IntroductionBased on the most recent National Health Survey selfreports 13 of the

IntroductionBased on the most recent National Health Survey self-reports, 1.3% of the population have Heart Failure (HF). HF accounts for 2% of all deaths and is the third-largest cause of cardiovascular-related death (Brown et al. 2015, p. 775). As population grows and life expectancy increases, more people will be affected by this condition and with the likelihood to double in the next 20 years (Howard 2017). Congestive Heart Failure (CHF) is inadequate pumping and/or filling of the heart, unable to produce adequate levels of oxygenate blood to the tissues; this is most evident amongst the elderly (Brown et al. 2015). This essay will discuss and investigate the possible aetiologies relating to Mr. Smith’s CHF, by using the ABCDE framework to assist with nursing diagnosis for the patient. The ABCDE framework is best described; Airway, Breathing, Circulation, Disability and Exposure; this case study is of Mr. Smith, who is 70 years old, experiencing an exacerbation of his Congestive Heart Failure (CHF). He has presented with chest pain with pleuritic nature, SOB, fatigue, weakness, a hacking cough with bilateral bibasal crackles. This tool will be used to perform triage of the patient for this case scenario, identifying the primary priorities, implementing interventions and goals to ultimately treat and discharge him (Smith & Bowden 2017). Howard (2017) describes the disease to feature ventricular hypertrophy, which increases cardiac output and pushes the volume of blood into the circulation, and symptoms generally show after a long duration of time, For example; fatigue, inspiratory crackles on auscultation, weight changes, dyspnoea and nocturia. Primary PrioritiesDecreased cardiac output is when the heart is unable to clear blood. The pressure within the heart increases, making it difficult for blood to enter the heart (Craft et al. 2019). Signs and symptoms for CHF generally are age associated, and as the case study mentions, the patient presented with chest pain, Brown et al. (2019) states that angina is accompanied with CHF due to decreased carbon dioxide and artery perfusion which increases myocardial work load. Homeostasis is altered when the blood composition of volume is inadequate which decreases cardiac output; this is due to altered perfusion. One of the early clinical signs of heart failure is Tachycardia, and can be a recurrent factor to CHF. There is an increased heart rate is due to a failing ventricle which the body tries to compensate by increasing the HR. Heart failure can cause systolic hemodynamic disturbances, which increase excessive cardiac workload, caused by the volume overload. This can result in aortic stenosis/systemic hypertension. Mr. Smith’s vitals showed his blood pressure of 170 systolic and 90 diastolic, which causes resistance to ventricular emptying and decreases cardiac output, there can also be other aetiological explanations to the patient having hypertension (Howard 2017). To provide optimal perfusion to the vital organs, the goal is to maintain adequate blood pressure. The primary course of action for Mr. Smith is; monitoring the cardiac rhythm, minimizing activity (bed rest) until prescribed, and oxygen delivery to try and improve oxygenation to due to the decreased cardiac output. Purvey and Allen (2017) state, the best action for fluid overload in the lungs (pulmonary oedema) is 40mg Furoemide IV Stat. This has to be prescribed by the doctor however, the nursing action is to gather and use objective data based on the fluid overload and evidence will determine if the doctor will refer the patient to the hospital for IV therapy, if this is not available in the General Practice (GP) practice. Excess fluid volume is a result from congestive heart failure; the contributing factors why this occurs: patient’s impaired gas exchange could be related to water retention leading to pulmonary oedema; which is a result from CHF, the symptoms include dyspnea, fatigue and weakness. Renal dysfunction is a result from CHF and the medications that are associated with the disease. Hypervolaemia can occur with patients who have CHF, which lead to osmotic or oncotic pressure that’s drawn into plasma from the insterstitual place; are at increased risk of peripheral oedema. This can also disrupt skin integrity and venous return causing possible venous ulcers. Activity intolerance related to increased water retention, from fluid accumulating in the lungs (pulmonary oedema), and peripheral oedema. Implementing the plan of care for Mr. Smith is to maintain homeostasis with fluid and electrolyte balance, monitoring patients daily weight to ensure fluid retention is subsiding and decreasing peripheral oedema with compression gradient stockings. Reduce excess extracellular fluid, promotion of skin integrity (Bellomo et al 2006).Decreased cardiac outputIntervention 1: Administer required oxygenIncrease oxygen delivery to the myocardium and other vital organs and tissues by administering oxygen. Maintaining homeostasis by achieving adequate oxygen “02” and carbon dioxide “C02” gas exchange, meeting the oxygen levels of the body. Heart Failure leaves the left ventricle or right ventricle unable to adequately pump due to dead tissue, which in turn is unable to distribute the