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Stenberg College NURS 201-3 Weekly Case Study and Care PlanClinical group Members: Fredesminda Guevara, Kelsey Landsburg, Theresa Lee, Kim Monkman, Roberta Power, Angel St. Denis, Kari WalkerDate: June 25, 2014Case Study Critical thinking questions1. Explain the pathophysiology of Mrs. E’s heart disease.?Mrs. E’s history of myocardial infarction had resulted to a weakened myocardial function due to scarring of cardiac muscle and subsequent ventricular remodelling (or the hypertrophy of myocardium to compensate for the infarcted portion), thus increasing her risk for developing heart failure at a later date (Buscher & Castellucci, 2014). Her current presentations are indicative of acute decompensated heart failure (ADHF) due to systolic heart failure as evidenced by her low EF of 20%, resulting to decreased ability of the left ventricle to pump blood through the aorta and subsequently to elevated pulmonary pressure leading to pulmonary edema as characterized by increasingly severe dyspnea, orthopnea (need for head elevation while lying down), tachypnea (36 breaths/min), moist crackles in lungs, cyanosis of lips and extremities, and cool skin, as well as hypertrophy of both ventricles (Bouffard, 2014). Although it is not specifically stated that Mrs. E. has had hypertension, her myocardial infarction could be related to long-standing hypertension which, with her loose medication adherence, could also have exacerbated this ventricular damage. Her recent bout with respiratory tract infection had increased her oxygen requirement and placed additional strain on her left ventricle’s already impaired ability to pump blood pass the aorta and into systemic circulation. This resulted to increased preload (blood in ventricle at the end of diastole), heightened pulmonary vascular resistance and blood pressure, and increased end-diastolic pressure in the left ventricle (LVEDP). Eventually, the left ventricle could not keep up, leading to this decompensated state. The resultant increase in pulmonary pressure also affected right ventricular function (that may lead to right-sided heart failure) causing backflow to the right atrium, right ventricular enlargement, peripheral edema (in legs) and increase in weight as a common consequence to left-sided heart failure (Bouffard, 2014).2. What clinical manifestations of heart failure did Mrs. E. exhibit? Mrs. E exhibits clinical manifestations of both left sided and right sided heart failure. First of all, Mrs. E has experienced increased dyspnea on exertion for the last two years. This is evidenced by her being in respiratory distress, using accessory muscles to breath, having a respiratory rate of 39 as well as her not being able to walk two blocks without SOBOE. According to Fancher-House & Foell (2010), dyspnea is caused by “increased pulmonary pressures secondary to interstitial and alveolar edema” (p.887). Mrs. E is also having orthopnea as evidenced by her need to use three pillows to elevate herself when she is lying in a recumbent position. Mrs. E has also had a persistent cough which is a symptom of left-sided heart failure. Individuals with HF may have a frequent, dry cough that is not relieved when changing positions. One should note that the first clinical symptom of HF can by a dry hacking cough (Fancher-House & Foell, 2010). Another clinical manifestation of HF that Mrs. E is exhibiting is peripheral edema (a common sign of right sided HF) (Fancher-House & Foell, 2010). Mrs. E is having memory loss as evidenced by her not always remembering to take her medications. According to Fancher-House and Foell (2010), an individual with HF may show signs of confusion, memory loss, and decreased attention span due to the cerebral circulation impairment of chronic HF and it may also be secondary to poor gas exchange as well as renal failure (Fancher-House & Foell, 2010). Another manifestation Mrs. E is having is a systolic heart murmur and her chest x-ray results show hypertrophy bilaterally of the right and left ventricles. In chronic HF, an enlargement of the heart chambers occurs and it may cause an alteration in the electrical pathway of her heart as well as causing many sites within the atria to fire off spontaneously (Fancher-House & Foell, 2010). Mrs. E’s echocardiogram revealed that her ejection fraction is only at 20%. This is not a good sign for Mrs. E as individuals with an ejection fraction of less than 35% have a high risk of fatal dysrhythmias and could potentially go into sudden cardiac death (Fancher-House & Foell, 2010). Upon auscultating Mrs. E’s lungs the nurse has heard crackles bilaterally and her x-ray results also reveal fluid