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Stenberg College NURS 201-3 Weekly Case Study and Care Plan Clinical group Members: Sasha Yunick, Michelle Couper, Jillian Shaw, Lorna Muenz, Kristina Day & Andrea Geib__________________________________________________________ Date: June 29 2014___________________ Case Study Critical thinking questions 1. Explain the pathophysiology of Mrs E’s heart disease. Mrs. Estrela has acute decompensated heart failure (ADHF) of systolic origin that has resulted in impaired ventricular emptying, as evidenced by her EF being 20% when normal values are greater than 55% (p. 929) (Bouffard, 2014). . If the functioning myocardium cannot compensate for this loss, the ventricle is unable to generate enough pressure to eject blood forward through the high-pressure aorta. Inability to move blood forward through the aorta results in (1) a decreased left ventricular ejection fraction (EF), (2) an increase in left ventricular end-diastolic pressure (LVEDP), (3) an increase in preload and pulmonary vascular resistance, and (4) an increase in fluid accumulation in the pulmonary vascular bed (pulmonary edema). The pulmonary edema results in dyspnea (shortness of breath) and may result in the development of pink, frothy sputum. The left-sided failure will eventually result in right-sided failure. The pulmonary congestion and increased pulmonary hypertension lead to right-sided hypertrophy and failure resulting in peripheral edema and weight gain. Ventricular dilation is the “enlargement of the chambers of the heart” (Bouffard, 2014, p.930) this happens when there is a elevated volume of blood over time , the chambers of the heart will lose their elasticity, and remain dilated reducing cardiac output. Ventricular hypertrophy is “the increase in the muscle mass and cardiac wall thickness” (Bouffard, 2014, p.930) this is due to chronic dilation of the heart ventricles. The thickened heart muscle helps to increase the strength of the heart contractions, yet the thickened heart muscle has “poor contractility” (Bouffard, 2014, p.931) needs more oxygen to work, has poor circulation and is prone to dysrhythmias (Bouffard, 2014). Increase in the SNS activity due to low cardiac output, will activate the release of epinephrine and norepinephrine, resulting in an “increase in the heart rate, myocardial contractility and peripheral vascular dilation” (Bouffard, 2014, p.931). This works to increase the CO initially but over time the efficiency of the heart declines. Neurohormonal responses to decreased CO are the releasing of hormones to facilitate balance in the body including; sodium and water retention and increased peripheral vascular constriction to increase blood pressure, and stronger contractibility of the heart (Bouffard, 2014). All of these functions over time can lead to damaged heart tissue and an elevated fluid amount in the body. 2/2 2. What clinical manifestations of heart failure did Mrs E. exhibit? The clinical manifestations of heart failure that Mrs. E shows are edema, including pulmonary edema. Mrs E shows signs of chronic heart failure by her admissions of increasing dyspnea on exertion during the last 2 years accompanied by a frequent cough, as an adaptive measure to deal with the shortness of breath and the retained pulmonary fluid she noted that she has to sleep with head elevated on 3 pillows. This chronic condition is also noted in the behavioral changes that she seems to have, as she does not always remember to take medication. In recent weeks we see peripheral edema as evidenced by the swelling in her legs. Upon admittance to the hospital it is noted that she is in in respiratory distress, an she is using accessory muscles to breathe, with an increased respiratory rate 36 breaths/min. Upon auscultation the nurse finds moist crackles in both lungs and a systolic heart murmur, and while reviewing the diagnostic xray it was noted that she had fluid in lower lung fields. Bouffard, L. (2014) Nursing Management: Heart Failure. In M. Barry, S. Goldsworthy & D. Goodridge (Ed.) Medical-Surgical Nursing in Canada: Assessment and management of clinical problems (3rd Canadian ed.) (pp. 928-949) Toronto, ON: Elsevier Canada. 