Nursing Case Study Answers

Subject Name : Nursing

Case study 1

Outline the disease, causes, incidence and risk factors. Discuss the impact of the selected disease on the patient and their family (450 words)
Mrs Sharon Mckenzie is suffering from congestive cardiac failure as mentioned in the case study. Congestive cardiac failure is also known as a heart failure. It is a highly complex clinical syndrome in which the heart fails to meet the metabolic requirements due to the inability in performing its circulatory functions. Right amount of oxygen is required to be pumped by the heart to meet its metabolic needs. The desired efficiency is not met due to the structural and functional changes in the system (Mishra et al., 2018). The impaired ejection of blood and ventricular filling are due to the defects in the myocardium. The main pumping chambers that are ventricles change in size and thickness thus causing difficulty in contracting and relaxing of the heart. The ventricular relaxation failure leads to heart failure. It causes the blood pooling under back-pressure (State of Victoria, 2018). This causes the fluid retention in the legs, abdomen and lungs.
The causes of the congestive cardiac failure are the dysfunction of myocardium, endocardium, heart valve, pericardium all in combination or alone (Inamdar amp Inamdar, 2016). The fluid deposition around the heart muscles is also one of the causes of the hearts inability to function normally that leads to the congestive cardiac failure (Masetic amp Subasi, 2016). One of the common causes includes the decreased left ventricular myocardial function. One or both the upper and lower ventricles do not empty completely thus causing an increased pressure in atria and the veins. To respond to this, kidney begins fluid retention. This is the condition of oedema in lungs and kidney. Other causes of congestive cardiac failure are heart valve disease, congenital heart disease, high blood pressure (hypertension), alcoholism, myocarditis, heart arrhythmia, cardiomyopathy and so on.
There is an increase in prevalence of congestive cardiac failure. It has a global pandemic affecting 26 million people worldwide. Approximately 50 to 75 patients die within five years of the diagnosis of this disease. The people above the age of 65 years are more likely to suffer this disease. The poor quality of life, morbidity and mortality rates are high despite of the treatment techniques available (Savarese amp Lund, 2017). In Australia, approximately 30,000 cases are diagnosed and reported of heart failure every year.
Various significant risk factors associated with the congestive cardiac failure are the obesity, hypertension, diabetes, hypercholesterolaemia and so on (Norhammar et al., 2017).
There would be an extensive impact on the family members and the patient. The burden of the disease will cause significant effect on the patient and related members. They face the most difficulty in managing the medication due to its complexity and the negotiation of multiple appointments (Fry et al., 2016). This chronic condition will deteriorate the quality of the patients life. The important aspects of the lives of congestive cardiac failure patients are the psychosocial and existential issues affecting the psychological and emotional state (Leeming et al., 2014).
Discuss three (3) common signs and symptoms of the selected disease and explain the underlying pathophysiology of each (350 words).
Common sign and symptom Underlying pathophysiology
Edema (Ankle swelling) Fluid accumulation is a response to the hearts inability to pump adequate amount of blood. (Harvard Health Publishing, 2016).
Pathophysiology- In heart failure, the series of neuro-humoral and humoral pathways is activated that promotes the impaired regulation of sodium excretion by the kidneys thus leading to water and sodium reabsoprtion. Edema is formed due to the increase in venous capillary pressure and decrease in the plasma oncotic pressure (Arrigo et al., 2016).
Dyspnoea (Shortness of breath) Dyspnoea is one of the major symptoms of the congestive cardiac failure.
Pathophysiology The shortness of breath is caused in congestive cardiac failure due to the decreased capability of heart to empty and fill completely, causing the production of high pressures around the lungs in the blood vessels.
The congestive cardiac failure is led by the abnormal restrictive constraints on the expanding of the tidal volume (VT) and the excessive increase of the demand of ventilator with the development of critical mechanical limitation of ventilation (Laviolette amp Laveneziana, 2014). The pulmonary congestion gives rise to dyspnoea because left ventricular dysfunction causes the reduced cardiac output and the increase venous pressure. This ultimately leads to the accumulation of fluid in lung alveoli causing the reduction in ease of breathing and dyspnoea (Kupper at al., 2016).
Heart rate Every individual has varying normal heart rate but there is a range of normal limits. In adults, normal heart rate is between 60- 100 beats per minute. The lower and the higher rates both signify abnormality. Mrs. McKenzie has heart rate of 54 beats per minute which is lower than the optimal range.
