Congestive Heart Failure






























General Information


Case no.


6.A Congestive Heart Failure


Authors


Kelly M. Lindenberg, PT, MSPT, PhD, CSCS


Melissa L. Bednarek, PT, DPT, PhD, Board Certified Clinical Specialist in Cardiovascular & Pulmonary Physical Therapy


Kala M. Markel, PT, DPT


Diagnosis


Heart failure with atrial fibrillation


Setting


Emergency Department with transfer to Telemetry Unit


Learner expectations


☑ Initial evaluation


☐ Re-evaluation


☐ Treatment session


Learner objectives




  1. Explain the pathophysiology of the patient’s diagnosis.



  2. Relate the pathophysiology of cardiovascular disorders to the clinical manifestations and activity/participation limitations seen in physical therapy practice.



  3. Select, implement, and interpret physical therapy interventions based on the medical examination findings.



  4. Develop an understanding of medical management and how it influences physical therapy plan of care.
































Medical


Chief complaint


Shortness of breath, fatigue


History of present illness


Patient is a 73-year-old male who presents to the emergency department with increasing severity of shortness of breath over the past 2 days. He reports a decreased tolerance for activity, requiring frequent rest breaks. Patient denies chest pain, nausea, or vomiting. He reports currently having an upper respiratory infection, self-treating with Sudafed. Patient is to be admitted for medical workup and management.


Past medical history


Remote history of ST elevation myocardial infarction (STEMI) with stent placement 5 years ago, atrial fibrillation, hypertension, hyperlipidemia, osteoarthritis, cholecystectomy, anxiety/depression.


Past surgical history


Right total knee arthroplasty


Allergies


Penicillin


Medications


Coumadin, Prinivil, Lopressor, Lipitor, Tylenol


Precautions/Orders


Bed rest























Social history


Home setup




  • Lives in a two-story home with wife.



  • Flight of steps with unilateral rail to enter home.



  • Flight of steps with bilateral rails to the second floor.



  • Has two adult children, one lives nearby; has two grandchildren.


Occupation




  • Retired computer analyst.


Prior level of function




  • Independent with functional mobility and activities of daily living.



  • Independent for stairs; however, required increased time.



  • Spouse manages cooking/cleaning.



  • Poor tolerance for yard maintenance, hired help.



  • (+) Driver


Recreational activities




  • Vacation planned over summer to celebrate 50th wedding anniversary.



  • Enjoys reading, watching travel television shows, and fishing.






































Vital signs


Hospital day 0: emergency department


Hospital day 1: telemetry unit


Blood pressure (mmHg)


108/58, MAP = 75


134/78, MAP = 97


Heart rate (beat/min)


153, irregular rhythm


102, irregular rhythm


Respiratory rate (breath/min)


26


18


Pulse oximetry (SpO2)


91% on room air


96% on 2 L O2 via nasal cannula


Temperature (°F)


99.1


99.2


Body mass index


31.5


—————————————


























Imaging/Diagnostic test


Hospital day 0: emergency department


Hospital day 1: telemetry unit


EKG


1. Atrial fibrillation with rapid ventricular rate


1. Atrial fibrillation with rapid ventricular rate


Chest X-ray


1. Cardiomegaly, bilateral interstitial and alveolar infiltrates involving predominantly the mid- and lower lung fields


Fig. 6.1


—————————————


Transesophageal echocardiogram (TEE)


1. Ejection fraction, 40%; no signs of thrombus


1. Ejection fraction, 45%; no signs of thrombus



No Image Available!




Fig. 6.1 Cardiogenic pulmonary edema. Cardiomegaly, bilateral interstitial, and alveolar infiltrates involving predominantly the mid- and lower lung fields. (Source: Burgener F. Disease. In: Burgener F, Kormano M, Pudas T, ed. Differential Diagnosis in Conventional Radiology. 3rd ed. Stuttgart: Thieme; 2007.)






























