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Mrs Sharon McKenzie is a 77 year old female who has presented to the emergency department with increasing shortness of breath, swollen ankles, mild nausea and dizziness. She has a past history of MI at age 65. During your assessment Mrs McKenzie reports the shortness of breath has been ongoing for the last 7 days, and worsens when she does her gardening and goes for a walk with her husband. On examination her blood pressure was 170/110 mmHg, HR 54 bpm, respiratory rate of 30 bpm with inspiratory crackles at both lung bases, and Sp02 at 92% on RA. Her fingers are cool to touch with a capillary refill of 1-2 seconds. Mrs McKenzie states that this is normal and she always has to wear bed socks as Mr McKenzie complains about her cold feet.


Her current medications include: digoxin 250mcg daily, frusemide 40mg BD, enalapril 5mg daily, warfarin 4mg daily but she sometimes forgets to take all of her medications. The following blood tests were ordered: a full blood count (FBC), urea electrolytes and creatinine (UEC), liver function tests (LFT), digoxin test, CK and Troponin. Her potassium level is 2.5mmol/L.

Mrs McKenzie also has an ECG which showed sinus bradycardia, and a chest x-ray showing cardiac enlargement and lower-lobe infiltrates.

1. Outline the disease, causes, incidence and risk factors. Discuss the impact of the selected disease on the patient and their family.

2. Discuss three (3) common signs and symptoms of the selected disease and explain the underlying pathophysiology of each.

a. This can be done in the form of a table – each point needs to be appropriately referenced.

3. Discuss the pharmacodynamics & pharmacokinetics of one (1) common class of drug relevant to the chosen patient.

a. This does not mean specific drugs but rather the class that these drugs belong to.

4. In order of priority, develop a nursing care plan for your chosen patient who has just arrived on the ward from ED. Nursing care plan goals, interventions and rationales must relate to the first 8 hours post ward admission.

a. This can be done in the form of a table – each point needs to be appropriately referenced.
 

What is Congestive Heart Failure?

Congestive heart failure can be described as the chronic condition, which mainly affects the pumping ability of the muscles of the heart. It mainly refers to that of the particular stage in which fluid is seen to build up surrounding the heart and thereby causes the heart to pump in an inefficient manner. This disorder may result from many other health conditions that have the ability to directly affect the cardiovascular systems. The different conditions make the heart weak (Buck et al., 2015). In case of heart failure, the main pumping chambers of the heart which are ventricles become stiff and do not get filled up properly between the beats. It has been also seen that in some cases of congestive heart failure, the heart muscle might become damaged as well as weakened. Even the ventricles are also seen to stretch to the point that the heart cannot pump blood efficiently throughout the body (Riley et al., 2016). Over the time, the heart can no longer keep up with the normal demands placed on it to pump blood to the rest of the body and these results in congestive heart failure. These might have taken place in Sharon and therefore, she might have been affected by CHF.

Different symptoms that are usually noticed at first are fatigue, swelling in the ankles, legs and feet as well as weight gain and increase in the need for urination mainly in the night. Irregular heartbeats, cough developing from the congested lungs, wheezing as well as shortness of breath also show that  pulmonary edema might be present (Vedel et al., 2015). Chest pain that radiates through the upper body as well as  rapid breathing along with skin appearing blue due to lack of oxygen and fainting are other symptoms. Sharon is also seen to suffer from shortness of breath, mild nausea, dizziness and swollen ankles as well and all these show that she suffer from CHF.

One of the risk factors of CHF may be hypertension when the individual has high blood pressure than that of the normal. Hypertension can result from different causes like that of the narrowing of the arteries making it difficult for the blood in flowing through them. It might also occur due to coronary artery disorders where cholesterol and different types of other fatty substances block the coronary arteries. These arteries are actually the small arteries that can supply blood to the heart causing  the arteries in becoming narrow that restrict blood flow leading to the damage of the arteries. Valve conditions can also lead CHF (Mirkin et al., 2017). Valves regulate the flow of blood through the heart by opening and closing the blood in and out of the chambers. Valves that do not open and close correctly might force the ventricles to work harder for pumping the blood causing the disorder. 