required amount of oxygenated blood into the tissues and organs. This leaves the body deprived of oxygen and the patient will experience symptoms such as dyspnea, cyanosis, and fluid retention. The patient had a pulse oxygenation saturation reading of 92%. Brown et al (2019) states the adequate ranges should be within 94% and 98%. When administering the oxygen ensure the patient is also in high fowlers position due to the dyspnea and the fluid accumulated on the lungs. Arterial blood gases should be measured when the oxygen saturation is below 93%. Patients with a pulse oxygen saturation level >92% may have hypoxemia. With Mr. Smith’s oxygen saturation at 92%, the required amount of oxygen administration would be the minimum of 2L/min to ensure the patient’s oxygen saturation improves instead of declining.Intervention 2: Monitor cardiac rhythmThrough the cardiac valves the blood is moved and this produces normal heart sounds. Generally this can be heard through listening with a stethoscope in various places over the chest wall; this is called auscultation. Mr. Smith’s Electrocardiogram (ECG) has changes, high Blood Pressure (BP) and has slight tachycardia; auscultate heart sounds, monitor blood pressure and ECG. What to look for when auscultating heart sounds; apical pulse is the maximum impulse is palpitated. How this is found when auscultating is; the left midclavicular line and the fifth intercostal space. Patients with CHF require an electrocardiogram (ECG) for diagnosis but also with continual management. Generally patients with CHF will show common abnormalities on their ECG, left ventricular hypertrophy, left atrial abnormality and atrial fibrillation. Another alternative is taking the patients radial pulse; pulsus alternans may present which is the strength of the pulse and may vary with each beat, but has a regular rhythm. Mr. Smith will require continuous monitoring of the ECG and haemodynamic monitoring, and administered medication when required. A referral for cardiac rehabilition, and ensure to educate the patient about rest activity periods (Lewis 2015). The aim is to block the activity of the Renin Angiotensin Aldosterone System (RAAS); which impacts a patient with heart failure. Medications such as your angiotensin converting enzyme inhibitors are crucial for a patient with CHF, by blocking the angiotensin coverting enzyme (ACE). This drug lowers blood volume, blood pressure and causes vasodilation. Also angiotensin receptor blockers (ARBs) have very similar effects on the RAAS; this medication is used for a patient with a hackling cough (Heart foundation 2011).Intervention 3: Activity restrictionExercise intolerance due to dyspnea is highly evident with patients with CHF. Discussing the importance of aerobic exercise for the patient with CHF. The difficulty associated with the inability to exercise due to fatigue and weakness from the respiratory muscles. Activity intolerance for a patient with CHF is due to a few contributing factors: Mr. Smith is a falls risk due to hyperkalemia effects; muscle weakness, possible arrhythmias and seizures. Referral and an action plan for Mr.Smith; to see a specialist for a cardiac rehabilitation program through a care plan nurse from the general practice. This will be to implement a safe exercise regime for the patient. Once the specialist monitors the regime, the patient can keep up their activity at home; walking, riding or swimming. (Jerome, L 2008). Excess Fluid volumeIntervention 1: Application of antiembolism stockingsPeripheral oedema is generally a common sign of CHF it occurs when the interstitial fluid shifts to plasma; an increase in the plasma osmotic and oncotic pressure draws fluid into the plasma from the interstitial space. This could happen with administration of colloids, dextran, mannitol or hypertonic solutions. Increasing the tissue hydrostatic pressure is another way of causing a shift of fluid into plasma. Mr. Smith is fatigued, short of breath and weak, any patient that has limited movement or subjected to bed rest is at risk of developing peripheral oedema. Pressing the oedematous skin can leave an indentation (pitting oedema) is not generally associated with CHF, but kidney failure; by using this method can assist with the nursing diagnosis for the peripheral oedema. Using a holistic approach, applying the antiembolism/compression stockings for the prevention of venostasis and/or thrombosis forming. Providing education to the patient regarding the rational why and how they will help him, the application of the compression stockings and duration that they are required to remain on. Tracking urine output, asking the patient how they are tracking this at home, and what it is currently. Wearing compression gradient stockings will decrease the oedema, which is a therapeutic application of this effect (Kumarasinghe & Carroll 2015).Intervention 2: Reduce excess extracellular fluidExcess fluid volume is due to fluid retention and excessive fluid intake of the patient with CHF. When the heart isn’t able to adequately pump enough blood volume through the body with CHF, the long-term result is other fluids build up in the lower extremities, lungs, abdomen and liver. Assisting the patient with lifestyle modifications, to reduce the risk of fluid volume overload, which can lead to the patient returning to