According to the case study, patient is suffering from chronic heart failure which is characterized by a medical condition of low cardiac output and increased venous pressure. Her blood pressure is marked as 135/70 mmHg, respiration rate 32, pulse rate 98, O2 saturation level 89% and temperature noted as 36.6º C. Since she complained for shortness of breath and fatigued; and also, lower level of O2, therefore 2 litres of oxygen were given via nasal prongs. There can be 3 basic elements behind chronic heart failure;
These combined effects are known as “Neurohumoral mechanisms”. This mechanism can be categorized based on their effects, i.e., regulatory mechanism which involves vasoconstriction, sodium retention, inotropism and proliferation; and counter regulatory mechanism which involves the opposite effects (Obrezan & Kulikov, 2017). This ultimately leads to heart failure. Heart failure can be characterized by the inability of heart to pump blood as an adequate amount to the body. If there is not enough supply of blood flow to the body, all the body functions get disrupted and heart becomes stiffen and weak which eventually leads to the “Heart failure” (Messerli, Rimoldi & Bangalore, 2017).
Pathophysiology is a complex changes occurring in the body in relation to the disease process. This involves structural changes, apoptosis, loss of myofilaments and cytoskeleton disorganization, disturbed Ca2+ homeostasis, altered receptor density, collagen synthesis and receptor density. Heart failure is considered as a progressive disorder in which left ventricle remodelling is being effected. This clinical complication can be characterized by circulatory congestion and weakened cardiac function. New evolving therapies are designed to inhibit cytokine and neuroendocrine activation (Aimo et al., 2020). There are also drugs designed which can increase cardiac contractility. Based on Neurohormonal hypothesis, modern treatment for chronic heart failure is responsible for neuroendocrine activation which is important in terms of advancement of heart failure and neurohormone inhibition. In regards to morbidity and mortality, this can have a long term benefits. Thus, further studies based on clinical trials would help to understand the fundamental biology of this chronic disorder, i.e., basic science to clinical investigation (Gabriel-Costa, 2018).
To understand pathophysiology of chronic heart failure, one need to understand the signs and symptoms related to the underlying condition such as high blood pressure, sweating, irregular heartbeat, irregular pulse rate, low levels of oxygen saturation, low cardiac output and may be accompanied with many other symptoms mentioned in this case or beyond that. Patient is being advised for ECG and chest radiography which is being clinically correlated with BNP, NT- pro BNP or MR- pro ANP. If ECG report is normal and BNP <35 pg/ ml or NT- pro BNP <125 pg/ ml, then there are rarely any chances of heart failure. If ECG report is abnormal, BNP ≥ 35 pg/ ml or NT- pro BNP ≥ 125 pg/ml, then Echocardiography is to be done. If no cardiac dysfunction detected, then heart failure is unlikely to happen. If cardiac dysfunction is confirmed, then there is a high probability of heart failure (Brahmbhatt & Cowie, 2018). Hence, treatment plan must be recommended and followed as early as possible.
Bilateral oedema is a generalized systemic cause of swelling of legs which can be the cause due to chronic heart failure. This complication is generally accompanied by many other symptoms such a pulmonary hypertension, hepatic disease or chronic renal failure and severe malnutrition. Oedema in legs is caused due to fluid retention or fluid build- up in legs which can be because of prolonged standing or sitting and also can be due to injuries. This leads the legs to be swollen. If this oedema problem is not treated early, it can increase swelling which can be painful, cause’s difficulty in walking, stiffness, itchy skins, skin ulceration and low level of blood circulation. Since, Mrs. Yindi is an Aboriginal woman of 68 years of old age lady, she may be suffering from severe malnutrition too along with other mentioned health complications which leads to the cause of oedema. Usually, mild oedema goes away by its own but in case of severity, drugs may be prescribed for expelling excessive fluid retention from the body through urination (Mullens et al., 2019). Another accompanied condition with oedema is nocturia, i.e., frequent urination at night which may be due to excessive intakes of fluid, sleep disorders and ageing (Dutoglu et al., 2019). To treat nocturia, excessive fluid intakes may be restricted mostly after evening time, managing diuretics and elevating legs. Because of this overall condition and complication, the patient may be feeling shortness of breath and fatigued (Kowalik et al., 2018).
Assessment for patient with Heart failure is mainly focused by observing the therapy effectiveness and the ability of the patient so that self- management strategies can be understood and implemented. At first history of the patient is being assessed for different signs and symptoms like shortness of breath, dyspnoea, fatigue, oedema and disrupted sleep. Understanding the heart failure condition of the patient, self- managing strategies, the ability of a patient and a willingness to follow the management strategies is done. Physical examination is done to assess any crackling or wheezing sounds from the lungs, assessing different parts of the patient’s body, evaluating the level of sensorium and consciousness, measuring urinary output and assessing diuretic therapy effectiveness. Weight of a patient is a must to check regularly whether in hospital or at home (Rice, Say & Betihavas, 2018).
