Running head: CASE STUDY 1

Case Study: A Male Patient with Heart Failure and Multiple Comorbidities

Jocelyn Alexander

Old Dominion University

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Case Study: A Male Patient with Heart Failure and Multiple Comorbidities

The purpose of this case study is to integrate the knowledge from the humanities and

sciences, including nursing research and theory. A patient was selected to plan, implement, and

evaluate the care that was provided to a patient during this clinical rotation. The patient in this

case study was admitted on the cardiac and telemetry unit at Bon Secours De Paul Medical

Center. The patient, E.B., is a 92-year-old African American male with a history of hypertension,

hyperlipidemia, anemia, type 2 diabetes, atrial flutter, coronary artery disease, obstructive sleep

apnea, and systolic heart failure with diastolic dysfunction and an ejection fraction of 45-50%. In

addition, he has a recent history of cardiopulmonary arrest with successful resuscitation in April

of 2016. He was a former smoker, smoking half a pack a day for 30 years and does not drink

alcohol. E.B. was admitted to the emergency department with complaints of weight gain,

shortness of breath, and edema. His admitting medical diagnosis was acute respiratory failure

and acute on chronic systolic heart failure.

Medical Diagnoses

Systolic Heart Failure

E.B. has a medical diagnosis of acute on chronic systolic heart failure with diastolic

dysfunction. This means that he has chronic progressive changes to the heart that cause failure

but is experiencing an acute exacerbation upon admission. Heart failure is the inability of the

heart to meet the hemodynamic and metabolic demands of the body, producing a variety of

biochemical and neurohormonal changes and manifesting in a variety of ways (Gulanick &

Myers, 2014). Specifically, systolic heart failure is when the contractility of the myocardium is

poor and diastolic dysfunction is when the heart has trouble filling blood to pump. Acute

myocardial infraction, aging, coronary artery disease, and hypertension are all common possible
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causes that can contribute to this type of heart failure. Congestive systolic heart failure can cause

a back up of fluid and the congestion may extend to the pulmonary veins and alveoli causing

pulmonary edema or back up to the rest of the body affecting the body, brain, and muscles. This

may result in the patient to experience a variety of clinical manifestations such as extreme

shortness of breath, pink frothy sputum, diaphoresis, increased respiratory rate, crackles in lungs,

weight gain, peripheral edema, jugular vein distension, distended abdomen, confusion, fatigue,

and/or poor tissue perfusion.

The evidence specific to this patient that indicates heart failure is his ejection fraction of a

value of 45-50%, which is low compared to the ideal ejection fraction value of 60-70%. Ejection

fraction is an important measurement in determining how well your heart is pumping out blood

and in diagnosing and tracking heart failure. In addition, the 12-lead EKG revealed an abnormal

EKG with dysrhythmias of atrial flutter and pre-mature ventricular contraction. The clinical

manifestations that support the diagnosis of heart failure are weight gain, shortness of breath,

crackles in lungs, peripheral edema, hypertension and tachycardia, tachypnea, fatigue, and poor

tissue perfusion. The lab values that support this diagnosis as well are a RBC value of 3.41

M/uL, hemoglobin of 10.6 g/dL, hematocrit of 32.6%, elevated troponin of 0.6 ng/mL, and an

elevated RDW of 14.7. The low RBC, hemoglobin and hematocrit levels also relate to his

anemia which may also contribute to heart failure. These values plus his increased BUN of 26

mg/dL and Creatinine of 1.85 mg/dL levels are supporting lab values because they indicate poor

perfusion to his kidneys and body.

Acute Respiratory Failure

Acute respiratory failure is a life-threatening inability to maintain adequate pulmonary

gas exchange. Individuals with acute respiratory failure cannot carry out the two major functions
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of gas exchange which is the delivery of adequate amounts of oxygen into the arterial blood and

the removal of a corresponding amount of carbon dioxide from the mixed venous blood

(Gulanick & Myers, 2014). Respiratory failure can result from obstructive diseases such as

emphysema, chronic bronchitis, asthma, or COPD; restrictive diseases such as atelectasis,

ARDS, or pneumonia; and ventilation-perfusion abnormalities such as pulmonary emboli. The

defining characteristics that patients will present with that have acute respiratory failure are signs

and symptoms such as shortness of breath, tachypnea, increased PaCO2 level (above or equal to

50 to 60 mm Hg), decreased PaO2 level (Less than 50 to 60 mm Hg), arterial pH less than 7.35,

oxygen saturation less than 90%, decreased level of consciousness, restlessness, tachycardia,

and/or cyanosis (Gulanick & Meyers, 2014).