Medical management


Hospital day 0: emergency department


Hospital day 1: telemetry unit


Medications


1. IV Cardizem


2. Coumadin


3. Prinivil


4. Lopressor


5. Lipitor


1. PO Cardizem


2. Coumadin


3. Prinivil


4. Lopressor


5. Lipitor


6. Lasix


Respiratory


1. Supplemental oxygen: 2 L via nasal cannula


1. Supplemental oxygen: 2 L via nasal cannula


2. Incentive spirometer, 10 times/hour


Consults


1. Cardiology


1. Physical therapy


2. Occupational therapy


Precautions


1. Telemetry


2. Fall risk


3. Bed rest


1. Telemetry


2. Fall risk


3. Activity as tolerated










































































































































Lab


Reference range


Hospital day 0: emergency department


Hospital day 1: telemetry unit


Complete blood count


WBC


5.0–10.0 × 109/L


11.5


11.7


RBC


4.5–5.5


4.5


4.3


Hemoglobin


14.0–17.4 d/dL


17


15


Hematocrit


42–52%


40


39


Platelet


150–400 k/μL


240


230


Electrolyte panel


Na


134–142 mEq/L


133


130


K


3.7–5.1 mEq/L


3.7


3.8


Ca


8.6–10.3 mg/dL


9.0


8.6


Cl


98–108 mEq/L


107


108


PO4


2.3–4.1 mg/dL


2.9


3.2


Mg


1.2–1.9 mEq/L


1.3


1.5


Lipid panel


HDL


> 40 mg/dL


38


——————


LDL


< 100 mg/dL


110


——————


Triglyceride


< 150 mg/dL


155


——————


Cholesterol


< 200 mg/dL


180


——————


Bleeding ratio/viscosity


INR


0.8–1.2


2.5


2.3


Physical therapy


11–13 seconds


11


12


Cardiovascular-specific labs


Troponin—1


< 0.03 ng/mL


0.02


——————


BNP


< 100 pg/mL


280


650


CK


30–170 U/L


80


——————


Other


Glucose


70–100 mg/dL


120


118


BUN


6–25 mg/dL


22


26


Creatinine


0.7–1.3 mg/dL


1.6


1.9












Pause points


Based on the above information, what are the priority




  • Examination tests and measures?



  • Outcome measures?



  • Treatment interventions?


































































































































Hospital Day 2, Telemetry Unit: Physical Therapy Examination


Subjective


“I am just so tired and have no energy to get up.”


Objective


Vital signs


Pre-treatment


Post-treatment


Supine


Sitting


Standing


Sitting


Blood pressure (BP; mmHg)


124/78


118/74


128/76


See post-mobility vital signs below


Heart rate (HR; beat/min)


88


96


104


Respiratory rate (RR; breath/min)


18


22


24


Pulse oximetry on 2 L/O2 via nasal cannula (SpO2)


96%


94%


93%


Modified BORG scale—dyspnea


2/10


2/10


3/10


2/10


Pain


0/10


0/10


0/10


0/10


General




  • Patient supine in bed, head of bed elevated at 30 degrees



  • Lines/tubes/drains notable for telemetry, 2 L/O2 via nasal cannula, IV access via left antecubital, urinary catheter


Head, ears, eyes, nose, and throat (HEENT)




  • Unremarkable


Cardiovascular and pulmonary




  • Normal sinus rhythm



  • 2 L/min O2 via nasal cannula



  • Auscultation: mildly diminished breath sounds and fine crackles in bilateral posterior lower lobes, S3 heart sound



  • Pulse: 1 + bilateral dorsalis pedis



  • Edema: 2 + foot to 1 inch above lateral malleolus



  • (+) JVD at 5 cm above sternal angle


Gastrointestinal




  • Reports constipation


Genitourinary




  • Urinary catheter in place



  • Input and Output (I&O) incongruence per EMR (I > O), now stabilizing


Musculoskeletal


Range of motion




  • Bilateral upper extremity (BUE): within functional limit (WFL)



  • Bilateral lower extremity (BLE): WFL with the exception of bilateral knees—right knee flexion at 100 degrees, left knee extension limited at 10 degrees


Strength




  • B shoulder flexion: 4/5



  • B elbow flexion: 5/5



  • B elbow extension: 5/5



  • B wrist extension: 5/5



  • B wrist flexion: 5/5



  • B hip flexion: 4/5



  • B hip abduction: 4/5



  • B knee flexion: 4/5



  • B knee extension: 4/5



  • B ankle dorsiflexion: 5/5



  • B ankle plantarflexion: 5/5


Aerobic




  • Not formally assessed



  • Reported 3/10 on RPE Scale during transfers


Flexibility




  • Not formally assessed



  • On observation, bilateral pectoralis major/minor and bilateral hamstring tightness, rounded shoulder posture.