According to Registered Nurse Standards of Practice, Principle 3.1b is the ICN code of ethics considered for the Aboriginals people. This principle advocates for facilitating access to various health services maintaining its quality and safe cultures. When patient is admitted in hospital, she must feel safe and respectful according to this code of conduct (Milligan et al., 2021). Nurse’s framework must include her in decision- making of her treatment plans and outcomes, which should be culturally safe for her and also providing care and support while she is in hospital admittance (Oldland et al., 2020). Patient must be aware of health services provided to her being an Aboriginal Islanders people. Nurses/ supporting staff must teach her regarding culturally safe health practices and diet plans for better outcome of her well- being and health. For patient- centric and evidence- based treatment decision of the patient, Registered Nurse Standards of Practice, code of conduct Principle 2.1 is applicable for safe practice treatment. This implies that nurses should treat the patient as a person- centered and it should be evidence- based decision- making and the outcome must maintain safety and quality for her complete assessments and treatment evaluation (Nursingmidwiferyboard, 2021). Therefore, complete nursing intervention must be carried out by nursing staff with proper care and support with appropriate diet plans, regular exercises, mental or psychological support if and when needed.
Following the assessment data, diagnosis for the patient is done by the nurses. Diagnosis of the patient includes (Belleza, 2021):
The care plan is important and must focus on the treatment goal:
Nursing interventions for the Heart failure patients is mainly focusing on the management of patient’s activities and excessive fluid retention in the body.
Following interventions are to be focused:
National Safety and Quality Health Service Standards (NSQHS) are to be maintained by the Health Service Organization of Australia. This Organization is responsible for providing safe and quality- based care and treatment that patient is expecting to get for her treatment. This standard works in collaboration with the Australian Government, States, Territories, Clinical experts, Patients and Care- givers. Based on the NSQHS Standards, the primary aim is to provide enough support and care to the patient and her needs, also to protect her or other patients from any harm (Redley & Raggatt, 2017). This also maintains to improve the Health Services which is being provided to the patient. According to NSQHS, Action 5.14 is to be considered for this patient with Chronic Heart Failure. This Action includes comprehensive care plan for the patient disease assessment, diagnosis, treatment interventions and Plans, goals or outcomes of the treatment strategies. Comprehensive care plan directly implies safe delivery of treatment and effective care and support according to the patient’s needs and requirements. This plan also suggests to reassess patient’s preferences, diagnosis, behavior, mental, emotional or psychological conditions if occur, needed to be delivered as early intervention strategy. Comprehensive care plan also involves teaching practice and training programs to be provided for clinicians, health workers, nursing staffs and other staffs so that they can understand the roles and responsibilities assigned to them to deliver care and support to the patient (NSQHS, 2022).
Though prognosis of Heart failure has increased since past two decades by various advent therapies such as Angiotensin- converting enzyme (ACE) blockers, Beta blockers, and Cardiac resynchronization therapy devices (CRT); but nursing care is much more important along with these promising treatments therapies. Different nursing care and intervention, specifically for older age patient, self- care management, physical exercises, routine nursing care and support, emotional and mental support is very important for better outcome of the patient.
For the expected better outcome of the patients, evaluation of the complete assessment is the most important part from clinical aspects as well as from the aspects of patient outcome.
Following parameters must be cross- checked and evaluated:
Therefore from overall aspects, proper nursing assessment, diagnosis of the health complications, treatment intervention and plan, appropriate evaluation of complete assessment in regards of patient disease is utmost important from the perspectives of clinical management, clinicians, health workers, nursing staffs for the better outcome of the patient and their family members or care- givers.
References
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https://doi.org/10.1016/j.archger.2019.103917
Gabriel-Costa, D. (2018). The pathophysiology of myocardial infarction-induced heart failure. Pathophysiology, 25(4), 277-284. https://doi.org/10.1016/j.pathophys.2018.04.003
Kowalik, C. G., Cohn, J. A., Delpe, S., Reynolds, W. S., Kaufman, M. R., Milam, D. F., … & Dmochowski, R. R. (2018). Nocturia: evaluation and current management strategies. Reviews in urology, 20(1), 1.
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Messerli, F. H., Rimoldi, S. F., & Bangalore, S. (2017). The transition from hypertension to heart failure: contemporary update. JACC: Heart Failure, 5(8), 543-551. https://www.jacc.org/doi/abs/10.1016/j.jchf.2017.04.012
Milligan, E., West, R., Saunders, V., Bialocerkowski, A., Creedy, D., Minniss, F. R., & Vervoort, S. (2021). Achieving cultural safety for Australia’s First Peoples: a review of the Australian Health Practitioner Regulation Agency-registered health practitioners’ Codes of Conduct and Codes of Ethics. Australian Health Review. https://doi.org/10.1071/AH20215
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