The appropriate nursing assessment in this patient will include a complete cardiovascular assessment, pain assessment and assessment of risk factors (Brunner, 2010). These are the priority assessments in this patient presenting with features of heart failure in a previous myocardial infarction. They are at increased risk of recurrence of cardiovascular disease hence risk factors that precipitate heart failure or worsen morbidity need to be assessed (Elliott & Coventry, 2012). Pain is a vital component of cardiovascular ischemia and in-hospital stay hence assessment of pain is warranted.
The cardiovascular examination involves physical, functional and psychosocial assessment by collecting objective and subjective data. Physical assessment starts by measuring the blood pressure, heart rate, assessment of edema, peripheral circulation, followed by inspection, palpation, and auscultation of the precordium and a 12 lead ECG recording (Glynn, Drake, & Hutchison, 2012). Due to the profound effect and interrelation with the respiratory system, a respiratory assessment should be done.
Blood pressure measurement should be done with the patient seated, using the right size cuff and a working sphygmomanometer (Glynn et al., 2012). Automated machines do exist if the intervals between measurements are small. Normal blood pressure should be a systolic pressure of 130 to 90mmHg and diastolic of 90 to 60 mmHg with a pulse pressure of 30 to 50 mmHg. The patient’s BP was 102/84 which was within the normal range. In heart failure, hypotension is a major concern due to reduced cardiac output (Böhm et al., 2010).
The pulse rate should be measured by assessing the carotid, radial, femoral popliteal and dorsalis pedis pulses (Glynn et al., 2012). In cardiogenic shock, tachycardia is expected as sympathetic discharge in compensation tries to maintain perfusion. The normal pulse is 60 to 100 beats per minute. The patient has a tachycardia of 118 beats per minute.
Assessment of edema is also warranted. Pedal edema is measured at bony prominences such as sternum and malleoli by blanching and noting for pitting (Douglas, Nicol, & Robertson, 2013). Weight should measured at the same time daily to assess weight changes. Peripheral circulation is assessed by measuring the capillary refill, which should be less than 3 seconds.
Inspection for a hyperactive precordium, palpation of the apex beat and auscultation of heart sounds will show any abnormalities of cardiac function (Douglas et al., 2013). A respiratory assessment by auscultating for basal crepitations and rales may pick signs of pulmonary edema expected in this patient. A 12 lead ECG should be conducted to assess for abnormal rhythm, rate, and features of heart failure. It is usually indicated in ischemia and infarction as it categorizes infarction as STEMI or non-STEMI (Glynn et al., 2012).
Pain assessment is warranted in this patient. The assessment should include the site of pain, character, aggravating and relieving factors, radiation and associated factors (Goodlin et al., 2012). This patient is at an increased risk of recurrent myocardial infarction hence recognition of angina is paramount (Turk & Melzack, 2011).
The patient has several lifestyle risk factors for cardiovascular disease including physical inactivity, smoking, alcohol use and unhealthy diet. These should be assessed and the level of each quantified. These risk factors play a crucial role in clinical intervention and a baseline for each will guide such interventions.
Note: Dot points recommended in care plan. Click and type in each cell, click enter in a cell to make it longer. Do not remove text from the template.
The patient is on anti-failure medication with ramipril, digoxin, and furosemide. These are among the drugs recommended for management of heart failure.
Furosemide 40mg PO twice daily
Furosemide is a loop-diuretic that functions to reduce fluid overload in heat failure. It functions as a diuretic at the kidney to enhance salt and water excretion thus reducing fluid accumulation (Katzung et al., 2012). Nursing responsibility during medication with furosemide should include assessment of fluid balance and appropriate dosing. Drug allergy should be asked for and any contraindications such as kidney disease and liver disease noted. Side effects include nausea, vomiting, dizziness, and bleeding.
Digoxin 62.5mcg PO daily
Cardiac glycosides have been used in heart failure for years, with digoxin being one of them. It is a positive inotrope that improves cardiac contractility thus improving cardiac output and perfusion in heart failure (Katzung et al., 2012). Digitalis toxicity is a recognized adverse effect when using this drug and can be fatal. Monitoring of dosage and adverse effects is an important nursing responsibility. They include a headache, dizziness, arrhythmias, blurred vision and confusion. The patient should be instructed to verbalize any of these side effects if they occur.
Ramipril 5mg PO twice daily
Ramipril is an angiotensin-converting enzyme blocker with profound action on smooth muscle causing vasodilation. It inhibits the formation of angiotensin II which is a vasoconstrictor thus causing vasodilation (Katzung et al., 2012). It has a role in heart failure as it improves perfusion by eliminating reflex vasoconstriction. The nurse should ensure no drug allergies in the patient exist and no contraindication are present in the patient. Dosage and monitoring of therapy should also be done.
Task 4: Patient education
Smoking is among the modifiable risk factors for most cardiovascular diseases. Smoking cessation should be considered in any patient with or without cardiovascular disease as it is unhealthy and has been implicated in many systemic diseases and cancers (US Department of Health and Human Services, 2014). The patient could enroll in a rehabilitation program that is equipped with support and medication to ensure smoking cessation, combating of withdrawal and positive behavior modification (Thomas, 2012; Stead et al., 2013). To make sure David understand the teaching, a teach-back method of patient education should be employed (Tamura-Lis, 2013). In this method, the patient is taught the health effects of smoking, complications, and hazards and given alternatives and options. They are then instructed to teach the health professional what they have learned. Effective understanding is considered to be achieved if David can correctly teach the nurse what he learned.
Task 5: ISBAR handover
I am ------------------ a registered nurse in this department handing over Mr. David Parker, a patient who was referred from the cardiology clinic under Dr-------------------- with a diagnosis of chronic heart failure after presenting with dyspnoea at rest.
The patient was received unstable in the ward following the referral from cardiology.
He is a patient who had been in our cared before due to a myocardial infarction. He had been discharged through a rehabilitation facility. However, he refused to attend the program and also refused diet guidelines as he did not eat the low-fat diet prepared by his wife. Other directives which he ignored included cessation of smoking and alcohol use. His medication included ramipril, digoxin and furosemide.
His vitals were as follows: tachycardia of 118 beats per minute, tachypnoea of 24 breaths per minute with a low oxygen saturation of 92%. His other vitals were within normal with a blood pressure of 102/84 and temperature of 36.5oC. He had dyspnoea at rest, a cough and was fatigued.
Recommendation and plan
The patient was put on 1000 ml fluid restriction which should be maintained. Monitor input and output and administer medication as charted
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