Congestive Heart Failure Introduction Of Patient Nursing Essay.
This cases study was conducted on February 13th, 2012. This patient will be identified by the initials AH throughout this paper. AH is a 91-year-old Caucasian female. Her mood is as expected for her age and culture. This patient agreed to work with me during her hospital stay and continuation of follow up information after discharge. AH was admitted to the hospital on February 09th, 2012 onto the medical floor. This patient was brought into the emergency department by her son, DH, at approximately 9:00 a.m. on February 09, 2012. AH stated she had an increase of shortness of breath, weakness throughout her body, and her ankles were swollen. When asked about the history of these symptoms, AH stated these symptoms have been present since Sunday February 05, 2012.Congestive Heart Failure Introduction Of Patient Nursing Essay.
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AH went into the doctors office in her hometown and was told to go into the emergency department at the hospital by the physician. On assessment at the emergency department, AH had a temperature of 96.9 degrees Fahrenheit, a pulse of 130 beats per minutes, respirations of 20 breaths per minute, blood pressure of 192 systolic over 105 diastolic, and a pain level of 0 out of 10 on the pain rating scale. Assessment findings were crackles, bilaterally with auscultation, a non-productive cough occasionally, irregular heart rate, 3+ pitting edema bilaterally in lower extremities from the knee down and in feet. This patient had a delayed capillary refill and neck vein distension. AH also had palpable pulses with upper extremity pulses being strong and lower extremity pulses being weak.Congestive Heart Failure Introduction Of Patient Nursing Essay. This patient was admitted with congestive heart failure and atrial flutter with rapid ventricular response. This patient has a history of hypertension, arthritis, hard of hearing, occasional urinary tract infections and had a myocardial infarction in 1990. AH had two previous surgical procedures in her life. She has had a left hip replacement in 2006 and a right hip replacement in 2007. AH denies any significant family health history. She also denies any current use or history of alcohol consumption, tobacco use, or drug use. She is not on any supplemental oxygen at home. AH was able to state name, dose, and reason for home medications. These medications are Bumex “water pill” 1 MG orally taken daily, Clonidine “blood pressure pill” 0.1 MG orally taken three times a day, Metoprolol “blood pressure pill” 50MG orally taken daily, and Nitroglycerin “for heart” 2.5MG orally taken two times a day.Congestive Heart Failure Introduction Of Patient Nursing Essay.
I was able to do a total head to toe assessment on February 13, 2012. AH is 182.90 pounds, 60.00 inches tall, and has a body mass index of 35.72. AH is categorized as obese with this body mass index result. This patient is alert and oriented to person, place, and time. This patients pupils are equal, responsive, and reacts to light upon inspection. AH does have slight pitosis of the right upper eyelid. This patient does wear eyeglasses to read. Her total Glasgow Coma Scale is rated at a 15 out of 15. This is a perfect score and shows no impairments. This patient communicates verbally with no problems.Congestive Heart Failure Introduction Of Patient Nursing Essay. AH has full movement in all four extremities and has intact circulation, movement, and sensation. When asked about history of falls, AH stated she had no current or past falls. Her skin is pink, warm, and dry without diaphoresis but has slight purplish discoloration bilaterally on shins from knee to ankle. When assessing AH respiratory status, she stated that she was not experiencing any distress or shortness of breath currently but does experience this with exertion. AH is not on any supplemental oxygen. Her oxygen saturation was at 94% on room air. Upon auscultation this patients lungs were clear bilaterally in upper lobes and diminished bilaterally in lower lobes. Her respirations were at 16 breaths per minute. Her chest configuration is symmetrical. I did observe a weak non-productive cough occasionally during this assessment. During the cardiovascular assessment, apical pulse was 84 and her radial pulse was 80. This showed a pulse deficit of 4 beats per minute, which could be due to the irregular heartbeat (atrial flutter) with the rapid ventricular response. Patient was on telemetry to monitor for abnormalities during admission. S1 and S2 were heart upon auscultation.Congestive Heart Failure Introduction Of Patient Nursing Essay. AH had a blood pressure of 167 systolic over 82 diastolic on her right upper extremity. AH did have distended neck veins upon inspection, which is a sign of congestive heart failure. AH denied any chest pain. This patient does not have any implanted cardiac defibrillator or pacemaker. This patients abdomen was soft and non-tender with bowel sounds active in all four quadrants. She is on a low sodium diet and states that she does follow the diet restrictions but when asked about exact amount of allowed sodium intake patient did not know. During her hospital stay AH was on a fluid restriction of 1.5 liters per 24 hours. Patient was able to adhere to fluid restriction but states she is on no fluid restriction at home. AH is continent of stool and urine but had Foley catheter in place per physician orders. AH is full weight bearing and has a steady gait but does use a walker for an assistive device while at the hospital. AH states she uses a wheelchair at home. AH has active range of motion and shows no limitations or discomfort within normal limits. AH was under no precautions or isolation. She had five different medications that I administered to her during her admission to the hospital that ranged from antibiotics, hypertension medications, to diuretics. These will be discussed individually in the following systems breakdowns.Congestive Heart Failure Introduction Of Patient Nursing Essay.
