Pathophysiology of Congestive Cardiac Failure:
It is the condition in which heart is not able to pump enough blood as a healthy heart does which results that there is not enough blood supply to the organs (Crandall et al., 2009). The leading chamber that is ventricle becomes thicker which makes it hard to contract or relax properly, the muscles become weakened, and heart is not able to circulate enough blood to the body. It is associated with many types of heart diseases, which includes coronary artery disease, AMI and HTN the common cause of this is myocardial infarction, hypertension, arrhythmias and pulmonary emboli (Fletcher & Thomas, 2001). There are two types of heart failures, left and right-sided heart failure, CCF is typically considered as left-sided which further divided into two forms, systolic heart failure and diastolic heart failure. In systolic, the left ventricle is unable to pump sufficient blood and in diastolic, left ventricles are not able to relax properly due to which blood remains in the heart (Fletcher & Thomas, 2001).
Process:
Her pulse is high (122), and irregular and blood pressure Are 160/100 this is because she had hypertension and had AMI in her history, she is non-complaint with taking medications, and this is the second reason for high blood pressure (Crandall et al., 2009). Her potassium level is also higher than average (3.5- 5 mEq/l) this is due to hyperkaliemia, this can also lead to changes in ECG, her creatinine level is 4.5mg/dl which is very high, due to her chronic renal failure (Risch et al., 2016). She is not following the fluid restriction as ordered from the last hospital which is causing swelling of legs, as there are more fluids in the body. Her ECG diagnosed with AF and auscultation shows a wide spread of consolidation due to too much pressure on the heart as it is unable to pump sufficient blood to the body which also means that her CCF is getting worse and leading to further complications like AF and pulmonary congestion. When ventricle fails, increased fluid pressure is transferred to the lungs, which then moved to legs and ankles, therefore, M .G, is prescribed frusemide which helps to reduce extra fluids in the body. In CCF, stroke volume decreased which result in fluid retention and causing pulmonary congestion, which is oedema that was evident on chest auscultation. Because of this reason she is complaining of SOB, and her RR is high, also with decreased stroke volume, and low cardiac output has also led to lower in tissue perfusion which results in low Spo2 saturation (Nicholson, 2014). To improve the condition, she needs to be compliant with her meds and manage her diet to avoid any more complications further.
Nursing care plans
To improve MG’s health condition, a care plan needs to be made to prioritise her needs and help her to a certain level, according to her needs and to enhance her lifestyle. The first nursing diagnosis is ineffective perfusion due to low levels of oxygen in the blood results in failure to nourish the cells and the tissues. MG is short of breath, abnormal pulse rhythm and rate which is 102(irregular), BP is 160/100 and her oedema these are the evidences due to which she is showing signs and symptoms. Insufficient tissue perfusion leads to decrease in cardiac output which reduces the stroke volume throughout the body (De Abreu Almeida et al., 2015). The short-term nursing goal is to slow the HR and hence relieve the patient from SOB, the second is to decrease the BP. On the other hand, the long-term goal is to increase the cardiac output. To achieve these goals, the first nursing intervention is the cardiac assessment and her circulatory system. The reason behind this is to get baseline of her to check for the changes that will refer to change in cardiac output. By this, MG can be prevented from further deterioration and symptoms. The second intervention is to change her position of her bed by elevating the head up. By this, the elevation is that it will help her improving chest expansion and oxygenation. This will evaluate that patient can breathe more efficiently, and her oxygen saturation will increase as well. Checking of the proper fluid balance is the third intervention (Riley, 2015). The rationale for this intervention is to monitor the fluid balance as it maintains the adequate filling pressures and increase the cardiac output required for tissue perfusion. The evaluation for this is the fluid balance is in within normal ranges and It helps in maintaining cardiac output. The fourth intervention for this diagnosis is to administer digoxin (Amalaki, 2015). The rationale for this is to improve contractions of heart muscles and cardiac output. The evaluation for this is heart rate will slow down. Another intervention is to administer ACE inhibitors (Amalaki, 2015). The rationale behind this is to prevent the conversion of angiotensin 1 to angiotensin 2 hence to inhibit the reabsorption of salts and fluids which results in lowering the blood pressure. The evaluation will be that blood pressure will be lower. Another intervention is to monitor the vital signs that are BP, HR and O2 saturation. The reason for this is any changes in the vital signs will decrease the cardiac output and further tissue perfusion, to prevent further complications it is necessary to monitor her vital signs.
