The goal of this case study is for you to apply knowledge of pathophysiology processes of disease to the assessment, planning, implementation and evaluation of care using the nursing process. You The goal of this case study is for you to apply knowledge of pathophysiology processes of disease to the assessment, planning, implementation and evaluation of care using the nursing process. You also critically appraise the professional standards that influence health care delivery.
Format/Product Written
Type Individual
Word Count 2000 words, +/- 10%. The Word count does not include the reference list.
Criteria
1. Application of pathophysiology of the patient\’s condition to the case study
2. Application of the nursing process to the medical/surgical context
3. Use of evidence to inform and support decision-making and responsive practice
4. Critically appraise nursing/midwifery standards that influence health care delivery
5. Apply principles and practices of academic communication, writing and referencing.
It is essential that you refer to the marking rubric in Canvas in order to meet all the criteria for th
Topic 1 – Chronic Heart Failure
2. Review pathophysiology, subjective and objective data Congenital heart disease more likely in twins It is essential to have sound knowledge of the pathophysiology of medical conditions to understand how the signs and symptoms people display manifest in the body, what assessments will need to be undertaken and how this information informs the treatment plan.
Firstly, use the information in the case study to provide a written explanation of the pathophysiological changes that occur in the body in relation to the disease process either heart failure or GORD
Secondly, provide a written explanation for each of the subjective and objective data presented in the case study (i.e. what causes the symptoms presented?)
(Approximately 800 words)
3. Review the 5 stages of the nursing process
Nursing assessment: Explain what assessments
Nursing assessment: Explain what assessments
Nursing assessment: Explain what assessments you would undertake and provide a rationale for each assessment process (Approx 500 words).
Nursing diagnosis: Provide nursing diagnoses in relation to the information provided in the case study. These can be in bullet point format (Approx 30 – 50 words).
Plan: Provide a brief plan of care that meets the person\’s care needs in relation to the case study. These can be in bullet point format (Approx 30 – 50 words).
Intervention: Explain what interventions you would undertake and provide a rationale for each intervention (Approx 500 words).
Evaluation: Provide an explanation for the evaluation of your care delivery you would
undertake at the end of your shift (Approx 100 words).
4. Sourcing evidence to support your assignment
Researching your topic Review what is published about this health issue. Remember to focus on the medical context and brainstorm your ideas.
5. Applying Standards for Practice Apply the Registered Nurse or Midwifery Standards for Practice to your assignment And Integrate the National Safety and Quality Health Service (NSQHS) Standards (developed by the Australian Commission on Safety and Quality in Health Care) into your answers.
6. Reference (Within 5 Years past) using APA 7 style
Chronic Heart Failure
Name
Institution
Date
Chronic Heart Failure
Application of Pathophysiology of the Patient’s Condition to the Case Study (800)
The paper will look at Mrs. Yindi’s case study who is an Aboriginal woman 68 years of age who was admitted to the ward two days ago with chronic heart failure. Chronic heart failure refers to a clinical syndrome that is caused by a functional cardiac abnormality that results in reduced cardiac output and or elevated intracardiac pressures either during rest or when an individual is stressed (Wright & Thomas, 2018). The patient has bilateral edema of her legs and nocturia, complains of shortness of breath and fatigue. Some of the documented signs and symptoms of chronic heart failure include shortness of breath, tiredness or weakness, swollen legs and ankles, fatigue, sleep problems, and difficulty breathing especially when one is sleeping (Mc Horney et al., 2021; King & Goldstein, 2021).
During the initial stages of chronic heart failure, cardiac physiology tries to adapt through various compensatory mechanisms aiming to maintain cardiac output while meeting the systemic demands (Schwinger, 2021). Some of the compensatory mechanisms include myocardial hypertrophy, the Frank-Starling mechanism, myocardial hypercontractility, and changes in myocyte regeneration. Due to an increase in the wall stress, the myocardium tries to compensate through remodeling which worsens the loading conditions as well as wall stress.