Causes of Congestive Heart Failure


Individuals are expiring in the nation due to this disorder where one in every 12 Australians is facing such severe deaths and is affecting around one in six Australians accounting for about 4.2 million people. In the year 2017, about 43477 deaths have been accounted as a result of cardiovascular disorders. Heart failure is found to be the cause of 1 to 2% of the Australian population and is found to be more dominant among 10%of the elderly.

Patients suffering from CHF might also face from many complications over the period of time like kidney failure as failure of the heart might result in reduced blood flow to kidneys resulting in the latter’s failure. Heart rhythm problems and liver damages also result. All these result in huge pain and suffering of the patients affecting the quality of life. Patients and their family members suffer from stress and anxiety because of the suffering of patients (Moore, 2016). Families are seen to suffer from feelings of guilt as well. Patients and caregivers have to go through restricted lives making them feel frustrated. Financial stabilities might be affected due to expenditures on healthcare services and resources. Sharon has developed CHF and her and her family members can develop such issues accordingly.

Three common signs, symptoms, and pathophysiology that underlie the symptoms:

Symptoms

pathophysiology

Sharon had developed swollen ankles in CHF which might be because of the conditions of edema  

When an individual suffer from CHF, one or both of the ventricles of the heart lose their ability to pump blood effectively. As result of these, researchers have found that fluid gets accumulated in feet, legs as well as ankle resulting in the structures to get swollen causing edema (Clark et al., 2016). This can also take place in the abdomen. Therefore, Sharon  is also seen to have swollen ankles

Sharon was seen to suffer shortness of breath

Pulmonary edema can be defined as the conditions where the lungs of the individuals get filled up with fluid. During the time of CHF, it is seen that the heart can no longer pump blood throughout the body. This contributes in creating a backup pressure in the small blood vessels of the lungs. These ultimately make the vessels to leak fluid (Ziaeian et al., 2016). When such fluid gets filled up in the lungs, oxygen cannot be put into the blood system causing deprivation of oxygen to the rest of the body. Therefore, when pulmonary edema occurs, body struggle in getting enough oxygen resulting in shortness of breath.

Sharon is seen to feel dizzy as well.

Individuals have complained of feeling dizzy when standing up quickly. Feeling of fainting is also seen to be common symptoms in people suffering from this disorder. Studies are of the opinion that these might be because of abnormal rhythms of the heart or narrowing of the arteries of heart (Binaei et al., 2016). Blood flow to the brain might get reduced and as a result of these, individuals might feel light headed or dizzy. Sudden loss of consciousness would show that the blood flow of the brain is severely impacted.

Warfarin can be described as the coumarin anticoagulant and is a racemic mixture of the two active isomers. This class of drugs of anticoagulants can be used in the prevention as well as treatment of the thromboembolic disorders like venous thrombosis, pulmonary embolism as well as pulmonary embolism and even in cases of ischemic stroke in patients with atrial fibrillation. This group of medication is seen to inhibit the vitamin k reductase that cause depletion of the reduced form of vitamin K. Vitamin k is the cofactor for the carboxylation of glutamate residues on the N-terminal regions of vitamin K-dependent proteins and this limits the gamma-carboxylation and subsequent activation of the vitamin K-dependent coagulant proteins (Fergusan et al., 2017). With the action of the anti-coagulants, the preparation of the vitamin K-dependent coagulation factors II, VII, IX, and X and anticoagulant proteins C and S is seen to undergo inhibition. As depression occurs among three of the four types of vitamin K-dependent coagulation factors (factors II, VII, and X), it causes reduction in the prothrombin levels as well as in the amount of the thrombin generated and bound to fibrin. Thereby, anticoagulants reduces the thrombogenicity of the clots.

