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1. Outline the causes, incidence and risk factors of the identified condition and how it can impact on the patient and family.

2. List five (5) common signs and symptoms of the identified condition; for each provide a link to the underlying pathophysiology.

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

3. Describe two (2) common classes of drugs used for patients with the identified condition including physiological effect of each class on the body.

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

4. Identify and explain, in order of priority the nursing care strategies you, as the registered nurse, should use within the first 24 hours post admission for this patient.

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.

Impression: Congestive cardiac failure

Classes of Drugs for CHF Patients

One of the most commonly known cause of congestive heart failure or CHF is impair in the pumping capability of heart (Schultz et al., 2013). High blood pressure or hypertension also contributes to the incident of CHF. In this case the patient’s report has indicated high blood pressure that may be responsible for the CHF in the patient (Suman-Horduna et al., 2013). Coronary artery disease and poor valve condition could lead to the consequence of CHF, because in such cases the blood flow to the heart is restricted, thus it becomes difficult for the heart to pump blood effectively (Verbrugge et al., 2013). In case of Mrs Sharon, she had a history of myocardial infraction which mainly caused due to arteriosclerosis along with narrow coronary arteries. Thus, it can be said that, such condition has led to the incident of CHF in this case. In addition, diabetes, thyroid disorder, allergy and obesity are other contributing factors in the development of CHF (Schultz et al., 2013). However, in this case there was no indication of such complications. Low potassium level leads to the heart disorder. As the report of the patient has indicate low potassium level it can be said that it is another cause of CHF within the patient (Verbrugge et al., 2013).

High blood pressure, diabetes, coronary artery disease and valvular heart disease are some potential risk factors of CHF. In some cases viral infection may lead to CHF (Suman-Horduna et al., 2013). Some medications such as nonsteroidal anti-inflammatory drugs, drugs for anesthetia and anti-arrythmic drugs and some over the counter medication could lead to the event of CHF (Ouwerkerk, Voors & Zwinderman, 2014). In addition, substance abuse and lack of physical activities are also considered as the risk factors of CHF. Furthermore, the risk of CHF is higher for the older adults and obese people (Ouwerkerk, Voors & Zwinderman, 2014).  In Australia the incidence of heart failure ranges between 1.0 to 2.0%. The illness impact on the patient and their family in an effective manner (Sahle et al., 2016). It could lead to long period of incapacity. It is not only the incident of biographical disruption but also disruption of lifestyle of individual suffering from the disease and their family as well. It becomes difficult for the patient and family member to cope up with functional limitations. The illness affects the socio-economic status due to the expenditure. Such complications impact the psychological health of the patient as well (Schultz et al., 2013).

  1. Swelling in ankles, feet and legs: In the primary stage of CHF it is difficult to identify any symptoms or changes in the health condition, however, with increasing severity the patient starts to experience gradual changes in health condition. For example, swelling in ankles, feet and legs is a common symptom of CHF that occur in the early stage (Suman-Horduna et al., 2013). In case of Mrs Sharon, it has been found that she was also suffering from swollen ankles.
  2. Shortness of breath: Shortness of breath is another potential symptom of CHF. Increase in the breathing problem may lead to the consequence of pulmonary edema that may indicate worse health condition (Schuetz et al., 2014). In this case it has been found that, the patient has reported that she has been suffering from shortness of breath especially during the time of gardening and walking with her husband.
  3. Chest pain: Chest is one of the most common symptom of congestive heart failure. Due to the correlation with coronary artery disease, valvular illness and myocardial infraction, chest pain is also associated with CHF (Packer et al., 2013). The patient in the case study has reported about past history of MI that could lead to the suffering from severe chest pain. In addition, cardiac enlargement and lower-lobe infiltrates have been found in the ECG and chest x-ray, which could be responsible for the chest pain (Ambrosy et al., 2013).
  4. Fatigue: Fatigue is another effective symptom that a patient with CHF experience at the primary stage. Due to fatigue the patient may experience nausea and dizziness as well (Suman-Horduna et al., 2013). In this case Mrs Sharon has also reported about suffering from mild nausea and dizziness during the time of admission in the emergency department.
  5. Rapid heart and respiratory rate: As in case of CHF the heart lack the efficiency of pumping blood effectively, increase in the heart rate and respiratory rate is observed (Packer et al., 2013). The report of the patient in this case has indicated that she was suffering from high BP due to CHF and her heart rate and respiratory rate were 54 bpm and 30 bpm respectively which are higher than the normal rate (Schuetz et al., 2014).
  1. ACE inhibitors: Using AE inhibitors could be beneficial in case of heart failure. It has been found that the drug is used to control the hypertension. The medication helps to prohibit the formation of angiotensin II that is responsible for various adverse effect on function of heart and circulation. Hence, using ACE inhibitors could help to improve the health condition of the patient with CHF by reducing the symptoms and risk of deterioration, thus helps to provide prolong survival. Some example of ACE inhibitors are Captopril, Enalapril, Lisinopril and Benazepril (Li, Heran & Wright, 2014). There are some side effects of the medication as well, for example, low BP, dry cough, electrolyte imbalance and allergic reaction (McMurray et al., 2013). In this case it has been found that the patient has been taking Enalapril. It has been found that higher level of digoxin in the serum is important to achieve improvement in the patient with heart failure. Thus, combination of Digoxin and captopril could be provided to the patient as it helps to increase the digoxin in serum by 30% (Li, Heran & Wright, 2014).
  2. Beta-blockers: Beta-blockers are also effective in order to prevent the severe effect of CHF (Rienstra et al., 2013). There are certain hormones such as norepinephrine and epinephrine that affect the beta receptors of various tissues. Such actions on the beta receptors of heart leads to forceful contraction of heart and sometimes block the function of beta receptors as well. Such actions lead to the dysfunction of heart and increase the risk of heart failure (Liu et al., 2014). Beta-blockers have stimulating effect on such hormones thus, it could provide effective clinical outcomes in order to improve the function of heart (Rienstra et al., 2013). However, there are some potential side effects of beta-blockers, for example, low pulse, fluid retention, fatigue and low BP (Liu et al., 2014). The beta-blocker Metoprolol has been found to be effective in case of CHF. In addition research regarding the effectiveness of Carvedilo along with other beta-blocker for the treatment of CHF is ongoing (Rienstra et al., 2013).

