Case study 1 – 77-year old female, indication congestive cardiac failure

Case study 1 – 77-year old female, indication: congestive cardiac failure

1. Outline the disease, causes, incidence and risk factors. Discuss the impact of the selected disease on the patient and their family (450 words)

Congestive cardiac failure CCF is the failure of the heart to pump blood effectively. There are many interrelated risks factors in CCF. Department of Health Services, Victoria (2018) summarises the major causes to be “coronary heart disease, hypertension, idiopathic cardiomyopathy and other heart diseases”.

Coronary heart diseases are related to the blood supply to the heart. If the blood vessels are blocked (e.g. by plagues) or restricted (e.g. fats deposited in the blood vessels), there is not enough blood to reach the heart muscles. Coronary heart diseases are associated with age and lifestyle. They have no cure. The scar from past coronary heart diseases may cause future coronary heart diseases. Treatment and lifestyle changes may help to prevent future coronary heart diseases.

Idiopathic cardiomyopathy refers the heart chambers being enlarged and the muscle weakened or damaged resulting in decreased ability to pump blood. Contributing causes include hypertension, tachycardia and dysrhythmia, damage to the heart tissue due to previous heart failure, obesity, diabetics or thyroid diseases, alcohol, drug use, pregnancy complications, chemotherapy and inflammation of the heart.

Smulyan, Mookherjee, & Safar (2016) found that the elastin, found in youth, became fragmented and degraded as a person age. The integrity of the blood vessel progressively depends on the remaining collagen which is stiffer than the elastin. The stiffness is also increased due to the cross links between the collagen and elastin fibre by advanced glycation end products. Inflammation with ageing is another contributing factor to the aortic stiffness. These result in hypertension.

Other heart diseases include heart valve diseases, abnormality which may be present since birth, virus damage to the heart muscle and over production of thyroid hormone, thyroxine, which increases the work load and causes CCF.

Chan et al., (2016) states the problem well in the title of their paper. CCF is a major health issue in Australia. They estimated that over 61,000 adult Australian over the age of 45 are diagnosed with heart failure every year resulting in about “150,000 hospitalisations in excess of 1 million days per year”. The estimated cost of the care is 2.68 Billion dollars per annum.

Chan et al., (2016) found that, based on Australian data, 37% of heart failure admissions is re-admitted within 12 months after the first incidence. Re-admissions are also clinically more complicated due to multi-morbidity. The risk of re-admission increases rapidly with age.

Fry et al., (2016) found that the sufferers have to endure disruption of lives arising from the “multiple and complex medication regimes and negotiating multiple appointments”. In the Australian context, Cowie et al., (2014) identified the smooth transition after the hospitalisations and education for the patients are important. “Where needed, access to end-of-life care and support for all patients, families, and caregivers should form part of a high-quality service.”

2. Discuss three (3) common signs and symptoms of the selected disease and explain the underlying pathophysiology of each (350 words)

a. This can be done in the form of a table – each point needs to be appropriately referenced Hypertension Hypertension is one of the major cause and symptoms of CCF. It may cause a blood vessel to burst leading to stroke, heart attack and other problems. There are two distinct form of hypertension, “systolic/diastolic hypertension in midlife and systolic hypertension of the aged.” Mrs McKenzie belongs to the latter group. As a person age, the aorta is stiffened. “The reduced cushioning function of a stiffened aorta causes the primary arterial pulse to travel more quickly to the periphery”, and reflected back. The reflected energy of the pulse is superimposed on the primary pulse, amplifying the pressure on the blood vessels. The stiffening of the arterial is another determinant of CCF. (Smulyan, Mookherjee, & Safar 2016)

