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Question:

Discuss about the Chronic Heart Failure.
 
 

Answer:

Introduction

The case study review concerns patient Giovanni aged 72 years diagnosed with chronic heart failure. The patient was admitted at the emergency section with symptoms, of shortness of breath, sensation and suffocation. He has experienced breathlessness in the recent days and has developed oedema in the feet. Further assessment of the patient reveals that he has been smoking and unable to change his diet with no success. His vital signs indicate that his temperature is below the normal range , it was indicating 36.9oc, his heart beat rate is 115/minutes, the ECG are normal and his blood pressure is 118/60. His respiratory rate is 26 /minutes. The parent upon physical assessments has developed auscultation and the cardiothoracic ratio is also enlarged, this case presentation is a classical acute heart failure. The nursing problem under this review will be to decrease the cardiac output under which the following two interventions will be initiated; monitoring and assessing abnormal heart and lung sounds and assessing the patients skin temperature and peripheral pulses and the second nursing issue is to manage oedema of the foot with key interventions being management of anxiety and depression management and management of fluid intake.

Cardiac output

The patient has a history of chronic heart failure and has been brought at the emergency centre. His prior history of medication is that he is smoker. Assesment of patient vital information reveals elevated blood pressure coupled with increased heart beat rate and respiration rates at 26 respirations per minute, which the recommended are below 20.  His blood pressure is relatively elevated at the systolic measurements being 118 while diastolic readings are 60. It is essential in that it determines the effectiveness of the heart to supply blood to the rest of the body effectively. Elevated cardiac activity have shown to increase the incidence of stroke,  it makes the  heart to pump more blood to fill the left ventricle before being pump out. It is evident in the case study in that there increased respiration rate due to the action of the heart beating faster than normal.

 

Abnormal heart and lung sounds

The rationale behind this intervention is that it allows for the detection of heart failure on the left side of the heart which often occur at episodes of chronic heart failure due elevated accumulation of blood due to poor excretion process of the kidney.  This intervention will be administered independently with the appropriate tools for measuring the vitals such as respiration rate and sounds of the heart. The theory behind this intervention is that it is defined by the amount of blood pumped by the heart, thus it is the product of the heart rate, number of beats per second with stroke volume of the heart. Abnormal heart and lung sounds refer to assessments of lung pathology and the heart in measuring the auscultation, which is an important clinical tool in assessing heart failure conditions, (Chen et al., 2015). Chest auscultation is performed using a stethoscope placed on the chest, placing it on the chest of the patient while heart sounds are assessed using stethoscope being placed on the diaphragm, sound recognition is heard when high pitch sounds are heard. Normal heart rate should be between 60-100 beats per minute in regular rhythm flow, (Gallie et al., 2015). These interventions are suitable in determining the heart beat flow and function ability. The vital signs displayed by the patient thus are relevant in assessing the abnormal heart sounds and chest for evidence of cardiac output fluids.

The advantage of this intervention is that onsets of gallop rhythm of the lungs if present can be an early warning of heart failure in the acute phase. Any presence of pulmonary oedema can signify presence of inspiration and occurrence of dyspnoea to the patient. The risk assessments are important in assessing the disease stage and progress. In most of the scenarios fluttering feelings in the chest are dangerous and hence the need for immediate treatment, hence there is need of identification of irregular heartbeats and the natural ways of managing the arrhythmias is. Irregular heartbeats are normally harmless but reoccurrence for long duration of episodes leads to development of symptoms such as fatigue, dizziness, fainting, and shortness of breath as typical in this case study, chest pain and cardiac arrest occurrence, (Liu et al., 2016). Hence assessment of the functioning of the heart and chest is a remedy for various associated complications which must be minimised at any medical costs, to avoid damage especially for older patients like Giovanne. Irregular beating of the heart can refer to faster rate of the heart or slower rates with or without presence of irregular rhythm. It often occurs as fluttering. the irregular heart beats are the cause of arrhythmia. The most significant type of these is the a trial fibrillation which happens due to the regular heart beat of the upper chambers is irregular and it limits blood flow. Premature heart beats have the main cause of the collapse and deaths in many incidences of heart failure, according to American Heart Association, (AHA, 2017). An associative risk on abnormal sounds and heart beats is the use of tobacco. Research has shown it is the single top most modifiable factor for heart related diseases an delay a significant role on irregular occurrence of heart beats, (D'alessandro et al., 2012). Heart and chest intervention measures are thus necessary, for managing heart failure, especially in presence of modifiable factor like smoking as evident form the case study patient.