Pathophysiology - Bradycardia is the main cause of the lower heart rate. In Bradycardia, the heart fails at pumping adequate amount of oxygen-rich blood throughout the body thus lowering the heart rate. This type of condition occurs due to the formation of low impulse from the sinus node to the arterial tissue (Botto amp Devereaux, 2015). Mrs. McKenzie is 77 years old so taking the age factor into consideration the heart failure could be caused by it. Due to the production of nodal cell fibrosis, the aging factor leads to the nodal dysfunction. The sinoartrial blockage, bradycardia may be the result of such conditions (Smith et al., 2018).
Discuss the pharmacodynamics amp pharmacokinetics of one (1) common class of drug relevant to the chosen patient (300 words)
a. This does not mean specific drugs but rather the class that these drugs belong to.
The patients with congestive cardiac failure are generally prescribed with ACE inhibitors because it relaxes the blood vessels. ACE inhibitor is one common class of drugs that is relevant to the congestive cardiac failure. The ACE inhibitors are the Angiotensin-converting enzyme inhibitors. According to the case study, Mrs McKenzie was also prescribed enalapril which is an ACE inhibitor. These inhibitors are a type of vasodilator, a drug that works by broadening the blood vessels that lowers the blood pressure and increases the flow of blood and ultimately decreases the heart workload.
Pharmacokinetics of ACE inhibitors
The ACE inhibitor drugs bind to the plasma protein and the tissues. The free form of drug is eliminated by the glomerular filteration through the kidney as compared to those that binds to tissue sites because the plasma concentration-time profile displays a long-lasting terminal phase of elimination. The most rapidly absorbed and eliminated form is the Captopril. The drug is metabolized by the hepatic cells of the body. The absorption rate is 40 to 75 and the Cmax is attained after one hour of administration. The half-life elimination is of 2 hours (Gomez-Diez et al., 2014).
Pharmacodynamics of ACE inhibitors
The mode of action of this class of drugs is to inhibit the ACE activity competitively to limit the production of the active angiotensin II from angiotensin I and active octapeptide from inactive decapeptide. This complete process occurs in blood and tissues of heart, brain, adrenal gland and kidney. Angiotensin II is a potent vasoconstrictor, that promotes release of aldosterone and activates the sympathetic activity and has multiple potential dangerous effects on the cardiovascular system. The rennin- angiotensin system stimulation causes the blood pressure to lower down secondary to vasodilation following ACE inhibition is maximum. ACE inhibitors lower the blood pressure at the minimum or normal rennin-angiotensin system activity (BIHS, 2017).
4. In order of priority, develop a nursing care plan for your chosen patient who has just arrived on the ward from ED. Nursing care plan goals, interventions and rationales must relate to the first 8 hours post ward admission (500 words)
a. This can be done in the form of a table each point needs to be appropriately referenced
The nursing plan is inclusive of all the interventions and rationales that is related to the first 8 hours post ward admission of the patient suffering from congestive cardiac failure. Mrs. McKenzie is suffering from congestive cardiac failure and has complications such as high blood pressure, dysponea, low heart rate, swelling in ankles and fatigue. The interventions taken by RN improve the condition of the patient and help them to recover fast. The duty of RN is to give physical and emotional aid to the patient and the family members. The nurses role is to educate them for the disease, its consequences, medications, its side effects, right doses, volume, proper medication regime, lifestyle changes, diet changes and so on. The nursing goals, interventions taken by the RN and its rationale would be as follows
S.No. Nursing goals Intervention Rationale
1. Administering oxygen therapy for maintaining oxygen saturation Proper oxygen therapy would be given by RN as prescribed by the doctor. Oxygen therapy is the first line of treatment given to the patients with shortness of breath. The RN would regularly check and monitor the vitals like BP, RR, HR and level of consciousness and so on.
The RN should be regularly check target oxygen saturation, indications, oxygen delivery device, range of oxygen flow and the percentage of inspired oxygen (Mayhob 2018). The right amount should be given to prevent the oxygen toxicity and it should be administered properly. The monitoring and regularly checking of the oxygen levels would help the RN understand the oxygen requirement by the patient (Urden, 2017).
2. Administration of medicines and reducing the medication error that occurs during the administration phase. Mrs. McKenzie was prescribed various medicines including the diuretics and ACE inhibitors as mentioned but she forgets to take all of them sometimes. It is the duty of RN to administer the medicines in a proper way and by the proper route to the patients. according to Amakali (2015) if the heart failure medicines are taken without discretions then they can have the lethal effect. The RN should educate the patient and his family members about the medication, timings and the side effects if they are concerning to reduce the medicational errors (Marynaik, 2018). The vitals should be checked and the patient should be observed by the RN and if any discomfort is observed then she should immediately inform the doctor about the same. The medication errors would be minimized and the efficacy would be maintained.
