NRSG524 Advanced Pathophysiology for Specialty Nursing Practice

Name of Course: Advanced Pathophysiology for Specialty Nursing Practice

Assignment: Case Study 2

Course Code: NRSG524

Instructors Name Dr Janet Green

Student Name Yolanda Bruzzese

Student Number: S00352183

Word Count:

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Date: 03/04/2023

Extension date

Introduction

Tom Smith 86-year-old male, with prior history of myocardial infarction, hypertension and high cholesterol. Mr.Smith quit smoking 20 years ago at age 66. He worked as an interstate truck driver for 40 years. Mr. Smith is Australian born and reports a history of cardiovascular disease in the family. His mother passed away at aged 76of chronic heart failure and had a history of hypertension. Mr. Smith lives alone with a supportive son and daughter, whose wife passed away 4 years ago after having suffered astroke.

Mr. Smithpresented to the emergency department with progressive shortness of breath (SOB) ongoing for approximately one week. Mr. Smith reports at times feeling SOB on rest and during daily physical activities however, he is denying any cough or chest pain. Mr. Smith has been waking up at night finding it difficult to breathe when lying; he also reports feeling more fatigue than usual, with weakness and swelling of bilateral legs, ankles, and feet.

On examination, the contact nurse observed elevated breathing at rest with the use of accessary muscles noted with chest retractions. Due to signs of respiratory distress, the contact nurse commenced Mr.Smith on non-invasive mechanical ventilation (NIV) with high support pressures and supplemental oxygen therapy, titrated to 10L/min. saturating at 86% on room air. Mild pitted edema to lower extremities, jugular pressure elevation, normal heart sounds on auscultation, pulmonary auscultation with bilateral crackles, in addition ECG showed normal sinus rhythm. Blood Pressure 99mmol/L/55mmol/L, Heart Rate 110(beats per minute), and Respiratory Rate 29 (breaths per minute), Temperature 37.2 C. During Mr.Smiths hospital admission, and futher investigations have showed that Mr. Smith has CHF

This assignment will discuss the anatomy and physiology of HF and how it can have an impact on the pathophysiology concepts associated with heart failure. This assignment will also cover the common causes, symptoms, and treatments of HF. With the use of peer review literature, this assignment will demonstrate the duty of care a healthcare professional has towards the patients. The nursing interventions that will be utilized and why it is important for the contact nurse to work collaboratively with the multidisciplinary team, allied health, all whilst showing holistic patient care. Furthermore, a discussion on the importance of providing education to the patient and family members on how lifestyle and diet can manage the symptoms and the importance adherence to medication and life style plays in managing the condition to reduce symptoms, improve quality of life, and to avoid re-hospital admissions.

Australian statistics

According to the research article Prevalence of heart failure in Australia; a systemic review (Sahle et al., 2016). Heart failure (HF) places a considerable amount of pressure on the health system including the patient. Around 50-75% of patients will die of heart failure within 5 years of their diagnosis and this has an increase of 10% in those 75 years and (Sahle et al., 2016). Studies showed that heart failure is higher among the indigenous culture than the non-indigenous and reported to be more widespread in women than men were (McGee et al., 2021). Heart failure has an expenditure of 1-3% on the health care system due to multiple hospital admissions and prolonged hospital stays. The proportion of HF ranges from 1-3% with an increase of 10% in those 75 years and older. It is undeniable that there has been a correlation between heart failure and obesity, smoking, hypertension, high cholesterol, with cardiovascular morbidity (Sahle et al., 2016)

Australia has invested significantly in identifying contributing risk factors of the disease. According to Marquina et al., 2021, the financial burden heart failure has had on the Australian healthcare system is estimated to be around 61.7988.66 billion per year, this in turn has a significant impact on the rates of morbidity, mortality, and lost expenditure to the healthcare system (Marquina et al., 2021). Due to the above statistics the financial burden heart failure has placed on the health care system has spurred the government into the direction of providing several programs, initiative support treatment and management of cardiovascular disease.

One of the programs known as; The Australias National Tobacco Campaign focus was to create television advertisement along with the changes to packaging of cigarettes showing the impact smoking has on our health; allowing the public to make informed choices when it comes to life-style choices (Australian Government Department of Health and Aged Care, 2022). The focus of this program is to educate the public about healthy lifestyles and behaviors, a healthy environment including better communities along with access to early and affordable detection and treatment (Australian Government Department of Health and Aged Care, 2022).

