Download Congestive Heart Failure

By: Ellinor Lagerberg
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Gain knowledge about CHF (congestive heart
failure) and its etiology.
To understand how nutrition education is
applied in acute care for patients with CHF.
To learn how comorbidities such as DM
(diabetes) and obesity impacts treatment
options for CHF.
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Heart failure is a chronic progressive disorder
that affects over 5 million people in the
United States and is expected to increase due
to the extended population life expectancy.
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The normal heart is about the size of a fist.
Muscular pump that continuously sends
oxygenated blood throughout the circulatory
system.
The heart contains four
chambers that beat in
a coordinated way
for the heart to function
properly.
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With heart failure this function is diminished
and the heart can no longer keep up with
demands to pump blood to the body.
Heart failure can affect all four chambers but
most often the left ventricular is affected.
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There are two types of heart failure systolic
and diastolic.
In systolic heart failure the ventricles
becomes stretched and dilated and are no
longer able to efficiently pump blood out of
the heart.
In diastolic heart failure the ventricles
become stiff and do not fill up efficiently
with blood in between beats.
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As HF progresses, the heart’s pumping
becomes less efficient causing blood to
collect in other areas of the body.
This may cause fluid to accumulate in the
lungs, liver, gastrointestinal tract and
extremities.
Referred to as congestive heart failure.
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L.M.
60 YOWM
Wt: 148.70 kg (41lb wt gain over past 4
months)
Ht: 200.66 cm
BMI: 36.9
Admitting diagnosis: SOB secondary to
decompensated CHF
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Disability
Military
Lives in SNF
Insured through Medicaid
Married w/o children
No alcohol/tobacco or drug use
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CHF
DM2
Hypothyroidism
GERD
Obstructive sleep apnea
COPD
Syncope
Obesity
Nephrolithiasis
Nonischemic cardiomyopathy
Atrial fibrillation
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Obesity is known to lead to several metabolic
disorders and thyroid dysfunctions that increases
mortality risks in adults.
Diabetes – research shows patients diagnosed
with type 2 DM have a 2 fold for risk for HF
hospitalization. High blood glucose levels can
over time lead to increased deposits of fatty
material on the insides of the blood vessel walls.
These deposits may affect blood flow, increasing
the chance of clogging and hardening of blood
vessels.
Hypothyroidism – reduced T3 hormone affects
the hearts ability to relax its smooth muscle.
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1998 – Left toe amputation, MRSA infection
2005- Endocarditis, MRSA
2008 – Biventricular pacemaker, right foot
transmetatarsal amputation
2010- Left second toe amputation
2012- Corrective amputation surgery
2013- Left hand infection, digit amputation,
UTI, MRSA, E. Coli.
CHF - progressed to stage D class IV
Stage D - Treatment-heart failure requiring specialized intervention.
Class IV - Patients with cardiac disease resulting in an inability to carry on any physical
activity without discomfort. Symptoms of heart failure or chest pain may be
present even at rest. If any physical activity is undertaken, discomfort increases.
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Evaluated by heart transplant team but was
not considered a candidate for any advanced
treatments including heart transplant or
LVAD secondary to multiple comorbidities.
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In stage D patients suffer from structural
heart disease with heart failure symptoms
that require specialized intervention if
suitable as a candidate:
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transplantation
left ventricular assist device (LVAD)
left ventricular surgical remodeling (LVSR)
stem cell therapy in clinical trials
compassionate end-of-life care
As CHF progresses, the ratio of palliative care to lifeprolonging care gradually increases. Eventually, lifeprolonging care is discontinued and a transition to hospice
care is made.
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Palliative care focuses on relieving &
preventing suffering of patients and is now
recommended by the American College of
Cardiology and American Heart Association to
improve outcomes in patients with end stage
CHF.
Their view is that aggressive procedures
performed in the last months of life are not
appropriate since quality of life is reduced.
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Admitted December 10th, 2013 for dyspnea,
fatigue and fluid retention.
At time of admission he was
hemodynamically stable.
L.M. was visited on
4 separate occasions.
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L.M. sleeping at time of visit.
