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Mr. X's Case History


How Common Condition Affecting About Half A Million Australians?

Heart failure(HF) is a common condition affecting about half a million Australians. It is associated with high morbidity and mortality, frequent hospitalization and massive cost to the health care system(Krum &Driscoll,2013).Heart failure is a pathophysiological state in which an abnormality of the heart interferes with its  ability to perform its normal blood pumping function.Hypertension, Diabetes, Hypercholesterolemia, Obesity and Coronary artery disease are some of the several factors contributing to heart failure (Fitchett, et al 2016).This paper closely examines treatment options and discusses priority aspects of clinical and nursing care of  a patient with heart failure.

Mr.X(Pseudonym) is a 58 year old male who has been diagnosed  with heart failure. The patient has past historyof hypertension, atrial fibrillation diabetes, obesity, sleep-apnea and hyperthyroidism. He is a social drinker and occasional smoker.He lost his parents to cardiac arrest and HF.He had been undergoing treatment with ACE(Angiotensin Converting Enzyme) inhibitors, Anti-platelets, Statinsand Diuretics in the ward .

The etiologyof HF most commonly is that of an ischemic event, primarily affecting the left ventricle causing loss of contractility and hence overtime, an excessive fluid overload in the body causing congestion in various organs. .The primary goal is to optimize cardiopulmonary function .Treatment was focused on treating Mr.X’s hypertension. He was treated with ACE inhibitors as his ejection fraction was 40%.Studies have shown that ACE inhibitors are vasodilators which help to control blood pressure and improve ventricular function and patients well-being. They can be inter changed with ARB(Angiotensin Receptor Blocker),if patient cannot tolerate ACEI(Lacey,2009).Mr.X was treated with diuretics (Spirinolactone) which is analdosterone receptor antagonist as he exhibited signs of pitting edema and dyspnea.These drugs help trigger the body to excrete excess sodium. This would in turn favor the healing process by lowering the volume of blood that the heart has to pump argues Valentova, and von Haehling, (2014). Close monitoring of renal function, electrolyte levels fluid balance and urine output are therefore needed(Riley,2015).Mr.Xwas advised to continue his regular dose of warfarin to keep his atrial fibrillation under control.Measures were taken to regularly check his blood sugars and administer medicationsin order to maintain tight glycemic control. Mr.X was advised about lifestyle modifications to control his weight and ways to relieve stress that contributed to the worsening of his condition.

The units policy is to educate patients and the family or career about the patients medication, side effects  including strict adherence to the medication and flexible diuretic regimen. Daily weight of the patient is done .Diet modification with less salt and fluid restriction, intake of lean meat and vegetables is encouraged with the advice from the dietician. Patients are involved in exercise programs with the assistance of physiotherapists.

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality for individuals.

Adults with diabetes are 2 to 4 times more likely to have heart hypertension and dyslipidemia and they commonly coexist in people with it (Worel,2016).Studies have shown that vasodilators (ACE inhibitors or ARB) reverse maladaptive neurohumoral and hemodynamic responses in heart failure, they are well tolerated, improve signs and symptoms, and reduce mortality by 15 to 40% depending upon the degree of initial cardiac functional impairment . It was seen that in patients with EF(ejection fraction)< 35%, the addition of spironolactone to a regime of ACE inhibitors and diuretics reduced morbidity by 35% and mortality by 30% at 24 months(Poppas&Rounds,2002). Warfarin should be reserved for patients with chronic heart failure and atrial fibrillation, although it is often prescribed (without supporting data) for patients with marked dilatation of their left atrium and/or ventricle because of concerns about an increased risk of thromboembolism(Krum&Driscoll,2013).

Treatment Options for Heart Failure

Among all therapies, increased success rates are found to be with changes in lifestyle measures, that have been found to be useful in supporting the patient. These include exercise (usually a graded exercise program, initially under the supervision of a physiotherapist or heart failure nurse), dietary salt restriction, alcohol restriction and weight loss in overweight patients. Patients should be encouraged to consume an adequate but restricted volume of fluid. This is particularly critical in patients who have low serum sodium levels, which is often seen in the setting of heart failure due to activation of neurohormones such as arginine vasopressin. Appropriate treatment of commonly associated conditions, such as hypertension, arrhythmia, sleep apnea, depression, anemia and iron deficiency, is also critical in the optimal management of patients with HF(Krum &Driscoll,2013).

In the initial treatment, Mr.Xseemed  non-compliant with the fluid restriction, use of his (Continuous Positive Airway Pressure)CPAP mask for  sleep apnea and refused to immobilize despite several attempts and proper explanation by the medical team. Due to his low EF(40%),his vital signs remained unstable with his heart rate increasing between 160-180in uncontrolled atrial fibrillation(Stone, et al 2014)and patient repeatedly suffering from flashes of pulmonary edema. The nurses had also underestimated the sleep apnea condition and could not force with the application of CPAP oververnight(Stone, et al 2014).With all the existing co-morbidities and non-compliance of the patient to the treatment the patient deteriorated and had to be transferred to the intensive care unit (ICU)for further care.