The two high-flow and low resistant organs are the brain and kidney. The increased blood pressure allows the pulse to penetrate further into their microcirculation. The higher pulse energy causes damages to their microcirculation and affecting the functions of these two organs.(Smulyan, Mookherjee, & Safar 2016)Dyspnea (shortness of breath) One definition of dyspnea is “a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity” (Parshall et al., 2012) It may be acute or chronic. It may be a normal response of heavy exertion or distress. It may be pathological. (Coccia, Palkowski, Schweitzer, Motsohi, & Ntusi, 2015)

In the case Mrs McKenzie When blood cannot be effectively pumped into the lungs, it is backed up in the veins. When the pressure of the blood veins builds up, fluids are not removed from the lung effectively reducing the lung’s ability to provide oxygen. Both pleural effusion (the accumulation of fluid in the lung) and hypoxia (reduced capacity of oxygen exchange) lead to dyspnea. (Department of Health Services, 2018) According to Coccia, Palkowski, Schweitzer, Motsohi, & Ntusi, (2015) it is a complex symptom arising from “physiological impairment and alerts one to the possibility of threatened homeo-stasis.”

Edema (Swelling of ankles, legs and abdomen) The backing up blood and fluid (congestion) consist of both sodium and water. Water retention is a response from the vasopression system. The retention of sodium, however, may cause damages to other organs via the “crosstalk between the heart and other organs”. (Sato, 2018) This crosstalk “is activated via both the neurohormonal activation including vasopressin system and the hemodynamic changes” in heart failure. It is a vicious cycle which may potentially lead to a life threatening situation. The buildup of fluid lead to the edema.

3. Discuss the pharmacodynamics & 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.

Diuretics: Mrs McKenzie takes frusemide 40mg BD. The active ingredient is furosemide which is a loop diuretics. Diuretics is one of the most common drug prescribed for hypertension. (Thorn, Ellison, Turner, Altman, & Klein, 2013) Faris, Flather, Purcell, Poole-Wilson, & Coats (2016) conducted a meta-analysis of the use of diuretics for congestive heart failure and found that diuretics reduce the risk of comorbidity and mortality.

There are three type of diuretics, loop, thiazide and potassium-sparing. Loop diuretics acts on the upper limb of the Henle loop to inhibit the absorption of fluid. (Capasso, Trepiccione, & Zacchia, 2019) According to Brater, (2011) all loop diuretic have similar pharmacology when given comparable dose. The response to dosage will level off after a certain dose. Hence increasing the dose beyond a certain dose will not improve the response, but will increase the risk for the patient. The potency, the effect of a certain dose, for a particular individual is different. Hence it is important to observe the response of a particular patient to a particular dosage to determine the appropriate dose.

According to the Canadian Drug Bank, (“Furosemide,” n.d.), furosemide has a half life of 2 hours. It is eliminated by the kidney. There are other loop diuretic which can be eliminated by the liver. The choice of diuretic, hence, depends on the function of different organs of the patient. The absorption rate of furosemide depends on the individual too. In general 50% of furosemide is absorbed orally. Hence intravenous dosage should be half that of oral.

Most diuretic has a short half life. In the case of Mrs McKenzie, she takes the diuretic twice a day. If her sodium load is available in the kidney immediately after taking frusemide, diuretic effect is active so that her sodium can be discharged via urine. However, if Mrs McKenzie takes in salt while furosemide is not available at the nephron sites, there is no diuretic effect.

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 bulkpost ward admission (500 words)

a. This can be done in the form of a table – each point needs to be appropriately referenced Nursing care plan goal Intervention Rationale

Patient information gathering and documentation

(Jensen, 2015, page 29)

Assess and document As Mrs McKenzie sometimes forgets to take all her medications, it is important to establish if she has taken any medication, if yes what and when. Digoxin, in particular, has a narrow range of safety. (Pincus, 2016) Overdosage leads to toxicity.

Document other vital signs Review and document laboratory reports, chart her vital signs.

Kellett & Sebat (2017) argue that vital signs “the simplest, cheapest and probably the most important information gathered on patients in hospital.” When the vital signs are more accurately and regularly taken and acted upon promptly and appropriately, “hospital care would be safer, better and cheaper.”