1.5/2 cyanosis of her lips and extremities 3. What is the significance of the findings of the diagnostic studies? The findings of Mrs. E’s x-ray shows: an increased blood pressure can make the heart pump inefficiently which would affect the strength of the heart, damages the heart muscle, give the patient heart problems and defects. The x-ray shows the patient having an enlarged heart (cardiomegaly) due to high blood pressure with in the left and right ventricles. The heart enlarges because it is trying to pump more blood to the body, due to the thickening and stiffening of the heart muscles. The fluid in the lower left and right ventricles shows us that she has a buildup of fluid. Mayo Clinic (2014) Diseases and Conditions: Enlarged heart. Retrieved from http://www.mayoclinic.org/diseases-conditions/enlarged-heart/basics/causes/con20034346 Bouffard, L.D., Kaan, A.F. (2014). Stress and stress management. In Barry, M. A., Goldsworthy, S. & Goodridge, D. (Eds.), Medical-Surgical nursing in Canada: Assessment and management of clinical problems (3rd Canadian Ed.) (pp. 928-947). Toronto, CA: Elsevier. 1/1 4. Explain the rationale for each of the medical orders prescribed for Mrs. E. •Enalapril (Vasotec) 5mg PO daily -a vasodilator usedto treat high blood pressure and is an ACE inhibitor. “It works by decreasing certain chemicals that tighten the blood vessels, so blood flows more smoothly and the heart can pump blood more efficiently”(nlm.gov,2012) •Digoxin 0.25mg PO daily- improves contraction of the heart and should not be given to patient unless the heart rate is over 50-60 BPM depending on location of the patient whether they are in LTC or the hospital.(Nnama,H.2010) Digoxin is a positive inotropic agent that increases the strength of cardiac contraction, decreases the conduction speed within the myocardium, and slows the heart rate, allowing for more complete emptying of the ventricles and an increase in cardiac output. •Furosemide (Lasix) 40 mg IV BID-a loop diuretic which is used a water pill for fluid retention in the lungs and legs as in the case of Mrs. E. It is also used to treat high blood pressure and causes the kidneys to release unwanted water and salt throughout the body by way of urine output.( Nlm.gov,2010) Digoxin is a positive inotropic agent that increases the strength of cardiac contraction, decreases the conduction speed within the myocardium, and slows the heart rate, allowing for more complete emptying of the ventricles and an increase in cardiac output. -Potassium 40 mEq PO BID-is used for function of the heart and muscle contractions. Potassium is an important and necessary use for a patient in order to avoid a drop in blood pressure (WebMD, 2012) Potassium supplements are prescribed for Mrs. E. to replace potassium lost through the use of furosemide and to prevent hypokalemia, which may lead to digitalis toxicity. -2-g sodium diet- a low sodium diet helps prevent the buildup of extra water in the body( that causes swelling and possible fluid retention in limbs) and is beneficial for patients with high blood pressure, heart failure, kidney disease. (Bouffard, et al, 2014) -Oxygen 6 L/min-is needed for Mrs. E due to her dyspnea (shortness of breath). She will also need to be positioned in a semi-Fowlers position as it improves her ventilation by decreasing venous return to the heart and increases her thoracic capacity (Bouffard, et al, 2014) Daily weights are taken to monitor the effectiveness of therapy, as well as to identify early signs of fluid retention. Nnama,H.(2010)Contraindications for Digoxin. Retrieved from http://www.livestrong.com/article/162594-contraindications-for-digoxin/ Nlm.gov(2010).Furosemide. Retrieved from http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682858.html Nlm.gov(2014)Enalapril. Retrieved from http://www.nlm.nih.gov/medlineplus/druginfo/meds/a686022.html#if-i-forget WebMB(2012) Potassium and your Heart. Retrieved from http://www.webmd.com/heartdisease/potassium-and-your-heart Bouffard, L.D., Kaan, A.F. (2014). Stress and stress management. In Barry, M. A., Goldsworthy, S. & Goodridge, D. (Eds.), Medical-Surgical nursing in Canada: Assessment and management of clinical problems (3rd Canadian Ed.) (pp. 928-947). Toronto, CA: Elsevier. 1.5/2 5. What teaching measures should be instituted to prevent recurrence of an acute episode of heart failure? The patient should be taught about her heart failure so she fully understands what it is, how it affects her, and about certain risks. She should learn about the importance of taking her medications on time and regularly, especially because she tends to forget. In addition to this, she should be taught about nutritional therapy including information about diet and weight management. The nurse should help the patient to create a diet plan which consists of mostly low sodium foods. The reason for teaching the patient about her diet is because reducing sodium intake can treat edema