Posture




  • Sitting: forward head, rounded thoracic spine



  • Standing: forward head, rounded thoracic spine, flattened lumbar spine


Neurological


Balance




  • Static sitting, unsupported: independent



  • Dynamic sitting, unsupported: supervision



  • Static standing, unsupported: close supervision



  • Dynamic standing, unsupported: close supervision


Cognition




  • Alert and oriented x 4


Coordination




  • Finger-to-nose: intact bilaterally



  • Heel-to-shin: intact bilaterally


Cranial nerves




  • II–XII: intact


Reflexes




  • Biceps: 2 + bilaterally



  • Patellar: 2 + bilaterally


Sensation




  • BLE dermatomes: intact to light touch


Tone




  • BUE and BLE: normal throughout


Functional status


Bed mobility




  • Supine to left side lying: supervision with head of bed elevated 30 degrees and use of bedrails



  • Left side lying to sitting: supervision with head of bed elevated 30 degrees and use of bedrails


Transfers




  • Sit to/from stand: supervision


Ambulation




  • Ambulated 75 feet with close supervision and no assistive device



  • Gait deviations notable for decreased cadence, decreased heel strike at initial contact bilaterally, and flexed posture



  • Gait speed: 0.6 m/s


Vital signs post ambulation:




  • BP: 140/78, HR: 116, RR: 28, SpO2: 91% on 2 L NC



  • 1-minute recovery: BP: 142/76, HR: 103, RR: 22, SpO2: 94% on 2 L NC



  • 3-minute recovery: BP: 132/74, HR: 98, RR: 18, SpO2: 95% on 2 L NC


Stairs




  • Ascend/descend four 6-inch steps with bilateral handrails with contact guard assistance


Vital signs post–stair negotiation:




  • BP: 144/76, HR: 124, RR: 30, SpO2: 90% on 2 L NC



  • 1-minute recovery: BP = 130/76, HR: 112, RR: 25, SpO2: 92% on 2 L NC



  • Worsening crackles with lung auscultation, (+) mild accessory muscle breathing

























Assessment


☑ Physical therapist’s


Assessment left blank for learner to develop.


Goals


Patient’s


“I just want to get out of this hospital.”


Short term


1.


Goals left blank for learner to develop.


2.


Long term


1.


Goals left blank for learner to develop.


2.














Plan


☑ Physical therapist’s


Will treat patient once daily, five days per week at bedside for functional mobility and endurance building activities. Treatment may include lower body ergometer; diaphragmatic breathing training; functional mobility training such as transfers, ambulation, and stair training; and patient education on energy conservation and symptom awareness.






























Bloom’s Taxonomy Level


Case 6.A Questions


Create


1. Synthesizing the medical data and physical examination findings, develop an appropriate physical therapy assessment of the patient.


2. Develop two short-term physical therapy goals, including an appropriate timeframe.


3. Develop two long-term physical therapy goals, including an appropriate timeframe.


Evaluate


4. Interpret the patient’s vital sign response to ambulation.


Analyze


5. What does the TEE result on hospital day 0 suggest about the patient’s cardiac function?


6. What does the presence of crackles during auscultation suggest about the patient’s condition?


Apply


7. Design two physical therapy interventions that address the patient’s goals


Understand


8. What does the jugular venous distention test assess for? What do the results indicate?


9. What is the relationship between atrial fibrillation and heart failure?


Remember


10. Why does the patient’s chest X-ray reveal cardiomegaly?


11. How is pitting edema quantified?

Only gold members can continue reading. Log In or Register to continue

Dec 11, 2021 | Posted by in MANUAL THERAPIST | Comments Off on Congestive Heart Failure
Premium Wordpress Themes by UFO Themes