The second nursing diagnosis is increased fluid volume. It relates to decreases in cardiac output which then slows or reduces the glomerular filtration rate (GFR) by increasing the rate of secretion of antidiuretic hormone and sodium water retention (Souza et al., 2015). Pulmonary congestion, weight gain, oedema and crackles upon auscultation is due to the excess fluid volume (Amakali, 2015). The short-term goal for this is to manage the respiratory distress, weight gain and to reduce the extra fluid from the body. The long-term goal is to prevent renal failure. The first nursing intervention is the positioning of her legs, her legs should be elevated when sitting and continues to assess the skin surface and keep the skin dry. The reason for this is to decrease the oedema formation and increase venous return to the heart, due to a decrease in circulation and her skin integrity is affected, so it is essential to monitor the skin on a daily basis. The evaluation is that the blood is circulating well, and skin integrity is maintained. The second nursing intervention is to manage the electrolytes and monitor blood such as creatinine, sodium and potassium levels. The rationale for doing this is to watch the function of kidneys, and the evaluation is to protect the organs from further damage. The third intervention is to administer diuretics like frusemide and monitor daily weight and increase her urine output to remove the excess fluids in body (Blowey, 2016). The evaluation is it will reduce the oedema and decrease her body weight. The fourth intervention is to maintain the sodium and fluid restriction and refer to a dietician. The reason for this is it will help in removing the extra fluids and dietician can guide her to maintain the calories with restriction to sodium. It is evaluated that by following the fluid limit, she is managing her body weight and the excess fluid is getting removed from her body.
The third nursing diagnosis is to provide education and knowledge of a particular disease. The lack of knowledge and understanding related to cardiac disease. It is evidenced by asking the patient and patient is not following the fluid restriction order (Mehran et al., 2012). The short-term goal is to prevent the ongoing complications with current disease and to know the symptoms that require immediate action. The long-term goal is to identify the risk factors and initiation of lifestyle to follow the restriction orders (Park, 2010). The first nursing intervention is to educate the patient about the difference between heart failure and heart attack. Provide the knowledge so that treatment should be followed by the patient. The rationale for this is that patient should have awareness about their disease, and they can act accordingly in the situation. It can be evaluated by following the proper treatment plan given to the patient. The second intervention is to provide education to the patient for the importance of sodium limitation and knowing the food containing high amount of sodium to prevent further complications (Grange, 2005). The rationale for this that patient should understand the complexities involved if not followed by plan and patient should know about the food they are eating. The evaluation for this is patient will follow the restriction orders as they are aware of the consequences. The third intervention is to advise the patient to avoid taking diuretics at night. The rationale for this is to prevent interruption when sleeping as they will go to the toilet often. The evaluation for this is patient will have a good sleep rather than waking up night several times for bathroom. The last nursing intervention is to assess the symptoms that require immediate treatment like shortness of breath, weight gain and pulmonary congestion (Araujo, Nobrega, & Garcia, 2013). The rationale for this is that patient will be able to monitor themselves and will be able to prevent the complications. The evaluation to this is patient will be able to self-monitor themselves and it will help in preventing further complications.
Reflection
Personally, I have gained a lot of knowledge from this case study. Particularly, educating the patient about the disease they are suffering from, the signs and symptoms they need to monitor which require immediate intervention. Concerning MG, it was vital for her to know about the fluid restrictions and the number of sodium salts in her diet. As they create more workload on her heart, it is essential to understand the consequences if she will not follow the fluid restrictions, from this I came to know the importance of fluid limits for the person who is suffering from heart disease. Another fact I have learnt from this case study is overweight, and excess fluids can lead to kidney failure. It decreases the cardiac output which affects the glomerular filtration rate and increases the workload for the kidneys. MG is overweight, and she has excess fluids in her body which is going to be a complication for her organs in the future, by educating her about managing her body weight and decreasing the excess fluids can ease the pressure on her kidneys. Again, it is imperative to teach and give the knowledge to the patient of the disease they are suffering. The third information from this case study is that to monitor the vital signs and manage them accordingly. About MG, her HR and BP are high and HR irregular, I have acknowledged that how essential can vital signs be and monitor them on a regular interval is also crucial and elevating the legs helps in reducing the blood pressure was a new lesson for me. It is also essential to learn about the pathophysiology of the CCF as discussed in the case study it is imperative for a nurse to know the diseases thoroughly as when they need any immediate intervention nurse needs to know what to do and how to solve the situation accordingly.