related to heart failure. To make this easier for the client, she should be taught about the DASH diet, which is rich in fruits, vegetables, low fat or nonfat dairy. The client should also be taught about restricting her fluid intake to 1.5-2 litres of water per day. The nurse should teach the patient about the importance of weighing herself daily around the same time, preferably before breakfast to monitor fluid retention. Setting up an exercise program for her once she can tolerate it a bit better will be important, and teaching her about the benefits of regular exercise and set rest periods as well. These are all important things to teach the patient to prevent recurrence of an acute episode of heart failure. Martinez, L. G. & Bucher, L. (2010). Nursing management: Coronary artery disease and acute coronary syndrome. 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. 884-902). Toronto, ON: Mosby Elsevier 1/2 • For her impaired gas exchange, the nurse should provide the following care: Elevate the head of the bed to Fowler’s position, with her arms supported on pillows away from her chest - Administer oxygen as prescribed - Use pulse oximetry to monitor oxygenation status Provide emotional and physical rest to decrease oxygen consumption Provide small, frequent feedings to decrease oxygen needed for digestion Monitor her lung and heart sounds and vital signs frequently to evaluate her response to treatment • For her fluid volume excess, the nurse should provide the following care: - Evaluate her peripheral edema and measure abdominal girth daily - Assess intake and output every shift and weigh client daily - Provide sodium-restricted diet as ordered • For her risk for impaired skin integrity, the nurse should provide the following care: - Assess edematous areas for skin breakdown Turn and reposition q2h and perform passive range of motion to extremities q4h • Pad bony prominences to reduce pressure For her activity intolerance, the nurse should provide the following care: Assess her dyspnea, fatigue, and pulse rate to determine appropriate activity - Provide emotional and physical rest to relieve dyspnea and fatigue 6. Based on the assessment data presented, write 3 appropriate nursing diagnoses. Nursing Focus of Care / Nursing Diagnosis Rationale for Priority Risk for Excess fluid volume. - Mrs. E has recently had a respiratory tract infection with frequent coughing. - Physical examination confirmed she has moist crackling in both lungs - Chest x-ray confirmed fluid in lower lung fields. Risk for activity intolerance. - Increased dyspnea on exertion for last two years - edema in legs 2 weeks ago - Cannot walk two blocks without getting short of breath Risk for impaired gas exchange. - Increased dyspnea on exertion - Cannot walk two blocks without getting short of breath - Examination showed respiratory distress - Respiratory rate @ 36 breaths/min - Cyanotic lips and extremities 5/5 7. Are there any collaborative problems? How will they affect Mrs. E’s treatment? Collaborative problems include the following: history of heart attack, edema in legs, shortness of breath, fluid in her lower lungs, and the fact that she does not remember to take her medications. First and foremost if Mrs. E does not remember to take her medication, her treatment will significantly be effected. Remembering to take her medication is the most important aspect of her treatment. If she continues to not take her medications for the fluid in her lungs she will continue to have shortness of breath. Mrs. E’s intolerance for activity can play a part of the reason for the edema in her legs. All of these problems raise her chances of having a heart attack considerably. Mrs. E needs to be active for a least 30 minutes a day, if she does this, her edema in her legs will decrease, her shortness of breath will get better, which all lead to decreased chances of having another heart attack. Martinez, L. G. & Bucher, L. (2010). Nursing management: Coronary artery disease and acute coronary syndrome. 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. 