 

Assessing the patients skin temperature and peripheral pulses

Assessing the patient’s skin temperature and peripheral pulses involves the inquest into the peripheral vascular path for isolation of clinical characteristics of pulse for ascertaining arterial bruits and inflammations cause associated with secondary vein thrombosis. This intervention is independent intervention which involves health care practitioner to administer. Elevated pulse rate can be an indicative of complication associated with the heart. Premature beats are evident observation of irregular pulse rates. Absence of pulse rate in the body parts can be an indicative measure of compromised blood flow to the heart due to the congestive heart failure. Assessments of pulse rates and temperature key factors should be considered which are he intensity of the beats, rate, rhythm and tenderness presence in the site of assessment. Patient is thus recommended to be examined in the room so that both pulses of the patient can be observed. Palpations can be conducted using the finger tips and grading done on the sale, (Ranganathan et al., 2015). Despite the patient vital signs showing the elevated pulse rates, continuous monitoring enables tracking down of the management for the patient for effective care.

Care is involved in the assessment of the patient status of the measuring the pulsations, at times confusion arises when unable to distinguish own pulses and the patients pulses, thus there should be no use of the thumb as its usage increases the like hood of false readings. Bruits can be further assessed further using auscultation in the arteries. Usage of stethoscope and diaphragm is important in taking these measurements.  In other cases the poor pulses readings is risk factor of impaired blood flow, which can be caused by congenital disorders, (Selvaraj et al., 2016).

The decline of perfusion and oxygen supply in the tissue levels associated to anaemia can lead to decline in the temperature and pulses in the peripheral region and can pose danger during the palpations, (Wray, Amann & Richardson, 2016). The clinical importance for taking pulses and temperature measurements for the patient is meant to detect for presence of diseases, in this case the patent is experiencing acute heart failure thus the reasons for the elevated readings of pulses and respirations arteries.

 

Evaluation

The nursing interventions will assist the patient to reduce the overall work load exposed to the heart, it is expected that the hemodynamic stability of the patient would have normalized and reduction in the pulse rates of the patient. The pulse rate should have fall below the normal range and the temperature stabilized to. Often patients with heart failure disease, experience shortness of breath and pulsations, under medical managements the signs and symptoms would have normalise and keen observation on managing any symptoms that might proof dangerous to the patient. The overall achievement of the intervention is the reduction of cardiac output which releases heavy burden on the state of the patient, (Mark, 2013).Thus cardiac output is relevant in managing hypertension for chronic disease diagnosis so as to reduce the blood fluid over load in the blood vessels and hence reduce the elevated pressure in the body.

Nursing issue is to manage oedema

The theoretical result of the oedema is the disproportionate balance between the body ability to filter substance in the capillary and intestinal spaces, (Trayes et al., 2013). The function of the kidneys is the regulation of extracellular fluid though adjustments to the sodium and water level in the body. Causative factors for oedema include obstruction of the venous, increasing the capillary action. Major treatment regime involves restriction of sodium, diuretic use and the treatment of underlying disorder which is congestive disorder in this case, (Yancy et al., 2013). The patient in this case is exacerbation oedema of the feet signifying fluid retention due to fluid overload in the blood system. In congestive heart failure the decline in the functionality of the heart affects the normal ability of the kidney to perform its function thus occurrence of the oedema, (Verbrugge et al., 2014).

