Shortness of breadth - Signs Symptoms Indications assessment answers

Subject Name : Nursing

Case Study

Question 1

A 77-year-old woman, Mrs. Sharon Mckenzie, presented to the emergency department with complaints of shortness of breath, mild nausea, dizziness, and swollen ankles. The patient stated that she had been experiencing shortness of breath for the last 7 days, which worsened while gardening or taking walks.

Upon examination, the patient was observed with hypertension (170/110 mmHg), lower heart rate, elevated respiratory rate, and lower blood oxygen levels. Progressive dyspnea on exertion was reported by the patient, which made walking difficult. A chest X-ray depicting enlargement of the left lobe indicated the presence of congestive cardiac failure (CHF).

Further investigations confirmed the impression of CHF. Congestive cardiac failure, also called coronary artery disease (CAD) or heart failure, does not indicate that the heart will stop working, but refers to the heart working less efficiently than normal. CHF can occur due to various causes, where blood moves less efficiently through the heart and body. Increased pressure inside the heart reduces its ability to pump oxygen and nutrients to meet the body’s demands. As the heart muscles weaken, the kidneys retain fluids and salts, causing congestion.

The patient’s hypertension and ECG showing sinus bradycardia suggest that the possible causes include CAD and hypertension (Benjamin et al., 2017). CAD occurs when arteries, responsible for pumping blood to the heart, narrow due to plaque deposition and other factors, limiting oxygen and nutrient supply.

Common risk factors observed in this patient include:

Age and gender: Increased risk for women due to physiological changes and plaque buildup over time.
Enhanced levels of LDL and HDL.
High blood pressure (Butler et al., 2008).

Patients with heart disease often experience multiple readmissions, poor prognosis, and varying quality of life. They and their families may experience fear, distress, and lifestyle restrictions, with difficulty coping and a lack of psychological support (Leeming et al., 2014).

1.2 Signs, Symptoms, and Indications

Signs	Symptoms	Indications / Pathophysiology
Shortness of breath	More pronounced during exertion or daily activities	Fluid accumulation and redistribution occur due to blocked humoral pathways caused by plaque deposition, disturbing the RAAS system. Vasopressin activation counters negative effects of heart failure on oxygen delivery, impairing perfusion of nearby tissues and sodium regulation via kidneys (Kelley et al., 2017).
Dyspnea	Shortness of breath common in patients with hypertension; increased risk with age and obesity	Age and gender-related factors exacerbate complications (Chang et al., 2016).
Swelling of ankles and feet	Common while traveling	Impaired perfusion leads to retention of ions and water, causing edema (Arrigo et al., 2016; Singal et al., 2017).
Oedema	Numbness and cold feet	Indicates chronic conditions (Yin et al., 2016).
Fatigue and weakness	Reduced exercise ability and rapid, irregular heartbeat	Imbalance in ionic concentration leads to altered distribution patterns, resulting in fatigue and weakness (Olshansky et al., 2015).
Irregular heartbeat	Chest pain, fainting, and difficulty breathing	Sign of serious illness, often associated with heart failure complications.

1.3 Pharmacological Management

Digoxin, a cardiac glycoside, is commonly prescribed for patients with CHF. It has an inotropic effect on the myocardial layer, improving heart contraction. Additional treatments often include angiotensin-converting enzyme (ACE) inhibitors and diuretics, each with specific pharmacodynamic and pharmacokinetic properties:

Pharmacodynamics: Decreases afterload and preload.
Pharmacokinetics: Enhances sodium and potassium ion binding, activates Na-K ATPase (sodium pump), with high Cmax, Tmax, large volume of distribution, long half-life, and rapid achievement of steady-state concentrations. The drug is retained for 24–36 hours from the initial dose, supporting fluid management in CHF (Jordan et al., 2015; Srinivas, 2019).

In vitro studies indicate the drug is safe and effective, providing positive clinical outcomes for patients and supporting nursing care interventions (Jing et al., 2014).

