Assessing the Heart Rhythm, Pulses, Skin Color, and Blood Pressure
One of the most important assessments that the nursing professionals should conduct is assessing the rhythm of the heart as well as the strength of the heart. The nursing professional also needs to assess the pulses of the patient as well as the skin color, blanching as well as tugor (Ponikowski et al., 2016). This should be mainly conducted because the handover that the nurse had received shows increased heart rate in the patient that is about 118 beats per minute when the normal heart rate in adults should be ranging from 60 to 100 beats per minute. Increased heart rate increases the chances of tachycardia that might have several complications like heart failure where the heart becomes unable to pump enough blood or stroke or heart attack may also occur due to blood clot formation.
The next assessment that should be taken is called the respiratory assessment where the nursing professional should assess the lung sounds for congestion as well as rales. The handover given by the nurse showed that the respiration rate of the patients was 24 breaths per minute when the normal respiration rate of individuals should be between 12 to 20 breaths per minute (Pandey et al., 2015). This shows that the person has breathing difficulties causing shortness of breaths. When the heart fails to pump up blood sufficiently, blood is seen to back in the veins that take blood through the lungs fluid is pushed in the alveoli in the air spaces in the lungs when the pressure in the blood vessels increases. The fluid reduced normal movement of oxygen through the lungs resulting in shortness of breath. This assessment would help to understand whether such actions are occurring or not.
Blood pressure assessment needs to be done by the nursing professionals as well. The handover had already shown that the blood pressure was also quite low for about 102/84 mmHg. The normal blood pressure is 120/80 mmHg and therefore this needs to be taken care. Researchers have found out that among hospitalized patients with conditions of heart failure along with that of the preserved ejection fraction (HFpEF), a systolic blood pressure with levels lesser than 120/80 mmHG is associated with poor outcomes and even higher risk of death (Black et al., 2014). Therefore, the nursing professionals need to take interventions for development of the blood pressure to the normal levels.
Task 2: Care planning
Importance of Respiratory Assessment for Patients with Heart Failure
Nursing Care Plan: David
Note: Dot points recommended in care plan. Click and type in each cell, clickenter in a cell to make it longer. Do not remove text from the template.
A reminder that all rationales must be referenced
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Nursing problem: Imbalanced fluid volume |
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Underlying cause or reason: In chronic heart failure, the peripheral blood flow gets affected and therefore the kidney seems to respond to the situation by making the body retain more fluids and salt for a misguided attempt in boosting the blood volume. This is mainly because the kidney does not get enough blood to perform its activities. Therefore, fluid is seen to accumulate in arms, legs, feet, lungs, ankles and many others. |
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effective maintenance of the fluid in the body by decreasing the fluid content of the body |
· Monitoring the urine output and noting the amount as well as the color, time of the day when the dieresis is seen to take place · Monitoring and calculating the 24 hour intake as well as the output balance · Changing the position of the patient frequently and elevating the feet of the patient while sitting, inspecting the surface of the skin of the patient, keeping it dry and providing padding system as indicated · Ausculating the breathing sounds, noting the decreased and the adventitious sounds like the cracking and the wheezing, noting down the presence of absence of the orthopnea, paroxysmal nocturnal dyspnea, tachypnea, persistent cough · Palpation of the abdomen noting down the reports of the upper quadrant pain as well as tenderness · Diuretics therapy can be provided like that of the furosemide (Lasix), bumetanide (Bumex) Thiazides |
· Urine output can be seen to be scanty as well as concentrated as the renal perfusion gets reduced, recumbency is seen to favor dieresis; for this reason output of urine might be seen to get increased in the time of the night and even during the time of the bed rest 9Pittete et al., 2015) · Diuretic therapy might result in increasing the fluid loss of the body despite the presence of edema as well as ascites and so monitoring is important (Feltner et al., 2014) · Researchers are of the opinion that formation of edema, slowing of the circulation, prolonged immobility as well as altered nutritional intake are the cumulative stressors which are seen to affect skin integrity, these requiring close supervision (Mahramus et al., 2014) · Excess fluid volume might result in the pulmonary congestion and so inspection is necessary (Cowie et al., 2015) · Advancement of the heart failure is seen to lead to the conditions of the venous congestion, this causes abdominal distension, liver engorgement and others; to prevent this, the interventions need to be taken (Sioutta, 2016) · This also helps in promotion of the system of dieresis and the potassium sparing agents like potassium-sparing agents if used would prevent excessive potassium potassium losses (Clark et al., 2015). 1. t. |
Urine output should be measured to check whether water that is excess is getting released from the body, edema if present was getting normal and others |
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Nursing problem: Impaired gas exchange |
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Underlying cause or reason: The patient is suffering from breathlessness when he is trying to conduct any work. The breathlessness is not getting relieved even when he is resting and is even seen to be increasing when he is trying to lie down. This needs to be taken care. Pulmonary edema is mainly the fluid accumulation in the tissue and the air spaces in the lung and this leads to impairment in the gas exchange. This causes respiratory failure. |