As previously stated, E.B. has congestive systolic heart failure which is the underlying

cause to his acute respiratory failure. He presented in the emergency department restless, short of

breath, an increase in respiratory rate of 26 breaths per minute, and tachycardia with a heart rate

of 116. His arterial blood gas values indicated that he was in respiratory acidosis with an arterial

pH of 7.301, CO2 of 55.8, oxygen saturation of 88%, and bicarbonate level of 27.6. In addition,

E.B. had a cough present, he had use of accessory muscles due to the increase work of breathing,

and crackles were auscultated bilaterally. Aforementioned E.B. has heart failure which is also

contributed to his acute respiratory failure due to the back up of fluids in the lungs and his body

tissues not being perfused with oxygen. All of these signs and symptoms support the diagnosis of

acute respiratory failure for this patient.

Nursing Diagnoses and Theory

Considering the patients admitting diagnosis of systolic congestive heart failure and acute

respiratory failure along with multiple comorbidities, the following nursing diagnoses were
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prioritized with highest priority first and so forth in order of priority as follows: Decreased

cardiac output, impaired gas exchange, ineffective tissue perfusion, excess fluid volume, and fear

as the psychosocial nursing diagnosis. The nursing theory used to prioritize the nursing

diagnoses was Virginia Hendersons nursing need theory. The theory emphasizes the importance

of increasing the patient's independence so that progress after hospitalization would not be

delayed. Henderson emphasizes on basic human needs as the central focus of nursing practice

which has led to further theory development regarding the needs of the patient and how nurses

can assist in meeting those needs. In the case with E.B., the two major organs of heart and lungs

require adequate functioning for survival so by using this theory the two nursing diagnosis of

decreased cardiac output and impaired gas exchange were top two priorities to increase the

patients independence after hospitalization.

Following decreased cardiac output and impaired gas exchange, ineffective tissue

perfusion was third priority because if the heart and lungs arent working adequately then the

tissues wouldnt be perfused correctly. This was evidenced by weak peripheral pulses, cool

extremities, and prolonged capillary refill. Excess fluid volume was another priority nursing

diagnosis for this patient due to the heart failure, fluid backed up to the peripheral extremities.

The patient presented with +2 edema bilaterally, weight gain, tachycardic heart rate of 116,

shortness of breath, crackles in the lungs, and restlessness. The patient diet was then changed to

restricted fluid intake of 1500 mL and restrict salt intake of less than 2 grams every 24 hours. In

a psychosocial aspect, fear was a priority nursing diagnosis for this patient relating to the threat

of death. In conjunction with E.B. old age in April of 2016 he needed to receive cardiopulmonary

resuscitation. E.B. verbalized his fear of dying and stated, I know I am an old fellow, but I am

not ready to die. For this reason, fear is an appropriate nursing diagnosis.
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Expected Outcomes

Considering the health consequences of heart failure, the main attention is directed to

identify and treat early in those that are at risk for heart failure. In this case with E.B., his heart

failure is so progressed that the goal of treatment is to prevent even further progression, reduce

exacerbations, recognize early signs of decompensation, control symptoms, assist in co-

managing the disease, and improve quality of life (Gulanick & Myers, 2014). The top two

priority nursing diagnosis outcomes that will be discussed are decreased cardiac output and

impaired gas exchange.

Decreased Cardiac Output Outcomes

The expected outcomes for E.B. for decreased cardiac output would be the patient to have

adequate cardiac output within one week upon admission as evidenced by systolic BP within 20

mmHg of baseline, heart rate with the normal limits of 60 to 100 beats per minute with regular

rhythm, strong peripheral pulses, warm and dry skin, eupnea with absence of crackles, decreased

edema and normovolemic (Price, 2012). The idea to is treat the underlying cause behind the poor

peripheral perfusion and excess fluid volume in order to correct the associated problems with this

patient. It is important to assess peripheral pulses because weak pulses indicate reduced stroke

volume and cardiac output (Price, 2012). In addition, having a blood pressure and heart rate

within normal limits is important because most patients have compensatory tachycardia and

reduced blood pressure in response to reduced cardiac output. Therefore, the goal for E.B. blood

pressure is 120/80 mmHg and a heart rate within 60-100 beats per minute. E.B. previously had

cold and clammy skin, but it is expected the skin to be warm and dry to show improved cardiac

output and oxygen saturation (Price, 2012).

