Congestive Heart Failure

Minor Case Study #2

Bryanna Rucinski
Andrews University
February 2017
 V.R. is a ninety one year old female who was admitted to the hospital for shortness of

breath. She was diagnosed with acute on chronic congestive heart failure and atrial fibrillation

with rapid ventricular rate. V.R. weighs 141 pounds (63.957 kg), and is 5 foot, 5 inches tall. She

has a normal BMI of 23.46. She was 112% of her ideal body weight of 56.8 kg. We saw this

patient for an education on the heart healthy diet, as well as unplanned weight loss, and loss of

appetite. This patient was chosen for my case study because it was a cardiac patient who I

thought was very kind, and very open about her disease, so I was able to get a lot of

information in only the initial assessment.

V.R. is a widow for the past two years, but has close family members near her: daughter,

son, and daughter-in-law. They often take her to appointments, pick her up for errands, and

check in with her at least every other day. They take care of her and visit often at the nursing

home where V.R. lives. She is currently residing in Lincoln Park Manor where she is fed and

taken care of by nurses. She usually eats 3 meals a day at the cafeteria, but is recently getting

tired of the food they serve there, which is a factor of her decreased intake. She gets around

the house with a rollator due to a recent fall in the past year and is currently on Hemana

Medicare. V.R. has been in and out of the hospital a lot in the past year, often due to shortness

of breath, recent surgery for cardiac stent placement, and other issues often relating to heart

problems

When the heart muscle is unable to pump enough blood and oxygen to other body

systems and cannot correctly support other organs it is considered to be a stage of heart

failure. According to the Centers for Disease Control and Prevention, about 5.7 million adults in

the United States have heart failure and one in every nine deaths included heart failure as a
contributing cause. Unhealthy behaviors can increase the risk of developing congestive heart

failure. Smoking, inactivity, obesity, and a high fat, sodium, and/or cholesterol diet are some of

these factors. Shortness of breath, fatigue, weakness, edema, irregular heartbeat, and

coughing, increased urination, lack of appetite, difficulty concentration, and chest pain are

symptoms of heart failure. According to the UCSF Medical Center, early detection and

treatment can help prevent complications and help with symptoms. Some simple lifestyle

changes can allow the heart to not work as hard. One dietary change is reducing salt intake in

the diet. It is important to eat food items lower in salt by choosing fresh or frozen product,

avoiding canned foods. Choose items that have low sodium, no salt added or reduced sodium

on the label. Season food items using lemon juice or fresh herbs and spices. Also reading food

labels is important to choose foods that are less than 350 mg sodium per serving. Physical

activity is also a lifestyle change that can impact the health of a person with heart problems. If

the patient is retaining fluids, a fluid restriction may be required to decrease the volume the

heart has to pump. Medications can also be recommended to help. Some of these medications

include Ace Inhibitors, Beta Blockers and diuretics. Often time, a doctor will refer a heart

specialist or cardiologist if a patient has congestive heart failure symptoms (Cherney). The

heart specialist will then do a physical exam such as listening to the heart for abnormal beats,

and may also order tests to understand the hearts valves, vessels, and chambers. Some of

these tests include an electrocardiogram, echocardiogram, an MRI, stress tests, blood tests, or

cardiac catheterization, which all can help determine the level of heart failure.

There are many different surgeries that can help prolong the life of patient, stop further

damage to the heart, and improving the hearts function. The coronary artery bypass surgery
restores normal blood flow by using a blood vessel from a leg, chest, or arm, and completely

bypasses a vessel near the heart which is blocked by a blood clot or plaque formation

(Cleveland). As heart failure gets worse, the heart muscles become stiff and can cause leaky

valves, resulting in the muscle to work even more. These leaky valves can be fixed from surgery

aortic valve repair and aortic valve replacement (Cleveland). Once the heart muscles become

stiff, they cannot function properly and can cause the pericardium (thin surrounding sac that

protects heart) can form into scar tissue. The pericardiectomy surgery is the removal of the

stiff scar tissue pericardium to relieve pressure (Recognizing). A pacemaker can also be placed

to synchronize the ventricles to properly pump (Recognizing). The cardiac angioplasty is a

procedure that uses a balloon to open up blocked arteries to restore the blood flow to the

heart. These are some options to help better patients health due to heart conditions.

During the counseling session, V.R. stated that her appetite has been improving in the

past six months. She originally lost her appetite due to living in an assistant living situation and

not being happy about it. She states she has lost 10-15 pounds in the past 6 months due to

getting tired of eating the same things during meal times at her home. She also has some

intermittent confusion, and sometimes forgets if she ate or not during the days. This may have

also impacted her weight loss. Overall, in a year, V.R. lost 13.5% of her weight within a year

which is a mild sign of malnutrition. Upon finishing her malnutrition screen, her PO intake has

at least been less than 75% of her normal intake, which is a moderate sign of malnutrition, as

well as the loss of muscle and subcutaneous fat in the following areas: temporal, clavicle,

shoulder, biceps, eyes, triceps, chest, and interosseous. She also had diminished grip strength,

and bilateral lower extremity non-pitting & +1 edema. V.R.s abnormal lab levels are located in
appendix A, and her medication list is located in appendix B. Overall she is moderately

malnourished. Unfortunately, V.R. declined all nutritional supplements, but did agree to snacks

in between meals such has cottage cheese & fruit between breakfast and lunch, and cheese &

unsalted crackers for a evening snack. V.R. was encouraged on her calorie and protein intake,

as well as improving her PO to increase her caloric intake. V.R. was also educated on a low

sodium, heart healthy diet. We discussed easy ways to limit sodium in foods, how to correctly

read food labels, and how to try to eat fresh or frozen items instead of canned or processed

foods. V.R. had a very good understanding of what to do, but did state that due to her age, she

might not follow the diet as strictly as is recommended. With her malnutrition, and edema, 28-

32 calories per kg was recommended for her, giving her a range of 7189-2044 calories. Due to

her age, and malnutrition, 1.4-1.8 g protein per kg was recommended, giving her a range of 89-

115 g of protein per day. Due to her lack of appetite, weight loss, and poor oral intake, a

multivitamin was recommended to increase her nutrient intake. V.R. seemed interested in

learning the information, but was not motivated to change. This was mainly due to her age,

and her habits V.R. stated. She enjoys what she is currently eating and is not ready to make a

lifestyle change.

