Medical History
This assessment is based on patient M.G aged 68 years old female having admission to the emergency department with a diagnosis of congestive heart failure. She was discharged in the hospital one and a half weeks ago and has just visited back due to complications arising from her breathing ability and difficulty in walking. The patient assessment indicates inability in following her fluid management and salt intake, further she has not been following her medication correctly. Her past medical history indicates the presence of hypertension, chronic renal failure, and anterior myocardial infection 4 years ago. Family history assessment shows that she has lost both her parents, while she has a sister who is alive and well as well as a brother age 62 years and 70 years respectively. The brother has been diagnosed with coronary heart disease and hypertension. She has two children and six grandchildren.
Her medical assessments reveal that the blood pressure during discharge was bp140/90 while two weeks before discharge was BP156/94, which led to the commencement of hydrochlorothiazide 25 mg PO. During patient admission, her pulse rate was irregular at 122, BP 160/100, respiratory rate 26, temperature 37.3 Celsius degrees, and oxygen saturation 93% on room air. The patient presented with widespread palpitation on chest auscultation examination in both lungs. Chest x-ray reveals widespread consolidation and cardiomegaly. The apical pulse is elevated, skin assessment shows pink color while peripheral edema present at a score of 2.
Electrolyte assessment indicates elevated potassium levels of 5.5mEq/l against normal levels of 3.5-5.0 mEq/l which indicates mild hyperkalemia. Creatine assessment on the functionality of the kidney shows impaired function. The patient creatine levels are 4.5mg/dl against normal ranges of 0.6 to 1.2 ml/dL. The blood urea nitrogen indicates elevated levels of signifying stress levels with a high of 43 mg/dl against normal ranges of around 7 to 20 mg/dL. Further CXR Assesment shows cardiomegaly presence signifying enlarged heart, while a pulmonary score of a grade of 2 indicating fluid accumulation.
Congestive heart failure occurs due to the inability of the heart to pump the blood normally. Heart failure state reflects a pathophysiologic state where abnormal cardiac function occurs. Heart failure can be linked to myocardial failure which leads to circulatory failure. The pathophysiological occurrence of CHF occurs due to the state of the inability of the heart to be able to acquire the normal maintenance of oxygen delivered. It indicates the systematic response in an attempt to compensate for the inadequacy occurring. The stroke volume is further assessed based on the preload and afterload in the left ventricular valves (Harjola, et al., 2017).
Physical Examination
The occurring significance of the heart in the reaction of the heart muscle through the overload or damage reducing the efficiency of the heart leading to lower output levels while myocardial dysfunction defined by the systolic and diastolic, acute or chronic depicts changes of the heart. In assessing heart failure, various mechanisms take place which is activated depending on the heart failure duration. Neurohormonal reflexes like the adrenergic system, renal, peripheral alterations, and renin-angiotensin systems aim at restoring the cardiac output and terminating the perfusion of tissue perfusions. The occurrence of stroke volume cannot be removed from the left ventricle thus shifting the pressure-volume on to the systolic failure. Filing of adequate cannot be achieved due to the occurrence of stiffness in the diastolic region, thus shifting the diastolic pressure-volume curving upward without effects on the diastolic pressure increasing without effects on the systolic volume-pressure curve, leading to diastolic failure. The left ventricle heart failure often reflects the dominance of heart failure syndrome while the right heart develops as an isolated failure, the occurrence of bi-ventricular syndrome indicates an end-stage clinical assessment of the heart failure state (Münzel, 2015).
In fluid mechanism congestion, the presence of cardiac dysfunction often leads to a serious state of the neruo humoral pathway which entails changes on the nervous system, vasopressin system; arginine activation and aldosterone system is activated by the negative consequences of the heart failure on the delivery of oxygen to the peripheral tissues. The activation of neurohumoral leads to impairment of sodium excretion regulation through eh kidney organs which leads to increased levels of sodium and fluid accumulation, thus increasing cardiac filling pressures and congestion of the venous is observed recurrent (McKie et al., 2011). The occurrence of venous congestion has often been indicated in cardiac failure, it plays a crucial role in the overall pathophysiological process of cardiac failure.
