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’.
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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 daughter’s 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, CABG’s 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 body’s 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 ventricle’s 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 patient’s 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 patient’s 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 patient’s sleep cycle. Lastly, monitor patient’s sleep pattern and number of sleep hours to determine hours 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. Patient’s 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.
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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. Toscana’s 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).
