Congestive Cardiac Failure Case Study

Congestive Cardiac Failure Case Study Mr. Sam Toscana is a 70 year old client admitted to the ward with congestive cardiac failure (CCF). The client states that he has had increasing SOB over the last 3 days and his feet are as swollen as he cannot put his shoes on. The cardiologist saw him this morning and he admitted for management of his CCF. The client states he has had a fluid problem on and off for the last five year. History Age: 70 Allergies: NKA Ht: 165 cm WT: 75 kg Next of kin: Wife Maria Children: 1 daughter Mr. Toscana lives with his wife in the family home; they have lived there for 40 years. His daughters house is near by and she is very helpful and takes him and his wife to appointments. However she has 3 children at school that keep her very busy. They remain very sociable attending the local Italian club. He was diagnosed with CCF 10 years ago. Past History AF, Hypercholesterolemia, CCF, CABGs 10 years ago, ex-smoker, positive coronary artery disease family history. Medical Management The following about medications were told by Mr. Toscana: Lasix is not taken when they go outings organized by the Italian club. Digoxin is taken one in the morning (blue pills). Aspirin is taken in the morning with water. Warfarin is taken in the night and blood test is getting every couple of days. Perindopril is taken one in the morning for his heart. Observations on admission BP 95/50, AF pulse irregular 80, SaO2 93% on room air, Temp 36.9, R Rate 22 bpm, Crackles noted in the right lung base. This essay will explain the pathophysiology of presenting condition of Mr. Toscana. Secondly, this paper will explain what nursing assessment will be performed on Mr. Toscana and justify the framework for assessment chosen. Thirdly, education and psychosocial support will be offered on Mr. Toscana will be described with justifying. In addition, nursing care plan for Mr. Toscana with two short term and two long term goals including nursing interventions, rationales, and evaluations will be provided. Furthermore, diagnostic tests that will assist with the assessment and management of Mr. Toscana will be investigated. Moreover, this essay will perform a risk assessment on the client drawing on the information provided. Lastly, two of the medications Mr. Toscana is taking will be discussed and including action, use (as discuss why this client been prescribed this medication), relevant interaction, three adverse effects, and three nursing points or precautions. Pathophysiology of the presenting condition of Mr. Toscana Heart failure is defined as a condition that results from some abnormality in myocardial function. The abnormality, whatever the cause, results in the inability of the heart to deliver enough oxygenated blood to meet the metabolic needs of the body. When the right and left ventricles fail as pumps, pulmonary and systemic venous hypertension ensue, resulting in the syndrome of congestive heart failure (Fletcher Thomas 2001). Dyspnoea or shortness of breath, orthopnoea and pulmonary crackles are signs and symptoms of pulmonary edema and pleural effusion when left ventricular in the heart failure. There are two major consequences occur when the left ventricle is unable to pump enough blood to meet the bodys demands: signs and symptoms of decreased cardiac output and pulmonary congestion. Increased pressure in the left side of the heart backs up into the pulmonary system, and the lungs become congested with fluid. Fluid leaks through the engorged capillaries and permeates air spaces in lung (Christensen Kockrow 2011). According to Christensen and Kockrow (2011) edema appears in the body as right ventricular failure. Right ventricular failure occurs when the right ventricle in unable to pump effectively against increased pressure in the pulmonary circulation. The right ventricles inability to pump blood forward into the lungs results in peripheral congestion and an inability to accommodate all the venous blood that is normally returned to the right side of the heart. Venous blood in reflected backward into the systemic circulation. Increased venous volume and pressure force fluid out of the vasculature into interstitial tissue or peripheral edema. Nursing assessment with justifying Christensen and Kockrow (2011) state that subjective data to assess Mr. Toscana include complaints of dyspnea, orthopnea or sudden awakening from sleep because shortness of breath (paroxysmal nocturnal dyspnea), and cough. Besides that, fatigue, anxiety, weight gain from fluid retention, and edema may be reported by patient. In addition, any pain such as angina or abdominal and the patients stated ability to perform activity of daily living needs to be documented. Collection of objective date includes noting presence of respiratory distress, the number of pillows required to breath comfortably while attempting to rest (orthopnea), edema (site, degree of pitting), abdominal distension secondary to ascites, weight gain, adventitious breath sounds, abnormal heart sounds such as gallop and