A decrease in the cardiac output results in the stimulation of the neuroendocrine system with a release of epinephrine, vasopressin, norepinephrine, and endothelin-1. The above leads to vasoconstriction resulting in increased afterload. An increased afterload results in an increase in the cyclic adenosine monophosphate (cAMP) which subsequently increases systolic calcium in the myocytes. The aftermath is increased myocardial contractility which prevents myocardial relaxation. An increased afterload and myocardial contractility as well as impaired myocardial relaxation results in an increase in the oxygen demand. The need to meet myocardial demand results in the death of myocardial cells and apoptosis. Continued apoptosis, a decrease in cardiac output with a high demand results in a cycle of neurohumoral stimulation, myocardial and maladaptive hemodynamic responses.
A decreased cardiac output results in the stimulation of the renin-angiotensin-aldosterone system (RAAS) leading to increased sodium and water retention alongside increased vasoconstriction (Malik et al., 2021). The RAAS system has also been shown to release angiotensin II which has been linked to an increase in myocardial cellular hypertrophy as well as interstitial fibrosis. An increase in myocardial remodeling has been linked to the maladaptive function of angiotensin II.
Explanation of the Subjective and Objective Data
The patient’s subjective data shows that she has bilateral edema of her legs and nocturia, she feels short of breath and is fatigued. Edema of the legs occurs when the heart’s lower chambers lose their ability to pump blood. A decrease in the cardiac output results in increased vasoconstriction, as well as fluid and sodium retention. Nocturia occurs because at night the lying down position allows for the blood circulation in the renal arteries to be ameliorated hence the interstitial fluid accumulated in the legs usually disappears by morning. Shortness of breath on the patient was caused by an elevated end-diastolic pressure which causes pulmonary edema resulting in difficulty during breathing. The patient also has fatigue which can be attributed to the peripheral sequelae of the cardiac dysfunction (Williams, 2017).
The objective data from the patient’s case study include a high blood pressure of 135/70 mm Hg, a pulse rate of 98, a respiration rate of 32, oxygen saturation of 89 percent on 2 litres of oxygen via nasal prongs, and a temperature of 36.6. The patient’s blood pressure is 135/70 which is an indication of pre-hypertension. A patient with a blood pressure reading of 135/70 is more likely to have a heart attack or a stroke. Mrs. Yindi who has chronic heart failure, therefore, is at more risk of developing complications with a high blood pressure reading. High blood pressure is a risk factor for developing heart disease as it results in narrowing and constriction of the blood vessels resulting in a higher heart workload (Jones et al., 2018). A pulse rate of 98 is considerably high for a heart failure patient. Kurgansky et al. (2020) indicate that patients that have had a pulse rate higher than 70 bpm in the last six months are likely to have more hospitalizations as compared to those with a pulse rate of below 70 bpm.
The patient’s respiratory rate is 32 which is significantly high and an indication of heart disease. A normal respiration rate for an adult is 12 to 20 breaths per minute (Rolfe, 2019). A high respiratory rate in patients with heart failure is caused by congestion in the lungs as well as pulmonary edema. The patient’s oxygen saturation levels are at 89 percent on 2 litres of oxygen via nasal prongs which is an indication that the patient has been put on oxygen and has achieved the recommended saturation levels.
Application of the Nursing Process to the Medical Context/Surgical
Nursing Assessment
Nursing assessment is of paramount importance as it would ensure that the nurse understands the cause and severity of the disease. Standard four of the Nursing and Midwifery Board requires that registered nurses ‘Comprehensively conducts assessments.’ (Nursing and Midwifery Board, 2022). Registered nurses should conduct comprehensive assessments which will facilitate data analysis and communication of outcomes as a basis for practice. The assessments should be holistic and culturally appropriate, RNs should work in partnership with others and should similarly assess the resources available for planning.
Echocardiography is the most commonly used assessment used for heart failure. The procedure assesses for both systolic and diastolic dysfunction helping to determine the presence of focal wall motion abnormalities or the valvular pathology (Choi et al., 2019).
Computed tomography (CT) and magnetic resonance imaging (MRI) are assessment procedures that are primarily used for the diagnosis of congenital cardiac abnormalities. It is equally important to know that cardiac MRI is the gold standard test for testing for right ventricular function.
Chest radiographs are used to assess the degree of pulmonary congestion as well as cardiac contour. Some findings which would indicate congestive heart failure would include edema at the lung bases, vascular congestion, and enlarged cardiac silhouette (Malik, 2021).
