Question

Background Jeraldine Yates is a 70-year-old woman originally from Alabama. She lives alone and is able to manage herself independently. She is active in her community and church. Mrs. Yates was admitted to the hospital two months ago with heart failure. Since her discharge, a visiting nurse visits every other week to assess for symptoms of heart failure and see that Mrs. Yates is continuing to manage well on her own. Case Study The visiting nurse stops in to see Mrs. Yates today. The nurse immediately notices that Mrs. Yates’s legs are very swollen. Mrs. Yates states, “I noticed they were getting a bit bigger. They are achy, too.” The nurse asks Mrs. Yates if she has been weighing herself daily to which Mrs. Yates replies, “I got on that scale the last time you were here, remember?” The nurse weighs Mrs. Yates and she has gained 10 pounds. Additional assessment findings indicate that Mrs. Yates gets short of breath when ambulating from one room to the other (approximately 20 feet) and must sit down to catch her breath. Her oxygen saturation is 95% on room air. Bibasilar crackles are heard when auscultating her lung sounds. The nurse asks Mrs. Yates if she is currently or has in the past few days experienced any chest, arm, or jaw pain or become nauseous or sweaty. Mrs. Yates states, “No, I didn’t have any of that. I would know another heart attack. I didn’t have one of those.” The nurse asks about any back pain, stomach pain, con- fusion, dizziness, or a feeling that Mrs. Yates might faint. Mrs. Yates denies these symptoms stating, “No. None of that. Just a little more tired than usual lately.” Her vital signs are temperature 97.6 F, blood pressure 140/70, pulse 93, and respirations 22. The nurse reviews Mrs. Yates’s list of current medications. Mrs. Yates is taking aspirin, clopidogrel bisulfate, lisinopril, and carvedilol. The nurse calls the health care provider who asks the nurse to draw blood for a complete blood count (CBC), basic metabolic panel (BMP), brain natriuretic pep- tide (B-type natriuretic peptide assay or BNP), troponin, creatine kinase (CPK), creatine kinase-MB (CKMB), and albumin. The health care provider also prescribes oral (PO) furosemide and asks the nurse to arrange an outpatient electrocardiogram (ECG, EKG), chest X-ray, and echocardiogram.

Questions 1. Which assessment findings during the nurse’s visit are consistent with heart failure?

2. Why did the visiting nurse ask Mrs. Yates about back pain, stomach pain, confusion, dizziness, or a feeling that she might faint?

3. Discuss anything else the nurse should assess during her visit with Mrs. Yates.

4. Explain what the following terms indicate and include the normal values: cardiac output, stroke volume, afterload, preload, ejection fraction, and central venous pressure.

5. Discuss the body’s compensatory mechanisms during heart failure. Include an explanation of the Frank- Starling law and the neuro-hormonal model in your discussion.

6. Heart failure can be classified as left or right ventricular failure, systolic versus diastolic, according to the New York Heart Association (NYHA) and using the ACC/AHA (American Heart Association) guidelines. Explain these four classification systems and the signs and symptoms that characterize each.

7. According to each classification system discussed above in question #6, how would you label the type of heart failure Mrs. Yates is experiencing?

8. Discuss Mrs. Yates’s predisposing risk factors for heart failure. Is her age, gender, or ethnicity significant?

9. Provide a rationale for why each of the following medications are included in Mrs. Yates’s medication regimen: aspirin, clopidogrel bisulfate, lisinopril, and carvedilol.

10. The nurse is teaching Mrs. Yates about her newly prescribed furosemide. Explain the rationale for adding furosemide to Mrs. Yates’s medication regimen, when she should expect to see the therapeutic results (urination), and instructions regarding the administration of furosemide.

11. The visiting nurses asks the primary health care provider if he/she will prescribe potassium chloride for Mrs. Yates. Why has the nurse suggested this? What information will each of the following blood tests provide: CBC, BMP, BNP, troponin, CPK, CK-MB, and albumin?

12. Mrs. Yates’s son comes to stay with his mother so she will not be alone. What should the nurse tell Mr. Yates about when he should bring his mother to the hospital?

