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Organization of ideas and information On successful completion of this unit, you should be able to:

1. Apply clinical decision-making skills to identify and prioritise health problems for individuals experiencing acute medical health alterations

2. Explain the impact of acute medical health alterations for the individual and their family/carers

3. Minimise the psychosocial effects of acute alterations in health for individuals and their families/carers

4. Identify the links between the pathophysiology and manifestations of acute medical health alterations (GA 4)

5. Plan evidence-based, holistic, person-centred care for individuals experiencing acute medical health alterations, including education and discharge planning (GA 5)

6. Determine appropriate nursing therapies and describe medical and allied health interventions for selected acute medical health alterations

7. Evaluate the effectiveness of nursing therapies and interventions

8. Apply evidence, standards and guidelines to analyse selected acute critical incidents and their management

9. Debate legal, ethical and risk issues specific to caring for an individual experiencing an acute medical health alteration
 

Risk factors associated with CHF

1. Congestive heart failure (CHF) is a diseased status in which heart loses its ability to pump the necessary amount of blood. Insufficient quantity of blood pumping by heart mainly occurs due to cardiovascular conditions like high blood pressure and constricted arteries (Povsic, 2018).   CHF is associated with risk factors like demographic factor like age, social factor like smoking and inadequate physical activity and biological factors like high blood pressure, obesity, diabetes and raised levels of cholesterol (Dhingra et al., 2014). In case of Mckenzie (77 years), age is one of the risk factors for the occurrence of CHF. Probability of CHF increases with increase in the age of the person. 2 and 5 % individuals upto age 60 and 70 years respectively are at risk of CHF. Moreover, Mckenzie is associated with hypertension. Hence, it also can contribute to the occurrence of CHF in her. Females with hypertension are four times at more risk with CHF relative to the normal female. Male and female are 40 and 60 % respectively at risk of CHF (Maahmood and Wang, 2013). High and low levels of low-density lipoproteins and high-density lipoproteins respectively are responsible for the occurrence of CHF. More saturated fat intake and β-type natriuretic peptides are also risk factors of CHF (Díaz-Toro,Verdejo, and Castro, 2015). Obesity (36 %) and smoking (20 %), also are risk factor for CHF (Australian Institute of Health and Welfare (2014).

Individuals with cardiovascular abnormalities and dysfunctioning like cardiomyopathy, coronary artery disease (CAD), myocarditis, arrhythmias, defective heart valves and myocardial infraction (MI) are at higher risk of CHF. Since, Mckenzie is associated with MI; she is at higher risk of CHF. Medication consumption like antidiabetic drugs, nonsteroidal anti-inflammatory drugs (NSAIDs), anaesthetic and anticancer might lead to development of CHF (Chow and Senderovich, 2018). Individuals with CHF might survive maximum upto five years after its diagnosis and these individuals are with 10 % higher death rate relative to the normal individuals (Australian Institute of Health and Welfare, 2014).

Mckenzie might not be able complete routine activities due to cardio-pulmonary diseased condition. Hence, family members need to extend support to her to carry out these activities; and observe and monitor her activities. It would be helpful in extending psychological and emotional support to her. Diseased condition of Mckenzie might impart psychological stress and economical load on family members. Both family and staff members need to regulate her medicines, diet and risk factors to achieve her speedy recovery. Positive communication of family and staff members with Mckenzie would be helpful in achieving her speedy recovery (Cooper, DeVore, and Michael Felker, 2015).

Symptoms of CHF

Q2.:

Symptom

Pathophysiology

Dyspnoea

Dyspnoea is a condition in which individual experience breathlessness. Patients with CHF are usually associated with dyspnoea due to decreased cardiac output. Reduced cardiac output lead to lessened blood supply to skeletal muscles which results in the skeletal muscle dysfunction. Skeletal muscle dysfunction results in the rise in the left ventricular pressure which is helpful in increasing cardiac output. It leads to cascade of events like pulmonary diffusion followed by interstitial oedema and finally breathlessness. Raised ventricular pressure require more amount of energy due to extra expenditure of energy. It results in the development of myocardial ischemia and raised requirement of oxygen. (Güde, Brenner, Störk, Hoes, and Rutten, 2014). As a result, there is development of dyspnoea in Mckenzie due augmented oxygen requirement.

Swollen ankle

Swollen ankle is condition in which there is swelling in the ankle. Fluid build-up is the prominent factor for swelling. Reduced ventricular filling and raised levels of natriuretic peptide and β-type natriuretic peptide are accountable for vasodilation. Reduced cardiac preload and afterload mainly occur due to vasodilation and reduced ventricular pressure. Subsequently, it produces diminished blood back flow to the heart through the veins. Diminished blood back flow mainly occurs due to constriction of the valve. It led to the insufficient blood pumping by the heart (Eisen, 2014). In McKenzie, swollen ankle mainly occurs due to cardiovascular abnormality like diminished cardiac output.   

