiomyopathy.
According to the American Heart Association, dilated cardiomyopathy (DCM) is the most common type of the disease and affects the heart's ventricles and atria. The disease often starts in the left ventricle where the heart muscle begins to dilate (stretch and become thinner) and as a result, cardiac output decreases and the inside of the chamber begin to enlarge. The problem often spreads to the right ventricle and then to the atria as the disease gets worse (American Heart Association, 2015). When the heart chambers begin to dilate, the heart muscle doesn't contract normally, and therefore, the heart can't pump blood effectively. Over time, the heart becomes weaker and heart failure can occur. Common symptoms of heart failure include shortness of breath, fatigue, and swelling of the ankles, feet, legs, abdomen and veins in the neck (American Heart Association, 2015). Dilated cardiomyopathy also can lead to heart valve
problems, arrhythmias and blood clots in the heart (American Heart Association, 2015).
What current ebp and standards of care are there for heart failure? What would be appropriate for managing Mrs. Smith’s condition?
guidance states that all patients with a history of a previous heart attack who present with clinical signs or symptoms of heart failure such as breathlessness, fluid retention or fatigue should be referred for urgent echocardiography and specialist assessment, which should be provided within two weeks (Nursing Times, 2010). For patients without previous history of a heart attack where heart failure is suspected, a blood test for serum natriuretic peptide (BNP) must be arranged immediately and be referred for specialist assessment if elevated. The specialist clinical review should be led by a multidisciplinary heart failure team and include careful assessment and echocardiography for further diagnostic assessment.
When considering the advised pharmacological treatment of heart failure due to left ventricular systolic dysfunction there have been several changes to the guidance since 2003 (Nursing Times, 2010). All patients should continue to be offered both angiotensin-converting enzyme inhibitors and beta blockers licensed for heart failure as previously recommended. If the patient remains symptomatic after the intervention of ACE-inhibitors and beta blockers, it is recommended that the patient should be referred to his or her specialist and the heart failure multi-disciplinary team. Recent evidence shows best practices include prescribing an aldosterone antagonist, an angiotensin II receptor antagonist, or a combination of nitrates and hydralazine (Nursing Times, 2010). Recent evidence now shows triple therapy with ACEI, ARB and aldosterone antagonist is not advised. Also, according to the National Guideline Clearinghouse, evidence suggests BNP levels and/or an electrocardiogram should be recorded to indicate the need for echocardiography in patients with suspected heart failure and a chest X-ray is
excessive alcohol consumption and strongly advising patients with chronic heart failure not to smoke by offering smoking and alcohol cessation advice and community support. Motivational techniques should be used to promote regular low intensity physical activity amongst patients with stable heart failure. (AHRQ, 2012). The same suggested practices could be offered to the patient in this study, such as encouraging to quit smoking and lessen the amount of alcoholic beverages consumed in a day; suggesting community support to aid in the cessation of alcohol and smoking; speaking to a counselor or psychologist to deal with the recent loss of her husband; encouraging routine follow ups with cardiologist; recommending a medication organizer with daily reminders of when medication is due; and lastly, ensuring family support is available as needed to facilitate proper medication administration and follow-up visits.
Heart failure can be a chronic condition. What health promotion practices would you address with Mrs. Smith?
need to be initiated and education on how to monitor fluid intake will have to be given. Other recommended health promotion activities suggested by the AHA include avoiding or limiting caffeine; being physically active; relaxation techniques to better manage stress; getting adequate rest; reaching out to support groups when needed; and avoiding the flu and pneumonia by receiving proper immunizations all of which Mrs. Smith could largely benefit from (American Heart Association, 2015).
What pharmacological interventions would be appropriate for Mrs. Smith? Why? What would influence choice of these interventions in her case?
What techniques and medications would you employ in a larger similar population with heart failure?
Some commonly prescribed medications for heart failure patients include the following: anticoagulants, antiplatelet agents, ACE inhibitors, beta blockers, calcium channel blockers, digoxin, diuretics, and vasodilators (American Heart Association, 2015). Medication selection is individualized and dependent on the type and classification of heart failure. Drugs can be used to manage the symptoms of heart failure by a number of different mechanisms such as slowing the heart rate, increasing contractility, and reducing the workload on the heart.
For best disease management practices, patients with heart failure should be advised to utilize tools and community resources for support and guidance. For example, the AHA website provides such tools to include using a printable medicine tracker to better manage prescribed medications and utilizing an online printable blood pressure tracker to help monitor blood pressure and record suggestions from the doctor (American Heart Association, 2015). The ‘Heart 360’ is an to easy-to-use set of online tracking tools for medications, blood pressure, cholesterol, blood glucose, weight and physical activity, and is also recommended by the AHA for disease management. This application allows one to set goals and track progress each time a new level is inputted and to print comprehensive reports to share with one’s healthcare team (American Heart Association, 2015). As a nurse, it is important to stress the importance of sodium restriction and drug adherence to maintain a properly functioning heart or prevent worsening of condition. What methods would you use to assess quality improvement in this disease?
having the patient follow up with their cardiologist routinely should be advised to review treatment options, monitor the progression of disease, and prevent exacerbation or further complications. To ensure kidney function isn’t effected, monitoring the BUN/Creatine is also recommended. Closely observing blood work is also of importance to ensure fluid and
electrolyte homeostasis is achieved. Routine EKG assessments is also recommended to ensure no further complications result from disease process, such as dysrhythmias. By assessing these diagnostic findings and laboratory results while reviewing the patient’s presenting symptoms upon follow up visit, the healthcare provider can evaluate whether interventions were successful, and also to see if improvement strategies were achieved.
References:
Agency for Healthcare Research and Quality (AHRQ). (2012). National Guideline
Clearinghouse. Retrieved from: http://www.guideline.gov/content.aspx?id=10587#Section420 American Heart Association. (2015). Dilated Cardiomyopathy (DCM). Retrieved from:
http://www.heart.org/HEARTORG/Conditions/More/Cardiomyopathy/Dilated-Cardiomyopathy_UCM_444187_Article.jsp
Brashers, V., Huether, S., McCane, K., & Rote, N. (2014). Pathophysiology the Biologic Basis for Disease in Adults and Children. 7th e. Elsevier. (P1175-1181).
Mandal, A. (2013). Heart Failure Pathophysiology. News Medical. Retrieved from: http://www.news-medical.net/health/Heart-Failure-Pathophysiology.aspx
Nursing Times. (2010). Caring for adults with chronic heart failure: rapid diagnosis and enhanced management. Retrieved from: http://www.nursingtimes.net/nursing-practice/clinical-