in the lower lung fields these are signs of pulmonary edema which is a sign of acute decompensated heart failure and is also a life-threatening situation because the lung alveoli are becoming filled with serous or serosanguineous fluid and it increases the pulmonary venous pressure (Fancher-House & Foell, 2010). As a result, there is an increase of resistance in the small airways and the lung become less compliant causing respiratory distress as Mrs. E is experiencing (Fancher-House & Foell, 2010). Mrs. E’s skin is cool to touch which is a result of diaphoresis and also from vasoconstriction that is caused by the SNS being stimulated Fancher-House & Foell, 2010).Finally, Mrs. E has cyanotic lips and extremities which are a direct result of the pulmonary edema she is experiencing from HF. In conclusion, Mrs. E shows just about all of the clinical manifestations of heart failure and furthermore is showing signs of acute decompensated heart failure and is in a life threatening state. 3. What is the significance of the findings of the diagnostic studies?These findings of cardiomegaly with left and right ventricle hypertrophy, indicate that the client’s heart is unable to keep up with the demands of pumping blood throughout the body. As such, his heart ventricles have stiffened and no longer fill properly with each contraction, additionally his heart muscles have weakened and dilated so much that his heart is unable to effectively pump blood (Mayo Clinic, 2014). Additionally, with the presence of fluid in the lower lung fields this further indicates pulmonary edema, a clinical manifestation of heart failure (Bouffard, 2014). Lastly, the diagnostic study reporting the client’s ejection fraction (EF) at 20% [EF < 50% is considered reduced (Grogan, n.d.)], is evidence of heart failure or cardiomyopathy (American Heart Association. 2014). 4. Explain the rationale for each of the medical orders prescribed for Mrs. E. Enalapril (Vasotec) 5mg PO daily – Enalapril is an ACE inhibitor, which are a first-line therapeutic medication in the treatment of chronic heart failure (Bouffard, 2014). ACE inhibitors block the effect of the enzyme required to convert angiotensin I to angiotensin II leading to decreased levels of angiotensin II as well as aldosterone (Bouffard, 2014). This results in a reduction in systemic vascular resistance (SVR) which leads to a significant increase in cardiac output (CO) (Bouffard, 2014). Additional benefits of ACE inhibitors include improvement redistribution in regional blood flow improve tissue perfusion, as well as reductions in pulmonary artery pressure (PAP), right arterial pressure, and left ventricular filling pressure (Bouffard, 2014, p. 938). Digoxin 0.25mg PO daily – Digoxin has both positive inotropic and negative chronotropic effects (Bouffard, 2014). The positive inotropic improve cardiac contractility which in turn increases CO, decreases left ventricular diastolic pressure, and decreases SVR (Bouffard, 2014, p. 938). The negative chronotropic effects decrease conduction speed with in the myocardium thereby reducing the heart rate (Bouffard, 2014). The effects of these effects on the heart allow for a more complete emptying of the ventricles and improved CO (Bouffard, 2014). Furosemide (Lasix) 40 mg IV BID – Is a potent loop diuretic that is more commonly used with acute heart failure and pulmonary edema (Bouffard, 2014). Diuretics in general are utilized to “mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload” (Bouffard, 2014, p. 937). A reduction in preload will allow the ventricle to contract more efficiently thereby improving CO (Bouffard, 2014). The action of Lasix is on the ascending loop of Henle where it stimulates sodium, chloride, and water excretion (Bouffard, 2014). Potassium 40 mEq PO BID – A side effect of the Lasix is a reduction in serum potassium levels (Bouffard, 2014). Therefore, the supplementation of potassium is used to counteract this expected loss.2-g sodium diet – The inclusion of a diet limited to 2g of sodium is indicated for those with mild heart failure (Bouffard, 2014). A dietary restriction of sodium can often aid in the treatment of the edema that is associated with heart failure (Bouffard, 2014). Oxygen 6 L/min – Heart failure can lead to a reduction of oxygen saturation in the blood related to blood that is inadequately oxygenated in the lungs (Bouffard, 2014). Supplemental administration of oxygen can help to relieve dyspnea and fatigue, improve tissue oxygenation (Bouffard, 2014). Oxygen should be titrated to a level that maximizes oxygen saturation, for cardiac patients monitoring SpO2 and ensuring that these levels are ≥ 95% (Norris, 2014). Daily weight