murmurs, activity intolerance, and jugular vein distension. Blood flow to the kidneys is diminished, resulting in oliguria. Oxygen deficit in tissues results in cyanosis and general debilitation (Christensen Kockrow 2011). Education and psychosocial support with justifying According to Washburn and Hornberger (2008) heart failure is a complex, chronic illness often requiring major lifestyle modifications for patients and their families. Nurses play a key role in educating and counseling patients and their families about these changes. Education should be provided to patients about symptom and weight management, dietary and exercise recommendations, and medications. Patient should be taught the signs and symptoms of worsening congestive cardiac failure such as increased dyspnea, development or worsening of orthopnea, weight gain, and exercise intolerance or inability to perform the normal activities of daily living without increased fatigue (Fletcher Thomas 2001). The research shows that up to more than fifty percent of hospital admissions are due to noncompliance with both pharmacologic and non-pharmacologic treatment regimes. Non-pharmacologic therapies include a no added salt diet, which constitutes about two three grams of salt per day. Patients should be instructed to avoid foods containing large amounts of sodium, such as highly processed foods, canned foods, and luncheon meats. A nutrition consult is helpful especially if patient is overweight. Some patients may need to have their daily fluid restricted to 1.5-2.0 liters per day. This is a clinical judgment based on signs of congestion, fluid over load and weight gain. Patients should be instructed to weigh themselves daily or every other day and record the data in a log, which should be taken to every visit with the clinician. A weight gain of two to three pounds should trigger a visit to the clinician. All patients with CCF should be encouraged to exercise to improve overall physical conditioning. The established standard for assessment of physical capacity is an exercise test, which provides objective data regarding exercise time, distance, peak workload, and oxygen consumption (Fletcher Thomas 2001). Washburn and Hornberger (2008) state that it is importance for nurses providing education to patients with heart failure to have an understanding of the drugs used in the management of heart failure. So patient should be taught the name of each drug and its purpose, dosage, frequency, and significant side effects. Patients should be advised to bring all prescriptive and non-prescriptive medications to office visits for review and assessment of patients understanding of them. Nursing diagnoses include interventions, rationale, and evaluations for two short term and two long term goals (use the nursing care plan template) In Mr. Toscana situation, excess fluid volume is the first nursing short term diagnosis as edema, dyspnoea on exertion, and weight gain. The expected outcome for Mr. Toscana is fluid balance. Fluid balance can be demonstrated as peripheral pulses palpable, peripheral edema not present, orthostatic hypotension not present, skin hydration, and body weight stable. To achieve this expected outcome, patient should be weighted daily and monitor trends to monitor fluid retention and weight reduction. Serum electrolyte levels and therapeutic effect of diuretic are monitored to assess as a response to treatment. In addition, respiratory pattern is monitored for symptoms of respiratory difficulty for early recognition of pulmonary congestion. Moreover, fluid balance is monitored by monitoring renal function and intake and output (Brown et al. 2008). The second short term nursing diagnosis is impaired gas exchange as manifested by increased respiratory rate, dyspnoea on exertion and Mr. Toscana states that he has had increasing shortness of breath over the last three days. The evaluation for this diagnosis expects patient breathe easily, dyspnoea with exertion not present, oxygen saturation and respiration rate are in normal range limit. Nursing interventions include respiratory monitoring, oxygen therapy, and positioning. To monitor respiratory, auscultative breath sound, noting areas of decreased or absent ventilation and presence of adventitious sounds, to assess congestion. Dyspnoea and events that improve worsen it are also monitored to detect events that can influence activities daily living. Oxygen therapy such as administer supplemental oxygen as ordered to maintain oxygen levels and change oxygen delivery device from mask to nasal prongs during meals as tolerated sustain oxygen levels while doing activities daily living (Brown et al. 2008). Besides short term diagnosis, Mr. Toscana may be faced with long term effecting due to congestive cardiac failure. Disturbed sleep pattern and deficient knowledge are considered as Mr. Toscana long term diagnosis. Disturbed sleep pattern related to nocturnal dyspnoes, unable to assume favored sleep position, nocturia and manifested by inability to sleep during the night. There are six