Congestive Heart Failure Case Study - Weebly



Heart Failure Case Study Name_____________________

Instructions: Please type all answers. Submit a paper copy of this case study in class and an electronic copy of the case study through Blackboard. You may need to look up terms and abbreviations included in the case study. In addition to the questions related to this case study, you will need to fill out the nutrition documentation form (Swedish Medical Center Nutrition Assessment form). Bring the typed case study with you to class on the due.

PRESENTATION OF ILLNESS

A 70-year-old male presents to the emergency room complaining of breathlessness for the past three days. Cardiac history is positive for a myocardial infarction three years ago followed by four-vessel coronary artery bypass surgery. The patient has been asymptomatic since surgery with no complaints of chest pain.

Over the last three months PTA, the patient notes onset of shortness of breath while unloading groceries, walking stairs, and other strenuous ADLs.

Two weeks ago, he was unable to complete his daily one-mile walk at the high school track. He noted swelling in his feet and ankles. Four days PTA he woke at 2 am short of breath and had to sleep in his recliner the rest of the night. He has been unable to lay flat in bed at night since then and has slept on 3 pillows. Yesterday, he became breathless walking from one room to another. He presents today with extreme shortness of breath. He denies chest pain.

PAST MEDICAL HISTORY

Sleep apnea (but he does not like to wear his bi-pap machine at night). MI in 2011, CABG x 4 vessel in 2011. SOB PTA for 3 months. Vague history of hypercholesterolemia. History of HTN. Surgical history also positive for inguinal hernia repair 15 years prior.

Current Medications

Lipitor, Zocor, Coumadin, coreg

Allergies

NKDA

Habits

Walks one mile daily until one week PTA. Smoked 1ppd until 2011. 30 pack/year history. ETOH- 3-4 drinks daily. Works 8-12 hours/day in a grocery store.

Family History

Father died at 60 - sudden death of unknown cause, no CAD documented.

Mother A&W at 92 with DJD only.

Sister died at 58 with AMI.

No other siblings. 2 children, A&W.

Social History

Owns and manages own grocery store. Lives with wife in own home.

PHYSICAL EXAMINATION

BP 170/98

Pulse 140, irreg.

Respirations 30 and labored

Temp 99°F

Ht: 5'10"

Wt: 210.

General: Breathless, moderately obese male in acute distress sitting upright complaining "I am going to die. Please help me."

HEENT: Normocephalic. Eyes, ears, and throat normal.

Neck:. Carotids without bruits.

Chest: Scattered rhonchi throughout, rales bilateral one third lower bases. Cough is productive and frothy.

Heart: Tachycardia and irregular. Grade 3/6 systolic murmur at LSB, S3 gallop noted.

Abdomen: Liver palpable three centimeters below right costal margin. Non-tender to palpation, +Bowel sounds 4 quadrants.

Extremities: 4+ pitting edema of lower extremities. Nail beds minimally cyanotic, no clubbing. Pulses intact.

Neurologic: Anxious with feeling of impending doom. No localized or sensory deficits. Mental status intact.

Initial Laboratory Data

Na 130 (low), K 3.8 (WNL), BUN 18 (WNL). Cr 1.0 (WNL).

Total cholesterol: 270

HDL: 30

LDL: 210

TGY: 160

EKG: Left bundle branch block. Atrial fibrillation with ventricular rate of 140.

CXR: Cardiomegaly with diffuse pulmonary infiltrate consistent with pulmonary edema.

TREATMENT

Pt had increasing shortness of breath and was emergently intubated, and the physician orders were:

1. NPO

2. Propofol-10 ml/hr x 24 hours a day

3. digitalis/digoxin

4. heparin

5. propanolol

6. furosemide

7. 1000 cc total fluid qd including IV

QUESTIONS

1. What is his medical history could have contributed to his heart failure? (4pts)

Many people with cardiovascular problems have a high prevelance of sleep apnea but whether it causes it is unclear. His Myocardial infarctain and his bypass surgery are likely to have caused the damage leading to this heart failure.

2. Why might his sodium be low? Would you recommend a low sodium diet for him? Why or why not? (4pts)

His sodium may be low because he is retaining so much fluid that it will dilute the sodium numbers. I would put him on a low sodium diet to reduce his blood pressure and stop any further fluid retention.

3. If you had additional nutrition-related lab values such as albumin, hemoglobin and hematocrit, would you have any concerns interpreting them to assess nutrition status?

(4pts)

Yes again the numbers would seem inaccurate since he is so hemodiluted.

4. What are the medications he has been prescribed used for, and what are the relevant drug/nutrient interactions of each to be aware of? (7 points)

Drug Indication Drug/Nutrient interactions

Lipitor is a statin that lowers blood cholesterol, avoid citrus/ grapefruit, avoid alcohol

Zocor is another statin drug to lower cholesterol “”

Coumadin lowers blood clot risk, should not be taken with other anti-coagulants, keep K steady limit vitamin E.

Coreg is a beta blocker used to lower blood pressure and help circulation, be careful with alcohol

5. Why was he placed on a fluid restriction? (3pt)

His heart is already having so many problems pumping the already elevated volume of blood, any additional fluidic volume would only exacerbate the situation. We want to get fluid out not put more in.

6. What needs to be taken into consideration when evaluating his anthropometric data? (eg, weight/BMI) What anthropometric measures would you use to assess his nutritional status? (2pts)

What needs to be taken into consideration is that he is retaining a lot of fluid and measuring him may make him appear bigger with a higher BMI. WE could look at his calf thigh and mid arm circumference for protein status.

7. Calculate IBW, %IBW, calorie needs, protein needs, fluid needs (keep in mind fluid restriction). Recommend a nutrition intervention. Write a nutrition prescription. (12pts)

166 pounds is his ideal body weight.

He is at 126% his ideal bodyweight.

At 25-28 kcal for every kg of his 95.25kg frame we will give him approx. 2400- 2800 kcal per day. Since he is overweight he may get around 2000 calories a day to encourage weight loss. Though heavier may be more likely to live longer.

He should have .80-1.0 g of protein for each kg. so that is about 75-100 g of protein a day.

His fluid should be below 2L per day.

Outcome Goals:

Decrease weight to a more healthful level

Reduce sodium intake

Eat primarily whole foods

This is all to help reduce his blood pressure and decrease the strain on his heart from excess fluid.

Short term goals:

Help patient identify which foods contain high sodium

Identify what would be included in a healthful diet based on whole foods instead of highly processed.

8. What dietary recommendations would you make for when he is released? (include kcal, protein needs and any other recommendations ) (6points)

I would tell him to keep his sodium intake very low (give him a list of the top ten sodium foods), avoid alcohol, limited caffeine. I would tell him to eat lots of fruits and vegetables, nuts and seeds to help with oxidative stress. He should be having around 2000 calories a day to promote further weight loss and around 100g of protein. His carbohydrates should be unrefined and in the form of sweet potatoes and fruit. We would like to keep his triglyceride levels low. I would recommend him going on an ultra low fat diet to possibly reverse some of the damage done to his heart.

9. Complete the Swedish Medical Center Nutrition Assessment form including nutrition diagnosis (PES) and specific and measurable goals (8 pts).

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