Discuss About The International Journal People Older Nursing.
Congestive heart failure (CHF) affects the pumping capacity of the heart muscles and is a chronic progressive condition. CHF refers to the specific stage where the fluids build up around the heart resulting in ineffective pumping. The blood is unable to move efficiently through the circulatory system, increases the pressure in the blood vessels and as a result, forces fluid out of blood vessels into the body tissues (Roger, 2013). The symptoms depend on the body area that is mostly involved in the reduction of pumping action. CHF is caused by health conditions that direct affect the cardiovascular system like coronary heart disease, hypertension, cardiomyopathy and abnormal heart rhythms (Damasceno et al., 2012). The patient has high blood pressure (170/110 mmHg) that forces the heart to work harder for circulating the blood. This extra exertion management the heart muscles become too weak or stiff in order to pump blood effectively. The damage to the heart or cardiomyopathy makes the heart muscle become thick, enlarged or rigid making it hard for the heart to pump blood throughout the body (Hall, Levant & DeFrances, 2012).
In the given case study, the patient has a history of myocardial infarction (MI) that caused sinus bradycardia making the heart weak. CHF is frequent in patients who have a history of MI and is a clear manifestation of acute alternations that occur in left ventricular functioning. The individuals who have acute myocardial infarction with no complications are likely to be prone to CHF. The left ventricular dysfunction causes the heart failure progression and this left ventricular dysfunction contributes to arrhythmic substrate (Heusch et al., 2014). Therefore, in the given case study, the risk factors for the patient are high blood pressure and myocardial infarction that contributed to the CHF condition. As mentioned in the case study, Mrs. Mckenzie forgets to take her medicines that aggravated the MI condition resulting in CHF.
CHF is a significant burden for the Australian healthcare system where ~50-75% is diagnosed with the disease and 1-3% healthcare spending. Cardiovascular diseases (CVDs) affect every one in six Australians that is equivalent to 4.2 million resulting in 490,000 hospitalizations during the year 2014-2015. About 30% of the deaths that occurred during the year 2015 were largely preventable (Atherton et al., 2012).
CHF is a personal tragedy for the patients and their families. The individuals with CHF have impaired Quality of Life (QOL) as compared to a healthy population. This poor QOL has a multidimensional impact on the daily living and treatment of the patients (Yeh & Bull, 2012). The unpredictable symptoms leave patients helpless and dependent on others with lack of motivation. There is lack of control over the illness and a burden on the healthcare system. There is burden on the family members while taking care of the patients with heart failure, as there is a great responsibility for care. There is also financial burden on the family members due to expenditures related to patient’s care. These factors greatly have a psychological and economic impact on the patient and their family members. In addition, these factors affect the patient’s well-being and family functioning (Burton et al., 2012).
The symptoms of cardiac failure are seen when the heart is unable to pump enough blood to the rest parts of the body. This does not mean that heart is not working rather pumping power is weak than normal. The blood moves to the body at slow rate and as a result, the blood pressure increases. In this situation, the heart is unable to pump enough nutrients and oxygen to meet the needs of the body. The chambers of the heart stretch hard to hold more blood for pumping through the body and as a result, the heart walls become eventually weak and stiffness prevails (Kemp & Conte, 2012). Although, the blood keeps moving, the heart wall muscles become unstable and weak to cause efficient blood pumping. As a result, the kidneys causes retention of water and fluid by responding to this situation that builds up in the ankles, legs, lungs, feet and other organs. Eventually, the body comes in a congested state and heart failure describing CHF.
During the early stages, the patient may feel tired with shortness of breath, dizziness, mild nausea, swollen ankles and irregular heartbeats. Mrs McKenzie manifested these symptoms in the given case scenario. In CHF, the fluid backs up in the lungs that interfere with the oxygen uptake into the blood that may result in shortness of breath or laboured breathing. This lung congestion can also cause wheezing or hacking cough (Ambrosy et al., 2013). Nausea or loss of appetite is another symptom that is caused by water and fluid retention as less blood flows to the kidneys (Marti et al., 2012). This results in swollen ankles or oedema as Mrs. Sharon reported that she has to wear bed socks as she complains about her cold feet. There is less pumping of blood to the major organs and muscles that makes the patient feel weak and tired. In addition, there is also less blood reaching brain that causes confusion or dizziness.
The class of drugs used for heart failure are shown to be effective in many ways where one drug treats a different contributing factor or symptom. Among all, ACE inhibitors (angiotensin converting enzyme) are the best medicines for hypertension treatment and extensively used for CHF. The drug has the potentiality to blocks the Angiotensin II formation as it has adverse effects on heart and its circulation. ACE inhibitors can be helpful for Mrs. McKenzie as it demonstrates remarkable improvement in symptoms, prevention of the clinical deterioration and survival prolongation (McMurray et al., 2013). ACE inhibitors are vasodilators that relax the smooth muscles in blood vessels and make them dilate. The dilation of arterial vessels results in reduction of systemic vascular resistance that in turn results in arterial blood pressure fall. The dilation of venous vessels significantly decreases the venous pressure. ACE inhibitors cause vasodilation by inhibiting the vasoconstrictor, Angiotensin II formation. ACE breaks the vasodilator, bradykinin by blocking its breakdown and increasing its levels contributing to vasodilation action (Yancy et al., 2016). In CHF, AC inhibitors reduce the after load that enhances the stroke volume and ejection fraction improvement.