Over the years the use of medications to treat cardiovascular disease such as cholesterol and blood pressure lowering medications have come a long way with some noted improvements, however, statistics show an increase in obesity and diabetes which are both contributing factors to HF (Bell & Goncalves, 2019).

There is a problem with the data collected on the epidemiology of heart failure in Australia. (Sahle et al., 2016) states that the data collected from the Australian National Health Surveys (NHS) was based on patients self-reporting the condition. This can be difficult to verify and may not reflect the actual proportion of the problem as many may have mild symptoms and are not aware that they have the condition thus not giving a true indication of the impact HF has on the Australian population.

Anatomy of heart

The heart is located slightly to the left of the sternum between the lungs behind and above the diaphragm. The pericardium is the sac that surrounds the heart (Mahadevan, 2018). The heart is roughly the size of your fist and is a hollow muscular organ. The heart structure contains four chambers (Buckberg et al., 2018). Two upper chambers are the left and right atriums, and two lower chambers are the left and right ventricles (Buckberg et al., 2018. The heart is the muscle responsible pumping oxygenated blood to the body (Buckberg et al., 2018). The interventricular septum is the wall in the middle if the heart that divides the heart into the left and right. The top chambers contain by four chambers these chambers separate the top chambers from the bottom chambers (Habijan et al., 2020). These chambers are atrioventricular valves, which separate the atria from the ventricles, the tricuspid valve separates the right side, and the mitral valve separates the left side (Habijan et al., 2020). In addition, the heart has two more valves; the pulmonic valve located between the right ventricle and the pulmonary artery its function is to carry blood to the lungs to pick up oxygen, and the aortic valve is located between the left ventricle and the aorta and its function is to carry oxygenated blood to the body (Boxt, 2005). The electrical system is what keeps your heart pumping this electrical system involves the sinoatrial node (the natural pacemaker of the heart) (Boxt, 2005). In the right atrium the sin-oatrial node is located it sends an electrical current through the atrium causing the atrium to contract; during contraction, the blood is pumped through the valve and into the ventricle (Boxt, 2005). The atria-ventricular node sends signals to your heart muscle resulting in the contraction of the ventricle (Habijan et al., 2020). Blood then flows through the pulmonary and aortic valve, through the main arteries, and throughout the body (Habijan et al., 2020).

In a normal heart deoxygenated blood, travels back to the right side atrium and then the left ventricle were it is transported into the lungs were it receives oxygen (Trifunovi??Zamaklar et al., 2022). The left atrium will then receive the oxygenated blood and it pumps it into the left ventricle. The left ventricle is responsible for pumping blood back into the circulatory system or the body (Trifunovi??Zamaklar et al., 2022).When a person is engaging in any physical activity the muscles will need more oxygen for this to happen the heart will need to relax in order to pump blood more efficiently (Trifunovi??Zamaklar et al., 2022)

In Mr. Smiths case in HF the left ventricle muscle is either weakened or become stiff, the heart cannot pump blood as well as it should especially during physical activity. This will then lead to inadequate blood flow and poor oxygen delivery to the rest of the body and vital organs this will then result in a buildup of fluid into vital organs and the lungs (Trifunovi??Zamaklar et al., 2022)

There are two types of Heart failure, the first with reduced ejection fraction (HFrEF) less than 40% also known as systolic heart failure. This happens when the heart muscle weakens and as a result is unable to squeeze as a normal healthy heart would. This type of HF, predominately diagnosed in men (Groenewegen et al., 2020).

The second type is with preserved ejection fraction (HFpEF) >50% also known as diastolic heart failure and occurs when the heart muscle is stiff as a result the heart is unable to relax and refill with blood, as normal healthy heart would, predominately diagnosed in women (Groenewegen et al., 2020).

Heart failure will commonly affect the left or right side but can affect both left and right ventricular.

PATHOPHYSIOLOGY OF CHF

Considering Mr. Smiths symptoms and existing co-morbidities with a strong family history of hypertension and heart failure it is possible that Mr. Smith is pesenting with HF.

Mr. Smith was later diagnosed with Congestive Heart Failure (CHF).