When asked about cancer screenings, AH denied any annual appointments. AH stated that she was not worried about this currently. AH also does not obtain influenza or pneumococcal vaccines annually and her last tetanus vaccine was unknown. From observation, this patients health promotion is low and patient may need education on importance to her health.Congestive Heart Failure Introduction Of Patient Nursing Essay. When assessing this patients home life, AH stated she has never had any physical or emotional abuse. AH lives at home with her son DH. Her husband passed away several years ago so she arranged for her son to come live with her. DH provides transportation and assistance with activities of daily living for AH. She has a loving relationship with her son and he assists her with medical decisions. She states she is not afraid of her living situation. AH complied with medical regimen and asked questions when she was not sure of the situation. When asked about the history of her congestive heart failure and length of time she has been diagnosed, AH did not understand that she had congestive heart failure and did not know how long she has had this condition. She stated she would speak with her new physician. She will be set up with a new primary physician since she does not currently have one. With this information, this indicates an need for additional information about primary condition due to deficient knowledge stated by patient.Congestive Heart Failure Introduction Of Patient Nursing Essay.
Pathophysiology of Congestive Heart Failure
The heart, blood vessels, and blood are components that make up the cardiovascular system. The pumping action of the heart consists of contraction and relaxation of the myocardial (muscle) layer of the heart. Each contraction and relaxation that occurs consists of one cardiac cycle. During diastole (relaxation), the ventricles fill with blood. Systole (ventricular contraction) then occurs, which propels the blood out of the ventricles and into the circulation. Cardiac performance can be calculated by measuring the cardiac output. Cardiac output is the amount of blood moving through either systemic or the pulmonary circuit per minute. (Huether & McCance, 2008) Cardiac output is calculated by multiplying stroke volume (volume of blood ejected per beat during systole) and heart rate. The amount of blood a ventricle ejects during the cardiac cycle is called ejection fraction. Ejection fraction is calculated by stroke volume divided by end-diastolic volume (blood left in the blood after diastole). The normal ejection fraction is from 50%-70%. A decrease of ejection fraction is a hallmark sign of ventricular fraction, such as left-sided heart failure. The factors that determine cardiac output are preload, afterload, contractility, and heart rate. Preload is the volume and associated pressure generated in the ventricle at the end of diastole (ventricular end-diastolic volume). Preload is determined by the amount of venous return to the ventricle and the blood left in the ventricle after systole (end-systolic volume). Afterload is the resistance the heart has to overcome to eject blood from the left ventricle.
Heart failure is a term for the inability of the heart to work effectively as a pump. It results from different acute and chronic cardiovascular problems. The major types of heart failure are left-sided heart failure, right-sided heart failure, and high-output heart failure. The focus of this case study will be on left sided heart failure.Congestive Heart Failure Introduction Of Patient Nursing Essay.
Most heart failure starts out with failure of the left ventricle and progresses to both ventricles failing. Typical causes of left-sided heart failure are hypertension, coronary artery, and valvular disease. Decreased tissue perfusion from poor cardiac output and pulmonary congestion indicate left ventricular failure. Left-sided heart failure is also known as congestive heart failure; however not all cases of left ventricular failure involve fluid accumulation. Left-sided heart failure can be further broke down to systolic heart failure and diastolic heart failure. (Ignatavicius & Workman, 2010)Congestive Heart Failure Introduction Of Patient Nursing Essay.
Systolic heart failure happens when the heart is unable to contract forcefully enough during systole to eject sufficient amounts of blood into the circulation. Preload increases with decreased contractility, and afterload increases as a result of increased peripheral resistance in the vascular spaces (hypertension). The percentage of blood ejected from the heart during systole (ejection fraction) drops from the normal range (50%-70%) down to 40%. As this percentage decreases, tissue perfusion decreases and blood backs up into the pulmonary vessels. This creates symptoms of systemic and pulmonary congestion. Diastolic heart failure occurs when the left ventricle cannot relax enough during the rest period. When the ventricle cannot relax enough, stiffening of the ventricle occurs and prevents the ventricle from filling up with sufficient blood to ensure adequate cardiac output. This ventricle becomes less compliant because more pressure is needed to move the same amount of volume compared to a healthy heart. (Ignatavicius & Workman, 2010)Congestive Heart Failure Introduction Of Patient Nursing Essay.
When cardiac output is unable to meet the demands of the body, other areas of the body start to increase their workload to improve cardiac output. Theses mechanisms start off helping cardiac output increase but eventually have a damaging effect on the function of cardiac pumping. The compensatory mechanisms of heart failure are stimulation of the sympathetic nervous system, activation of the renin-angiotension system, release of pro-inflammatory cytokines, release of natriuretic peptides, release of vasopressin, and myocardial hypertrophy. (Ignatavicius & Workman, 2010) These compensatory mechanisms will be discussed further in the appropriate body systems throughout this case study.Congestive Heart Failure Introduction Of Patient Nursing Essay.