846-882). Toronto, ON: Mosby Elsevier 2/2 Stenberg College RDPN Program Nursing Care Plan Nursing Diagnosis Desired Outcomes Interventions (I)Independent (C) - Collaborative Rationale & APA “Reference Evaluation of Interventions NDX: (Problem) Risk for excess fluid volume Goal (Reversal of Problem) N1-(I) (C) R1- E1- Position to alleviate dyspnea (e.g., semiFowler’s position with legs dangling To improve ventilation by decreasing venous return to the heart and increasing thoracic capacity and facilitating breathing(p. 943). Patient has regular, non-labored respirations Assess ABC’S and supplement patient’s oxygen by mask or nasal catheter 6 L-min Patient is in respiratory distress and has an increased respiratory rate. Oxygen will increase CO and help relax the pt (p. 935). Patient has regular, non-labored respirations Auscultate lungs for presence of normal or adventitious sounds Crackles may indicate heart failure which can contribute to decreased cardiac output (p. 622). Patients lung sounds are clear to auscultation in all lobes Decrease intravascular volume (p. 934). R/T: (etiology/factor) Client will list : measurable Cardiac failure outcomes; reverse signs Pulmonary and symptoms Edema Restrict sodium Right and Left to 2-g per day Ventricular Hypertrophy Restrict fluids to 100 mL per day Take AEB: medications as In respiratory prescribed – distress, use of Enalapril accessory (Vasotec) 5mg PO daily muscles, Nursing Diagnosis Desired Outcomes respiratory rate 36 breaths/min Digoxin 0.25mg PO daily Moist crackles in both lungs Furosemide (Lasix) 40 mg IV BID The patient’s statement, “I’m short of breath and my ankles, are so big and puffy!” Cyanotic lips and extremities Frequent coughing Has to sleep with head elevated on 3 pillows Increasing dyspnea on exertion during the last 2 years. Potassium 40 mEq PO BID Interventions (I)Independent (C) - Collaborative Rationale & APA “Reference Evaluation of Interventions N2-(I) (C) R2- E2- Administer diuretic (Lasix) as per doctors’ orders Diuretics mobilize edematous fluid, reduces pulmonary venous pressure, & reduces preload improving CO (p. 937). Left ventricular function has improved Daily Weight Measurements Evaluation of Outcomes (address each outcome) Fluid and electrolyte management – Monitor serum electrolytes especially sodium and potassium 1.restricted sodium intake will reduce fluid volume 2. measuring weight daily and restricting fluid intake to 6-8 glasses fluid a day helps monitor fluid retention 3. Drug adherence is necessary to reduce and treat signs and symptoms of CHF. Serum Sodium levels will determine if therapeutic measures have been effective or not as volume imbalances are often associated with changes in serum sodium levels and serum potassium levels indicate secondary HTN Monitor respiratory pattern for symptoms of respiratory difficulty Enables early detection of pulmonary congestion (p. 943). Evaluates the effectiveness of therapy (p. 943). Monitor hemodynamic status, including CVP, MAP, and PAOP, if available Evaluation of Goal: Monitor renal function and intake and output Goal met if patient adheres to care plan Monitor for the therapeutic effect of a diuretic (↑ urine output,↑ CVP, To monitor fluid balance (p. 943). To assess the patient’s response to treatment Pt’s serum electrolyte levels came back with normal results ensuring that her treatment plan has been effective Pt responded to treatment well and no longer displays symptoms associated with hypovolemia and edema Nursing Diagnosis Desired Outcomes Interventions (I)Independent (C) - Collaborative Rationale & APA “Reference Continuation of plan: improvement of breath sounds) (p. 943). Ensures valid Weigh the patient, same comparisons day to day and identifies early time every day, before signs of fluid retention breakfast making sure as a sudden weight gain they are wearing the of more than 2 kg in 2 same thing (p. 940). days is often indicative of exacerbated HF (p. 940). Patient’s weight has been consistent since day after admission and she doesn’t appear to be retaining any water N4-(I) (C) R4- E4- Appraise the patients current level of knowledge related to specific disease process This will open conversation and assist in identifying what areas the patient may require some more information in (p. 944). Pt will understand and can explain disease process and will know what signs and symptoms to report to HCP. N5- (I) (C) R5- R5- Nutritional Therapy : obtain a diet history from patient and appraise their current knowledge regarding sodium restricted diet To assess areas needing additional instruction and clarification (p. 944). Pt will show collaboration of low sodium recipes and food journal documenting daily intake. Continue plan and closely monitor patient. Will make adjustments accordingly Evaluation of Interventions 4.5/5 References Bouffard, L. (2014) Nursing Management: Heart Failure. In M. Barry, S. Goldsworthy & D. Goodridge (Ed.) Medical-Surgical Nursing in Canada: Assessment and management of clinical problems (3rd Canadian ed.) (pp. 928-949) Toronto, ON: Elsevier Canada 18.5/20