It is documented that CHF is the leading cause illness and fatality in patients. Acording to Garci?a & Wright, 2010 when ventricle filling or ejection is impaired the heart is unable to meet the bodys requirements to supply adequate circulating blood to the body. The outcome is congestion and oedema bulidup within the tissues. Therefore the inability to efectivly pump blood to the tissues leads to the pulmonary venouse compensating due to the increase in pressure to effectly provide the tissues with adequate amounts of blood (Garci?a & Wright, 2010).

During this process, the blood moves through the capillaries causing a leakage in the aveolo-capillary membrane due to the hydrostatic pressure within the capillaries (Garci?a & Wright, 2010). The resulting outcome is insufficient lymphatic outflow causing a build-up of fluid in the interstitial space. This then leads to increased intravascular pressure and extravascular liquid, the lungs then become permeable resulting in difficulties in breathing, respiratory discomfort (dyspnoea), low level of oxygen (hypoxemia) in the blood and rapid breathing (tachypnoea) (Garci?a & Wright, 2010). During the progression of CHF the volume of fluid surpasses the capacity of the interstitial space leading to fluid leaking into the alveoli and airways causing cardiac pulmonary oedema thus patients will experience respiratory distress making it a major medical emergency (Garci?a & Wright, 2010)

DIAGNOSIS AND TREATMENT.

As Mr. Smiths, contact nurse a thorough evaluation assessment will need to be completed in order to diagnose and treat Mr.Smith for his presenting problems. Basic nursing interventions would be first point of observation. The contact nurse would have to gain a detailed background history of identifing risk factors, including past family history, high blood pressure, myocardial infarct, coronary artery disease or diabetes (McDonagh et al., 2021).

The following nursing interventions and explanation of further diagnostic involvements are stated down below as researched and backed up by McDonagh et al., 2021 European Heart Journal:

• Physical examination observe for signs of hypoxia eg: cyanosis


• Symptom reviewsuch as shortness of breath on exertion (SOB), nocturnal dysponea, fatigue, swelling of the lower extremities


• Auscultating lungs to listen for bilateral rhonchi or crackles


• Heart auscultation as a heart murmur is suggestive of HF


• Blood test for B-type natriuretic peptides (BNP) or n-terminal pro BNP (NTproBNP) when a person has heart failure these hormones are usually higher than normal


• Electrocardiogram will help to identify which part of the heart is damaged as well as the extent of the damage it can also pickup whether there is reduced blood flow to the heart.


• Echocardiogram measures is used to determine the size and function of the hearts chambers, function of the heart valve, measure the contractility of the left ventricle


• Stress test is use to monitor how well your heart copes when put under stress with physical activity


• Cardio computerized tomography (CT) to identify inflammation of the heart or to look for coronary artery disease


• Magnetic resonance imaging (MRI) is used to monitor cardiac disease by asses the anatomy and function of the heart chambers, blood flow through major vessels


• Coronary angiogram shows blocked or narrowed blood vessels in the heart that may be causing any restriction in blood flow to the heart


• Chest x-ray will show any fluid in the lungs

TREATMENTS

According to Overview of the management of heart failure with reduced ejection fraction in adults (Colucci, 2022), the goal of treatment for heart failure is to improve quality of life, function status, reduce symptoms, slow the progression, and avoid re-hospital admissions. Heart failure is a chronic condition that requires long-life ongoing treatment that will include a combination of, medications, diet and life-style changes and at times, devices (Colucci, 2021).

An investigation of Mr. Smiths underlying causes or risk factors will need to be accesses such as hypertension and diabetes. Hypertension is the most common modifiable risk factor in the progress of CHF and is responsible for the development of coronary artery disease another risk factor in the development of CHF (Colucci, 2022). Hypertension increases the size of the left ventricle due to the increase in cardiac function. The goal of manging hypertension with antihypertensive medications is to reduce left ventriclular afterload. This improves cardiac function by decreasing the progression of remodelling of the left ventricle such as size, shape and function of the left ventricle (Colucci, 2022).

Ischemic heart diease will need to be ruled out due to prior myocardium infarction (MI) patients with a history of MI are at a higher risk of the development of ischemic heart disease however other causes may be the contributing factor in the development of ischemic heart disease (Colucci, 2022).