interventions for this diagnosis. First, determine patients sleep or activity pattern to establish routine. Secondly, patient is encouraged to establish a bedtime routine to facilitate transition from wakefulness to sleep in order to establish a pattern and decrease number of waking periods. Thirdly, adjust environment to promote sleep. Fourthly, regulate environmental stimuli to maintain normal day-night cycles to help promote sleep cycle. Fifthly, adjust medication administration schedule to support patients sleep cycle. Lastly, monitor patients sleep pattern and number of sleep hours to determine hou rs of sleep. Expected outcomes of those nursing interventions are uninterrupted sleep, increase hours of sleep, feelings of rejuvenation after sleep, and vital sign in expected range (Brown et al. 2008). According to Brown et al. (2008) deficient knowledge related to disease process as Mr. Toscana states that he has had a fluid problem frequently come and gone for the last year. Patient expects to descript of disease process, descript of signs and symptoms of complications, and descript of precautions to prevent complications after been educated. Patients current level knowledge related to heart failure is assessed to demonstrate areas of teaching needed. Describe common signs and symptoms of heart failure so patient will know signs and symptom of worsening heart failure. Patient is instructed on measures to prevent or minimize side effects of treatment for the disease as patient may be able to decrease number of acute episodes of heart failure. Family member or significant others encourage to include in teaching to provide support for the patient. (Would like to see the N Diagnostic tests that will assist with the assessment and management of Mr. Toscana According to Christensen and Kockrow (2011) the most noninvasive diagnostic tool for evaluating a patient with heart failure is an echocardiogram. Echocardiography is done to determine valvular heart disease, presence of pericardial fluid, heart failure as the percentage of end diastolic blood volume ejected during systole, and ejection fraction. Secondly, a chest radiograph reveals pulmonary vascular congestion, pleural effusion, and cardiac enlargement. Thirdly, ECG reveals cardiac dysrhythmias. Moreover, pulmonary artery catheterization is done to assess right and left ventricular function. Exercise stress testing is also done to determine activity tolerance and severity of underlying ischemic cardiovascular disease. In addition, laboratory tests include electrolytes, sodium, calcium, magnesium, and potassium levels will assist with the assessment and management of Mr. Toscana. Blood chemistry will reveal elevated blood urea nitrogen and creatinine resulting from decreased glomerular filtration; liver function values will be mildly elevated. BNP, a neurohormone secreted by the heart in response to expansion of ventricular volume and pressure over load, is useful in monitoring chronic heart failure (Christensen Kockrow 2011). Perform a risk assessment on the client drawing on the information provided (examples of risk assessment tools that would be appropriate) Firstly, since depression was a significant predictor of fatigue in congestive heart failure patients, fatigue patterns should be closely monitored. Congestive heart failure patients mood should be monitored for obvious disturbance, and if necessary, they should be referred to mental health or psychiatric practitioners for further assessment and proper treatment (Tang, Yu Yeh 2010). Secondly, according to Brown et al. (2008) nocturia is one of a risk assessment should be performed on Mr. Toscana. A person with chronic heart failure will have impaired renal perfusion and decreased urinary output during the day. However, when the person lies down at night, fluid movement from interstitial spaces back into the circulatory system is enhance. This cause increased renal blood flow and diuresis. The patient may complain of having to void six or seven times during the night. Thirdly, because the tissue capillary oxygen extraction is increased in a person with chronic heart failure, the skin may appear dusky. It may also be cool to the touch from diaphoresis. Often the lower extremities are shiny any swollen, with diminished or absent hair growth. Chronic swelling may result in pigment changes, causing the skin to appear brown or brawny in areas covering the ankles and lower legs (Brown et al. 2008). Discuss two of the medications Mr. Toscana is taking Lasix or Frusemide is one of high-ceiling (loop) diuretics medication. Action of this group is potent diuretics that inhibit sodium, potassium and chloride re-absorption in the proximal and distal renal convoluted tubules, but mainly in the ascending limb of the loop of Henle, resulting in increased water excretion. Frusemide is effective within one hour by oral, peak one to two hours, and duration on six to eight hours (Tiziani 2006). According to Pharmaceutical Society of Australia (2010) one of indications of Frusemide is oedema associated with