Radionuclide multiple-gated acquisition (MUGA) scan is a scan that has been reliably used for evaluating the left and right ventricles’ functions. It has been ascertained as the most accurate test for ejection fraction (EF) and is commonly used in patients where there is a disparity of EF measurements.
Electrocardiogram (ECG) -gated myocardial perfusion imaging is a tool that is used for assessing ejection fraction, regional wall thickening, and regional wall motion (Taylor et al., 2017). The ECG images are equally useful in recognizing defects such as diaphragmatic attenuation and breast tissue.
Serum electrolytes and kidney function tests are used for screening of kidney disease and renal function.
A complete blood count test is a common test that is usually recommended as a routine medical examination to monitor one’s general health while at the same time screening for diseases such as anemia.
A lipid level test is used to monitor while at the same time maintaining healthy levels of cholesterols. It is vital to acknowledge that cholesterol levels help to determine a person’s risk of cardiovascular diseases.
Liver function tests are normally used to screen the liver for infections while at the same time determining how well your liver is functioning. The tests check the levels of certain proteins and enzymes in the blood. The tests include Alanine transaminase test, Aspartate transaminase test, Alkaline phosphate test, L-lactase dehydrogenase test, Gamma-glutamyltransferase’s test, and Bilirubin test.
Troponin level tests are often used to diagnose a heart attack. The test is used to monitor angina which is a condition that limits blood flow to the heart causing chest pains. The condition could often lead to a heart attack.
The thyroid function test aims at assessing the thyroid gland. The test measures the level of thyroid-stimulating hormone in the blood to determine thyroid function. The test helps to diagnose hypothyroidism and hyperthyroidism.
Nursing Diagnosis
The nursing diagnosis for Mrs. Yindi is chronic heart failure. The diagnosis was reached based on her clinical manifestation. The patient complains of shortness of breath, fatigue, bilateral edema in her legs, and nocturia. The above signs and symptoms are used by registered nurses as diagnosing criteria for patients with chronic heart failure. Based on the patient diagnosis, it is expected that the patient could be put on diuretics and ACE inhibitors which have been shown to improve congestion related symptoms and overall reduction of hospitalization and mortality rates respectively.
Plan
Standard 5 of the Nursing and Midwifery Board requires that registered nurses ‘Develop a plan for nursing practice.’ (Nursing and Midwifery Board, 2022). Registered nurses should develop nursing plans in partnership based on relevant information, and appraised and documented information. A nursing plan for Mrs. Yindi would entail support to improve her heart pumping function considering that her heart problem has been prevalent for a considerable amount of time. The plan would therefore include nursing interventions based on her clinical manifestation and history of the disease, prevention, and the identification of complications while at the same time providing her with patient education for symptom management at home and lifestyle modification.
Intervention
The goal of treatment for patients with chronic heart failure is to improve symptom management, decrease hospitalization rates, improve the quality of life as well as overall decrease the mortality rate associated with the disease (McDonagh et al., 2021). Standard six of the Nursing and Midwifery Board (2022) states that registered nurses should ‘Provide safe, appropriate and responsive quality nursing practice.’ Nurses should therefore provide safe and responsive care to the needs of the people, comply with the relevant polices and guidelines and practices within their scope of practice. It is equally important for the nurse practitioners and the medical team to understand the underlying pathophysiology of heart failure to facilitate the initiation of an effective therapeutic option. National Safety and Quality Health Service (NSQHS) Medication Safety Standard recommends that clinicians should prescribe, dispense and administer appropriate medication. They should similarly monitor medicine use to ensure consumers understand own medicine needs and risks. Nursing literature supports the use of guideline-directed therapy and device-based therapies based on individual patients’ needs.
Neurohormonal antagonists which include ACE inhibitors, beta-blockers, and MRAs have been shown to significantly lower the rate of hospitalizations among patients diagnosed with heart failure. The medications are recommended in the management of heart failure unless they are not tolerated or are contraindicated. Some of the ACE inhibitors that can be used include captopril, quinapril, and enalapril. The beta-blocker that has been approved by the Food and Drug Agency for chronic heart failure is carvedilol. It is important to note that ACE inhibitors and Beta-blockers are complementary and hence can be used together once the diagnosis has been made. The combination therapy of Angiotensin II receptor blockers (ARB) AND Angiotensin receptor neprilysin inhibitor (ARNI) has been shown to lower cardiovascular-related deaths as well as heart failure hospitalizations as compared to Angiotensin-converting enzyme (Khan et al., 2017). Diuretics are recommended for patients with congestion and fluid retention as they ease congestive symptoms of heart failure (Kennelly et al., 2020).