3. Monitoring of serum level and decreasing the fluid overloading The colour of the urine was tracked at fixed intervals of time. The electrolyte imbalance is monitored b y monitoring the potassium, sodium and bicarbonate levels. Due to the diuretics administration, the electrolyte imbalance monitoring is very essential (Doenges et al., 2016). Any imbalance noticed, is noted down and the proper steps to mitigate it are taken wither by the doctor or the nurse depending on the severity. Hypokalaemia monitoring due to diuretics administration is essential.

References
Amakali, K. 2015. Clinical care for the patient with heart failure a nursing care perspective.Cardiovascular Pharmacology, 4(2), 3-5.
Arrigo, M., Parissis, J. T., Akiyama, E., amp Mebazaa, A. (2016). Understanding acute heart failure pathophysiology and diagnosis.European Heart Journal Supplements,18(suppl_G), G11-G18.
Botto, F., amp Devereaux, P. J. (2015). Myocardial injury after noncardiac surgery.Perioperative Medicine for the Junior Clinician, 472.
BIHS. (2017). Angiotensin converting enzyme (ACE) inhibitors. Retrieved from https//bihsoc.org/wp-content/uploads/2017/11/Angiotensin-Converting-Enzyme-Final-2017.pdfFry, M., McLachlan, S., Purdy, S., Sanders, T., Kadam, U. T., amp Chew-Graham, C. A. (2016). The implications of living with heart failure the impact on everyday life, family support, co-morbidities and access to healthcare a secondary qualitative analysis.BMC Family Practice,17(1), 139.
Gmez-Dez, M., Muoz, A., Caballero, J. M. S., Riber, C., Castejn, F., amp Serrano-Rodrguez, J. M. (2014). Pharmacokinetics and pharmacodynamics of enalapril and its active metabolite, enalaprilat, at four different doses in healthy horses.Research in Veterinary Science,97(1), 105-110.
Harvard Health Publishing. (2016). 5 warning signs of early heart failure. Retrieved from https//www.health.harvard.edu/heart-health/5-warning-signs-of-early-heart-failureInamdar, A., amp Inamdar, A. (2016). Heart failure Diagnosis, management and utilization.Journal of Clinical Medicine,5(7), 62.
Kupper, N., Bonhof, C., Westerhuis, B., Widdershoven, J., amp Denollet, J. (2016). Determinants of dyspnea in chronic heart failure.Journal of Cardiac Failure,22(3), 201-209.
Leeming, A., Murray, S. A., amp Kendall, M. (2014). The impact of advanced heart failure on social, psychological and existential aspects and personhood.European Journal of Cardiovascular Nursing,13(2), 162-167.
Laviolette, L., amp Laveneziana, P. (2014). Dyspnoea A multidimensional and multidisciplinary approach.European Respiratory Journal,43(6), 1750-1762.
Mahob M.M. (2018). Nurses knowledge, practice and barriers affecting a safe administration of oxygen therapy. IOSR Journal of Nursing and Health Science, 7(3), 42-51.
Marynaik K. 2018. How to avoid medication errors in nursing. Retrieved from https//www.rn.com/nursing-news/nurses-role-in-medication-error-prevention/Masetic, Z., amp Subasi, A. (2016). Congestive heart failure detection using random forest classifier.Computer Methods and Programs in Biomedicine,130, 54-64.
Mishra, S., Mohan, J. C., Nair, T., Chopra, V. K., Harikrishnan, S., Guha, S., amp Chandra, K. S. (2018). Management protocols for chronic heart failure in India.Indian Heart Journal,70(1), 105-127.
Norhammar, A., Johansson, I., Thrainsdottir, I. S., amp Rydn, L. (2017). Congestive heart failure.Textbook of Diabetes, 659-672.
Savarese, G., amp Lund, L. H. (2017). Global public health burden of heart failure.Cardiac Failure Review,3(1), 7.
Smith, G., Shore, S., Mitchell, A., Moore, M., Morris, A., Speight, C., amp Dickert, N. (2018). Discussing out-of-pocket costs with patients shared decision-making for sacubutril-valsartan in congestive heart failure.Journal of the American College of Cardiology,71(11 Supplement), A2626.
State of Victoria. (2018). Congestive heart failure (CHF). Retrieved from https//www.betterhealth.vic.gov.au/health/conditionsandtreatments/congestive-heart-failure-chfUrden, L. D., Stacy, K. M., amp Lough, M. E. (2017).Critical care nursing diagnosis and management. London Elsevier Health Sciences.