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proper exchange of the gas exchange system reducing the uneasy feelings of the patient |
· Auscultation of the breathing sounds along with the noting of the crackles and the wheezes · Instruction given to the patient in effective coughing as well as deep breathing · Encouraging of frequent position changes · Placing the patient in the fowler’s position and giving of the supplemental oxygen · Administering the supplemental oxygen to be indicated · Using of the diuretics like furosemide (Lasix) · Using of the bronchodilator like aminophylline |
· This would help in the revealing of the presence of the pulmonary as well as collection of the secretions along with the need for the further interventions (Butcher et al., 2018) · This would help in the cleaning of the airways and thereby facilitating the oxygen delivery (Mahramus et al., 2014) · This would help in the prevention of the atelectasis as well as the pneumonia (Budts et al., 2016) · This would help the patient in breathing more easily and thereby would help in promoting maximum expansion of the chest (Sagar et al., 2015). · This would help in the increasing of the alveolar concentration and this might have resulted in reduction of the tissue of hypoxia (Kitsiou et al., 2015) · Results in reduction of the alveolar congestion ultimately helping in the enhancing of the gas exchange (Pittete et al., 2015) · Increasing the delivery of the oxygen by the dilation of the small airways and exerting the mild diuretic effects help in aiding and reduction of the pulmonary congestion (Taylor et al., 2014) |
The patient is able to breathe appropriately in every of the positions along with the sleeping position and the occurrence of breathlessness situations have reduced. |
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Nursing problem Activity intolerance |
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Underlying cause or reason: The patient is suffering from fatigue that is affecting his will to conduct his daily activities of life. He feels highly stressed from his daily activities that make him to drink and smoke to overcome his stress and fatigue. Fatigue mainly occurs due to an overwhelming and even sustained sense of exhaustion and decreased capacity for physical and even mental work at usual levels. Heart failure is described as the physiologic state where the heart cannot pump the enough blood important for meeting the metabolic demands of the body (Jurgens et al., 2015). The patient in this case study has resulted in inadequate cardiac output that leads to hypoxic tissue as well as slowed removal of the metabolic wastes. This is making the patient get tired easily. |
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would be to help the patient to overcome tiredness and feelings of fatigue |
· the nursing professional need to plan the interventions that would be allowing adequate rest periods for the patient, · The patients will not be exposed to temperature as well as the humidity extremes. · The nurse should also promote overall health measures · Supplemental oxygen should be provided · The client should be helped in identifying the appropriate coping behaviours. · Implementation of the graded cardiac as well as the rehabilitation interventions |
· as this will maximize the participation of the patient, as the plan would be done according to his will. · This would be having negative impact on the energy levels (Lewis et al., 2016). · that would be helping in the development and promotion of energy · Researchers are of the opinion that presence of hypoxemia has the capability of the reduction of the oxygen and therefore ensures the availability of oxygen for the cellular uptakes. This results in the contribution of the fatigue · Researchers suggest that it helps in the promotion of the sense of control along with the improvement of the self-esteem. The nursing professionals also need to determine the presence or degree of the sleep disturbances (Mahramus et al., 2014). This is mainly because fatigue can be also consequences of sleep deprivation. As the patient has issues while sleeping due to increased breathing problems, therefore, this should be also taken care of. · Helps in the strengthening as well as improvement of the cardiac function under the stress if the cardiac dysfunction is not available, gradual increment in the activity is helpful in the avoiding of the excessive myocardial workload and consumption of the oxygen (Cowie et al., 2015). |
The client should be asked to rate on the degree of fatigued he is feeling and should be queried about development of health or the presence of fatigue. His reply as well as the degree of fatigability would help in ensuring whether the person is overcoming fatigue or not |
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Nursing problem: |
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Frusemide:
Frusemide is mainly a loop diuretic or is a water pill that mainly helps by prevention of the body from absorbing too much salt and allowing the salt to be passed on the urine. This is mainly given to the persons for the treatment of the fluid retention like that of edema in the people with different types of congestive heart failures, liver disorders, kidney disorders and mainly others. The patient is also suffering from heart failure symptoms and other associated with signs. The nursing professionals should provide this in the daytime so that prevention of sleep disturbances can occur (Moorhead et al., 2018). The nurse should also ensure that she would be monitoring the patient for the blood pressure as well as the electrolytes level. The nurse should provide knowledge to the patient about the side effects that might occur and the ways to handle them like hearing impairment, headache, weakness, muscle spasms and skin rash. The patients need to mention this immediately in order if such reactions occur. The nurse should clearly indicator the negative impacts of this medication when taken with alcohol and should warm him beforehand to avoid adverse outcomes.