Nursing Care Strategies within First 24 Hours of Admission

It is important to observe the vital signs of the patient such as pain, BP, heart rate, respiratory rate, breathing and verbal and non-verbal cues such as moaning, restlessness, clutching of chest and diaphoresis. It would help to understand the current health condition of the patient and introduce effective interventions in order to address the health issues in an effective manner. In this case difference behaviour due to pain may create difficulties in the vital sign assessment (Feltner et al., 2014). Next the nurse should obtain the detail description of pain regarding the location, duration, intensity and characteristics of pain. It would help to introduce effective pain relief interventions in order to reduce the pain in an effective manner (Wakefield et al., 2013). The nurses need to monitor the vital sign and pain of the patient in every 30 minutes and inform the patient about reporting the nurse regarding the increase in chest pain and discomfort (Mebazaa et al., 2015). The nurses need to administer 0.4 mg Nitroglycerin Sublingual in every 5 minutes in order to relief the chest pain, because increase in pain may lead to shock due to stimulating sympathetic nervous system (Ponikowski et al., 2016). The vital signs need to be monitored before and after providing narcotic medications. This is because, severe respiratory depression and hypotension may occur due to the narcotic administration. Such conditions may lead to the increase in the myocardial damage. If the narcotic such as nitroglycerin fails to relief the pain, it is important to provide intravenous morphine in order to relief the pain (Wakefield et al., 2013).

The nurses should provide comfortable environment. Calm activities and should approach the patient with patience and calm. It would help to reduce the external stimuli that may create cardiac strain and anxiety, thus could limit the ability to cope up with illness (Feltner et al., 2014). It is important to administer adequate supplemental oxygen via face mask or nasal cannula according to the comfort of the patient as shortness in breathing has been reported. It would help to increase the amount of oxygen for the uptake of myocardia and could help to reduce the level of discomfort in an effective manner (Ponikowski et al., 2016). It is important to review the history of previous case of myocardial infraction. It would help to understand the potential risk factors and cause of illness (Mebazaa et al., 2015). In addition effective medication could be used such as Antianginals containing nitrates, because it would help to increase the coronary blood flow and perfusion (Wakefield et al., 2013). Such nursing care strategies could help to control the effect of congestive heart failure and improve the health condition of the patient in an effective manner.

Potential Risk Factors for CHF

References:

Ambrosy, A. P., Pang, P. S., Khan, S., Konstam, M. A., Fonarow, G. C., Traver, B., ... & Grinfeld, L. (2013). Clinical course and predictive value of congestion during hospitalization in patients admitted for worsening signs and symptoms of heart failure with reduced ejection fraction: findings from the EVEREST trial. European heart journal, 34(11), 835-843.