Lab values
Normal Range
First Visit
135-145 mEq
WNL
K
3.5-5 mEq
WNL
Cl
100-106 mEq
93
Co2
23-29 mEq/L
WNL
BUN
7-21 mg/dL
48
Creatinine
0.5-1.4
2.54
Glucose
70-100
170
>60
26
3.0-4.5 mg/dL
WNL
Na
GFR
Phosphorus
Elevated BUNCHF contributes
to poor renal
perfusion
Elevated creatinine –
CHF contributes to
poor blood flow
causing
Diminishing GFRCHF contributes to
reduction in renal
function
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Coumadin/Warfarin and moderate 60-75g
carbohydrate diet providing 1400-1600
calories per day.
Recommendations left for the physician to
change diet to fluid restriction, cardiac and to
liberalize carbohydrate diet to allow for 90105g carbohydrates per meal allowing for
approximately 2200-2600 calories per day.
Reported Height in Cm
200.66 cm
Reported Admit Weight in kg
148.7 kg
IBW
100 kg
% IBW
149%
Adjusted Weight
112.2
BMI
36.9
Estimated Kcal Needed per Day
3370-3930 kcal/day ( 30-35 kcal/kg adj. wt
2’ wounds)
1 ml per kcal or per physician
Estimated Fluid Needed per Day
Estimated Protein Needed per Day
135-168 g/kg ( 1.2-1.5g/kg adj. wt 2’
wounds)
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L.M. awake and alert, but disinterested in
diet education focused on cardiac, lowsodium intake and fluid restrictions. He
kept falling asleep when asked specific food
related questions.
Lab values
Normal Range
Second Visit
135-145 mEq
WNL
K
3.5-5 mEq
WNL
Cl
100-106 mEq
95
Co2
23-29 mEq/L
30
BUN
7-21 mg/dL
51
Creatinine
0.5-1.4
2.59
Glucose
70-100
95
>60
25
3.0-4.5 mg/dL
WNL
Na
GFR
Phosphourus
Elevated
Elevated
Lower
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L.M. reports having struggled with his weight
for his whole life and referred to himself as a
“fat kid.” He also mentioned his mother
always telling him to watch the amount of
cookies he ate.
L.M. admitted that the only time he followed
a specific diet was during his time in the
military and that was because he didn’t have
the options of choosing meals and only ate
what was served.
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On a usual day in the nursing home L.M.
typically eats two individual boxes of fruit
loops along with two cups of low fat milk.
Lunch is usually a turkey sandwich with
potato chips and 12oz can of diet coke. His
snack is typically cookies and for dinner L.M.
orders takeout food. His favorite is Chinese
food.
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L.M. typical diet history. The 24-hour recall
shows his diet being low in fiber, calcium,
iron, Vitamin A and Vitamin C. L.M doesn’t
consume recommended amount of fruits and
vegetables.
Diet is high in fat.
Estimated intake approximately
2000calories/day, 80g total fat, 1700g
sodium.
Servings
Calories
Total fat
Cholesterol
Fiber
Sodium
Calcium
Iron
Vitamin A
Vitamin C
Fruit loops
(27g/serving)
2
200
2g
0g
6g
250mg
0%
20%
8%
20%
Milk 1%
(1 cup/serving)
2
200
6g
20mg
0g
240mg
30%
0%
10%
4%
Potato chips
1
160
10g
0mg
1.4g
170mg
0%
2%
0%
10%
Turkey
sandwich
1
280
8g
50mg
1.3g
990 mg
15%
13%
29%
2%
Mayonnaise
(1pkg)
1
68
7g
4mg
0g
64mg
0%
0%
0%
0%
Diet Coke
1
-
-
-
0g
40mg
0%
0%
0%
0%
Chocolate chip
cookie
1
120
10g
0
119mg
1%
8%
0%
0%
White rice
(1 cup/serving)
1
242
-
-
-
0%
15%
0%
0%
Chinese food
Beef &
broccoli
Total
2
676
36g
160mg
810mg
0%
0%
0%
0%
1946
79g
184mg
1693mg
31%
45%
18%
34%
Breakfast
Lunch
Dinner
8.7g
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L.M.’s nutrition related diagnosis was food
and nutrition knowledge deficit related to
disinterest in learning/applying information,
as evidenced by verbalizing unwillingness and
disinterest in learning information.