Reduction of fluid levels in the body

The goal of management of is to reduce and minimize fluid intake in the body. Reduction of the fluid intake by the patient is a collaborative intervention which must be initiating by the nursing care and the patient.  The theory underlying fluid intake correlates with the kidneys ability to remove water in the body and to manage fluid balance. The patient fluid intake will be limited till the normal organ function is resolved. Anti diuretic use has been implemented to oedema in patients as observed in the case study, application of anti diuretic use for the patient is beneficial,(Mebazaa et al., 2016). Oedema thus occurs due to imbalance of the fluid controlling forces and the various interplay of hemodynamic in the patient, (Packer et al., 2013). For effective assessment of the patient and practice of effective treatment, management of oedema is important in reducing the diseases over load.

Peripheral congestion of congestive heart failure  develops over long duration of time and patients often exhibit excess accumulation of water in the body, (Campbell  et al., 2014). The patient in the case study was admitted with oedema of the feet, which caused immobility thus signifying its prior development. Heart failure is associated with renal perfusion falls, which leads to production of aldosterone and elevated sodium levels thus initiating water retention in the legs, (Miles & Griffiths, 2014). Risk associated with the oedema is complicate management and excess accumulation of water retain in the body which leads to worsening of the patient condition.

 

Controlling anxiety and depression

Excitement and anxiety is often seen in patients with heart failure. It is a serious condition characterised by feeling of fatigued and worn out, (Hwang, Moser, & Dracup, 2014). It is further worsened by breathlessness which the body anxious and vulnerable. Observed symptoms may include prevention of normal actives for the patient like talking and even being jovial. It can be observed with the patient, in that the fear of dying and pain causes depression, (Hare,  Toukhsati, Johansson, & Jaarsma, 2013). Advising the patient to have a positive attitude for better management of conditions is essential for improving the patient condition status. Concerning the age of the patient will be key in managing the psychological status of the patient and enabling recovery.

The disadvantage of depression is that it reduces the quality of life, (Huffman et al., 2014) when depression persists for so long then treatment can be sought as it could signal other underlying condition in the body, (Carney & Freedland, 2016). Risks associated with depression are that it can lead to high blood pressure, increased platelet activity and increases probability of heart attacks. In heart failure, it can be fatal to cause mortality. Hence nursing intervention for the patient should be geared eliminating stress related mood despite the age state. This intervention id beneficial to the patient as he is at risks as stress and depression at this age states could be fatal.

Evaluation of the care plan

With the patient current state, experiencing oedema of the foot, their is need for effective fluid balance for the patients. Fluid intake should be managed effectively and monitored closely. The auscultation the lung is aimed at ensuring the lung pathway is clear. For the patient daily monitoring of the weight will be a key indicator for the reduction and retention of fluid in the body. Measuring of daily output of fluid by the patient will be used as a measure in evaluation the effectiveness of the intervention adoption low salt diets will be definitive measure. Patient relaxed state is key to managing effectively the depression and anxiety state of the patient. Maintenance of fluid balance will be key evaluator outcome and the patient become less anxious of his state as suggested by Yancy et al.,(2013) in guidelines for  management of heart failure. He fluid management if carefully managed is able to prevent further complication such as acute kidney failure, (Prowle et al., 2014).

Conclusion

The patient under review is experiencing acute chronic failure with exonerating symptoms like shortness of breath and hypothermal and increased respiratory rates which must be managed medically. This management hence is dependent on several key factors such as symptoms measure, illness presences, medical history and other factors which have been highlighted. In care management, the key issue is to manage the associated factors; in this case we identified two nursing issues for reviews which include decrease the cardiac output manage oedema. The nursing strategy is thus to promote restorative health and manage the patient symptoms using evidence based centred care, (Paul & Hice, 2014). The benefits to the patient will be summed up as improved patient status and better diagnosis of the disease.

 

References

Campbell, R. T., McKean, A. R., & McMurray, J. J. (2014). Acute heart failure: have we got it all wrong?. European journal of heart failure, 16(12), 1263-1267.

Carney, R. M., & Freedland, K. E. (2016). Depression and coronary heart disease. Nature Reviews Cardiology.

Chen, C. H., Huang, W. T., Tan, T. H., Chang, C. C., & Chang, Y. J. (2015). Using K-nearest neighbor classification to diagnose abnormal lung sounds. Sensors, 15(6), 13132-13158.