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Impaired Gas Exchange Outcomes

Based on the assessment of the patient respiratory status, appropriate outcomes for E.B.

impaired gas exchange nursing diagnosis should be achievable within 1 week of admission. The

patient will maintain optimal gas exchange as evidenced by arterial blood gases within baseline

range for E.B, alert responsive mentation, relaxed breathing, and oxygen saturation above 95%.

In addition, the outcomes the patient will have maintenance of a patent airway, absence of

trauma or infection, attainment of optimal mobility, and absence of complications (Hinkle &

Cheever, 2013).

Interventions

Decreased Cardiac Output Interventions

The interventions performed to care for E.B. include both an ongoing thorough

assessment of the patient cardiovascular system and status and various interventions such as

medication administration, edema management, education, nutritional support, and managing

fatigue. The electrocardiogram is monitored because cardiac dysrhythmias may occur from low

perfusion, acidosis, or hypoxia. E.B. currently has all three of these conditions and his EKG

revealed atrial flutter with premature ventricular contractions. It is important to monitor EKG

because these abnormalities can further compromise cardiac output.

The collaborative interventions with the primary physician will be based on medications

and the nurse will have to educate about side effects or adverse effects. The medications that

E.B. will be administered to the patient that will improve cardiac output is the alpha adrenergic

blocker and beta blocker Carvedilol (Coreg). Coreg will vasodilate the blood vessels and

decrease heart rate which in result will decrease afterload and cardiac workload (Kizior &

Hodgson, 2015). In addition, Furosemide (Lasix) is used to decrease circulating blood volume
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and reduce systemic vascular resistance and for edema management to diuresis the patient and

reduce preload (Kizior & Hodgson, 2015). Restricting fluids to 1500 mL per day and salt intake

to less than 2 grams per day will also aid in edema management and improve fluid balance.

Another intervention the nurse will perform for E.B. is to educate him to take his

mediations as directed once discharged, keep a daily weight log, exercise, and maintain a cardiac

diet with low sodium diet to support his cardiovascular system health. The education and

nutritional support will consist of the nurse educating E.B. on the different types of foods that

should be eaten and avoid to benefit for their cardiovascular system such as avoiding alcohol,

food with high saturated fat and cholesterol, and avoiding foods with high salt intake. In

addition, managing fatigue by planning activities, providing periods of rest, teaching energy

conservation techniques such as sitting to do tasks, pushing rather than pulling and sliding

instead of lifting. By doing so this will decrease the workload of the heart which is an

appropriate intervention for E.B.

Impaired Gas Exchange Interventions

In acute respiratory failure, the healthcare team treats the underlying cause while

supporting the patients respiratory status. With E.B., the interventions that will be performed are

assessment of his lung songs every shift to identify if the crackles are improving. It is appropriate

to assess for abnormal lungs sounds because it may indicate poor ventilation and fluid overload

in this case. In addition to assessing lung sounds, E.B. respiratory rate and rhythm will be

assessed which will show if he can facilitate gas exchange. The ABGs will also be monitored

daily to investigate the acid-base balance and indicate severity of condition. The nurse can use

collaborative interventions with the physician by administering the prescribed amount of 3 liters

per minute of supplemental oxygen, albuterol-ipratropium (Dueo-neb), and steroid of prednisone

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(Deltasone) as prescribed. Prednisone is a steroid which will help reduce the inflammation and

Duo-neb will be used as a bronchodilator to decrease the work of breathing and provide airway

clearance (Gulanick & Myers, 2014). Supplemental oxygen will be administered because the

failing heart may not be able to respond to increased oxygen demand so this intervention is

appropriate to supply the body with oxygen. Another intervention will be regular use of incentive

spirometry to help maximize diffusion and alveolar surface area and can help prevent atelectasis

(Fournier, 2014). Another intervention that is appropriate for E.B. is in order to enhance

ventilation and perfusion matching, turning the patient on a regular and timely basis will

maximize lung zones (Fournier, 2014). Education will also be provided to the patient and family

to promote adherence with treatment and help prevent the need for readmission and an

explanation of the purpose of nursing measures, such as turning and incentive spirometry, as well

as medications to promote adherence (Fournier, 2014). The use of a BiPAP machine will also be

used while the patient is sleeping. This therapy is to aid in maintain adequate ventilation and

oxygenation.