This is mainly seen to increase the strength and efficiency of the contractions of the heart and is extremely useful in treatment of heart failure. This helps in controlling the rhythm as well as the rate of the heart. This mainly increases the force of contraction of the muscle of the heart by causing inhibition of the action of the enzyme (ATPase) which is actually helping in controlling of the movement of the calcium, sodium, and potassium in the cardiac muscles (Dalal et al., 2015). It is mainly used in patients with congestive heart failure as well as treatment for atrial fibrillation. Different types of side effects might occur like nausea, diarrhoea, headache, dizziness, vomiting, skin rash and many others. The patient should immediately report if any such things occur. Digoxin may cause sleepiness, confusion, and problems with balance and if alcohol is taken with this, it might worsen the issues.
Ramipril is mainly seen to lower the blood pressure and is excessively helpful in patients suffering from high blood pressure as in case of the patient of this case study. It usually makes it easier for the heart to pump the blood around the body and therefore it is often prescribed for patients with hypertension as well as heart failure and after heart attack. Some of the side effects that this medication can result are dry as well as irritating cough and therefore the nursing professionals should provide effective intervention accordingly (Albert et al., 2015). The nursing professional should be ensuring the decreasing of the patient in the drinking of alcohol. This would be increasing the blood pressure lowering effect of ramipril and there might be caches that the patients would be feeling dizzy or light headed.
The Need for Blood Pressure Assessment in Patients with Chronic Heart Failure
The nursing professionals need to make the patient understand the ways by which smoking increases the chance of development of cardiovascular diseases resulting in heart failure. However, while educating the patient, the nurse should keep in mind not to include medical terms or technical jargons as that might make the patients confused as they would not be able to understand the terms (Clarke et al., 2015). One important thing is that the patient should only provide the amount of information that is understood by the patient and not extensive elaborations of critical mechanism and pathways.
Smoking has the capacity of damaging the lining of the arteries and this might cause building up of the fatty materials that cause narrowing of the artery. This might result in the occurrence of angina or pain, a stroke as well as the heart attack. The patients should be also educated about the constituents of the smoke (Superiva et al., 2017). The carbon monoxide that is present in the tobacco smoke causes reduction for oxygen in the blood. This makes the heart to pump faster and harder for supplying of the oxygen to the body that it needs. Therefore, it should be avoided.
The nicotine in the cigarettes mainly causes stimulation of the body and this produces adrenaline. This makes the heart beat faster and thereby causes increase in the blood pressure. This makes the heart work much faster.
All these increase the risk of making the blood clot and this is seen to increase the risk of having heart attack as well as failure.
Stating these, the nurse should instruct the patient to maintain a record when he smokes and what he is doing when he feels the need to smoke. Once the triggers are recognized, specialized strategies should be taken to avoid the situations or to overcome the situations successfully (Anderson et al., 2016). The patient can also make a list of things that he can do whenever he gets the urge to smoke. The nurse might also suggest him nicotine gum, patches, or other medications for overcoming smoking urges.
ISBAR communication:
Identification of the patient:
The patient had suffered from myocardial infarction in the past. He had been admitted to the hospital after he was diagnosed with chronic heart failures. He is overweight and as smoking issues. He remains stressed.
The patient is suffering from the chronic heart failure. He is experiencing breathlessness, which is not being relieved even after rest and is getting worse day by day. He has developed cough and is also feeling extremely fatigued. He is stressed and smoking about 10 cigarettes a day for coping with stress. His appetite had decreased.
Nursing Care Plan for Imbalanced Fluid Volume
The patient had myocardial infarction about one month ago. However, he has not attended the outpatient rehabilitation program that was advised to him after discharge.
The patient has increased heart rate, respiration rate and increased blood pressure. Breathlessness, increased heart rate and fatigue issues need to be handed.