Hypokalaemia

Desired outcome: restore to normal range 3.5-5.0 mmole/L Assess A spot urine potassium concentration measurement help to distinguish between renal and non-renal underlying causes. Mrs McKenzie is mildly hypokalaemic. Check plasma magnesium as well because it is closely linked to hypokalaemia. Consider adding a potassium-sparing diuretic to the current loop diuretic .(Sprigings, Chambers, & Sprigings, 2018)

Dyspnea

Desired outcome: breathing return to normal Respiratory function – listen to breath sound and monitor O2 saturation Fluid back up at the lung causes dyspnea. Listening to the breath sound can assess the fluid condition in the lung.

If needed, provide O2. “Patients with dyspnoea often report that movement of cool air reduces breathlessness, and laboratory studies have shown that cold air directed on the face decreases dyspnoea induced in healthy individuals.” (Coccia, Palkowski, Schweitzer, Motsohi, & Ntusi, 2015)

Edema

Desired outcome: reduce fluid load in the body and reduce edema Edema – establish a chart to monitor edema (pitting edema) (Ferreira-Filho et al., 2012) Mrs McKenzie’s signs and symptoms will improve once edema is resolved.

Further appropriate interventions depend on the laboratory outcome of the urea electrolytes and creatinine (UEC), liver function tests (LFT)

Urine output measurement As the diuretics get to work, Mrs McKenzie will pee quite a lot. Mrs McKenzie may be weak and nurses should prepare a bed side potty or be prepared assist her to the toilet. The amount of pee discharged should be recorded. The data can provide an indication of the fluid load in her body

Administer and document diuretics as indicated Diuretics can reduce the fluid load in the body. Consider adding a potassium-sparing diuretics to manage Hypokalaemia.

Restrict Sodium Intake Mrs McKenzie has too much fluid in the body and need to get rid of them. Sodium is closely linked to the accumulation of water.

Restrict water intake Establish a fluid intake goal with the doctor and administer the water intake plan. In general, Mrs McKenzie should not drink more than 2 litre per day.

Record Mrs McKenzie water intake.

Blood Pressure

Desired outcome: maintain BP within acceptable range Check laboratory data To identify factors contributing to her hypertension

Monitor and document BP Data of BP can provide a better understanding of the vascular performance.

Activity restriction Lower physical stress that affect blood pressure

Cardiac Output

Desired outcome: demonstrate stable cardiac rhythm and improved output Monitor the heart rhythm Mrs McKenzie’s ECG will have low voltage. Once the peripheral edema is resolved, the voltage should become normal.

Observe and document peripheral condition Record skin colour, moisture, temperature and capillary refill time. Mrs McKenzie reported cold fingers. Such data can review the cardiac output.

Patient Safety and comfort

Calm and restful environment Reduce sympathetic stimulation and promote relaxation

Call button Ensure that Mrs McKenzie can use the call button readily

Laying position Elevate her feet to help the edema

Educate Sodium intake Educate Mrs McKenzie in low sodium diet

Exercise Moderate appropriate amount of exercise has proved to be helpful in CCF patients

Relaxation techniques Reduce stress, provide calm and thus reduce BP

References

Brater, D. C. (2011). Update in Diuretic Therapy: Clinical Pharmacology. Seminars in Nephrology, 31(6), 483–494. https://doi.org/10.1016/j.semnephrol.2011.09.003

Capasso, G., Trepiccione, F., & Zacchia, M. (2019). The Physiology of the Loop of Henle. In Critical care nephrology (pp. 42–47). Retrieved from http://ezproxy.usherbrooke.ca/login?url=https://www.clinicalkey.com/#!/browse/book/3-s2.0-C20150004129

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). https://doi.org/10.1186/s12913-016-1748-0