Symptoms of Congestive Heart Failure

These drugs are rapidly absorbed after oral administration with that of the considerable inter-individual variations. They are also found to be absorbed percutaneously. Their volume of distribution is .01 L/kg and has 99% bound parimarily to albumin. They can be metabolized stereo- and regio-selectively by hepatic microsomal enzymes as well as by cytochrome P450 (CYP) 2C9 to yield the 6- and 7-hydroxylated metabolites or by CYP1A1, 1A2, and 3A4 to yield 6-, 8-, and 10-hydroxylated metabolites. The elimination happens entirely by metabolism and very little is excreted unchanged in urine. The metabolites are excreted mainly through urine and to lesser extent into the bile (Iungkaran et al., 2015).  

Nursing goal

Interventions with rationale

Management of the shortness of the breath

Oxygen therapy can be applied for Sharon. In case of CHF, the heart muscles fail to pump blood efficiently and therefore blood is not pumped in the way that it actually does when the heart is in normal condition without any disorder. Therefore, the different body parts do not get enough oxygen as required. Therefore, in such situations, nurses need to initiate oxygen therapy sessions (Luttik et al., 2016). This therapy mainly helps the patients by allowing them to breathe in extra oxygen for making sure that all the parts of the bodies are getting enough oxygen. This can help in prevention of failures of different organs that might take place because of the inability of the oxygen in reaching the different organs. In this way, damages to important organs like kidney, heart as well as brain can be prevented. With this intervention, the nurses can manage not only the breathing problems of Sharon but also would help in overcoming swelling of ankles.. Nurses can also use more pillows allowing Sharon to sleep in the recliner chair and providing her cushion for supporting Sharon while resting upright.

Preventing further deterioration of the condition of Sharon and preventing her from relapsing once again.

Studies are of the opinion that monitoring the vital signs of the patients in time to time would help the nurses in identifying whether any deteriorating situations are present or not or that the patient is under stable condition out of danger (Clark et al., 2016). The vital signs monitoring makes the nurses aware of deteriorating situation making them take ready actions when threatening values are observed. The basic sets of vital signs measurements mainly include blood pressure, pulse rate, respiration rate, temperature and heart rate (Condon et al., 2016). Time to time ECG, SpO2 and weight should be also measured to find out how Sharon is responding to treatments and whether she is recovering or deteriorating. All such information needs to be documented from time to time so that the trend in the values can be identified to understand how the patient is recovering and what further interventions need to be taken (Binaei et al., 2016).

Management of blood pressure and edema.

Pharmacological treatment should be carried on by the nurses. the set of medications that need to be given to Sharon is beta-blockers. This mainly helps by countering the effects of that of the sympathetic nervous system and help in reduction of the blood pressure. They work by creating blockage to the effects of the epinephrine hormone. When beta blocker would be given to Sharon, the heart rhythm would slow down with lesser force and this would cause reduction of the blood pressure in Sharon. Beta blockers mainly help by opening up the blood vessels and helping in improvement of the blood flow (Nieminen et al., 2015). Another medication that can be provided is the diuretics that can help in relieving congestive symptoms and that of fluid retention. This would help in the management of the symptoms of edema and fluid accumulation in the lungs as well (Daamen et al., 2016). Another set of drugs that can be also provided is the Angiotensin Converting Enzyme inhibitors. This enzyme helps in preventing the enzyme in the body that causes production of angiotensin II which actually causes narrowing of the blood vessels thereby increasing blood pressure and making the heart to work faster (Li et al., 2016). Angiotensin Converting Enzyme inhibitors mainly helps in preventing the action of the enzyme thereby relaxing the blood vessels and blood pressure gets reduced.