Dizziness

CHF characterised by the diminished supply of blood to organs comprising of brain. Individuals with diminished supply of blood to brain tend to develop dizziness due to inadequate supply of oxygen. Irregularity in the cardiovascular parameters like heart rate and rhythm are the prominent factors responsible for the development of dizziness in the CHF patients.

Six primary neurotransmitters of three-neuron arc regulate functions of vestibulo-ocular reflex (VOR). Acetylcholine acts as an excitatory neurotransmitter and regulate functioning of both peripheral and central synapses. GABA is an inhibitory neurotransmitter and exhibits its action in VOR and lateral and medical vestibular nucleus. Dopamine and norepinephrine acts as accelerator and controller for vestibular compensation respectively. Histamine role in the dizziness need to be fully explored (Fife, 2017). Hence, McKenzie experiences dizziness due to diminished cardiac output.  

3. Cardiovascular patients like McKenzie need to be treated with Angiotensin-converting-enzyme inhibitor (ACE inhibitor).

Mechanism of action of ACE inhibitors is inhibition of angiotensin-converting enzyme. Angiotensin-converting enzyme in an essential component of renin–angiotensin- aldosterone (RAAS) system. Disturbance in the physiological functioning of the RAAS results in the development of hypertension. It is essential for ACE inhibitors to inhibit Angiotensin I (ATI) conversion to Angiotensin II (ATII) to reduce hypertension. Consequently, ACE inhibitors exhibit varied actions such as diminished cardiac output diminished arteriolar resistance, diminished resistance in blood vessels and augmented sodium excretion in the urine (Scott and Winters, 2015). Different effects of ACE inhibitors like blood vessel relaxation and diminished blood volume are also responsible for its antihypertensive effects. Consequently, it results in lessened both oxygen requirement and consumption by the cardiovascular system (Dinicolantonio, Lavie, and O'Keefe, 2013). Henceforth, ACE inhibitors like enalapril is the first choice of drug for the treatment of patients like Mckenzie. Enalapril exhibited its effect in different cardiovascular conditions like hypertension, asymptomatic left ventricular dysfunction and symptomatic heart failure which are related to CHF.

Enalapril also exhibited its effect in chronic kidney failure and psychogenic polydipsia. It is necessary to treat all these conditions in Mckenzie; since, these are the predisposing factors for CHF (Sayer and Bhat, 2014).

Enalapril exhibit pharmacokinetic factors which are suitable for cardiovascular patients because in cardiovascular patients’ drugs ADME properties alters due to alteration in the blood flow and alteration in the kidney functions. Pharmacokinetic properties of enalapril are as follows: onset of drug action is - 1-hour, it exhibits peak action between 4 – 6 hours, oral bioavailability 60 % and total duration of action 12 – 24 hours. Enalapril is a prodrug. Enalapril produce its effect through metabolite Enalaprilat (Opie and Gersh, 2011).

Q.4. Nursing Intervention for Mckenzie within first 8 hours of her admission.

Goals

Intervention

Rationale

To sustain normal cardiovascular system function.

Observe and record cardiovascular signs such as  heart rate and heart beat rhythm.

Auscultate apical pulse.

Monitor and interpret heart sound.

Observe, record and interpret peripheral pulses.

Record and interpret blood pressure.

Estimate quantity of urine output and monitor urine concentration.  

Regulate medication adherence in McKenzie and confirm furosemide and enalapril consumption on regular basis.   

McKenzie is experiencing bradycardia. CHF in her lead to other cardiovascular disfunction like dysrhythmias. Dysrhythmias can be of different types like premature atrial and ventricular contractions, multifocal atrial tachycardia, atrial fibrillation and paroxysmal atrial tachycardia (Habal, and Garan, 2017).

CHF in McKenzie might lead to diminished heart pumping action which results in the weak S1 and S2 sounds.  Valvular insufficiency occurs due to incomplete closing of the leaflets which produces murmurs in the heart sound (Habal, and Garan, 2017).

CHF patients might produce peripheral pulses such as radial and dorsalis pedis, popliteal and post tibial pulse (Habal, and Garan, 2017).

CHF produces systemic vascular resistance which results in the high blood pressure (Habal, and Garan, 2017).

Patients associated with cardiovascular conditions like CHF would have diminished cardiac output which results in the lessened urine output.

CHF patients are usually associated with lessened cardiac output which is mainly responsible for reduced urine output. Sodium and water retention are mainly responsible for the alteration in the urine concentration (Habal, and Garan, 2017).

Furosemide belongs to class of loop diuretic. Loop diuretics exhibits actions like maintenance of normal cardiac output and diminished preload (Paul and Hice, 2014)

Mechanism of action of enalapril is ACE inhibition. ACE inhibitors produces its action by raising ventricular filling pressure and cardiac output (Paul and Hice, 2014).

To sustain normal respiratory system function.

Estimate, record and interpret respiratory rate on regular basis.

Estimate, record, and interpret ABG levels.  

Monitor and interpret breathing pattern.