hospital. The patient should be on fluid and sodium restriction as prescribed by the doctor; this should be tracked over a 24 hour period of the patient’s fluid intake and output. Daily weight should be done daily at home at the same time each day with the same clothes and same scales that have been calibrated. An increase of 1kg equates to 1 litre of fluid retention. Educating the patient and highlighting the importance of fluid balance and the management of their medications; loop diuretics such as furosedmide and torsemide are used to remove excess fluid volume; this is one of the goals of treatment for a patient with CHF, as long it there is isn’t much interference with the electrolyte balance (Baird 2010).Intervention 3: Monitor potassium levelsExcessive renal excretion shifts the potassium from Intracellular Fluid ‘ICF’ to the Extracellular Fluid ‘ECF’ causing Hyperkalemia. Patients with CHF are at risk of hyperkalemia and can lead to acidosis. Side effects from hyperkalemia are cardiac arrhythmia and possibility of death. Thomson et al (2018) highlights that people with heart failure, kidney disease or both; are at risk of hyperkalemia, this is described as cardiorenal syndrome. The drugs used for a patient with CHF, angiotensin-converting enzyme (ACE) inhibitors (enalapril), aldosterone receptor blockers (spironolactone) and the potassium-sparing diuretics (amiloride) interfere with renal excretion and this in turn may lead to hyperkalemia. Check the patient’s potassium level and implement the nursing actions required: One example is; Teaching Mr. Smith about the diuretic he is taking and the potential risks with increasing the dose, and loosing too much potassium with renal excretion. Some patients think by also taking a potassium supplement this will balance them both out, however this can lead to too much potassium serum, and cause issues such as head dysrhythmias. A few types of treatment of hyperkalemia will consist of: eliminating oral potassium intake, forcing the potassium from ECF to ICF; achieved by intravenous therapy (insulin/glucose), and intravenous therapy with calcium gluconate. Nursing considerations are: patients should be monitored via electrocardiogram ‘ECG’ and blood pressure, as calcium can cause hypotension. However in a general practice the resources of intravenous therapy might be limited and the patient would be referred to hospital. By implementing these interventions the aim is to reduce potassium serum levels (Thomsen et al. 2017). Most patients will generally be taking a loop diuretic; which is for symptom relief, hence why frequent monitoring of fluid and salt intake is to be performed and education is to be given to the patient.Discharge PlanningBurke (2010) emphasises the importance of the six elements of discharge planning for a patient with CHF; diet, discharge medications, activity level, weight monitoring, follow up appointments and patient being aware of when their symptoms worsen.Educating Mr. Smith of the signs and symptoms to look out for when he is at home, and know when to present to his General Practitioner or the hospital. Oedema of the lower extremities, feeling short of breath and increase in weight gain. A health care nurse referral within a general practice is highly recommended to patients with chronic diseases, assisting with management of the disease and education for the patient with their activities of daily living. Health care in the home ‘HITH’ is another alternative to assist Mr. Smith with his CHF. The aim of discharge planning is to have the plan before the patient leaves the general practice. This aim is to reduce the amount of re-admissions (Mabire 2017). An example of how the education for Mr. Smith and monitoring his daily weight is to be delivered is; to emphasise how and why they need to take their daily weight at the same time each day. By advising Mr. Smith to use the same scales (ensure they are calabrated), in the morning preferably post urination and before eating, with either wearing the same clothing or nothing. Help and assist the patient with follow up appointments by educating them, regarding the importance of the visit and write down the appointment day, time and location. Medications are very important and the patient needs to understand the rational why they are taking it and some side effects. Once Mr. Smith’s dyspnea has improved, prescribe exercise regime can be encouraged (ambulate from kitchen to bedroom). The ultimate goal for adequate discharge planning is to acquire the best quality of life for a patient with CHF. ConclusionThis essay has analysed the diagnostic and therapeutic techniques that have greatly improved the outlook for patients with Congestive Heart Failure. Using critical thinking has outlined how better nursing practices for the patient with CHF, and can be used to minimise diagnostic errors. Using the ABCDE framework, collecting objective data and how it is vital to complete the nursing assessment, having knowledge for interpretative skills to collecting the data, interventions and discharging the patient. This enables registered nurses to be more active and aware in the processes of analysing data and applying nursing assessment, that’s applied to each nursing diagnosis (Wilson & Giddens 2013). Referencing

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