measurements – Weight measurement daily can help to monitor and aid in the identification fluid retention changes (Bouffard, 2014). Patients should weigh themselves at the same time each day and with similarly weighted clothing on (preferably before breakfast) to help to ensure accurate comparisons (Bouffard, 2014). Bouffard (2014) notes that if an increase in weight of “2 kg over a 2-to 5-day period” is noted, the primary care provider should be notified (p. 940). Daily 12 lead ECG – The daily 12 lead ECG will help to identify changes in heart rate and rhythm. Those with heart failure may experience alteration in the conductive pathways in the heart (especially the atria) (Bouffard, 2014). This can lead to the development of dysrhythmias, atrial fibrillation in particular and eventually atrial systole (Bouffard, 2014). Patient’s with an ejection fraction (EF) <35% are at a “high risk of fatal dysrhythmias” (Bouffard, 2014, p. 934). Mrs. E’s EF is recorded at 20%. Cardiac enzymes Q8h x 3 – Monitoring of the cardiac enzymes can help to determine if the patient has suffered from an acute myocardial infarction (MI) (Bucher & Castellucci, 2014). They “are released into the blood in large quantities from necrotic heart muscle after an MI” (Bucher & Castellucci, 2014, p. 912). Specifically troponin and CK are typically measured to aid in the diagnosis of an MI (Bucher & Castellucci, 2014).5. What teaching measures should be instituted to prevent recurrence of an acute episode of heart failure? An important problem with this patient is that she does not always remember to take her medications. This patient must come to understand that heart failure (HF) is a chronic disease and she will be required to take medications for the rest of her life in order to ensure the best quality of life (Bouffard, 2014). Even when this patient is asymptomatic and feels that her HF is under control, her medications must be continued as prescribed to prevent another acute episode of decompensation (Bouffard, 2014). Preventative care focuses on slowing the progression of the disease as there is no cure, and she needs to be aware of this (Bouffard, 2014). If the patient has difficulty remembering to take her medications she should be encouraged to set up a system using blister packs or pill boxes that the pharmacy can set up for her, or to keep a checklist of her daily medications at hand. As well, adhering to the 2 g sodium diet and fluid restrictions will be important in preventing another acute episode of HF. Reading labels on food items and not adding salt when cooking or at the table will keep sodium intake within acceptable levels. A list of permitted and restricted foods should be consulted when planning meals (Bouffard, 2014). Also, the patient should get into the habit of weighing herself daily, preferably in the morning after voiding, using the same scale and in the same kind of clothing (Bouffard, 2014). It will be important to note any weight gain of 2 kg or more over the course of 2-5 days (Bouffard, 2014). Any weight gain will need to be reported to her healthcare provider. These measures will help control the edema and fluid-overload which stresses the heart. An exercise regimen should be implemented as physical exercise, such as cardiac rehabilitation programs, improves symptoms of chronic HF (Bouffard, 2014). ?Referrals to a cardiac rehab group or physiotherapist should be obtained. This patient should also be taught to recognize symptoms of an exacerbation of her heart disease such as fatigue, cough and congestion, edema, or shortness of breath (Bouffard, 2014) and to report these symptoms immediately to her healthcare provider. Annual flu shots are important and should be recommended to help prevent the respiratory complications of influenza (Bouffard, 2014). A referral for home health care services may be pertinent if the patient lives alone or has trouble maintaining her care plan recommendations. Her family and caregivers should be included in all teaching measures and be able to recognize the signs and symptoms of another acute episode of HF in order to get her to treatment should it occur. 6a. Are there any collaborative problems?Potential complications (Bouffard, 2014):Pulmonary edema related to ineffective control of fluid build-up in the lungs.Pleural effusion related to fluid entering into the pleural space.Dysrhythmias related to ventricular hypertrophy altering the normal cardiac electrical pathways. This leads to a potential for sudden cardiac death.Left Ventricular Thrombus related to “enlarged LV and decreased cardiac output combine to increase chance of thrombus formation” (p. 934). A thrombus may develop into an embolus putting Mrs. E at risk for stroke.Hepatomegaly related to RV hypertrophy which may lead to RV failure and congestion of venous blood in the liver. This congestion could lead to liver impairment, cell death, and cirrhosis. 