Captopril, benazepril and drugs like lisinopril are used widely for CHF. These drugs also reduce the preload that in turn decreases the systemic and pulmonary congestion. There is also reduction in sympathetic activation that is deleterious in CHF. The cardiac remodeling is reduced through angiotensin II prevention and as a result, oxygen supply is improved by decreasing demand in preload and after load (Lapi et al., 2013).
Cardioinhibitory drugs are another class of drugs that contains beta-blockers. This class of drugs depresses cardiac function that decreases heart rate, myocardial contractibility that in turn decreases the arterial pressure and cardiac output. Although, it may be counterintuitive that this class of drugs is used in CHF, clinical studies have shown that beta-blockers improve cardiac function. The benefit of this drug is that it is derived from their blockade of sympathetic influences on heart that is harmful to the failing cardiac condition. Beta-blockers are beta-adrenoceptor antagonists that bind to these receptors that are located in the cardiac nodal tissue, contracting myocytes and conducting system (Swedberg et al., 2012). Beta1 (β1) and beta2 (β2) adrenoceptors are present in the heart, although, Beta1 (β1) is the predominant receptor type that binds to norepinephrine released from sympathetic adrenergic nerves. They also bind to epinephrine and norepinephrine circulating in the blood and thus, preventing their normal ligand from binding to beta-adrenoceptor. They act as competitors for the binding site and significantly reduce the sympathetic influences. Moreover, it reduces the elevated sympathetic activity and is relatively selective β1 or non-selective (β1/β2) blockers (Vanhoutte & Gao, 2013). Therefore, these classes of drugs are shown to improve the heart’s function and prolong life in case of Mrs. McKenzie.
The main nursing priorities within first 24 hours post emergency department (ED) admission of Mrs. Mckenzie is aimed at alleviation of symptoms by accurately recognizing the signs and symptoms and managing the exacerbated state. Immediate assessment and triage is required as there is acute shortness of breath, nausea, dizziness, weakness and irregular heartbeats. The nursing goals for the patient comprises of management of acute breathlessness or instability in cardiopulmonary status through ongoing monitoring and management. After the diagnosis of CHF, diuretics can be given to the patients for relieving dyspnoea (Shchekochikhin et al., 2013). The diuretic is given at the lowest dose for the reduction of fluid congestion and balancing the positive action with negative effect on the functioning of kidney.
Careful monitoring of renal functioning, urine output and fluid is required. Most importantly, there is need for ongoing monitoring of patient response to treatment, stability in cardiopulmonary status and need for close monitoring of haemodynamic parameters. During the immediate stabilization period, the vasodilators and diuretics may lead to hypotension and therefore, monitoring of early warning scores and vital signs need to be summed and monitored to get a single composite score (Hung et al., 2014).
For arrhythmia, the cardiovascular functioning analysis is important along with monitoring of patient’s exertion. The regularity and frequency of pulse need to be observed for any sort of alterations. The level of consciousness of the patient also needs to be observed for verifying the signs of arrhythmia (Bardy, 2013). The patient needs to be appropriately positioned on the bed and reduction in physical exertion. The fluid volume need to be controlled and monitoring of cardiac rate.
For stabilizing the functional dyspnoea, the nurse should monitor the respiratory rate (abnormal 30 breaths per minute) and hemodynamic status. The pulmonary conditions need to be examined and the nurse should observe the pulse oximetry levels if less than 90%. There should be monitoring of level of consciousness, pulse, body temperature, arterial pressure and breathing pattern to look for any abnormal vital signs (Yancy et al., 2013). As she is having cold and swollen feet, the nurse should control water intake and evaluate the extent of water retention in the body. The signs like oedema, cold skin and pulmonary congestion need to be monitored and the nurse should warm the limbs and reduce the risk of injury.
The nurse should look for the signs of dizziness, weakness and hypoperfusion along with monitoring of presence of sudden dyspnoea. The patient needs to be positioned properly in bed with monitoring of oxygen saturation levels above 92%. Most importantly, the water intake of the patient needs to be reduced to avoid further congestion. The inter-disciplinary team comprises of skilled heart failure team like nurse specialist, cardiologist and ward nurses (Mebazaa et al., 2015). They perform close monitoring and management of CHF of the patient to stabilize his condition, reduce hospitalization length and prolong survival providing a better quality of life. The systematic care by nurses that is based on evidence-based practices can help to reduce the negative impact of CHF and other cardiovascular complications on the patient outcomes.
References
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