Patient would benefit from diet education and
the goal was for him to be able to name 3
concepts of a heart healthy diet.
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L.M. stated he had reviewed the material
since last visit but he still unable to name 3
heart healthy concepts.
Lab values
Normal Range
Third visit
Na
135-145 mEq
WNL
K
3.5-5 mEq
WNL
Cl
100-106 mEq
92
Co2
23-29 mEq/L
WNL
BUN
7-21 mg/dL
67
Creatinine
0.5-1.4
3.38
Glucose
70-100
117
GFR
>60
19
Phosphorus
3.0-4.5 mg/dL
5.6
Elevated
Reduced
Elevated,
indication of
renal failure
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Although current recommendations for
hospitalized patients with end stage heart
failure includes sodium restriction, new
research has emerged implying that sodium
restriction can cause damage through
increased neurohormonal activation and
hypovolemia. Currently, there are insufficient
data to endorse any specific level of sodium
intake with certainty.
At the fourth follow up, L.M.’s condition had
severely worsened. He showed signs of lethargy,
drowsiness and was diagnosed with acute
hypercapnic respiratory insufficiency. Not
appropriate for diet education.
Lab values
Normal Range
Fourth visit
135-145 mEq
WNL
K
3.5-5 mEq
WNL
Cl
100-106 mEq
94
Co2
23-29 mEq/L
WNL
BUN
7-21 mg/dL
91
Creatinine
0.5-1.4
3.75
Glucose
70-100
106
>60
17
3.0-4.5 mg/dL
WNL
Na
GFR
Phosphorus
Elevated
Significantly
lower
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The following day a consult for tube feeding
received.
L.M. was transferred to the ICU where he was
intubated.
Scheduled to receive hemodialysis.
Lab values BUN 91, creatinine 3.75 and GFR
17.
L.M.’s wife was present and per
documentation, she had requested a change
from “do not resuscitate” to “full code.”
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Allopurinol (Zyloprim)
Alprazolam (Xanex)
Belladonna-opium
Bumex (Bumetanide)
Bupropion (Wellbutrin)
Calcium acetate
Docusate
Fenofibrate
Finasteride (Proscar)
Lantus
Humalog
Iron sucrose
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Synthroid
Metoprolol
Aldactone
Coumadin
IV Medication- started
on 12/20
Fentanyl
Versed
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L.M. was recently extubated and his tube
feeding was removed. However, he has not
been cooperating with his diet advancement
and is refusing meals. He is rejecting some of
his essential medications and is not willing to
provide verbal responses.
L.M.’s prognosis is poor due to his
comorbidities and noncompliance to follow
recommended medical and nutritional
treatment.
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Longhi, S., Radettis, G. (2013). Thyroid Function and Obesity. Journal of Clinical
Research in Pediatric Endocrinology 5(Suppl 1), 40–44.
Adler, E., Goldfinger, J., Jill Kalman, K., Park, M., Meier, D. (2009). Contemporary
Reviews in Cardiovascular Medicine: Palliative Care in the Treatment of Advanced
Heart Failure. Circulation, 120, 2597-2606.
Mahan, K. L., Escott-Stump, S., (2008). Medical Nutrition Therapy for Heart Failure.
In Krause's Food and Nutrition therapy. (12th ed., p 888). Canada: Saunders
Elsevier
Gupta., D., Georgiopoulou. V., Kalogeropoulos. A., Dunbar. S., Reilley. C., Sands.
J., Fonarow. G., Jessup. M., Gheorghiade. M., Yancy. C., Butler. J. (2012) Dietary
Sodium Intake in Heart Failure. Circulation, 126, 479-485.
Zouein, F., Zgheib, C., Kenneth W., Liechty, K., Booz, G. (2013). Post-infarct
biomaterials, left ventricular remodeling, and heart failure: Is good good enough?
Congestive Heart Failure 18(5), 284-290.
PubMed Health. (n.d.). Heart Failure Overview. Retrieved December 24, 2013 from
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001211/