Heart Failure Essay Example

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    Nursing
  • Document type:
    Essay
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    Undergraduate
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Heart failure management 13

Lecturer

Submission Date

Pathophysiology of heart failure

ESC (2008) defines Heart failure as a clinical syndrome that epitomizes itself following impairment of the heart function and/ or structure. The situation in turn results into dyspnea and fatigue when the body is at rest or upon physical exertion HFSA (2010) adds. Heart failure effects from a single heart related disease to multiple heart diseases and or conditions as Clifford & Grevson (2008) explains. Some of major causes of heart failure include and not limited to: cardiomyopathies both genetic and primary, valvular heart disease and poorly controlled hypertension (which raises the contraction forces required to pump blood) and coronary artery diseases. According to AIHW (2011) Cardiovascular disease is a burden both to the developed and developing nations. Going by statistics carried in 2011 in Australia, CVD is a leading killer. The data shows that 45 600 death were as a result of CVD. This means that every 12 minutes there is actually one death arising from CVD related diseases and conditions. Conversely, is good noting that in relation to the previous years this rate was an improvement; but then again CVD remains the largest health burden in Australia’s economy AIHW (2008) & AIHW (2011).

Clifford & Grevson (2008) highlights that; there are two types of HF systolic and diastolic which are either chronic or acute. Acute heart failure is experienced when heart functions are altered rapidly within a short period of time (hours or days) like in the cases of familial cardiomyopathy. In acute HF, cardiac output drops drastically which is life threatening. Chronic heart failure on the other hand means that; the cardiac functions are gradually affected. Over a prolonged period(months or years) the heart’s function (systolic and diastolic) are altered such as volume overloads and pressure impairment caused by coronary heart disease or valvular ESC (2008) explains. Mrs. Yates in this case suffers from chronic heart failure since she has had the condition for eight years. A heart in a normal condition produces no murmur sound. However, when the heart structure is altered in anyway a health specialist can hear murmur sound using the stethoscope. Nonetheless, not all murmur sounds are bad Clifford & Grevson (2008). According to NHFA/CSANZ (2011) heart failure progress goes through stages some of which are not easily detectable by both the patient and the doctor like the asymptomatic and latent phase. These stages, most often leaves the patient untreated as the problems advances. Consequently, the patient visits the clinic when the symptoms of HF at a late stage are in place.

Diastolic dysfunction

Diastolic heart failure occurs when the ventricles fail to relax passably HFSA (2010) explains. This signifies stiff ventricular wall. Patients suffering from DHF have impaired diastolic function; echocardiography indicates preserved systolic function, left ventricular cavities are smaller and left ventricular wall is dense. Consequently, the ventricles do not fill sufficiently resulting into deficient in stroke volume. Valve regurgitation is prevalent allowing back flow of blood against the normal flow. When ventricular relaxation is not achieved there is raised end-diastolic pressure. ESC (2008) adds that, the ultimate results include left heart failure presenting with pulmonary edema and right heart failure presenting with peripheral edema. This factor explains why Mrs. Yates upon examination was found to have moist fine crackles in both lungs. This can also occur when heart failure is also accompanied with pulmonary congestion Clifford & Grevson (2008) adds.

Following Clifford & Grevson (2008) major causes of diastolic dysfunction include restrictive cardiomyopathy, hypertrophic cardiomyopathy, ischemic heart disease and hypertension Diastolic heart failure (DHF) is common among the elderly population, patients with restrictive cardiomyopathy, who suffer from left ventricular hypertrophy and persons who have been suffering from hypertension for a period of time. DHF in addition to affecting the old generation, it is also common among the female gender Chen, Normand, Wang, & Krumholz (2011) analysis.

Systolic dysfunction

Systolic heart failure occurs when the heart fails to contract effectively HFSA (2010) explains. Systolic dysfunction is caused by valvular heart disease, hypertension, dilated cardiomyopathies and ischemic heart disease NHFA/CSANZ (2011). Abraham & Abraham, (2009) says patients suffering from systolic function have impaired pumping mechanism and large dilated ventricles. Strength of Ventricular contraction is conical and insufficient to create sufficient stroke volume contributing to derisory cardiac output. In addition, the architecture of the normal papillary muscle is disrupted following the effects arising from the dilated ventricles. In reference to Prior & Coller (2010) the ventricles are not emptied completely a factor which leads to volume and ventricular end-diastolic pressures increment. This in turn distresses the atrium. The increased pressure experienced on the left heart side is conveyed to the pulmonary vasculature. This results into building up of hydrostatic pressure which consequently leads to building up of fluid into the parenchyma of the lungs resulting to pulmonary edema. Haddad, Doyle, Murphy & Hunt (2008)) adds that, the increased pressure puts weight on the right heart side. In this case, the building pressure is taken through the systemic capillary beds and systemic venous circulation. This results into fluid extravassation on the extremities and target organs. These overall events results into dependent peripheral edema.