13. The visiting nurse returns the next day. Mrs. Yates does not seem to be diuresing as well as the nurse anticipated. Mrs. Yates is not worse, but the swelling in her legs is still considerable and there is no change in her weight. When asked about her frequency of voiding, Mrs. Yates does not seem to have noticed much difference. While the nurse is unpacking her stethoscope to assess lung sounds, Mrs. Yates says, “Honey, I was just making myself a ham salad sandwich. Would you like one?” The nurse declines and becomes concerned because of this offer. Why is the nurse concerned?

14. The nurse asks Mrs. Yates to tell her more about how she cooks. Specifically, the nurse asks Mrs. Yates about the types of foods and food preparation. With great pride, Mrs. Yates leads the nurse to the kitchen and explains, “Honey. I am from the South and we cook soul food. Today I am cooking my famous pea soup for the church dinner tonight. I use ham hocks. Have you ever had those? My son says they are not good for me. He has been trying to get me to eat healthier foods. Last week he brought me turkey sausage to try instead of my pork sausage in the morning. I know he means well but some foods are tradition and you don’t break soul food tradition.” What information has the nurse gathered that is of concern?

15. The nurse arranges for Mrs. Yates’s son to be present at the next home visit so that the nurse can teach them both about proper dietary choices and fluid restrictions. List five points of information that the nurse should include in the teaching. Suggested teaching points include: 16. During the dietary teaching, the nurse asks Mrs. Yates to describe a typical day of meals and snacks. Mrs. Yates lists coffee with whole milk, eggs and sausage for breakfast, a sandwich or soup for lunch, fried chicken with vegetables for dinner, and fruit, pretzels, or rice pudding for snacks. Which of these foods will the nurse instruct Mrs. Yates to limit and are there alternatives that the nurse can suggest?

17. Prioritize five nursing diagnoses that the visiting nurse should consider for the recent events regarding Mrs. Yates’s care.

Answer 1

1. The  assessment findings consistent with heart failure are swollen legs, shortness of breath, bibasilar crackles.

2.The nurses asks Mrs. Yates about dizziness or feeling that she might faint, confusion, because these are warning signs of heart failure .Stomach pain and back pain may be a sign of heart attack as she already has shortness of breath. Also these all are symptoms of end stage congestive heart failure.

3.Additionally she should assess weight of Mrs. Yates along with the vital signs. Fluid intake and output should be assessed. Note for presence of cyanosis and serum electrolytes analysis to be made.

4.Volume of blood pumped by each ventricle is termed as cardiac output. A normal adult has a cardiac output of 4.7 liters of blood per minute.

Amount of blood pumped by left ventricle in a contraction is stroke volume . Normal stroke volume is 70 ml. stroke volume is determined by three factors preload, after load and contractility. Preload is the degree of stretch of cardiac muscle fibres at end of a diastole which is the period of ventricular relaxation resulting in ventricular filling. After load is amount of resistance to ejection of blood from the ventricle .Percentage of end diastolic blood volume that is ejected from the ventricle with each beat is ejection fraction.

Central venous pressure is the pressure exhibited in the veins near to heart. Normal CVP is 2-6 mm Hg

5. Compensatory mechanisms during heart failure are

Cardiac

• Frank-Starling mechanism- The ability of the heart to change its force of contraction and therefore stroke volume in response to changes in venous return is called the Frank-Starling mechanism (or Starling's Law of the heart) .It shows the ventricular preload lead to changes in stroke volume(Klabunde,2015)
• Chronic ventricular dilation or hypertrophy
• Tachycardia

Autonomic Nerves

• Increased sympathetic adrenergic activity
• Reduced vagal activity to heart

Hormones

• Renin-angiotensin-aldosterone system
• Vasopressin (antidiuretic hormone)
• Natriuretic peptides

Sympathetic nervous system (SNS) activation ,neurohormonal responses,ventricular dilatation and
ventricular hypertrophy are the compensatory mechanisms during heart failure.

Neurohormonal response:

Activation of sympathetic nerves and the renin-angiotensin system,increased release of antidiuretic hormone (vasopressin) and atrial natriuretic peptide are responses during congestive heart failure. These lead to narrowing of arteries and venous constriction to increase the blood to ventricles and serves as a compensatory mechanism.

Ref:

1. Richard.E.Klabunde,2015,Frank starling mechanism, Cardiovascular physiological concepts.