The association of cardiac function and renal dysfunction referred to as cardio-renal syndrome occurs in CCF. The congestion of the venous is the key hemodynamic determinant for the development of renal dysfunction and low index of cardiac functionality. The increased occurrence of central pressure of the venous and low index of the cardiac is particularly not favorable for renal function (Nijs et al., 2015).
The resultant effect of congestive heart failure leads to reduce contraction force due to overloading of the ventricular. This leads to failure of ventricle lading with blood in the heart muscle contraction reducing leading to reduced ability of the cross-link actin and myosin in stretching the muscles of the heart (Arrigo, Parissis, Akiyama & Mebazaa, 2016).
Laboratory Results
Chronic renal failure indicates the gradual loss of the kidney function. The kidney performs filtration of waste and fluids from blood which is then excreted inform of urine. In chronic disease advance stages, elevated levels of fluid, electrolytes and waste often build up in the body. This occurs as a result of a progressive decline in kidney function ability. The occurrence of modulation and adaptation occur at glomerular functionality which keeps the kidney function normal, the remaining glomerular experience rise in pressure due to hyperfiltration (Malek & Nematbakhsh, 2015).
The consequential release of the cytokines and growth factors yield hypertrophy and hyperplasia, while the function of glomerular is hampered, leading to excess demand on them. This leads to increase levels of permeability and proteinuria, while there is increased permeability and proteinuria. The increased concentrations in the proximal tube lead to direct nephrotoxins which deteriorate the state of the kidney function (DiLullo et al., 2015).
Chronic renal failure leads to the reduced ability of excretory functionality, leading to accumulation of endogenous and other extraneous substances. This leads to pharmacodynamic changes due to increased metabolic concentration leading to maximal concentration capacity of the kidney is reduced.
The reduced secretory ability of the renal results from the endocrinal balance while decreased levels of erythropoietin lead to lowered levels of erythrocytes causing renal anemia and reduction of functional erythrocytes occurring due to hemolysis. Production of vitamin D is impaired while the excretion of phosphate is reduced. The occurrence of renal osteopathy leads to disruption of bone metabolisms and disruption of bone mass leading to a decreased reduction of bone metabolisms. Thirst feelings occur a leading a to increase in sodium excretion levels. The function of the glomeruli dictates the levels of water and electrolytes in the body. The occurrence of hypertension, pulmonary edema occurs due to overhydration. The excretion of water and salt occur with critical glomerular damage leading to utilization of diuretics (Schrezenmeier et al., 2017).
With the consequential adaption of the glomeruli, the tubular transport mechanism occurs to prevent the onset of hyperkalemia through elevated potassium secretion. The hypokalemia effect occurs due to hyperstimulation and resorption capacity. The occurrence of acidosis can occur due to hypokalemia effect. The ability of kidneys to sufficiently eliminate the protons due to reduced function of the glomerular filtration process. The metabolic acidosis leads to elevated levels of calcium release and improves renal osteopathy leading to more gastrointestinal problems and impairing protein metabolism.
Pathophysiology of Congestive Heart Failure
Congestive heart failure is associated with the chronic renal disease with an association of about one-quarter of patients of the former developing kidney disease. Congestive heart failure prevalence increases significantly as the renal function ability deteriorates and enteral end stage, with evidence showing about 65%-70% of the congestive heart failure cases progressing to a kidney disease state. There is growing evidence on the chronic renal disease as a major contributor to severe cardiac impairment and vice versa. Exacerbate congestive failure often leads to elevated rapid decline of renal function (Kato, Steinberg & Gladwin, 2017).
The patient electrolyte assessment indicted high levels. The eventual occurrence of chronic renal failure leads to an inability of the maintenance of electrolyte balances leading to increased levels of potassium in the body. The potassium functions by maintaining the level of electrolyte in the body and the pH levels. Elevated levels of hypokalemia can lead to cardiac arrhythmias and even death and often in critical stage leads to mortality. Kidney state of the patient reflects elevated levels of potassium with a dynamic association of cardiorenal syndrome affecting the heart (Ter Maaten et al., 2016).