Coccia, C. B. I., Palkowski, G. H., Schweitzer, B., Motsohi, T., & Ntusi, N. (2015). Dyspnoea: Pathophysiology and a clinical approach. South African Medical Journal, 106(1), 32. https://doi.org/10.7196/SAMJ.2016.v106i1.10324

Cowie, M. R., Anker, S. D., Cleland, J. G. F., Felker, G. M., Filippatos, G., Jaarsma, T., … López‐Sendón, J. (2014). Improving care for patients with acute heart failure: before, during and after hospitalization. ESC Heart Failure, 1(2), 110–145. https://doi.org/10.1002/ehf2.12021

Department of Health Services. (2018, July). Congestive heart failure (CHF). Retrieved March 21, 2019, from https://www.betterhealth.vic.gov.au:443/health/conditionsandtreatments/congestive-heart-failure-chf

Faris, R. F., Flather, M., Purcell, H., Poole-Wilson, P. A., & Coats, A. J. (2016). Diuretics for heart failure. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD003838.pub4

Ferreira-Filho, S. R., Machado, G. R., Ferreira, V. C., Rodrigues, C. F. M. A., Proença de Moraes, T., Divino-Filho, J. C., … on behalf of the BRAZPD study investigators. (2012). Back to Basics: Pitting Edema and the Optimization of Hypertension Treatment in Incident Peritoneal Dialysis Patients (BRAZPD). PLoS ONE, 7(5), e36758. https://doi.org/10.1371/journal.pone.0036758

Fry, M., McLachlan, S., Purdy, S., Sanders, T., Kadam, U. T., & 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. https://doi.org/10.1186/s12875-016-0537-5

Furosemide. (n.d.). Retrieved March 27, 2019, from https://www.drugbank.ca/drugs/DB00695

Jensen, S. (2015). Nursing health assessment: a best practice approach (Second edition). Philadelphia: Wolters Kluwer Health.

Kellett, J., & Sebat, F. (2017). Make vital signs great again – A call for action. European Journal of Internal Medicine, 45, 13–19. https://doi.org/10.1016/j.ejim.2017.09.018

Kucharska-Newton, A., Selvin, E., Viera, A., Keyserling, T., Shah, A., Ballantyne, C., … Heiss, G. (2016). Abstract P097. Circulation, 133(Suppl_1). Retrieved from insights.ovid.com

Parshall, M. B., Schwartzstein, R. M., Adams, L., Banzett, R. B., Manning, H. L., Bourbeau, J., … O’Donnell, D. E. (2012). An Official American Thoracic Society Statement: Update on the Mechanisms, Assessment, and Management of Dyspnea. American Journal of Respiratory and Critical Care Medicine, 185(4), 435–452. https://doi.org/10.1164/rccm.201111-2042ST

Pincus, M. (2016). Management of digoxin toxicity. Australian Prescriber, 39(1), 18–20. https://doi.org/10.18773/austprescr.2016.006

Sato, N. (2018). Congestion: Historical and Pathophysiological Review and the Concept of Fundamental Management for Hospitalized Heart Failure. In N. Sato (Ed.), Therapeutic Strategies for Heart Failure (pp. 39–54). https://doi.org/10.1007/978-4-431-56065-4_3

Smulyan, H., Mookherjee, S., & Safar, M. E. (2016). The two faces of hypertension: role of aortic stiffness. Journal of the American Society of Hypertension, 10(2), 175–183. https://doi.org/10.1016/j.jash.2015.11.012

Sprigings, D., Chambers, J., & Sprigings, D. (Eds.). (2018). Disorders of plasma potassium concentration. In Acute medicine: a practical guide to the management of medical emergencies (Fifth edition, p. 512). Hoboken, NJ: John Wiley & Sons, Inc.

Thorn, C. F., Ellison, D. H., Turner, S. T., Altman, R. B., & Klein, T. E. (2013). PharmGKB summary: diuretics pathway, pharmacodynamics. Pharmacogenetics and Genomics, 23(8), 449–453. https://doi.org/10.1097/FPC.0b013e3283636822