References:

Binaei, N., Moeini, M., Sadeghi, M., Najafi, M., & Mohagheghian, Z. (2016). Effects of hope promoting interventions based on religious beliefs on quality of life of patients with congestive heart failure and their families. Iranian journal of nursing and midwifery research, 21(1), 77. doi: 10.4103/1735-9066.174755

Buck, H. G., Harkness, K., Wion, R., Carroll, S. L., Cosman, T., Kaasalainen, S., ... & Strachan, P. H. (2015). Caregivers’ contributions to heart failure self-care: a systematic review. European Journal of Cardiovascular Nursing, 14(1), 79-89. https://doi.org/10.1177/1474515113518434

Clark, A. M., Wiens, K. S., Banner, D., Kryworuchko, J., Thirsk, L., McLean, L., & Currie, K. (2016). A systematic review of the main mechanisms of heart failure disease management interventions. Heart, 102(9), 707-711. https://heart.bmj.com/content/102/9/707?papetoc=&utm_source=trendmd&utm_medium=cpc&utm_campaign=alljjs&utm_term=1-B&utm_content=americas

Condon, C., Lycan, S., Duncan, P., & Bushnell, C. (2016). Reducing readmissions after stroke with a structured nurse practitioner/registered nurse transitional stroke program. Stroke, 47(6), 1599-1604. https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.115.012524

Daamen, M. A., Hamers, J. P., Gorgels, A. P., Tan, F. E., Schols, J. M., & Brunner-la Rocca, H. P. (2016). Treatment of heart failure in nursing home residents. Journal of geriatric cardiology: JGC, 13(1), 44. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4753011/

Ferguson, C., Inglis, S. C., Newton, P. J., Middleton, S., Macdonald, P. S., & Davidson, P. M. (2017). Barriers and enablers to adherence to anticoagulation in heart failure with atrial fibrillation: patient and provider perspectives. Journal of clinical nursing, 26(23-24), 4325-4334. https://onlinelibrary.wiley.com/doi/abs/10.1111/jocn.13759

Iyngkaran, P., Toukhsati, S. R., Biddagardi, N., Zimmet, H., Atherton, J. J., & Hare, D. L. (2015). Technology-assisted congestive heart failure care. Current heart failure reports, 12(2), 173-186 https://link.springer.com/article/10.1007/s11897-014-0251-3

Li, C. C., & Shun, S. C. (2016). Understanding self care coping styles in patients with chronic heart failure: A systematic review. European Journal of Cardiovascular Nursing, 15(1), 12-19. https://doi.org/10.1177/1474515115572046

Luttik, M. L., Jaarsma, T., & Strömberg, A. (2016). Changing needs of heart failure patients and their families during the illness trajectory: a challenge for health care. https://doi.org/10.1177/1474515116653536

Mirkin, K. A., Enomoto, L. M., Caputo, G. M., & Hollenbeak, C. S. (2017). Risk factors for 30-day readmission in patients with congestive heart failure. Heart & Lung: The Journal of Acute and Critical Care, 46(5), 357-362. https://doi.org/10.1016/j.hrtlng.2017.06.005

Moore, J. A. M. (2016). Evaluation of the efficacy of a nurse practitioner-led home-based congestive heart failure clinical pathway. Home health care services quarterly, 35(1), 39-51. https://doi.org/10.1080/01621424.2016.1175992

Nieminen, M. S., Dickstein, K., Fonseca, C., Serrano, J. M., Parissis, J., Fedele, F., ... & Brito, D. (2015). The patient perspective: quality of life in advanced heart failure with frequent hospitalisations. International journal of cardiology, 191, 256-264. https://doi.org/10.1016/j.ijcard.2015.04.235

Riley, J. P., Astin, F., Crespo?Leiro, M. G., Deaton, C. M., Kienhorst, J., Lambrinou, E., ... & Anker, S. D. (2016). Heart Failure Association of the European Society of Cardiology heart failure nurse curriculum. European journal of heart failure, 18(7), 736-743. https://doi.org/10.1002/ejhf.568

Vedel, I., & Khanassov, V. (2015). Transitional care for patients with congestive heart failure: a systematic review and meta-analysis. The Annals of Family Medicine, 13(6), 562-571. https://www.annfammed.org/content/13/6/562.short

Ziaeian, B., & Fonarow, G. C. (2016). The prevention of hospital readmissions in heart failure. Progress in cardiovascular diseases, 58(4), 379-385. https://doi.org/10.1016/j.pcad.2015.09.004

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