6b. How will they affect Mrs. E’s treatment?Bouffard (2014) states the main focus for collaborative care is to improve left ventricular function. A diuretic has been prescribed as well as a low sodium diet in order to decrease intravascular volume. Daily weight and fluid in/out records need to be monitored to check that these interventions are effective. The moist crackles in her lungs should start clearing up as well. Inotropic drug therapy and vigilant monitoring of her ECG should reveal improvement in cardiac function. Cardiac perfusion diagnostics such as a MIBI may be ordered to ensure blood flow around the heart (no thrombus formation). If Mrs. E’s signs and symptoms worsen, more invasive interventions may be indicated. Once Mrs. E’s respiratory and cardiac conditions are stabilized, the collaborative team may decide how educate Mrs. E about self-care such as the pneumonia and flu vaccines, rest and exercise, as well as drug therapy. ?List in order of priority, three nursing diagnosis (NANDA based). Give the rationale for the priorities you have selected.Nursing Focus of Care / Nursing DiagnosisRationale for PriorityIneffective Breathing Pattern as related to Acute Decompensated Heart Failure and fluid in the lungs.As evidenced by respiratory distress, accessory muscle use, respiratory rate of 36 BPM, cyanosis, and shortness of breath upon exertion.Mrs. E is in respiratory distress, she is not getting enough oxygen and this is putting her heart, brain, kidneys, and all other body systems and tissues under duress. It is the top priority for this patient and interventions such as supplemental oxygen, positioning, medication, emotional support, and monitoring in hospital will need to be done in order to stabilize the patient.Risk for impaired gas exchange as related to pulmonary edema secondary to Acute and Chronic heart Failure. As evidenced by respiratory distress, increased respirations (over 30 breaths/min), auscultation of moist crackles in lungs, use of accessory muscles to breathe, cyanosis, dyspnea, skin cool to touch, fluid in the lungs, weight gain, and peripheral edema (Bouffard, 2014). Once an effective breathing pattern has been established through positioning, oxygen administration, rest, emotional support, and the monitoring of lung and heart sounds. Oxygen will be titrated to maximize oxygen saturation to assist in meeting tissue oxygen needs and to relieve dyspnea and fatigue (Evolve, 2014), the patient’s blood work will have to be monitored to ensure that proper oxygen and carbon dioxide levels return.Activity intolerance related to fatigue due to insufficient oxygen for activities of daily living secondary to chronic heart failure with cardiomegaly with right and left ventricular hypertrophy, pulmonary edema, and an oxygen supply and demand imbalance. As evidenced by history of dyspnea for the last 2 years. Patient’s statement “Cannot walk two blocks without getting short of breath”, having to sleep elevated on 3 pillows. Mrs. E’s heart damage from her previous MI and resulting cardiomegaly with right and left ventricular hypertrophy has her heart working harder to try and maintain enough blood flow to the brain and heart and is directing blood flow away from tissues that are less critical such as the extremities (evidenced by cyanosis in lips and extremities). This results in Mrs. E feeling fatigued and weak when taking on regular daily activities. Mrs. E’s quality of life is greatly affected because she does not have the energy to do simple tasks, this inability is not only physically draining but also takes a toll psychologically and can develop into depression. Interventions to help patient with planning her outings carefully to reduce fatigue, knowing her limitations, proper use of medications, taking time to rest, and the provision of emotional support will be a part of the interventions in helping Mrs. E function better with her everyday activities.Stenberg College RDPN ProgramNursing Care PlanNursing DiagnosisDesired OutcomesInterventions (I)-Independent(C) - CollaborativeRationale & APA ReferenceEvaluation of InterventionsNDX: (Problem)Ineffective breathing patternR/T: (etiology/factor):Acute decompensated heart failure Fluid in lungsAEB: (s/sx; defining characteristics)1. Respiratory distress2. Accessory muscle use3. Respiratory rate (RR) - 36 bpm4. Cyanosis5. Shortness of breath on exertion (SOBOE)*If ‘risk for’ would exhibit:Goal (Reversal of Problem)Mrs E will be able to breathe without