Patient should be give education about the importance of stress management, smoking cessation and physical activity as well as reduction of excess fluid volume. Cardiac glycosides medication should be continued along with medications for high blood pressure and others (Branstorm & Boman, 2014). Diuretics should be given for fluid congestion prevention.
The patient was gradually recovering well as all the needs and requirements of the patient were met. The patient was also properly educated about the lifestyle interventions that need to be met. I was pleased by the treatment.
References:
Albert, N. M., Barnason, S., Deswal, A., Hernandez, A., Kociol, R., Lee, E., … & White-Williams, C. (2015). Transitions of care in heart failure: a scientific statement from the American Heart Association. Circulation: Heart Failure, 8(2), 384-409. https://www.ahajournals.org/doi/abs/10.1161/hhf.0000000000000006
Anderson, L., Oldridge, N., Thompson, D. R., Zwisler, A. D., Rees, K., Martin, N., & Taylor, R. S. (2016). Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis. Journal of the American College of Cardiology, 67(1), 1-12. DOI: 10.1016/j.jacc.2015.10.044
Black, J. T., Romano, P. S., Sadeghi, B., Auerbach, A. D., Ganiats, T. G., Greenfield, S., … & Ong, M. K. (2014). A remote monitoring and telephone nurse coaching intervention to reduce readmissions among patients with heart failure: study protocol for the Better Effectiveness After Transition-Heart Failure (BEAT-HF) randomized controlled trial. Trials, 15(1), 124. https://doi.org/10.1186/1745-6215-15-124
Brännström, M., & Boman, K. (2014). Effects of person?centred and integrated chronic heart failure and palliative home care. PREFER: a randomized controlled study. European journal of heart failure, 16(10), 1142-1151. https://doi.org/10.1002/ejhf.151
Budts, W., Roos-Hesselink, J., Rädle-Hurst, T., Eicken, A., McDonagh, T. A., Lambrinou, E., … & Frogoudaki, A. A. (2016). Treatment of heart failure in adult congenital heart disease: a position paper of the Working Group of Grown-Up Congenital Heart Disease and the Heart Failure Association of the European Society of Cardiology. European heart journal, 37(18), 1419-1427.
Butcher, H. K., Bulechek, G. M., Dochterman, J. M. M., & Wagner, C. (2018). Nursing Interventions classification (NIC)-E-Book. Elsevier Health Sciences. https://books.google.co.in/books?hl=en&lr=&id=L4lIDwAAQBAJ&oi=fnd&pg=PP1&dq=nursing+assessment+and+intervention+for+chronic+heart+failure&ots=AgjRVGg6-Y&sig=KIc7lWY2TRN8tI6obuXygtPRcg0#v=onepage&q=nursing%20assessment%20and%20intervention%20for%20chronic%20heart%20failure&f=false
Clark, A. P., McDougall, G., Riegel, B., Joiner-Rogers, G., Innerarity, S., Meraviglia, M., … & Davila, A. (2015). Health status and self-care outcomes following an education-support intervention for people with chronic heart failure. The Journal of cardiovascular nursing, 30(4 0 1), S3. doi: 10.1097/JCN.0000000000000169
Nursing Care Plan for Impaired Gas Exchange
Clark, R. A., Conway, A., Poulsen, V., Keech, W., Tirimacco, R., & Tideman, P. (2015). Alternative models of cardiac rehabilitation: a systematic review. European journal of preventive cardiology, 22(1), 35-74. https://doi.org/10.1177/2047487313501093
Cowie, M. R., Woehrle, H., Wegscheider, K., Angermann, C., d’Ortho, M. P., Erdmann, E., … & Teschler, H. (2015). Adaptive servo-ventilation for central sleep apnea in systolic heart failure. New England Journal of Medicine, 373(12), 1095-1105.
Dalal, H. M., Doherty, P., & Taylor, R. S. (2015). Cardiac rehabilitation. bmj, 351, h5000. doi: https://doi.org/10.1136/bmj.h5000
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Mahramus, T., Penoyer, D. A., Frewin, S., Chamberlain, L., Wilson, D., & Sole, M. L. (2014). Assessment of an educational intervention on nurses’ knowledge and retention of heart failure self-care principles and the Teach Back method. Heart & Lung: The Journal of Acute and Critical Care, 43(3), 204-212. https://doi.org/10.1016/j.hrtlng.2013.11.012
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Sagar, V. A., Davies, E. J., Briscoe, S., Coats, A. J., Dalal, H. M., Lough, F., … & Taylor, R. S. (2015). Exercise-based rehabilitation for heart failure: systematic review and meta-analysis. Open heart, 2(1), e000163.
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