Ensure McKenzie is aware of the deep breathing technique and practicing it regularly. End respiration hold, passive exhalation and slow inhalation are the different deep breathing techniques.  

Demonstrate diaphragmatic breathing to McKenzie and ensure she is performing it on regular basis.

Confirm McKenzie is following other breathing techniques like abdominal breathing and lip breathing.

Monitor bronchodilator medication consumption by McKenzie. Supplemental oxygen needs to be administered to her upon consultation with doctor.  

Ensure healthcare staff accompanying her during respiratory distress episodes.

Ensure McKenzie is consuming small quantities of meals in recurrent intervals.

Assess nutritional status of McKenzie through measurement of body weight, haemoglobin level and electrolyte balance.  

Respiratory rate in normal adults is 10 – 20 bpm. Respiratory system is considered as diseased when respiratory rate deviate from this normal range which results in the uneven breathing pattern (Suter, Gorski, Hennessey, and Suter, 2012).  

ABG estimation comprises of parameters such as HCO3, pH, PaCO2 and PaO2. Acidosis and hypoxia condition of the patient can be effectively determining through ABG estimation. ABG estimation is useful in the assessment of oxygen saturation level and ventilation pattern. Breathlessness is mainly responsible for the altered ventilation pattern (Suter, Gorski, Hennessey, and Suter, 2012).    

Abnormal breathing pattern is the indication of the diseased respiratory system (Paul and Hice, 2014).  

Deep breathing is helpful in improving oxygen saturation level. Moreover, long duration expiration is helpful to prevent air trap (Suter, Gorski, Hennessey, and Suter, 2012).    

Diaphragmatic breathing is helpful in muscles relaxation and subsequently oxygen saturation (Suter, Gorski, Hennessey, and Suter, 2012).   

It is helpful in improving ventilation (Paul and Hice, 2014).

Bronchodilator medicines exhibit its effect through  bronchodilation and opening of airway passage (Paul and Hice, 2014).

It is helpful in reducing anxiety and oxygen demand. Stressful condition in an individual lad to disturbance in breathing.  

It is helpful in reducing burden on the diaphragm.

Respiratory failure can occur due to effect on respiratory mass and strength (Suter, Gorski, Hennessey, and Suter, 2012).

References:

Dhingra, A., Garg, A., Kaur, S., Chopra, S., Batra, J.S., Pandey, A., Chaanine, A.H., and  Agarwal SK. (2014).  Epidemiology of heart failure with preserved ejection fraction. Current Heart Failure Reports, 11(4), 354-65.

Chow, J., and Senderovich, H. (2018).  It's Time to Talk: Challenges in Providing Integrated Palliative Care in Advanced Congestive Heart Failure. A Narrative Review. Current Cardiology Reviews, 14(2), 128-137.

Cooper, L.B., DeVore, A.D., and Michael Felker, G. (2015). The Impact of Worsening Heart

Failure in the United States. Heart Failure Clinics, 11(4), 603-14.

Díaz-Toro, F., Verdejo, H.E., and Castro, P.F. (2015). Socioeconomic Inequalities in Heart

Failure. Heart Failure Clinics, 11(4), 507-13.

Dinicolantonio, J.J., Lavie, C.J., and O'Keefe, J.H. (2013). Not all angiotensin-converting enzyme inhibitors are equal: focus on ramipril and perindopril. Postgraduate Medicine, 125(4), 154-68.

Eisen, H. J. (2014). Heart Failure, An Issue of Cardiology Clinics, E-Book. Elsevier Health Sciences. New York. United States.

Fife, T.D. (2017). Dizziness in the Outpatient Care Setting. Continuum, 23(2), 359-395.

Güde, G., Brenner, S., Störk, S., Hoes, A., and Rutten, H. Chronic obstructive pulmonary disease in heart failure: accurate diagnosis and treatment. European Journal of Heart Failure, 16(12), 1273-82.

Habal, M.V., and Garan, A.R. (2017). Long-term management of end-stage heart failure. Best Practice & Research: Clinical Anaesthesiology, 31(2), 153-166.

Mahmood, S. S., and Wang, T. J. (2013). The epidemiology of congestive heart failure: the Framingham Heart Study perspective. Global Heart, 8(1), 77–82. 

Opie, L. H., and Gersh, B. J. (2011). Drugs for the Heart E-Book. Elsevier Health Sciences. New York. United States.

Paul, S., and Hice, A. (2014). Role of the acute care nurse in managing patients with heart

failure using evidence-based care. Critical Care Nursing Q, 37(4), 357-76.

Povsic, T.J. (2018). Emerging Therapies for Congestive Heart Failure. Clinical Pharmacology & Therapeutics, 103(1), 77-87.

Sayer, G., and Bhat, G. (2014). The renin-angiotensin-aldosterone system and heart failure.

Cardiology Clinics, 32(1), 21-32.

Scott, M.C., and Winters, M.E. (2015). Congestive Heart Failure. Emergency Medicine

Clinics of North America, 33(3), 553-62.

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