Mr. P. presents with cardiomyopathy and congestive heart failure (CHF) with recent frequent hospitalizations. Cardiomyopathy is defined as a disease of the myocardium or heart muscle resulting in dysfunction (Cooper, 2017). Congestive heart failure is the clinical syndrome secondary to cardiac dysfunction (Borlaug, 2019). The treatment of congestive heart failure includes medications and thorough patient education.
My approach to this patient’s care would be a combination of patient education as well as close follow-ups. Given his recent hospitalizations and evidence of recurrent fluid overload, he would benefit from a care manager. He has evidence of fluid overload as well as labored breathing so he should be re-hospitalized for diuresis. During hospitalization, I would order a dietary consultation to discuss diet changes needed - perhaps recommending the DASH diet. I would consult the hospitalist to see if any of his medications can be discontinued to decrease polypharmacy. I would also consult social worker to see if Mr. P. would qualify for a home care nurse to come in 1-2 times weekly to set up his medications as both Mr. P. and his wife seem overwhelmed with his medication management and polypharmacy. I would also plan for close follow-up within 1-2 days after discharge to have Mr. P. and his wife bring in all of his medication pill bottles and medication list so they can be verified.
Given Mr. P.’s evidence of fluid overload on examination, the first part of management would be diuresis with IV furosemide in a hospital setting given his labored breathing and difficulty managing things at home. With IV furosemide, he will need strict input and output monitoring and thus should have a Foley catheter placed to decrease fall risk secondary to urinary frequency. Blood pressures will need to be closely monitored to ensure he does not become hypotensive with diuresis. He will also need close monitoring of renal function and electrolytes with regular labs. He will need to adhere to fluid restriction (less than 8 cups or 64 ounces daily) as well as sodium restriction (less than 2,000 mg daily). Once he has diuresed and breathing has improved, he will transition to oral diuretics for at least 24 hours prior to discharge and then should have close follow-up with a primary cardiologist and primary care provider.
To provide Mr. P. and his wife with patient education, I would use a multidisciplinary approach. I would have dietary see Mr. P. and his wife to discuss low sodium options. I would provide handouts with educational material in a simplified table format showing foods with higher sodium content as well as foods with lower sodium content. This would show both Mr. P. and his wife better food choices to try to avoid future CHF exacerbations and hospitalizations. I would also provide Mr. P. and his wife with a weight log and recommend checking and recording weights daily. I would provide parameters for Mr. P. and his wife to contact the clinic with a weight gain of 2 pounds in one day or 5 pounds in one week. By close adherence to daily weights and low sodium diet as well as better medication management through a homecare nurse, Mr. P.’s CHF will be easier to manage and hospitalizations should decrease.
My approach to Mr. P.’s patient education would be as follows:
• You have cardiomyopathy which means your heart muscle is not functioning normally. This causes congestive heart failure and difficulty controlling your fluid. When you retain more fluid, your breathing worsens and your legs swell.
• To avoid further hospitalizations or a case of deep vein thrombosis, we need to monitor your fluid more closely at home. This is best done with daily weights first thing in the morning after going to the bathroom. You should keep a log of your weights and bring this along to further appointments. If your weight increases 2 pounds in one day or 5 pounds in one week, you should call us. The sooner we know about your weight gain, the faster we can get the fluid under control and keep you out of the hospital.
• It is very important that you restrict your salt to less than 2,000 mg daily. Eating more salt can cause you to retain more fluid.
• It is very important to restrict your fluids to less than 8 cups daily. Drinking more fluid, makes you retain more fluid causing more shortness of breath.
• It is very important to take your medications daily to try to control your CHF. You should buy a pillbox and have medications set up weekly.
Borlaug, B. A. (2019). Clinical manifestations and diagnosis of heart failure with preserved ejection fraction. Up to Date. Retrieved from https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-heart-failure-with-preserved-ejection-fraction
Cooper, L. T. (2017). Definition and classification of the cardiomyopathies. Up to Date. Retrieved from https://www.uptodate.com/contents/definition-and-classification-of-the-cardiomyopathies