In reference to Mrs. Yates these sequences are the reason behind the findings by the physician upon examination. Such include: Respiratory distress; HFSA (2010) found that respiratory distress arises when there is fluid build up in the lungs. The fluid accumulation hinders gaseous exchange. Therefore, oxygen does not sufficiently enter the lungs during inspiration and carbon dioxide is not exhaustively eliminated from the body. Mrs. Yates in her case was found to have SpO2 84% on Room Air. In reference to ESC (2008) the normal level of blood oxygen saturation ranges from 95-100%. However, levels going below up to 90% have been realized and hence it is not a cause of alarm.

According to NICE, (2011) hypoxemia is common when there is deficit of oxygen transmission across the cell membrane, inequality of ventilation-perfusion, hypoventilation of alveolar and low levels of inspired oxygen. NICE (2010) points that, ventilation-perfusion inequality is the leading cause of hypoxemia among patients suffering from cardiac problems, lung diseases or those with syndromes of acute respiratory distress. Mrs. Yates SpO2 of 84% is a sign of low cardiac output following weakened heart muscles. Therefore, the heart is unable to pump blood sufficiently in the whole body. In order for the body to make up for required gas supply respiration rates also increases as found to be in Mrs. Yates case. That is 36 breaths/minute habitually this is usually 15-20 breaths per minute for an adult. The heart is also forced to pump more rapidly. This is portrayed by the increased heart rate of Mrs. Yates; Heart Rate 125 beats/minute which is an indicator of tachycardia (normal beats per minute 60-100) for adults. This factor explains why there is increased use of accessory muscles as the patient has to breath extra hard to make up for the obligatory respiratory function HFSA, (2010) highlights.

Mrs. Yates BP is 90/60mmHg. Prior & Coller (2010) says normal blood pressure among the adult range from 90mmHg-140mmHg systolic and 60mmHg-90mmHg diastolic. Further classifications by HFSA (2010) shows that 90-100mmHg systolic and 60-65mmHg diastolic is a low normal cluster, 100-130mmHg and 65-85mmHg is normal and 130-140mmHg and 85mmHg-90 mmHg is a high normal cluster. Therefore, Mrs. Yates BP is on the lower side due to abridged cardiac output same study explores. This factor also explains the reason behind Cyanotic lips and extremities which is a blue coloration. Haddad, Doyle, Murphy & Hunt (2008) says cyanosis is an indicator of insufficient supply of blood oxygen to the extremities or fingers (hypoxia). Hypothermia is another condition accompanied by reduced blood pressure as was found to be 36.4oC for Mrs. Yates (normal 36.5-37.2 adult). Due to reduced fluid movement within the cell membrane as explained earlier in this script, Mrs. Yates was found to have 4+ pitting edema in lower extremities. This factor explains why the skin was found to feel cool and diaphoretic Clifford & Grevson (2008) correlates.

Assessment, diagnosis and findings in line with heart failure

Different symptoms present in a patient during clinical visits assist the physician to get a tip of whether the person suffers from HF. Such include ESC (2008) dyspnea and fatigue either upon doing minute activity or even at rest. This is an indication that the body is not receiving enough oxygenated blood. In addition, it shows there is build up of waste gases/ metabolic products within the respiratory system. In addition, HFSA (2010) to the information gathered from the client, the physician using a stethoscope examines the lungs and the heart functions for any sign related to HF. According to AIHW (2011) some of telltale sign include gallops “irregular heart sounds” kind of heart sound, murmurs from the valves of the heart, a rapid heart rate and pulse rate. Presence of these factors is a clear indication of ineffective cardiac system Clifford & Grevson (2008) emphasizes. Upon examining the lungs if the patient suffers from HF the breathing rate is likely to increase to cater for oxygen supply and remove carbon dioxide from the body system efficiently. When the ventricles are not completely emptied there is a volume and ventricular end-diastolic pressures increment. This in turn distresses the atrium. The increased pressure experienced on the left heart side is conveyed to the pulmonary vasculature. This creates hydrostatic pressure which consequently leads to build up of fluid into the parenchyma of the lungs resulting to edema of the lungs. Upon examination crackling sounds is heard a pointer that there is fluid build up in the lungs NHFA/CSANZ (2011) highlights.