References
Araújo, A. A., Nóbrega, M. M., & Garcia, T. R. (2013). Nursing diagnoses and
interventions for patients with congestive heart failure using the ICNP ®. Revista
da Escola de Enfermagem da USP, 47(2), 385-392. doi:dx.doi.org/S0080-
62342013000200016
Blowey, D. (2016). Diuretics in the treatment of hypertension. Pediatric Nephrology,
31(12), 2223-2233. doi:10.1007/s00467-016- 3334-4
De Abreu Almeida, M., Barragan da Silva, M., Paulsen Panato, B., de Oliveira
Siqueira, A. P., Palma da Silva, M., Engelman, B., Gaedke Nomura, A. T.
(2015). Clinical indicators to monitor patients with risk for ineffective cerebral
Tissue perfusion. Investigacion & Educacion en Enfermeria, 33(1), 155-163.
doi:10.1590/S0120-53072015000100018
Fletcher, L., & Thomas, D. (2001). Clinical practice. Congestive heart failure:
understanding the pathophysiology and management. Journal of the American
Academy of Nurse Practitioners, 13(6), 249-257. doi:10.1111/j.1745-
7599.2001.tb00030.x
Mehran, L., Nazeri, P., Delshad, H., Mirmiran, P., Mehrabi, Y., & Azizi, F. (2012).
Does a text messaging intervention improve knowledge, attitudes and practice
regarding iodine deficiency and iodized salt consumption? Public Health
Nutrition, 15(12), 2320-2325. doi:10.1017/S1368980012000869
Park, H. J. (2010). NANDA-I, NOC, and NIC linkages in nursing care plans for
hospitalized patients with Congestive Heart Failure. (Ph.D.), University of Iowa,
Retrieved from
https://login.ezproxy.holmesglen.edu.au/login?url=http://search.ebscohost.com
/login.aspx?direct=true&db=ccm&AN=109853974&site=ehost-
live&scope=site&profile=cinahl Available from EBSCOhost ccm database.
Souza, V., Salloum Zeitoun, S., Takao Lopes, C., Dias de Oliveira, A. P., Lima Lopes,
J., & Bottura Leite de Barros, A. L. (2015). Clinical usefulness of the definitions
for defining characteristics of activity intolerance, excess fluid volume and
decreased cardiac output in decompensated heart failure: a descriptive
exploratory study. Journal of Clinical Nursing, 24(17/18), 2478-2487.
doi:10.1111/jocn.12832
Crandall, M. A., Horne, B. D., Day, J. D., Anderson, J. L., Muhlestein, J. B., Crandall, B. G., . . . Bunch, T. J. (2009). Atrial fibrillation significantly increases total mortality and stroke risk beyond that conveyed by the CHADS2 risk factors…congestive heart failure, hypertension, age
Nicholson, C. (2014). Chronic Heart Failure: Pathophysiology, diagnosis and treatment, Nursing Older People, 26(7), 29-38 doi:10.7748/nop.26.7.29.e584
Risch, M., Risch, L., Purde, M.-T., Renz, H., Ambühl, P., Szucs, T., & Tomonaga, Y. (2016). Association of the cystatin C/creatinine ratio with the renally cleared hormones parathyroid hormone (PTH) and brain natriuretic peptide (BNP) in primary care patients: a cross-sectional study. Scandinavian Journal of Clinical & Laboratory Investigation, 76(5), 379-385. doi:10.1080/00365513.2016.1183262
Fletcher, L., & Thomas, D. (2001). Clinical practice. Congestive heart failure: understanding the pathophysiology and management. Journal of the American Academy of Nurse Practitioners, 13(6), 249-257. doi:10.1111/j.1745-7599.2001.tb00030.x