distress at rest and show effective tissue perfusion within 2 hours Client will (list measurable outcomes; reverse signs and symptoms)1. Show normal vital signs (RR and SpO2) within normal range within 30 minutes.2. Show a decrease in work of breathing (WOB) within 30 minutes.3. Lips and extremities will return to tones consistent with Mrs. E’s normal skin color and temperature (i.e. not blue or cold) within 2 hours.Evaluation of Outcomes (address each outcome)Evaluation of Goal:(circle one) Goal met Goal not met Goal partially met(If goal not met, describe outcomes not met)Continuation of plan:(circle one) Continue plan of care Discontinue plan of care Revise plan of care(Explain revisions as needed)N1-(I) (C)Increase supplemental O2 to achieve SpO2 ≥ 95% and monitor SpO2 continuously until respiratory distress resolved and stable.Use of a simple face mask is indicated as the device will ensure increased O2 delivery to the patient.R1-It is imperative to relieve the respiratory distress to avoid respiratory arrest and cardiac stress.Increasing supplemental O2 can decrease WOB. Continuous O2 monitoring is important to ensure that the patients SpO2 is being maintained at a level ≥ 95% as well as to enable proper titration of O2(Norris, 2014).E1-SpO2 will (have) been maintained ≥ 95% as evidenced by the pulse oximetry reading. Cyanosis will no longer be noted in patient’s lips and extremities within 2 hours. N2-(I) (C)Help patient into a comfortable (appropriate) position – elevate head of bed to high Fowler’s or semi-Fowler’s position, place pillows behind patient, place table in position that the patient can lean on.Positioning will be guided by the patient as to what provides to most relief to the increased WOB.R2-Positioning in semi-Fowler’s or high Fowler’s position to alleviate dyspnea improves ventilation “by decreasing venous return to heart and increasing thoracic capacity” (Bouffard, 2014, p. 943). This will also help reduce the fluid overload (pooling) in the ventricle which will facilitate more efficient pumping of the fluid towards the aorta instead of fluid backing up into the lungs, adding to congestion and difficulty in breathing (Gulanick & Myers, 2014).E2-At 30 minute assessment the patient will have shown a decreased WOB as evidenced by: patient’s statement that WOB has decreased; a decreased use of accessory muscle use; and vital signs will stabilize (RR 12-20 bpm, HR 60-100 bpm, BP back to within patient’s normal range).N3-(I) (C)Review MAR to determine if there is a prn Lasix order and possibly give a prn Lasix dose.R3-Lasix is a loop diuretic, a potent diuretic commonly used in acute heart failure and pulmonary edema treatment. This drug “acts on the ascending loop of Henle to promote sodium, chloride, and water excretion”. This results to reduction in preload and assists the left ventricle to contract more efficiently, thus increasing cardiac output (CO) and oxygen perfusion to tissues, and improving gas exchange. (Bouffard, 2014, p. 937).E3-On auscultation, a decrease in moist crackles will have been noted to both lung fields.On repeat CXR fluid in lower lung fields will have shown reduction.N4-(I) (C)R4-E4-N5- (I) (C)R5-R5-N6- (I) (C)R6-E6-N7- (I) (C)R7-E7-N8- (I) (C)R8-E8-Compiled for Stenberg College RDPN program2014ReferencesAmerican Heart Association. (2014). Ejection fraction heart failure measurement. Retrieved from , L.D. (2014). Nursing management: Heart failure. In Barry, M., Goldsworthy, S., & Goodridge,?D. (Eds.).?Medical-surgical nursing in Canada?(3rd ed. pp. 928-949). Toronto, Canada: Elsevier CanadaBucher, L. & Castellucci, D. (2014). Nursing management: Coronary artery disease and acute coronary syndrome. In Barry, M., Goldsworthy, S., & Goodridge,?D. (Eds.).?Medical-surgical nursing in Canada?(3rd ed. pp. 891-927). Toronto, Canada: Elsevier CanadaEvolve (2014). Nursing management: Heart failure. Retrieved from , M. & Foell, H. (2010). Nursing management: Heart failure. In Lewis, S., Heitkemper, M., Dirksen, S. R., O'Brien, P. G., Barry, M., Goldsworthy, S., & Goodridge,?D. (Eds.).?Medical-surgical nursing in Canada?(2nd ed. pp. 883-903). Toronto, ON: Mosby ElsevierGulanick, M. & Myers, J. (2014). Nursing care plans: Diagnosis, interventions and outcomes [Kindle digital version]. Retrieved from , M. (n.d.). Ejection fraction: What does it measure? Retrieved from Clinic. (2014). Disease and conditions: Heart failure. Retrieved from , C. (2014). Nursing assessment: Respiratory system. In Barry, M., Goldsworthy, S., & Goodridge,?D. (Eds.).?Medical-surgical nursing in Canada?(3rd ed. pp. 608-632). Toronto, Canada: Elsevier Canada ................
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