heart failure and it is reason why Mr. Toscana has been prescribed this medication. Pharmaceutical Society of Australia (2010) shows that non steroid anti -inflammatory drugs (NSAIDs) reduce renal function and may reduce diuretic effect and increase risk of nephrotoxicity. However, low dose aspirin is unlikely to be a problem. The combination of loop diuretics and ACE inhibitors (Perindopril) may increase the risk of ACE inhibitor-induced renal impairment, so renal function should be monitored closely (Pharmaceutical Society of Australia 2010). The first adverse effect of Lasix is fluid and electrolyte disturbances. Secondly, hypovolaemia and dehydration should be considered. The third adverse effect is postural hypotension (Tiziani 2006). Christensen and Kockrow (2011) argue that when patient is prescribed loop diuretic such as Lasix, it should be administered in the morning to prevent nocturia. The second of nursing interventions is monitoring for electrolyte depletion. Thirdly, sulfa allergy is encouraged to consider. Perindopril (Angiotensin-converting enzyme inhibitors) is indicated for heart failure due to Mr. Toscanas situation. ACE inhibitors block conversion of angiotensin I to angiotensin II and also inhibit the breakdown of bradykinin. They reduce the effects of angiotensin II-induced vasoconstriction, sodium retention and aldosterone release. They also reduce the effect of angiotensin on sympathetic nervous activity and as a growth factor (Pharmaceutical Society of Australia 2010). Common adverse effects of ACE inhibitors are hypotension, cough, hyperkalaemia, headache, dizziness, fatigue, nausea and renal impairment (Pharmaceutical Society of Australia 2010). Following Mr. Toscana case, the first nursing point or caution of Perindopril is nurses need to know that heart failure is usually treated with a diuretic and digoxin in associated with ACE inhibitor. Secondly, patient is advised that a low salt diet may be beneficial in reducing blood pressure. However, potassium containing salt substitutes are not recommended because of the increased risk of hyperkalaemia. Thirdly, for patient with congestive heart failure, blood pressure and renal function should be monitored before starting and regularly during therapy (Tiziani 2006). Congestive Cardiac Failure Case Study Congestive Cardiac Failure Case Study Congestive cardiac failure or congestive heart failure can be defined as the inability of the heart muscles to pump enough blood to all parts of the body, for example brain, liver and kidneys. Heart failure can develop slowly over time as the result of other conditions (such as high blood pressure and coronary artery disease) that weaken the heart. It can also occur suddenly as the result of damage to the heart muscle.(university of Maryland medical center 2014) Congestive heart failure affects several organs in our bodies and it includes, heart, kidneys, lungs, brain, liver, skin and spleen. Then organ systems that are affected are, cardiovascular system, respiratory system, nervous system, circulatory system skeletal system, and urinary system A brief overview of the normal functioning of the affected body systems. one of the body systems that is affected with congestive heart failure is the cardiovascular system, this system consists of heart, blood vessels and blood. Its responsible for pumping blood through the body as well as oxygen, nutrient, hormones and cellular waste. It regulates blood pressure through the contraction of the heart pumping and also helps to maintain fluid balance within the body. The main function of respiratory system is to supply blood rich in oxygen to all parts of the body. The respiratory system does this through breathing. When we breathe, we inhale oxygen and exhale carbon dioxide. This exchange of gases usually takes place in the alveoli and the capillaries. The inhaled oxygen passes into the alveoli and then diffuses through the capillaries into the arterial blood. Meanwhile, the waste-rich blood from the veins releases its carbon dioxide into the alveoli. The carbon dioxide follows the same path out of the lungs when you exhale. The circulatory system has its main functions as to pump blood containing oxygen and other nutrients around the body. the system consists of the heart, arteries, capillaries and veins. The heart, the lungs, and the blood vessels work together to form the circle part of the circulatory system, the circulatory system contains of two loops of circulatory, the pulmonary circulation which transports de-oxygenated blood from the right atrium and right ventricle to the lungs to pick up oxygen and nutrients and returns to the left side of the heart. The systemic circulatory which transports blood rich in oxygen from left side of the body and transports it all the body tissues. The circulatory system control the pressure of the blood as it travels through the body and taking away the wastes The urinary system consists of the kidneys, bladder, ureters and urethra. its main function is to filter metabolic wastes, excess ions, and chemicals