D'alessandro, A., Boeckelmann, I., Hammwhöner, M., & Goette, A. (2012). Nicotine, cigarette smoking and cardiac arrhythmia: an overview. European journal of preventive cardiology, 19(3), 297-305.

Galiè, N., Humbert, M., Vachiery, J. L., Gibbs, S., Lang, I., Torbicki, A., ... & Ghofrani, A. (2015). 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. European heart journal, ehv317.

Heart Failure - American Heart Association , (2017) . accesed on 13/05/2017. Http://www.heart.org/HEARTORG/.../HeartFailure/Heart-Failure_UCM_002019_SubHome

Huffman, J. C., Mastromauro, C. A., Beach, S. R., Celano, C. M., DuBois, C. M., Healy, B. C., ... & Januzzi, J. L. (2014). Collaborative care for depression and anxiety disorders in patients with recent cardiac events: the Management of Sadness and Anxiety in Cardiology (MOSAIC) randomized clinical trial. JAMA internal medicine, 174(6), 927-935.

Hwang, B., Moser, D. K., & Dracup, K. (2014). Knowledge is insufficient for self-care among heart failure patients with psychological distress. Health Psychology, 33(7), 588.

Liu, C., Springer, D., Li, Q., Moody, B., Juan, R. A., Chorro, F. J., ... & Syed, Z. (2016). An open access database for the evaluation of heart sound algorithms. Physiological Measurement, 37(12), 2181.

Marik, P. E. (2013). Noninvasive cardiac output monitors: a state-of the-art review. J Cardiothorac Vasc Anesth, 27(1), 121-134.

Mebazaa, A., Tolppanen, H., Mueller, C., Lassus, J., DiSomma, S., Baksyte, G., ... & Masip, J. (2016). Acute heart failure and cardiogenic shock: a multidisciplinary practical guidance. Intensive care medicine, 42(2), 147-163.

Miles, Kenneth A., and M. R. Griffiths. "Perfusion CT: a worthwhile enhancement?." The British journal of radiology (2014).

Packer, M., Carson, P., Elkayam, U., Konstam, M. A., Moe, G., O'Connor, C., ... & PRAISE-2 Study Group. (2013). Effect of amlodipine on the survival of patients with severe chronic heart failure due to a nonischemic cardiomyopathy: results of the PRAISE-2 study (prospective randomized amlodipine survival evaluation 2). JACC: Heart Failure, 1(4), 308-314

 Paul, S., & Hice, A. (2014). Role of the Acute Care Nurse in Managing Patients With Heart Failure Using Evidence-Based Care. Critical care nursing quarterly, 37(4), 357-376.

Prowle, J. R., Kirwan, C. J., & Bellomo, R. (2014). Fluid management for the prevention and attenuation of acute kidney injury. Nature Reviews Nephrology, 10(1), 37-47.

Ranganathan, N., Sivaciyan, V., & Saksena, F. B. (2015). The art and science of cardiac physical examination. JP Medical Ltd.

Selvaraj, S., Steg, P. G., Elbez, Y., Sorbets, E., Feldman, L. J., Eagle, K. A., ... & REACH Registry Investigators. (2016). Pulse pressure and risk for cardiovascular events in patients with atherothrombosis: from the REACH registry. Journal of the American College of Cardiology, 67(4), 392-403.

Trayes, K. P., Studdiford, J. S., Pickle, S., & Tully, A. S. (2013). Edema: diagnosis and management. Am Fam Physician, 88(2), 102-110.

Verbrugge, F. H., Dupont, M., Steels, P., Grieten, L., Swennen, Q., Tang, W. H., & Mullens, W. (2014). The kidney in congestive heart failure:‘are natriuresis, sodium, and diuretics really the good, the bad and the ugly?’. European journal of heart failure, 16(2), 133-142.

Wray, D. W., Amann, M., & Richardson, R. S. (2016). Peripheral vascular function, oxygen delivery and utilization: the impact of oxidative stress in aging and heart failure with reduced ejection fraction. Heart Failure Reviews, 1-18.

Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Drazner, M. H., ... & Johnson, M. R. (2013). 2013 ACCF/AHA guideline for the management of heart failure. Circulation, CIR-0b013e31829e8776.

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