1.4 Nursing Intervention Plan

Cues	Nursing Diagnosis	Goals	Nursing Intervention	Rationale	Evaluation
Shortness of breath	Decreased cardiac output	Increase activity level	Administer diuretics cautiously, administer medications per patient condition, monitor input/output, observe dyspnea	Prevent renal/liver function compromise and avoid toxicity (Obiego, 2016)	Patient returned to normal activity with normal vitals and respiratory outcomes
Cold and clammy skin of feet	Activity intolerance	Gradually improve activity level and monitor vitals	Administer oxygen, assess radial/epical pulse every 2–4 hours, report to physician	Early detection of MI symptoms, prevent dyspnea (Gutierrez, 2019; Obiego, 2016)	Fewer episodes of dyspnea, no syncope
Fatigue and dizziness	Compromised oxygen supply	Conserve energy while performing daily activities	Provide adequate rest and calm environment	Prevent complications from dizziness/confusion, enhance health outcomes	Patient resumed daily activities, arrhythmias absent

References

Arrigo, M., Parissis, J. T., Akiyama, E., & Mebazaa, A. (2016). Understanding acute heart failure pathophysiology and diagnosis. European Heart Journal Supplements, 18(suppl_G), G11-G18.
Ayalasomayajula, S., Jordaan, P., Pal, P., Chandra, P., Albrecht, D., Langenickel, T., … & Sunkara, G. (2015). Assessment of drug interaction potential between LCZ696, an angiotensin receptor neprilysin inhibitor, and digoxin or warfarin. Clin Pharmacol Biopharm, 4(147), 2.
Benjamin, E. J., Blaha, M. J., Chiuve, S. E., Cushman, M., Das, S. R., Deo, R., … & Jiménez, M. C. (2017). Heart disease and stroke statistics-2017 update: A report from the American Heart Association. Circulation, 135(10), e146-e603.
Butler, et al. (2008). Circulation heart failure. Retrieved from https://doi.org/10.1161/CIRCHEARTFAILURE.108.768457
Chan, Y. K., Tuttle, C., Ball, J., Teng, T. H. K., Ahamed, Y., Carrington, M. J., & Stewart, S. (2016). Current and projected burden of heart failure in the Australian adult population: A substantive but still ill-defined major health issue. BMC Health Services Research, 16(1), 501.
Gutierrez, (2019). Nursing interventions. Retrieved from https://www.scribd.com/doc/22594386/Nursing-Care-Plan
Jing, H. Y., et al. (2014). Pharmacokinetic and pharmacodynamic. Routledge, London.
Kelley, R. C., & Ferreira, L. F. (2017). Diaphragm abnormalities in heart failure and aging: Mechanisms and integration of cardiovascular and respiratory pathophysiology. Heart Failure Reviews, 22(2), 191-207.
Leeming, A., Murray, S. A., & 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.
Obiego, M., Uchmanowicz, I., Wleklik, M., Jankowska-Polaska, B., & Kumierz, M. (2016). The effect of acceptance of illness on quality of life in patients with chronic heart failure. European Journal of Cardiovascular Nursing, 15(4), 241-247.
Olshansky, B., Sullivan, R. M., Colucci, W. S., & Sabbah, H. N. (2015). The parasympathetic nervous system and heart failure: Pathophysiology and potential therapeutic modalities for heart failure. In Pathophysiology and Pharmacotherapy of Cardiovascular Disease (pp. 107-128).
Singal, P. K., Iliskovic, N., Li, T., & Kumar, D. (2017). Adriamycin cardiomyopathy: Pathophysiology and prevention. The FASEB Journal, 11(13), 931-936.
Srinivas, N. R. (2019). Strategy for prediction of steady-state exposure of digoxin to determine drug-drug interaction potential in digitalization therapy. American Journal of Therapeutics, 26(1), e54-e65.
Yang, H., Wang, Y., Negishi, K., Nolan, M., & Marwick, T. H. (2016). Pathophysiological effects of different risk factors for heart failure. Open Heart, 3(1), e000339.