HFSA, 2010 & ESC, 2008 found that insufficient oxygen supply in the blood and low pressure which does not pump blood to reach the extremities; the patient is found to have a blue coloration on the toes and fingers’ skin. In addition, the skin will feel cold. Edema may result from other factors apart from heart failure ESC (2008) points out. However, the study supports that, poor fluid circulation during heart failure contributes to fluid retention within cell membrane.

Chest X-ray remains a vital diagnostic tool NICE (2011) note. Using the X-ray the physician is able to notice any heart valves abnormalities a fact accounted for heart murmurs. The size of the heart is also seen (whether it is enlarged) and whether there is fluid in the lungs an indicator of pulmonary edema. An ECG is crucial during HF diagnosis process Abraham. & Abraham (2009) explains. Electrocardiogram is used to provide information regarding the size and the rhythm of the heart. In addition, it is able to show whether the heart muscles are damaged and if the chambers of the heart are enlarged. A low left ventricular fraction (>40-50% normal ranges) indicates an overworked cardiac muscle.

Medical officer’s orders rationale and nursing precaution

Medical officer’s order

Rationale

Nursing precaution

Low sodium diet, and 1500ml

To reduce water retention in the body or edema.

Monitor dehydration.

Avoid overuse of non-sodium diet; they may contain high amount of potassium NHFA/CSANZ (2011).

Daily weighs

To monitor any weight increment. Increase in weight is an indication of increased edema.

Monitor abrupt weight loss or increment as this might damage body cells

Electrocardiogram (ECG) if reports chest pain

To rule out ACS (Acute Coronary Syndrome)

There is likelihood of intermitted ACS pain which might appear to resolve providing false reassurances.

Chest physio/spirometry

To clear the airway. It combines breathing techniques, coughing, strategically position of the client to ensure mucus is drained and thumping of the walls of the chest by the care giver. The technique aim to strengthen the respiratory muscles, respiratory system secretion removal, lungs expansion promotion, and improve respiratory efficiency

Monitor heart irregularities, ensure the patient does not inhale vomitus and respiratory products (suction out any products) NHFA/CSANZ (2011) & HFSA (2010)

O26L/min

To elevate oxygen saturation

Ensure the patient breathes out to release CO2.

Do not oversaturate O2 as this can lead to bursting of red cells (hemolysis) ESC (2008).

Digoxin 0.25mg orally daily

To increase heart contractions, vigor and strength

Monitor kidney function and arrhythmias, monitor decrease in Mg2+, increase in Ca2+ and decrease in K1+ NHFA/CSANZ (2011) & HFSA (2010). Monitor its toxicity 8-12 hours after the last dose

Frusemide 40 mg IV BD 2

diuresis

Look out for dehydration features, ensure there is no urine retention and check for electrolyte balances especially potassium and do creatinine test ESC (2008)

Enalapril 5mg orally daily

Improve heart functioning by broadening the vessels of the blood and easing the ability of the heart to pump blood to reach all body parts. Maintain blood pressure. Lower chances of heart attack

Monitor blood pressure to rule out hypotension. Laboratory test for hyperkalemia possibilities. Check whether the patient suffer from persistent dry cough as this is an adverse effect of the angiotensin-converting enzyme inhibitor (ACE inhibitor) ESC (2008)

KCL 40mmol/L orally BD

Serum electrolyte balance

Request laboratory test to rule out hyperkalemia ESC (2008)

Mrs. Yates nursing care intervention plan

According to AIHW (2011) findings, HF remains a chief public health burden. The same studies found that HF condition continues to increase early mortality, high morbidity and prevalence. Patients with heart failure are best managed following a multidisciplinary approach as Kodner (2009) says. This approach has been found to raise clinical outcome in the patient. Findings by NICE (2011), NICE (2010) & Kwok & Lee (2008) show that; nursing interventions is essential in managing heart failure patients similar to Mrs. Yates.

Nursing intervention

Rationale

Monitoring anomalous sounds of the lungs and heart

To investigate left-sided heart failure following edema

Assess pulse rate and blood pressure

To ensure the patient does not go to hypotension or hypertension.

Monitor conscious level and mental status

When waste products accumulate in the blood stream, O2 consumption by cerebral tissues and its transport is impaired. This is easily manifested as altered consciousness, lethargy and confusion.