According to Malik et al. (2021), Ivabradine inhibits a funny current (I-F) in the sinoatrial node. The drug is mostly recommended for patients with persistently symptomatic heart failure and ejection fraction which is less than or equal to 35 percent in sinus rhythm. Vericiguat is another agent that was approved by the Food Drugs Agency in 2021 for the reduction of risk of mortality and heart failure hospitalizations among patients admitted to hospital with heart failure exacerbation presenting with chronic symptomatic heart failure and an ejection fraction of less than 45 percent (Malik et al., 2021). Patients suffering from heart failure can also be put on an implantable cardioverter-defibrillator (ICD) which is recommended for the prevention of sudden cardiac deaths among patients with heart failure with an LVEF of either less or equal to 35 percent and a New York Heart Association (NYHA) functional class of II to III while still put on goal-directed therapy (Malik et al., 2021). It is also vital to note that patients that present with HFrEF are recommended to be put on cardiac resynchronization therapy (CRT) with biventricular pacing.
Besides the use of pharmacological agents, patients should be offered a personalized, exercise–based cardiac rehabilitation program when their condition is stable (Hopper & Easton, 2017). The patient should have access to education emphasizing self-care as well as symptom management (Austin et al., 2020). Self-care activities include symptom monitoring, medication adherence, dietary adherence, weight monitoring, fluid restriction, and exercise (Jackevicius et al., 2018). Nursing literature shows that improving a patient’s knowledge and understanding of their health condition is paramount to ensuring they develop self-care skills (McDonagh et al., 2021). After discharge, the patient should receive follow-up care such as clinics, tele-monitoring, and home visits. It is also vital to acknowledge that since patients are not likely to recover from heart failure, there should be more emphasis on psychosocial support from caregivers and family. Similarly, the patient should have advanced treatment options like heart transplantation and even palliative care (Taylor et al., 2018). The Comprehensive Care Standard by the NSQH aims at ensuring that patients receive a comprehensive care which meets their needs and overall wellbeing (Australian Commission on Safety and Quality in Healthcare, 2022). Comprehensive care ensures care coordination aligning care provided with the patient’s health needs and goals.
Evaluation
The evaluation process will be determined by the intervention chosen. The Nursing and Midwifery Board standard 7 requires that a registered nurse ‘Evaluates outcomes to inform nursing practice.’ (Nursing and Midwifery Board, 2022). The nurse should therefore evaluate and monitor a patient’s progress based on the agreed goals, plans priorities and most importantly revises the practice when necessary. If the treatment plan will include a diuretic, the evaluation will be based on the diuretic’s ability to lower edema and other clinical symptoms that the patient presents with like shortness of breath. Diuretics act by promoting an increase in urine output and altering sodium and water excretion (Ellison & Felker, 2017). If the patient’s treatment plan will entail the use of ACEIs, the evaluation will depend on the medication’s ability to minimize the degradation of bradykinin promoting its role in β2 receptors resulting in endothelial protection, dilation of the blood vessels, and anti-proliferation (Tai et al., 2017).
References
Austin, R. C., Schoonhoven, L., Clancy, M., Richardson, A., Kalra, P. R., & May, C. R. (2021). Do chronic heart failure symptoms interact with burden of treatment? Qualitative literature systematic review. BMJ open, 11(7), e047060. https://doi.org/10.1136/bmjopen-2020-047060
Australian Commission on Safety and Quality in Healthcare. (2022). Retrieved 25 March 2022, from https://www.safetyandquality.gov.au/standards/nsqhs-standards/comprehensive-care-standard.
Choi, H. M., Park, M. S., & Youn, J. C. (2019). Update on heart failure management and future directions. The Korean journal of internal medicine, 34(1), 11–43. https://doi.org/10.3904/kjim.2018.428
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