Question

Case Study

Felicia Jones is a 25-year-old pregnant woman. She is married to Barry, a salesman at a new car dealership. This is her third pregnancy. Her first two pregnancies were uncomplicated, resulting in normal spontaneous vaginal deliveries at 39 and 40 weeks’ gestation. She recuperated well from her first two deliveries, and both mother and baby were discharged home in the usual 3 days. Mrs. Jones has not been employed outside the home since her first pregnancy. She devotes her life to her children and is active in her church. Her mother, a widow, lives nearby and often finds occasion to visit and enjoy her grandchildren. Mrs. Jones has two siblings, both living out of town. Having had two pregnancies in rapid succession, Mrs. Jones failed to lose the pregnancy weight gain between the first pregnancy and the second. She avoids alcohol and does not smoke but finds it difficult to exercise. She weighs 220 pounds, is 65 inches tall, and has a BMI of 36.6.

Mrs. Jones’s third pregnancy is very different from the others. During the 26th week of pregnancy, she develops influenza and has to spend several days in bed. Even after she recuperates, she feels as though she never quite regains the stamina and energy level she had earlier in her pregnancy. She finds that she is dyspneic on exertion while caring for her two daughters, ages 3 and 2. Carrying laundry up the stairs is nearly impossible. She is constantly fatigued, and she begins to lose weight despite being in advanced stages of pregnancy. She finds herself enlisting the help of her mother more and more often for what she considers routine tasks that she should be fully capable of doing. This depresses her, but she explains it away, thinking that she is older and three pregnancies have taken a toll on her.

Mrs. Jones begin to develop lower extremity edema. Her obstetrician performs testing for pre-eclampsia. Her nonstress test is negative, and she does not have protein in her urine. Her blood pressure is normal, and her obstetrician is fairly certain that Mrs. Jones does not have pre-eclampsia. She is told to rest, keep her legs elevated, and reduce the salt in her diet. Several weeks pass. Mrs. Jones’s weight is now increasing, but her lower extremity edema is getting worse. Her energy level is poor, and she is tired all the time. When she develops acute shortness of breath, she goes to the emergency department.

A chest x-ray demonstrates a large cardiac shadow and pulmonary edema. A stat echocardiogram is ordered. Her left ventricular EF is severely decreased to 20%. IV diuretics are initiated, and Mrs. Jones is admitted to the coronary care unit. She is at 38 weeks’ gestation. Special precautions are taken because of her state of advanced pregnancy. Exposure to radiation is kept to a minimum. Her cardiologists and obstetricians develop a plan for monitoring and delivery. Because of the stress of delivery and the fluid shifts that are anticipated, a cesarean birth is proposed, which Mrs. Jones refuses. The experts reconvene and decide to optimize Mrs. Jones’s fluid status with diuretics, begin afterload reduction with hydralazine, a vasodilator, and to keep Mrs. Jones in the intensive care unit until delivery. At the first sign of labor, a pulmonary artery catheter will be placed, and Mrs. Jones agrees that in the event of acute decompensation, a cesarean delivery will be done.

At 40 weeks’ gestation, Mrs. Jones goes into labor 3 days before her due date. The PAC is placed as directed, and she is carefully monitored. After 8 hours of labor, a healthy 7 pound, 3 ounce baby boy is born, and Mrs. and Mr. Jones name him Jamie.She agrees to start medical therapy for HF immediately after delivery, even though it means that she cannot breastfeed because the medications would have damaging effects on her baby. She is started on metoprolol, a beta blocker; lisinopril; spironolactone; and furosemide, a loop diuretic. She is followed closely by her cardiologists, and her symptoms stabilize. She is advised to avoid further pregnancies.

Mrs. Jones remains on medical therapy for several months, and her EF eventually improves to normal. Her beta blockers are decreased and finally terminated, but she remains on lisinopril. She feels normal and is able to fully participate in caring for her children. She returns to choir singing and even starts taking classes at the local community college.

During the following year, Mr. Jones loses his job at the car dealership. He is able to find another job as a security guard, but the pay is lower. To help make ends meet, Mrs. Jones takes a job at a school cafeteria, as her two older daughters are now in school all day. Her mother watches Jamie while Mr. and Mrs. Jones are at work. After 6 months, Mr. Jones is able to find another job with a pay increase large enough that Mrs. Jones can quit her job. She is happy to stay home once again, and her HF symptoms remain stable. She continues on her ACE inhibitor and visits her cardiologist regularly. Then, to her cardiologist’s dismay, Mrs. Jones becomes pregnant again. Mrs. Jones is advised to terminate the pregnancy, but she refuses. Her ACE inhibitor is discontinued, and hydralazine is started. Her spironolactone is also discontinued, and she ultimately requires potassium supplementation. With careful monitoring and sodium management, her condition remains stable, but her EF deteriorates, at first to 30%, then to 20%. She delivers a healthy baby boy and has her fallopian tubes ligated.

Mrs. Jones is placed back on standard HF medical therapy, but her EF does not improve. She develops mitral regurgitation and pulmonary hypertension. She soon begins to notice increasing lower extremity edema and decreasing appetite. She feels full after eating a small amount of food and is unable to eat an entire meal. Her medications are continually adjusted, and her diuretic regimen requires increasing doses. With her low EF, the cardiologist decides to implant an implantable cardioverter-defibrillator. Mrs. Jones’s QRS complex is wide so a biventricular implantable cardioverter-defibrillator/pacemaker is placed.

After placement of the biventricular implantable cardioverter-defibrillator/pacemaker, Mrs. Jones feels better almost instantly. Her physical endurance improves, and her lower extremity edema decreases. She is maintained on evidence-based medical therapy and remains stable, NYHA class I. She exercises regularly and follows a low-sodium diet. Her BMI is 25. She avoids alcohol. She sees her doctor every 6 months. She weighs herself every morning, notifying her doctor if she notices a weight gain over       2 pounds. She monitors her blood pressure and heart rate. Her husband remains an important source of support. Although he works full-time to support his family financially, he is attentive to Mrs. Jones and perceptive about her condition. He encourages her to maintain her active lifestyle and to continue her self-care activities. Mr. Jones is able to adjust his work schedule so that he can accompany his wife to her doctor visits.

Answer the following questions in 2-3 sentences.

1. What could cause Mrs. Jones to have heart failure?

2. What is one activity that Mrs. Jones could start doing to help with congestive heart failure?

3. What early signs and symptoms of systolic HF does Mrs. Jones experience?

4. What late signs and symptoms of systolic HF does Mrs. Jones experience?

5. What medication therapy was Mrs. Jones put on after delivery of Jamie to manage her HF?

6. What surgical intervention was needed for Mrs. Jones in light of her decline in EF?

7. What are some of the self-care activities that Mrs. Jones is doing to decrease HF exacerbations?

8. What does Mr. Jones do to provide support to Mrs. Jones?

Answer 1

1.The probable cause of to have heart failure can be because of influenza .This infection can affect the heart .The other cause is her overweight which could have contributed to have heart failure over a period of time.

2.One of the best activity which Mrs. Jones can could start doing to help with congestive heart failure is walking. This is the best activity which can improve the cardiovascular function .

3.The early signs and symptoms of systolic heart failure in the patient are

• Shortness of breath
• Edema or swelling observed in the leg
• Tiredness

4.The late signs and symptoms of systolic heart failure in the patient are

• Weight gain
• Increased shortness of breath
• Extreme tiredness