Item 1: Clinical Presentation
Sylvie was brought from the cardiac outpatient clinic with following symptoms and signs; dyspnoeic, tachycardia, peripheral oedema and some central cyanosis. The patient reports increased weight gain the last few weeks, shortness of breath and easily tires loss of memory and confusion (Nicholson, 2005).
Cardiac dyspnoea occasionally can be linked to heart failure especially when the heart’s pumping ability is weakened or an obstruction prevents free flow of blood through the blood vessels this can be as a result of heart muscle weakening due to coronary artery disease and/ or narrowing the valves found between heart chambers. In case only a small amount of blood is pumped forward with every heart beat, pressure will build up in the diminished pumping ability leads to shortness of breath due to fluids and blood building up. Pressure builds up in the lungs via the pulmonary. The increased pressure in the pulmonary veins leads to leaking of fluid from the blood vessels into the air sacs. Breathing becomes difficult gradually as the fluid accumulates in the air sacs (Schwartz & Schmidt, 2013).
1. Oedema is clearly observed in Sylvie’s lower limbs which are a sign for cardiovascular disease. The site of oedema will mean different problems in the heart. For example, oedema found in the abdomen or even legs will indicate right side heart muscle weakening. Swelling of ankles in the evening after standing during the day may indicate that an individual is retaining electrons and fluids, which is a result of right-sided heart failure. Sylvie indicates that she becomes too tired to do her activities of the living, this indicates lack of exercise and this leads to blood build up in the lower legs and not returning to the heart, hence oedema (Stevens, Jackson, & Milligan, 2009).
Cyanosis refers to the bluish discoloration of the mucous membranes and the skin. It is mostly caused by little oxygen carrying haemoglobin in the blood in the small blood vessels. This is mostly observed around the lips and in fingernail beds. Cyanosis is a sign of heart disease. Central cyanosis occurs when arterial and venous blood are mixed in the heart, because of a congenital opening between the right and left sides of the heart or due to a genetic defect occurring in the heart where there is a common mixing chamber for blood.
Fatigue that is associated with diminished heart pumping ability is often described by patients as general weakness or heaviness of the lower limbs. Such patients have tendencies to have poor eating habits and can develop malnutrition. This kind of fatigue can occur with or without breath shortness of breath. Cardiac disease patients also can experience fatigue because of the kind of medication they take for the heart disease. Fatigue is possible in about 10 % of people on blood-pressure lowering drugs like those Sylvie takes; diuretics, angiocholinergic enzyme inhibitors and cardiac glycosides
Item 2: Nursing Priorities
Altered cardiac disease impacts quality of life, interfering with activities of the daily living such as role performance and self-care.
Reduce cardiac workload-supplemental oxygen will be administered as required. This will improve blood oxygenation, hence decreasing the effects of ischemia and hypoxia. Administration of prescribed medications will decrease the cardiac workload hence increase the effectiveness and restore cardiac contractility. Rest will be encouraged to save the heart of high oxygen demands which will mean increased workload. The head of the bed will be elevated to reduce breathing effort. Also assist the patient in activities of the living to enhance rest. Discourage the patient from Valsava manoeuvre as it takes away a lot of energy.
Improve cardiac function- this will involve measures such as providing oxygen as prescribed amounts to the patient, administering prescribed medication that will improve the heart muscle functionality.
Control fluid retention- input and output of fluids will be monitored closely. Report to the physician if urine output goes blow 30ml/h. Diuretics will be administered with the aim of reducing circulating volume. An acute decrease in urine output may suggest significantly low cardiac output and therefore renal ischemia. Fluids will be restricted as ordered. Kalisch, Landstrom, & Hinshaw, 2009).
Item 3: Nursing Management: Assessment and Monitoring of Cardiac function
Assess for complaints of increasing dyspnoea upon exertion, shortness of breath, reduced activity tolerance; find out the number of pillows used for sleeping; any recent weight gain; chest and/ or presence of a cough; abdominal or pain; ask for patient for any nausea or anorexia; any history of cardiac disease in the family; ask if patient has had previous episodes of altered cardiac disease; assess for any other risk factors such as diabetes or hypertension; find out what medicine the client is using currently; find out the clients diet characteristics and activities.
Perform physical examination of Sylvie and observe the general appearance pattern and ease of breathing, how often she changes position in bed; assess for any vivid anxiety; observe the vital signs together with apical pulse; check the skin and mucous membrane colour; check if the neck vein is distended, palpate for peripheral pulses, check the capillary refill, palpate to find out presence and level of oedema; do auscultation for heart sounds and breath sounds.
Hourly hemodynamic pressure and vital signs measurements will be taken. Monitor the effects of the prescribed vasodilators and diuretics by observing input and output charts closely. Fluid restriction is maintained at 1500mL per 24 hours. Oxygen is administered per nasal at 2 litres per minute then monitor oxygen saturation regularly. The physician should be notified if oxygen saturation goes below 94 percent. The patient will be taught about the medications she has been prescribed for, how they are taken, side effects and correct doses. Sylvie and I will design an activity plans that will include preferred activities and rest periods. (Albert, Paul, & Murray, 2012)
Positive changes
Loss of weight will be an indicator that Sylvie’s oedema is subsiding hence a positive prognosis to the treatment. The patient verbalization that it is easier to breathe shows cardiac pattern returning to normal functioning. The patient will be able to do her own activities of the living with minimal assistance.