Another condition associated with CHF is Diabetes Mellitus (DM) and according to the article Heart failure in patients with diabetes mellitus: Epidemiology, pathophysiology, and management (Dunlay, 2022) DM is commonly associated with HFrEF and the treatment remains the same for diabetes as non-diabetes.

Greater risks of adverse outcomes have been associated with the combination of CHF and DM. According to Dunlay, 2022 evidence has shown that DM has contributed to the cause of myocardial dysfunction therefore, leading to CHF. CHF has been identified as a contributed to the development of DM (Dunlay, 2022). DM activates methods that encourage atherosclerosis and coronary artery disease (CAD) also known as diabetic cardiomyopathy (Dunlay, 2022). It is suggested that the cardiac function is affected by diabetes such as hyperglycaemia, and in type two diabetes insulin resistance and hyperinsulinemia (Dunlay, 2022).

Another intervention for Mr. Smith will need to be nurses including the multidisciplinary team to work collaboratively with the patient and family. The multidisciplinary team will need to be mindful when explaining or educating the patient without the use of medical jargon so the patient and family can understand (Rossignol et al., 2019). Part of the management and treating CHF includes, education according to the article Effects of self-management interventions on heart failure: Systematic review and meta-analysis of randomized controlled trials (Zhao et al., 2020) patients that have a good understanding of their condition and how to self-manage had a notably improved quality of life, lower CHF associated hospital admissions. Therefore, we see how knowledge can play an important role on the impact CHF has on our patients and on the hospital system (Zhao et al., 2020). In order for a patient with CHF to be equip to self-care and manage their CHF whilst out in the community this would include actions on the patient behalf such as adherence to medications, exersice, and diet recommendations. Pt would also need to be and to be able to recognize early signs and to re-adjust daily routine or activities accordingly and know when to see their GP. (Krumholz, 2022).

According to Krumholz, 2022 if the patient is commenced on medications to help manage heart failure the nurse will need to keep monitoring the patient to ensure the medications is having the desired effect or to report any adverse effects.

Some of the outcomes the nurse would monitor are

• Patient has reported an improvement in the quality of life


• Reduction in symptoms such as SOB on excursion


• Improve exercise tolerance


• Prevent or slow the progression of the disease


• Reduce complications including re hospital admissions reduce


• Improve prognosis


• Monitor any weight gain/loss if commenced on diuretics

This will include encouraging Mr. Smith to attend a heart failure management program by providing education, this can help Mr. Smith manage his condition at home, reduce hospital admission, reduce complications, and improve his quality of life. This will include education on how to manage heart failure medications. Mr. Smith will be better equipped in make informed choices about his life style and eating habits such as reducing salt intake in his diet once he is discharged home from hospital. Collective groups of health professionals are involved in the running of these programs and include

• Dieticians


• Heart failure nurse


• Cardiologist


• Pharmacist


• Physiotherapist

Depending on the results of the test performed, this will help the medical team determine the cause of signs and symptoms and develop a treatment plan. The chosen treatment plan will depend on the severity of the heart failure.

According to Sodium Intake and Heart Failure (Patel & Joseph, 2020) it is suggested that the evidence supporting the reduction in sodium intake in CHF patients is unclear when it comes to the rate of mortality however it has shown to improve or reduce symptoms of CHF. It is suggested in Heart Failure Self-Management Krumholz, 2022 to advise patients to follow a moderate sodium restricted diet in order to avoid fluid overload. If a patients choose to avoid sodium all together it is recommended to refer the patient to a dietician. A fluid restriction is also recommended as mentioned in Hyponatremia in patients with heart failure Sterns, 2022, depending on the severity of the of the hyponatraemia will depend on the treatment however in those with mild hyponatremia with the contributing factor will need to be identified and discontinued and the patients are commence on a fluid restriction.

CONCLUSION

In conclusion, to this assignment it is clear that patients with CHF need to be treated with upmost care considering mortality rates are high and the quality of life could be poor if not managed well. Allthough there is no cure for CHF it is imperative that health care profesionals treat and relive symptoms to reduce discomfort and better outcomes. This will also include better education to equip patient and family to be able to self-manage the condition when out in the community to decrease hospital admission and lessen the financial burden this can have on the patient and the healthcare system.

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