There are many presenting signs and symptoms of heart failure that a patient may have. Signs and symptoms of left-sided heart failure are restlessness, confusion, orthopnea, tachycardia, dyspnea with exertion, fatigue, cyanosis, cough, crackles, wheezes, blood-tinged sputum, and tachypnea. AH has several of these problems. She has tachycardia, dyspnea with exertion, fatigue, orthopnea, occasional cough, tachypnea, and crackles heard with auscultation. These problems make AH’s activities of daily living hard to perform at times. She does not use any supplemental oxygen during any of these times. AH is also showing signs and symptoms of right-sided heart failure that could indicate that her condition is progressing. These symptoms are distended jugular veins, and dependent edema. These symptoms of right-sided heart failure can be due to her history of a myocardial infarction, which could have caused the right ventricle to try and compensate for the increase in pulmonary circulation. This leads to the right ventricle to dilate and begin to fail. This is the cause of the distended jugular veins and edema because the systemic venous circulation increases with the compensation of the right ventricle. Treatment of these symptoms is managed with the treatment of left-sided heart failure. (Huether & McCance, 2008)
There are several risk factors that put a patient at risk for heart failure. Common risk factors that put a patient at risk for heart failure are hypertension, coronary artery disease, cardiomyopathy, substance abuse with alcohol and tobacco use, dysrhythmias, cardiac infections and inflammations, diabetes mellitus, family history, obesity, and conditions such as hyperthyroidism. (Ignatavicius & Workman, 2010) AH has several of these risk factors. She has a history of hypertension, obesity, atrial flutter (dysrhythmia), and past myocardial infarction. All of these have a negative affect on the cardiovascular system and lead to the worsening this patients heart failure. Lifestyle modifications can be made to decrease how some of these risk factors affect this patient. Dietary changes such as watching weight, low sodium, and balanced meals could reduce this patients obesity and hypertension. Also, adhering to medication regimen assists with controlling hypertension and removing retained water from the body.Congestive Heart Failure Introduction Of Patient Nursing Essay.
Chest x-rays can be helpful in the diagnosis of left ventricular failure. The problem with chest x-rays is that it may lag behind the clinical findings as much as 24 hours. You may see that the heart is enlarged (cardiomegaly) which can be due to hypertrophy and dilation. AH had a chest x-ray done on February 08, 2012. The reason this was done was because of dyspnea. Results obtained from physician were “trachea midline, mild prominence of interstitial markings in bilateral lung fields without lobar consolidation, basilar atelectasis, elevated left hemidiaphragm, no evidence of pneumothorax or pleural effusion, mild cardiomegaly, ectatic aorta with vascular calcification and degenerative changes involving shoulder joints”.Congestive Heart Failure Introduction Of Patient Nursing Essay. Echocardiograms are considered the best tool in the diagnosis of heart failure. You can see changes in the valves, fluid accumulation in the pericardial space (pericardial effusion), chamber enlargement, and ventricular hypertrophy. This test can also determine ejection fraction, which shows how bad the ventricular hypertrophy is decreasing the amount of blood ejected from that ventricle. An electrocardiogram may show ventricular hypertrophy, dysrhythmias such as atrial flutter with AH, and any degree of myocardial injury but is not helpful in determining the presence or extent of heart failure. (Ignatavicius & Workman, 2010). This test would be helpful for this patient due to the fact of having a dysrhythmia and also have a past myocardial infarction.Congestive Heart Failure Introduction Of Patient Nursing Essay.
Laboratory assessments can also be helpful in diagnosis of heart failure. Electrolyte imbalances may occur from heart failure or because of side effects of medications, especially diuretics such as Bumex with AH. Regular assessments of sodium, potassium, magnesium, calcium, and chloride, are obtained. Any impairment of renal function resulting from inadequate perfusion causes the patients blood urea nitrogen and serum creatinine to be elevated and a decrease in creatinine clearance levels. A urinalysis can show if there is an increased amount of protein present in the urine and an elevated specific gravity due to the kidneys not adequately working.Congestive Heart Failure Introduction Of Patient Nursing Essay. Hemoglobin and Hematocrit levels should be obtained to check to see if the heart failure is from anemia, which is a low level of red blood cells. This can be caused from the kidneys not creating enough erythropoietin, which regulates red blood cell production. B-Type natriuretic peptide (BNP) is used for diagnosing heart failure in patients with dyspnea. An increase in BNP helps determine whether it is dyspnea from heart failure or lung dysfunction. Patients with atrial dysrhythmias and renal disease may also have elevated BNP levels. (Ignatavicius & Workman, 2010) AH does have an atrial dysrhythmia (atrial flutter), which could cause an elevated BNP level even without the heart failure. Arterial blood gases could show if the patient is hypoxic due to the low oxygen level from fluid filled alveoli. Respiratory alkalosis could occur because of hyperventilation, respiratory acidosis could occur because of the carbon dioxide retention, and metabolic acidosis could be present from accumulation of lactic acid. (Ignatavicius & Workman, 2010). AH did not have arterial blood gas values drawn to look at any abnormalities.Congestive Heart Failure Introduction Of Patient Nursing Essay.