Item 4: Nursing Management: Reducing Cardiac Workload
Vital signs and oxygen saturation are monitored as indicated. Low cardiac output stimulates the sympathetic nervous system to increase the heart rate in an attempt to restore normal cardiac output. Diastolic blood pressure can be elevated initially because of vasoconstriction; , compensatory mechanisms may fail in late stages, and hence blood pressure falls. Gas exchange with tissue perfusion measures are provided by oxygen saturation levels. (Albert et al., 2012
Auscultation of heart sounds together with breath sounds regularly is vital. Sound 1 and Sound 2 may be faint if there is poor cardiac function. Sound 3 is an early indication of heart failure.
Monitor intake and output. The physician will be notified if urine output has gone below 30 millilitres per hour. Patient will be weighed daily to monitor changes. Fluid volume is monitored carefully as it is very important in heart failure treatment. Diuretics may reduce the circulating blood volume, hence producing hypovolemia. Urine output decrease shows significantly the reduced renal ischemia and cardiac output. (Burhans& Alligood, 2010).
Record patient’s abdominal girth per shift- Note the patient’s complaints of anorexia and discomfort of the abdomen. Ascites can result from venous congestion and may affect the gastrointestinal function and hence nutritional status. (Burhans& Alligood, 2010)
Monitor and record hemodynamic measurements every shift- Report every vital changes and negative trends in the measurements. These measurements provide the means that is used in monitoring the condition, and how patient responds to treatment(Burhans& Alligood, 2010)
Restrict fluids as ordered- the scheduling of most fluid intake should be during morning and afternoon shifts. Let the patient be allowed to choose the periods to increase patient’s sense of control (Burhans& Alligood, 2010).
Item 5: Nursing Management- Medication management
For angiotensin-converting enzyme medication: – monitor carefully if patient is blood volume depleted or if she has impaired renal function from blood-urea-nitrogen tests
. An infusion pump is used when administering angiotensin-converting enzyme inhibitors through intravenous line.
Blood pressure will be closely monitored for two hours after administration of the first dose and as indicated thereafter.
Monitor closely serum potassium levels as these drugs inhibitors can cause increased calcium levels.
For the diuretics: – a baseline weight and vital signs is obtained first to help in deciding which medication will be administered.
Blood pressure, weight, intake and output, oedema and skin turgor are monitored as indicators for fluid volume.
Avoid administering potassium replacements to the patient if she is on potassium-sparing diuretic.
For the glycosides: – Assess apical pulse before giving the drugs. Do not administer digitalis if heart rate is below 60 beats per minute.
Report if there are signs and symptoms of digitalis toxicity (Staveski et al., 2012).
Item 6: Preparation for discharge
Sylvie’s discharge plan will commence after she will be able to sleep in semi-Fowler’s position with only one pillow and once her peripheral oedema has resolved.
She will meet with the dietician, who will help her develop a realistic eating plan to avoid sodium and fats. The dietician will also provide her with a list of high-sodium foods to avoid. Sylvie will then be assigned a physical therapist who will design a progressive activity plan with her that will continue at home.
Sylvie will be taught on home activities plan as follows: she was advised to perform as many activities as she could at home.
She was advised to space her meals and daily activities. As follows; take 6 small equally spaced meals a day; to allow time for napping and resting between activities; to choose a comfortable space for all activities; she was advised not to do activities while tired; she was told to avoid activities that cause pain in the chest pain, difficulty in breathing and shortness of breath; she was told to report to her physician in case of any negative changes; she was advised to avoid straining during activities; she was advised to take high fibre die drink plenty of fluids and water to avoid constipation (Staveski et al., 2012).
References
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Kalisch, B. J., Landstrom, G. L., & Hinshaw, A. S. (2009). Missed nursing care: A concept analysis. Journal of Advanced Nursing, 65(7), 1509–1517.
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Schwartz, S. M., & Schmidt, A. (2013). Medical and nursing care of the child on mechanical circulatory support. Pediatric Critical Care Medicine : A Journal of the Society of Critical Care and the World Federation of Intensive and Critical Care Societies, 14(5 Suppl 1), S43–50.
Sri Hariyati, R. T., & Sahar, J. (2012). Perceptions of Nursing Care for Cardiovascular Cases, Knowledge on the Telehealth and Telecardiology in Indonesia. International Journal of Collaborative Research on Internal Medicine & Public Health (IJCRIMPH), 4, 115–128. Retrieved from http://ezproxy.net.ucf.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=edsoai&AN=edsoai.821837820&site=eds
Staveski, S., Leong, K., Graham, K., Pu, L., & Roth, S. (2012). Nursing morbidity and mortility journal club cycles: paving the way for nursing autonomy, patient safety, and evidence-based practice. AACN Advanced Critical Care, 23(2), 133–41.
Stevens, E., Jackson, S., & Milligan, S. (2009). Palliative Nursing: Across the Spectrum of Care. Palliative Nursing: Across the Spectrum of Care.
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