Physiology of a patient with medical history of Congestive Cardiac Failure

Scenario:

Mr Clive Jenkins

Consider the Patient Situation

Mr Clive Jenkins is a 78 year old retired navy engineer. He has a past medical history of Congestive Cardiac Failure (CCF). This developed after he experienced a severe myocardial infarction 2 years ago. Both ventricles were affected.

The recent death of several close friends have made it difficult for Clive to be concordant with his CCF management and sustain the necessary life-style adjustments required to prevent exacerbations. This has resulted in several admissions to hospital for management and review of his CCF.

For this current admission, Mr Jenkins was referred to hospital by his GP after recently rapidly gaining weight (currently 95kg), since his last visit the previous week.

The time now is 0800 and you have just come on for your morning shift. Mr Jenkins has been on the ward for only two hours after spending approximately 12 hours in emergency waiting for a bed to become available.

Mr Jenkins appears slightly disoriented. When repositioning himself in bed you observe that he becomes short of breath. You ask him if he will get out of bed for breakfast but he is reluctant to mobilise as he feels so tired. You also note that his water jug is empty.

Upon undertaking a further assessment of Mr Jenkins you obtain the following new information:

Vital Signs
RR: 24
Sp02: 94% on 2lt via nasal prongs
BP: 150/90
HR: 112bpm
Temp: 36.5oC

Other information
BGL within normal range
GCS 14 – Eye opening – 4; Verbal response – 4; Best motor response – 6

Hydration status assessment
Peripheral pulses difficult to palpate
Presence of pitting oedema bilaterally
Capillary refill – 5 seconds
Current weight 97kg.
Raised JVP
Output since midnight: 200ml; Input since midnight: approx 1672 mL (oral and IV)

Abdominal assessment
Abdomen soft and non-tender.
Bowel sounds present.

Respiratory assessment
Bibasilar posterior crackles
Increased work of breathing
Patient producing pink-tinged frothy sputum

 

10 Multi and Multiple Choice questions and 2 written answer questions

  1. Clive’s myocardial infarction caused the death of areas of his cardiac tissue. Which of the following is the mechanism of cell injury?
  2. a) Injury from biological agents
  3. b) Ischaemia
  4. c) Hypoxia
  5. d) Necrosis

 

  1. Clive’s myocardial infarction caused the death of areas of his cardiac tissue. Which of the following is the mechanism of cell death?
  2. a) Apoptosis
  3. b) Hypoxia
  4. c) Necrosis
  5. d) Ischaemia

 

 

  1. Clive suffered an acute myocardial infarction two years ago. Which of the following can be a consequence of this?
  2. a) Cardiogenic shock
  3. b) Stable angina
  4. c) Hypertension
  5. d) Paraesthesia

 

 

 

  1. Which of the following are possible manifestations (signs or symptoms) of an acute myocardial infarction?

Select all that apply, leave blank those that do not apply. Marks lost by incorrect choices (right minus wrong)

Sudden dizziness

Sudden elevation in blood pressure

Bradycardia

Fatigue

Sudden leg weakness

Cold and pale skin

Paraesthesia in arms or legs

Tachypnoea

Diaphoresis

Dyspnoea

Crushing chest pain relieved at rest

Sudden drop in blood pressure

Chest pain that is not relieved by glyceryl trinitrate

Hot, flushed skin.

 

 

 

 

 

 

 

 

 

  1. Clive has congestive heart failure. Which of the following are manifestations of this cardiac condition?

Select all that apply. Marks lost for incorrect answers (right minus wrong).

Pulmonary oedema

Peripheral oedema

Nocturia

Orthopnoea

Chest pain on exertion

Weight loss

Fatigue

Oliguria

Dyspnoea

Elevated JVP

Difficulty concentrating

Tachycardia

Bradycardia

Dry cough

 

 

 

 

 

 

 

 

 

 

  1. According to the “HFrEF Management algorithm” by The National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand (CSANZ) guidelines for heart failure, in which order should the therapeutic approaches to Congestive Heart Failure be introduced?

Ace inhibitors or arbs

Lifestyle modifications: exercise and reduction of salt intake

Mineralocorticoid receptor antagonist

Beta-blocker

Diuretics

 

  1. Clive’s peripheral oxygen saturation is 94% with oxygen supplementation. Which of the following is altering his oxygen homeostasis so that he needs the oxygen therapy?
  2. a) Excessive ventilation of the alveoli due to tachypnoea
  3. b) Oedema is interfering with the gas exchange
  4. c) Pulmonary blood circulation is too fast due to tachycardia
  5. d) Increased work of breathing causes ineffective alveolar ventilation

 

  1. Clive’s RR increased from 15-19 at 0600 to 24 breaths per minute in your last observation, but his oxygen saturation remained constant. What could be the reason for this?

Select all possible answers, leave the incorrect answers unselected. Marks lost for incorrect answers. (Right minus wrong).

His pulmonary circulation is less effective, causing the increase in RR.

The respiratory centres activate the sympathetic nervous system, increasing the RR.

His pulmonary oedema has worsened.

His brain is receiving less oxygenated blood and is compensating by increasing RR.

His SpO2 levels have dropped, not reflected in the oxygen saturation.

He is hypercapnic or becoming hypercapnic, which stimulates the increase in RR.

The gas exchange is less efficient and the increase in blood CO2.

His anxiety due to disorientation is activating the sympathetic nervous system.

  1. Clive was prescribed with Spironolactone 25mg for the management of his congestive heart failure. Which of the following can be achieved by taking this drug?

Select all that apply, leave blank all that do not apply. Marks lost for incorrect answers. (Right minus wrong).

Reduced blood return to the heart

Increased diuresis

Inhibition of aldosterone action

Peripheral vasodilation

Oliguria

Coronary artery vasodilation

Decreased mean arterial blood pressure

Increased strength of cardiac muscle contraction

Reduced heart rate

Decreased sodium reabsorption in the kidneys

Reduction of sympathetic nervous system activity

Reduced formation of angiotensin II

Decreased cardiac output

 

 

 

 

 

 

 

 

 

 

  1. Clive’s medication was augmented by adding furosemide for the management of this worsening of his congestive heart failure. Which of the following can be achieved by taking this drug?

Select all that apply, leave blank all that do not apply. Marks lost for incorrect answers. (Right minus wrong)

Suppression of aldosterone action

Reduced formation of angiotensin II

Reduced heart rate

Blockage of angiotensin receptors

Reduction of chloride reabsorption in the kidneys

Decreased cardiac output

Reduction of pitting oedema

Increased diuresis

Peripheral vasodilation

Reduction of sympathetic nervous system activity

Coronary artery vasodilation

Decreased sodium reabsorption in the kidneys

Decreases mean arterial blood pressure

Reduction to pulmonary oedema

 

 

 

 

 

 

 

 

 

11.

Explain the pathophysiological mechanisms through which Mr Jenkin’s congestive heart failure is leading to the current symptom of being Short of Breath on exertion.

Word limit: 200 words excluding in-text references. Use the School of Nursing guidelines for UTas Harvard referencing. These can be found in the “Assessment help and resources” section on MyLO

12.

eferring to specific Australian guidelines for the management of heart failure, explain why Clive has been prescribed with Ramipril, Spironolactone and Carvedilol.

Word limit: 200 words excluding in-text references. Use the School of Nursing guidelines for UTas Harvard referencing. These can be found in the “Assessment help and resources” section on MyLO.

 

 

 

 

 

 

 

 

 

 

 

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