Monitor peripheral pulse and skin temperature

To explore whether the peripheral tissues do receive sufficient supply of oxygen. Low temperatures indicate heart’s pumping mechanism is weak and mostly likely the tissues in extremities are not adequately supplied with oxygen.

Assess diagnostic tests and laboratory results

To understand how the patient responds to treatment and clues on the disease status.

Assess oxygen saturation

To understand how sufficiently perfuse distal tissues are supplied with oxygenated blood by the heart

Put in place measures to rectify fluid and electrolyte disparities

To ensures chances of reduced cardiac output development are lessened

Direct cardiac glycoside agent as per prescription and assess toxicity

To strengthen myocardium and improve cardiac output

Encourage the patient to rest and offer a helping hand with all other activities

To lower cardiac task and reduce myocardial oxygen consumption

Help patient to assume high fowler’s position

To ease chest expansion hence increasing pulmonary capacity

Educate the patient regarding the disease pathophysiology and medications

To ensure the patient understands and observes the management of the disease

Reposition the patient after every two hours

To avoid bed sores incidence

Educate the patient on the needs of adequate sleep and rest

To increase safety of the client and lower chances of accident that may lead to injuries.

Conclusion

In conclusion, Clifford & Grevson (2008) HF is a disease that affects the heart muscles and impairs heart and lung function. Subsequently, a person suffers from dyspnea and fatigue as basic symptoms which increases with HF progression. There are two types of HF diastolic dysfunction and systolic dysfunction. These types can be present at a go or one by one. Different factors predispose a person to heart failure such as hypertension, smoking or valvular diseases.

Imaging; ECG, X-ray and physical examination are some of assessment that are used to investigate the patient’s heart condition. Digoxin, reduced water and sodium intake are some of prescription given by physician HFSA (2010) managing HF. Treatment and management of HF patient calls for multidisciplinary approach Kodner (2009). In this case, the nurses play a key role in supporting and promoting quick recovery to HF patients.

References

Abraham J. & Abraham T.P., (2009) The role of echocardiography in hemodynamic assessment in heart failure, Heart Fail Clin 5(2):191-208

ACCF/AHA (2013) Guideline for the management of heart failure: a report of the American College of Cardiology Foundation? American heart association task force on practice guidelines. J Am Cardiol

Australian Institute of Health and Welfare (2008) Health care expenditure on cardiovasculare diseases 2004-5. Cardiovascular Disease Series no. 30. Cat. No. CVD 43. Canberra: AIHW

Australian Institute Of Health and Welfare (2011) cardiovascular diseases 2004-5. Cardiovascular Disease Series Cat. No. CVD 53. Canberra: AIHW

Chen J., Normand S.L., Wang Y., Krumholz H.M. (2011) National and regional trends in heart failure hospitalization and mortality rates for Medicare beneficiaries 1998-2008. JAMA 3006(15):1669-1678

Clifford R. & Grevson M.D. (2008) Pathophysiology of right ventricular failure. Crit Care Med.36(Suppl):S57-65

European Society of Cardiology (ESC) (2008) ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart Journal 19:2388-2442

Haddad F., Doyle R., Murphy D.J. & Hunt S.A. (2008) Right ventricular function in cardiovascular disease, part II: pathophysiology, clinical importance and management of right ventricular failure Circulations 117(13):1717-1731

Heart Failure Society of America (HFSA) 2010. Evaluation of patients for ventricular dysfunction and heart failure: HFSA 2010 comprehensive heart failure practice guideline. Journal Cardiac Failure 16(6):e44-56

Kodner D.L. (2009) All together now: a conceptual exploration of integrated care Healthc Q; 13: Sec No: 6-15

Kwok T. & Lee J. (2008). A randomized controlled trial of a community nurse supports hospital discharge programme in older patients with chronic heart failure. Journal of Clinical Nurse 17:109-117

National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand (NHFA/CSANZ) (2011) Guidelines for the prevention, detection and management of chronic heart failure in Australia. Sydney: National Heart Foundation of Australia

National Institute for Health and Care Excellence (NICE) (2011) Chronic Heart Failure Quality Standard, http://www.nice.org.uk/guidance/qualitystandards/chronicheartfailure/home.jsp, 10th August, 2013

National Institute for Health and Care Excellence (NICE) (2010). Chronic Heart Failure: Management of Chronic Heart Failure in Adults in Primary and Secondary Care, http://publications.nice.org.uk/chronic-heart-failure-cg108, 10th August, 2013

Prior D. & Coller J., (2010) Echocardiography in heart failure- a guide for general practice. Aust. Fam physician 39(12):904-909