from the blood to form urine. They also maintain the homeostasis of several important internal conditions by controlling the excretion of substances out of the body.through this it regulates the blood pressure. After the whole process of urine formation is completed the ureters carry urine to the urinary bladder and later discharged in the urethra. The nervous system consists of brain, spinal cord, sensory organs, and all of the nerves that connect these organs with the rest of the body. Together, these organs are responsible for the control of the body and communication among its parts. Neurons transmit information through electrical signals to the brain. chemical help to bridge gap between one neuron and the other. there are several signs and symptoms of heart failure and they are discussed here below: Shortness of breath. This is one of the signs and symptoms of heart failure, this happens due to the back up of blood in the pulmonary veins which leads fluid to leak and build up in the lungs because the heart cant keep up with the supply. Tiredness or fatigue. This happens because the heart cant keep up with the demand of supply of blood to all the body tissues so u feel tired because its being overworked. Edema. There build up of excess fluids in the body parts because the heart cant pump all the blood as a result there is the excess build up of fluids. there is slow cardiac output. Persistent coughing or wheezing due to the build up fluids in the lungs as a result of heart not pumping all the blood out of the lungs. Lack of appetite , nausea this occurs because there is less cardiac out as a result less blood reaches the digestive system which cause problems with the digestion process. Confusion. This is one of the symptoms and the reason behind is because there is less cardiac out the nutrients also is less and not enough for the body tissues, which will lead to less nutrients like sodium which will lead to someone having confusions and impaired thinking. Tachycardia. This is one of the signs and symptoms of heart failure. The increased heart rate is due to the heart pumping harder to meet the demands of supply of blood and nutrients to the rest of the body which is not enough.(American heart association 2014) sudden weight gain from fluid retention. Chest pain if the heart failure is caused by heart attack. Elevated blood pressure due to tachycardia as a result heart trying to pump more blood to other parts of the body. When critically analysing Mr wrights admission form it clearly indicates signs and symptoms of congestive cardiac failure. his circulation is not okay because he suffers from peripheral vascular disease which it can easily contribute to heart failure. secondly considering the loss of appetite which can be attributed to low blood supply to the digestive system. Checking his oxygen saturation levels which are low due to the heart failing to pump lots of blood out of the lungs which can lead to leak of fluids in the lungs. another sign is the confusion. Despite him having dementia but have low cardiac out supply to the rest of the body tissues can lead to confusion which is also a sign of heart failure. Well diabetes might be related to his leg ulcer considering the fact that patients who are diabetic at a certain stage they may have reduced sensation of the skin on there feet. They are nerve endings on the skin usually fails to detect any pain or sensation and as a result it can be a high risk of leg ulcer if the patient has a cut or blister on the feet it can easily develop to leg ulcer which can if its serious it may lead to amputation. for his case it might have played a role. In patients who are diabetic there might be poor circulation of blood to the feet which might be a contributing factor to his leg ulcer and finally the amputation of the left toe. Lasix (furosemide) is a diuretic (water pill) that prevents your body from absorbing too much salt, allowing the salt to instead be passed in your urine(drug14).if you got excess fluids it helps to reduce them. it treats fluid retention in people with congestive heart failure, kidney problems and liver diseases. He is given the drug in order to get rid of the excess fluids retention. the systems affected by this drug re cardiovascular and urinary system. Conditions that are commonly associated with aging according to Mr wrights relevant medical history. Arthritis the inflammation of the joints, and creates pain and stiffness when moving these joints. Osteoarthritis is the most common in the elderly. when cartilage is damaged or worn out the bone rub on each other causing friction which causes pain when moving the joints. diabetes mostly type 2 which affects the older people though young people Can also develop it. The risk of developing type 2 diabetes increase with age mostly over 55 years of age. Its where the pancreas produces insulin but its not sufficient enough to work effectively. Glaucoma is an eye diseases that results to blindness in the elderly especially over 80 years. Its a group of eye disease in which the optic nerve at the back of the eye is slowly destroyed. Poor blood supply to the vital optic nerve can lead to glaucoma.