Creatine levels assessment indicates the function of the kidneys. Elevated levels of creatine signals imparted damage on the kidney. The kidneys roles are to filter the blood through the use of nephrons which most of the fluid is reabsorbed back into the blood. Impaired ability of the kidney leads to low creatine clearance levels. The creatine level assesses the kidney function. Further, elevated levels of serum in the blood lead to toxic effects and heavy load on the blood, leading to low cardiac offload thus initiative congestive heart symptoms.
Blood urea nitrogen assesses the levels of waste in the blood. High levels of BUN indicate a lowered level of kidney function and heart failure. The elevated levels of BUN for the patient reflect malfunction of the kidney and secondary failure of congestive failure. The protein metabolic products are not efficiently removed in the blood due to the slow function ability of the kidney thus elevating the levels of BUN in the blood (Evrard et al., 2015).
The CXR X rays of the patient indicating the presence of cardiomegaly signify the elevated occurrence of blood pressure while pulmonary edema depicting the presence of fluid in the chest worsening breathing problems (Bartunek et al., 2016).The overall patient vital indicators show elevated levels. There is an increase on pulse rate due to breathing problems, high blood pressure, reduced respiratory rate, elevated temperature levels, low oxygen saturation levels, increased apical pulse and atrial fibrillation on heart functionality assessments status. The associative risks factors for developing CCF and CRF entail high blood pressures, diabetes, medication drugs, heart attack, obesity, hypertension, and congenital heart defects all depicting the patient status.
Pathophysiology of Chronic Renal Failure
Nursing Care Plan
|
Nursing Problem |
Goal |
Intervention |
Evidence-Based Rationale |
Expected Outcome |
|
1. Decreased cardiac output |
ST- Improved overall cardiac output of the patient during 24 hours of hospitalization. LT- To enhance the patient ability for management of fluid management at home |
1. Auscultation on the apical pulse with a key assessment on heart rhythm (Lancellotti, Price & Edvardsen 2018) 2. Monitoring of blood pressure (Daskalopoulou et al., 2015) 3. Inspection of the skin (Owens et al., 2018) 4. Monitoring urine output (Buckley et al., 2016) 5. Diuretics management (Harjola et al., 2017) |
1. Presence of tachycardia to offer computation on decreased contractility of ventricular and atrial fibrillation. 2. In chronic failure, BP is elevated due to SVR occurrence 3. Pallor skin origination is reactive of lowered peripheral perfusion due to decreased cardiac output 4. Kidney function with low cardiac output response with an increase during the day increased at night. 5. Use of diuretics leading with restriction of dietary sodium intake leads to clinical improvement of the patient. |
– Patient archiving acceptable ranges of vital signs assessment – Decreased occurrence of dyslexia – Engaging in activities which reduce cardiac workload |
|
2. Deficiency of cognitive information related to the patient status |
ST- improved awareness of self-management during the hospitalization stay. LT- Improved patient awareness on risks factors associated with elevated disease state after hospitalization. |
1. Assessment of fluid and sodium levels intakes (Wu et al., 2016) 2. Adequate intake of calorie based foods (Hall et al., 2019) 3. Establishing routine exercise engagement (Adam et al., 2017) 4. Empower on self-instructions assessment (Wild et al., 2018) 5. Drug therapy management (Aboyans et al., 2017) |
1. Fluid retention problems addressed with fluid intake restriction and restrict sodium intake 2. Offers sparing effect on protein which prevents wasting for the patient 3. Improves muscle flexibility and reduced immobility issues. 4. Increase occurrence of hypertension need often drug management and close monitoring of treatment effects 5. Aimed at reducing complications for the patient |
– The patient verbalizes the disease process and complications associated – Correct performance of procedures and offering reasons for those actions |
My overall assessment of this essay case study has strengthened my core skills and improved learning outcomes on human physiology process. Learning the functioning of the overall kidney process and heart function through patient assessment is critical. Application of my nursing skills in offering nursing diagnosis plays a key role in ensuring successful patient assessment. There is a need to further improve my nursing skills in order to offer a high level of nursing care.
References
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Association Between Congestive Heart Failure and Chronic Renal Failure
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