Overall I learned a lot. It was interesting to learn where V.R. came from and why she

doesnt want to change. I now understand why it is hard for elderly patients to be unwilling to

change their lifestyle because they have been doing things for so long. They know what they

like and know what they dont like. I also learned a lot about congestive heart failure and the

importance it is to catch heart problems early on to try to correct the situation before

medications and surgery is needed.

 Appendix

Appendix A Labs
Abnormal Labs Abnormal Levels Normal Levels What it means
BUN 28 mg/dL 7 - 20 mg/dL High BUN levels
indicate: heart failure,
dehydration, diet high
in protein
Creatinine 1.31 mg/dL 0.5-1.2 mg/dL High creatinine levels
indicate: kidney
problems,
dehydration, certain
medications
Anion Gap 5 mEq/L 8-16 mEq/L Low levels indicate:
lack of albumin
protein in blood
Glucose 113 mg/dL 70-100 mg/dL High levels indicate:
diabetes, stress,
dehydration, illness
Calcium 8.3 mg/dL 8.5-10.2 mg/dL Low levels indicate:
vitamin D deficiency,
kidney failure, liver
disease, pancreatitis
HGB 9.4 g/dL 12-15.5 g/dL Low levels indicate:
anemia, kidney
disease
Oxygen Saturation 80.4% 95-100% Low levels indicate:
hypoxemia,
respiratory distress

Appendix B Medications
Medication Use/Purpose Drug/Food Side Effects
Interaction
Aspirin Reduce fever, relieve Prilosec, Lasix Heartburn, nausea,
pain (minor), docusate, dyspepsia, epigastric
crestor, Miralax distress
Atenolol Treats chest pain and Prilosec, Plavix, Lasix, Cardiac Failure,
hypertension Nexium, Synthroid bradycardia,
dizziness, fatigue
Atorvastatin Reduces levels of bad Nexium, plavix, lasix, Diarrhea, UTI, muscle
cholesterol & lantus, januvia spasm, nausea,
 triglycerides, arthralgia
increases levels of
good cholesterol
Clonidine Lowers blood Abilify, ambient, lasix,
Drowsiness, fatigue,
pressure, treats Lipitor, norvasc, hypotension,
hypertension, relaxes plavix, nexium headache, upper
blood vessels abdominal pain
Escitalopram Antidepressant, treats Nexium, xanax, norco, Diarrhea, drowsiness,
anxiety metoprolol, crestor, nausea, headache
abilify
Ezetimibe Reduces cholesterol Lasix, Crestor, Bloating,
absorption Celebrex, metoprolol, constipation, bleeding
morvasc, plavix, gums, loss of
synthroid appetite, nausea
Furosemide Loop diuretic, Nexium, plavix, Chest pain, fever,
prevents body from spiriva, metoprolol, headache, shortness
absorbing too much Lipitor, cymbalta, of breath. weakness
salt, treats fluid crestor
retention
Heparin Anticoagulant, Coumadin, lasix, Constipation,
prevents formation of norvasc, plavix, stomach pain,
blood clots protonix dizziness, unexplained
nosebleeds,
headaches
Isosorbide Dinitrate Widens blood vessels Nexium, lavix, Dizziness, rapid heart
prilosec, ranexa, rate, fever, headache,
Lipitor, lasix, weakness
metoprolol, coreg
Levofloxacin Antibiotic Cymbalta, crestor, Diarrhea, insomnia
lasix, nexium,
paracetamol, spiriva,
xanax, multivitamins,
enteral tube feedings
Levothyroxine Replaces a hormone Lasix, lyric, Chest pain, fainting,
normally produced by metoprolol, crestor, fever, increased blood
thyroid gland mexium, plavix, pressure, sweating
singulair
Pantoprazole Decreases amount of Crestor, lasix, Lipitor, Stomach pain, blurred
acid produced in metoprolol, plavix, vision, dried skin,
stomach synthroid increased
thirst/hunger, nausea,
vomiting
 Works Cited

Diet and Congestive Heart Failure. UCSF Medical Center.

https://www.ucsfhealth.org/education/diet_and_congestive_heart_failure/. Published
2015. Accessed February 12, 2017.
Heart Failure Fact Sheet. Centers for Disease Control and Prevention.
https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm.
Published June 16, 2016. Accessed February 12, 2017
Cherney K. Congestive Heart Failure (CHF), HealthLine
http://www.healthline.com/health/congestive-heart-failure#Diagnosis5. Published
December 19, 2016.
Heart Failure Surgery. Cleveland Clinic. http://my.clevelandclinic.org/health/articles/heart-
failure-surgery. Published March 2015
Recognizing Advanced Heart Failure and Knowing Your Options. American Heart Association.
http://www.heart.org/HEARTORG/Conditions/HeartFailure/Recognizing-Advanced-
Heart-Failure-and-Knowing-Your-Options_UCM_441926_Article.jsp#.WKT54_krLIU.
Published May 25, 2016.