HF, irrespective of whether it has been detected on the basis of being actively treated (for example, during a hospital admission) or in otherwise asymptomatic individuals, is a lethal condition(Mcmurray&Stewart,2000). Mosterd and Hoes(2007),state that patients in heart failure acutely present with worsening clinical symptoms  like cardiogenic shock ,pulmonary edema ,  hypotension etc within 24 hours of hospital admission.

Nursing care during this unpredicted response changed to prioritize and stabilize Mr.X. Assessments were done to check the patients hemodynamic status (BP, Pulse, Temp), objective measurement of dyspnea status (RR, oxygen saturation, work of breathing),ECG,  check  were done for jugular venous pressure,chest auscultation for breath sounds and  for signs of pulmonary congestion(rales,rhonchi,pitting edema).Mr. X was given emotional support as he was anxious and social support was provided to his family during this situation.

HF is a leading cause of hospitalization among patients aged 65 years or older.The primary mode of death among HF patients is variable, according to New York Heart Association(NYHA) functional class. The NYHA classification is a useful way of categorizing the severity of heart failure in individual patients and this categorization also has prognostic utility. Patients with NYHA class II symptoms are at a proportionally higher risk of sudden cardiac death while those with NYHA class IV symptoms have a one-year mortality as high as 75% with a significantly higher risk of dying of progressive heart failure characterized by worsening shortness of breath, orthopnea, hypotension, and decreasing level of consciousness(Scarabelli etal,2015).Coronary artery disease may also play a role in the progression of heart failure through mechanisms such as endothelial dysfunction, ischemia, and infarction. Studies show that patients with anemia have known to deteriorate due to further neurohormonal activation(Dumitru etal,2016) and sleep apnea contributing to ventricular arrhythmias.These are some of the groups of patients with these co-morbidities who may not respond to the initial treatment.

Monitoring and Nursing Care

As in the case of Mr.X, he had most of the conditions as mentioned above like atrial fibrillation ,diabetes,sleep apnea, hypertension and obesity  and his non-compliance with the therapeutic regimen which contributed to influence his response to treatment in slow progression. The development of episodes of acute pulmonary edema and tachycardia made his condition critical.

Mann, et al (2014) suggests that the medications administered to the patient has always been important and plays a key role in the treatment of HF. There are no identified cases of people who did not respondto medications such as the ACE inhibitors ,ARB or to aldosterone antagonists. As a matter of fact, these interventions have always  beenthe common success for this condition.Some of the reasons and associated factors that may be identified in respect to this case may be the dilemma of the health practitioners in identifying the stage of failure and the exact treatment for the patient.

Mr.X was intubated for 3 days after which he was extubated and transferred to the Coronary Care Unit for the insertion of an Implantable Cardioverter Defibrillator(ICD).During his stay in the ICU, he was  started on inotropes  for his hypotension, and his anti-hypertensives were held during this time. He was on regular diuretics which prevent the retention of salt and water thus reducing preload .Anti-platelets such as Warfarin was continued to prevent the risk of thromboembolism along with regular checks onMr.X’s international normalized ratios( INR).Beta –blockers were introduced  in order to control his heart rate. Special care was taken to check his electrolytes  regularly.

Mr.X showed a positive response to the treatment and was given strict advice on the use of CPAP machine for his sleep apnea. The frequent periods of hypoxia and repeated nighttime arousals due to sleep apnea rigger adrenergic surges, which can worsen hypertension and impair systolic and diastolic function (Ramani et al,2010). He was involved in a weight control program and educated on healthy food habits and regular exercise. His family was involved in his care. He was educated about his medications ,to regularly check his blood pressure and to attend the follow-up visits.

The Nurse is an important member in the multi-disciplinary team.Coordination of care in this manner can reduce the need for hospitalization for heart failure and can result in improvement in quality of life for patients.Additional strategies which appear to be effective include the utilization of nurse practitioners who may follow up patients in their own home, following an episode of decompensated heart failure(Gillespie,2006).

The alternate treatment is included in the unit’s policy however on very strict conditions that it can only be done on patients who are in the intensive care unit. However, as observed from the case of Mr. X, it is clear that the alternate treatment which includes emotional support needs to be included in the unit’s policy in order to take care of such exceptional cases. Some of the nursing implications that may result from this treatment include loss of water and important mineral salts through the use of diuretics.

In conclusion, it is clear to suggest that surgical operations are essential in the treatment of heart failure which has complicated condition that is caused by secondary infections such as arterial fibrillation and sleep apnea. Amongst the many operations involved, heart transplant remains the last effective option of controlling the infection.  The initial treatment however remains medication mainly the use of ACE tablets, catheter ablation and use of BPAP. However for patients who do not respond to this treatment, surgical operations involving heart reconstruction and heart transplant then becomes the second operation for such patients (Yancy, et al 2013).


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