(glaucoma2014) Factors that may impact his safety whilst in hospital and when he returns home. Checking through his admission history and assessment increased level of confusion can be one of the factors that can impact his safety. He fails to remember because the low blood supply and low oxygen levels in the body which fail to supply enough to the brain and as a result this will lead to increased levels of confusion. He may not remember why he is in hospital, he may forget to take his medications as prescribed the correct dose at the right time and this is likely to occur when he is at home. Mr. Wright is receiving meals on wheels while he is at home, because of his loss of appetite as a result of congestive heart failure he may not take his meals and he can be at a risk of being malnutrition, which will eventually lead to a high falls risk because he will not have the strength and energy to walk. From the assessment it seemed he cared for his dog and as a result of being hospitalised he his anxious about the dog which can lay an impact on his safety. He is not settled at all and it may increase risk of more complicated health problems considering he has congestive heart failure. he worries a lot about the dog wondering who is going to care for it yet he is not well. While he is at home because of the level of consciousness which at time deteriorate he might just forget to walk with the walking stick at all times and combine with the nutritional problems he might be of high falls risk. Because he got glaucoma this might also play a role considering his safety back at home which can have a huge impact on hi mobility. Other health professionals that can be involved in Mr Wrights can and what services they can provide Dietician because he is diabetic and has lost appetite, the dietician would assess and provide the best solution to help improve his appetite. Physiotherapist would also be involved in Mr wrights care to assesses the mobility levels and recommend the best way of care he needs as fur as mobility is concerned. he would check if he is a high or low falls risk and provide the best tool to aid mobility. Optometrist would also be involved in his care, he would assess the level of glaucoma and check if its worsening or getting better and the likely impacts it can have on his levels of mobility. From the medical history he has dysphagia the speech pathologist will be involved to assess his level of swallowing if the problem is worsening or it has improved and make necessary recommendations so that when he goes home the meals on wheels can supply him with the recommended type of food that he can tolerate. An occupational therapist would also be involved in his care he or she will come in handy to assess the hazard at home and all the id tools that he requires in order to reduce any risk of injuries occurring at home. For example He may assess and recommend commode at night to avoid the walking to the toilet at night in order to reduce the risk of falling. A social worker will also be involved in his care considering he is at home alone with his dog, he might need home visits where the social worker will check how he is coping in the community and assess if he is socially isolated or he gets involved in the society, if family and friends visit him at all. The nursing documentation expected to be used in the care of MR. Wright are as followed. Admission form and passed medical history form. medications chart nursing care plan. progress notes allied health chart, ECG charts, observation charts fluid balance chart and bowel chart. References University of Maryland Medical Center 2014 viewed 18th sept 2013 http://umm.edu/health/medical/reports/articles/heart-failure#ixzz3CXXtD2EZ Virtual medical center 2014 last reviewed 7th may 2010 respiratory system http://www.myvmc.com/anatomy/respiratory-system/ Cardiovascular system the inner body last viewed 2013 http://www.innerbody.com/image/cardov.html Urinary system the inner body last viewed 2013, http://www.innerbody.com/image/urinov.html#full-description Nervous system the inner body last viewed 2013 http://www.innerbody.com/image/nervov.html#full-description American heart association (2014) warning-Signs-for-Heart-Failure last reviewed 20/8/2012 http://www.heart.org. Australia, Diabetes. (2014, January 6). Diabetes and Your Feet. Retrieved from Australia Diabetes: https://www.diabetesaustralia.com.au/Living-with-Diabetes/MindBody/DiabetesYour-Feet/ Drugs.com. (2014). Retrieved from Lasix: http://www.drugs.com/lasix.html Australian institute of health and well being (2013)osteoarthritis http://www.aihw.gov.au/osteoarthritis/ Gabrielle K, Kate S and Jodie H (2013)theory and practice Tabbners nursing care 6th edition. Glaucoma Australia (2014)Retrieved from Glaucoma http://www.glaucoma.org.au/what.html. The human heart circulatory system:(2014)retrieved from Franklin institute: http://learn.fi.edu/learn/heart/systems/circulation.html