Cultural Considerations

The main cultural consideration for this patient is based off the fact that in his subculture

in presents with many risk factors for heart failure. My patient is an African American male and

according to the CDC, African Americans are more likely to have heart failure than other races

and also more likely to present with symptoms at an earlier age. In addition, my patient has the

strongest predictors of heart failure which is high blood pressure, being over weight, and high

cholesterol. Studies have shown that African Americans often have less access to healthcare and

are less likely to visit a doctor and get routine screenings (Brunner & Cheever, 2013). While

having a discussion with my patient he stated that in his younger years he did not get routine
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screenings and also has had high blood pressure and cholesterol for over 30 years. It is important

for health care providers to consider this when providing care.

Evaluation

Additional considerations that must be taken into account are end-of-life considerations.

According to Hinkle & Cheever, 50% of patient diagnosis with heart failure die within 5 years.

Because heart failure is a chronic and often progressive condition, patients and families need to

consider issues related to end of life (Hinkle & Cheever, 2013). Discussions concerning the use

of technology, preferences for end-of-life care, and advance directives should be taken place

while the patient is able to participate and express preferences (Hinkle & Cheever, 2013). For

example, with E.B. the discussion of advance directives and code status were discussed. It was

evaluated that he would like extensive measures to be taken such as endotracheal tubes, feeding

tubes, and is a full code status. In addition, his daughter was declared power of attorney if in fact

he can not make his own decisions. Relating to the interventions for his decreased cardiac output

such as medication administration, edema management, education, nutritional support, and

managing fatigue, the progress toward outcomes are improving. The patient verbalized his

understanding for his variety of medications he should take at home such as his Coreg and Lasix.

In addition, he verbalized to perform and record daily weights, limit dietary sodium intake,

report signs and symptoms of worsening heart failure, and will make and keep up with follow-up

care appointments. The fluid, sodium restriction, and Lasix medication therapeutic regimen has

been improving as well. This was evidenced by a net loss of 4,080 mL upon admission which is a

loss of about 4 kg since he gained weight from fluid retention. He also verbalized the

understanding of fluid intake and diuretic use. The patient vital signs were stable during my

clinical rotation. His blood pressure was 140/80 mmHg, pulse 76 beats per minute, respiration
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rate 18 breaths per minute, and oxygen saturation 99%. Regarding the interventions for gas

exchange the patient is using the incentive spirometry during commercial breaks to promote

healthy lungs and uses the BIPAP machine at night while sleeping to improve ventilation and

oxygenation. His crackles are still present but are improving from the time of admission. Overall

the patient cardiovascular function and respiratory status are improving and is planned to be

discharged within 2 days.

Conclusion

This case study should have presented an accurate integration of the knowledge from the

humanities and sciences, including nursing research and theory. It presented a patient and

identified the steps in the nursing process of assessment, nursing diagnosis, outcomes,

implementation, and evaluation of the care that was provided to the patient during this clinical

rotation. During the assessment of the patient it was evident the top two priority nursing

diagnosis were decreased cardiac output and impaired gas exchange. Next, expected outcomes

that the patient should achieve within the measureable time frame were given and then

implement a variety of interventions to improve the patient quality of life. The various

interventions consisted of administration of medications, education, and more that could then be

evaluated. Alternative interventions that could be instituted would be placement of an ICD which

can prevent sudden cardiac death and extend survival or cardiac resynchronization therapy

(CRT) which involves the use of a biventricular pacemaker to treat the electrical conduction

defects (Brunner & Cheever, 2013). CRT would result in fewer symptoms, increased functional

status and fewer hospitalizations for patient with heart failure (Brunner & Cheever, 2013). The

knowledge gained from the care of this patient has been extensive. This opportunity has provided

a chance to understand how to assess a patient with heart failure and respiratory failure,
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diagnosis accordingly to the top priorities, critically think about the different interventions

implemented such as the rationale for different medications, and evaluate the effectiveness of the

plan of care.
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References

Albert, N. M. (2012). Fluid Management Strategies in Heart Failure. AACN, 32(2). doi:

http://dx.doi.org/10.4037/ccn2012877

Fournier, M. (2014). Caring for patients in respiratory failure. Journal of American Nurses

Association, 9(11), 34-40.

Gulanick, M., & Myers, J. L. (2011). Nursing care plans: Diagnoses, interventions, and

outcomes. St. Louis, MO: Elsevier Mosby.

Hinkle, J. L. & Cheever, K. H. (2013). Brunner and Suddarth's Textbook of Medical-surgical

Nursing (13th ed.). Lippincott Williams & Wilkins.

Kizior, R. J., & Hodgson, B. B. (2015). Saunders Nursing Drug Handbook 2015. St. Louis,, MO:

Elsevier.

Price, A. (2012). Specialist nurses improve outcomes in heart failure. Nursing Times, 108(40),

22-24.