Feltner, C., Jones, C. D., Cené, C. W., Zheng, Z. J., Sueta, C. A., Coker-Schwimmer, E. J., ... & Jonas, D. E. (2014). Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis. Annals of internal medicine, 160(11), 774-784.

Li, E. C., Heran, B. S., & Wright, J. M. (2014). Angiotensin converting enzyme (ACE) inhibitors versus angiotensin receptor blockers for primary hypertension. Cochrane Database Syst Rev, 8, CD009096.

Liu, F., Chen, Y., Feng, X., Teng, Z., Yuan, Y., & Bin, J. (2014). Effects of beta-blockers on heart failure with preserved ejection fraction: a meta-analysis. PloS one, 9(3), e90555.

McMurray, J. J., Packer, M., Desai, A. S., Gong, J., Lefkowitz, M. P., Rizkala, A. R., ... & Zile, M. R. (2013). Dual angiotensin receptor and neprilysin inhibition as an alternative to angiotensin?converting enzyme inhibition in patients with chronic systolic heart failure: rationale for and design of the Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure trial (PARADIGM?HF). European journal of heart failure, 15(9), 1062-1073.

Mebazaa, A., Yilmaz, M. B., Levy, P., Ponikowski, P., Peacock, W. F., Laribi, S., ... & McDonagh, T. (2015). Recommendations on pre?hospital & early hospital management of acute heart failure: a consensus paper from the Heart Failure Association of the European Society of Cardiology, the European Society of Emergency Medicine and the Society of Academic Emergency Medicine. European journal of heart failure, 17(6), 544-558.

Ouwerkerk, W., Voors, A. A., & Zwinderman, A. H. (2014). Factors influencing the predictive power of models for predicting mortality and/or heart failure hospitalization in patients with heart failure. JACC: Heart Failure, 2(5), 429-436.

Packer, M., Colucci, W., Fisher, L., Massie, B. M., Teerlink, J. R., Young, J., ... & Garratt, C. (2013). Effect of levosimendan on the short-term clinical course of patients with acutely decompensated heart failure. JACC: Heart Failure, 1(2), 103-111.

Ponikowski, P., Voors, A. A., Anker, S. D., Bueno, H., Cleland, J. G., Coats, A. J., ... & Jessup, M. (2016). 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. European journal of heart failure, 18(8), 891-975.

Ponikowski, P., Voors, A. A., Anker, S. D., Bueno, H., Cleland, J. G., Coats, A. J., ... & Jessup, M. (2016). 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. European journal of heart failure, 18(8), 891-975.

Rienstra, M., Damman, K., Mulder, B. A., Van Gelder, I. C., McMurray, J. J., & Van Veldhuisen, D. J. (2013). Beta-blockers and outcome in heart failure and atrial fibrillation: a meta-analysis. JACC: Heart Failure, 1(1), 21-28.

Sahle, B. W., Owen, A. J., Mutowo, M. P., Krum, H., & Reid, C. M. (2016). Prevalence of heart failure in Australia: a systematic review. BMC cardiovascular disorders, 16(1), 32.

Schuetz, P., Kutz, A., Grolimund, E., Haubitz, S., Demann, D., Vögeli, A., ... & Hoess, C. (2014). Excluding infection through procalcitonin testing improves outcomes of congestive heart failure patients presenting with acute respiratory symptoms: results from the randomized ProHOSP trial. International journal of cardiology, 175(3), 464-472.

Schultz, S. E., Rothwell, D. M., Chen, Z., & Tu, K. (2013). Identifying cases of congestive heart failure from administrative data: a validation study using primary care patient records. Chronic diseases and injuries in Canada, 33(3).

Suman-Horduna, I., Roy, D., Frasure-Smith, N., Talajic, M., Lespérance, F., Blondeau, L., ... & AF-CHF Trial Investigators. (2013). Quality of life and functional capacity in patients with atrial fibrillation and congestive heart failure. Journal of the American College of Cardiology, 61(4), 455-460.

Verbrugge, F. H., Dupont, M., Steels, P., Grieten, L., Malbrain, M., Tang, W. W., & Mullens, W. (2013). Abdominal contributions to cardiorenal dysfunction in congestive heart failure. Journal of the American College of Cardiology, 62(6), 485-495.

Wakefield, B. J., Boren, S. A., Groves, P. S., & Conn, V. S. (2013). Heart failure care management programs: a review of study interventions and meta-analysis of outcomes. Journal of Cardiovascular Nursing, 28(1), 8-19.

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