Question

PLEASE READ THE CASE STUDY AND ANSWER THE QUESTIONS TO THE BEST OF YOUR ABILITY:

Mr. Jackson is 86 years old. He is admitted to HUMC for congested heart failure. He also has a history of renal failure and goes for dialysis on Mondays, Wednesdays and Friday. He has an AV fistula in his right hand. He also has a history of diabetes, hypertension and depression.

He is allergic to shrimp. He is a nonsmoker. He lives with his wife and two sons.

He is on a renal, low sodium, low cholesterol diet.

He is positive for clostridium difficile.

He suffered a stroke while he was in the hospital and now has left sided weakness.

15. What will you use as a guide to provide care for Mr. Johnson?

Answer 1

Heart failure (HF) or Congestive Heart Failure (CHF) is a physiologic state in which the heart cannot pump enough blood to meet the metabolic needs of the body following any structural or functional impairment of ventricular filling or ejection of blood.

Heart failure results from changes in the systolic or diastolic function of the left ventricle. The heart fails when, because of intrinsic disease or structural it cannot handle a normal blood volume or, in absence of disease, cannot tolerate a sudden expansion in blood volume.

Heart failure is not a disease itself, instead, the term refers to a clinical syndrome characterized by manifestations of volume overload, inadequate tissue perfusion, and poor exercise tolerance. Whatever the cause, pump failure results in hypoperfusion of tissues, followed by pulmonary and systemic venous congestion.

NURSING CARE PLAN FOR MR.JOHNSON ARE-

Decreased Cardiac Output -  The heart fails to pump enough blood to meet the metabolic needs of the body. The blood flow that supplies the heart is also decreased therefore decrease in cardiac output occurs, blood then is insufficient and making it difficult to circulate the blood to all parts of the body thus may cause altered heart rate and rhythm, weakness, and paleness.

INTERVENTION FOR DECREASED CARDIAC OUTPUT-

Auscultate apical pulse, assess heart rate, rhythm. Document dysrhythmia if telemetry is available -Tachycardia is usually present (even at rest) to compensate for decreased ventricular contractility. Premature atrial contractions (PACs), paroxysmal atrial tachycardia (PAT), PVCs, multifocal atrial tachycardia (MAT), and atrial fibrillation (AF) are common dysrhythmias associated with HF, although others may also occur.

Inspect skin for pallor, cyanosis- Pallor is indicative of diminished peripheral perfusion secondary to inadequate cardiac output, vasoconstriction, and anemia. Cyanosis may develop in refractory HF. Dependent areas are often blue or mottled as venous congestion increases.

Check for calf tenderness, diminished pedal pulses, swelling, local redness, or pallor of extremity - Reduced cardiac output, venous pooling, and enforced bed rest increases risk of thrombophlebitis.

Elevate legs, avoiding pressure under knee. Encourage active and passive exercises- Decreases venous stasis, and may reduce incidence of thrombus or embolus formation.

2) Excess Fluid Volume - When blood flow through the renal artery is decreased, the baroreceptor reflex is stimulated and renin is released into the bloodstream. Renin interacts with angiotensinogen to produce angiotensin I. When angiotensin I contacts ACE, it is converted to angiotensin II, a potent vasoconstrictor. Angiotensin II increases arterial vasoconstriction, promote release of norepinephrine from sympathetic nerve endings, and stimulates the adrenal medulla to secrete aldosterone, which enhances sodium and water absorption. Stimulation of the renin-angiotensin system causes plasma volume to expand and preload to increase.

INTERVENTION FOR EXCESS FLUID VOLUME

Monitor urine output, noting amount and color, as well as time of day when diuresis occurs -Urine output may be scanty and concentrated (especially during the day) because of reduced renal perfusion. Recumbency favors diuresis; therefore, urine output may be increased at night and/or during bed rest.

Monitor and calculate 24-hour intake and output (I&O) balance - Diuretic therapy may result in sudden increase in fluid loss (circulating hypovolemia), even though edema or ascites remains.

Assess for distended neck and peripheral vessels. Inspect dependent body areas for edema (check for pitting); note presence of generalized body edema (anasarca) - Excessive fluid retention may be manifested by venous engorgement and edema formation. Peripheral edema begins in feet and ankles (or dependent areas) and ascends as failure worsens. Pitting edema is generally obvious only after retention of at least 10 lb of fluid.

Follow low-sodium diet and/or fluid restriction - The client senses thirst because the body senses dehydration. Oral care can alleviate the sensation without an increase in fluid intake.

3) Fear - Heart failure with renal failure along with hypertension,diabetes and depression is a chronic condition that patient may experience a sense of fear with regards of the symptoms, treatment modalities and prognosis of the disease.

INTERVENTION FOR FEAR

Encourage the patient to express fears, feelings regarding the condition -  Recognizing one’s feelings allows communication thus decreases fear.

Identify present and past measures that the patient uses to cope with fear - This information helps determine the effectiveness of coping strategies practiced by the patient.

Maintain a relaxed and accepting demeanor while communicating with the patient - The patient’s feeling of stability increases in a peaceful and non-threatening environment.

4)Powerlessness - Patients may have continuing perception of powerlessness because they are incapable of changing their inevitable outcomes. Powerlessness may be displayed at any time during the patient’s illness and may be observed in the hospital, ambulatory care, rehabilitation, or home environment. INTERVENTION FOR POWERLESSNESS

Assess for factors contributing to a sense of powerlessness -  Identifying the related factors with powerlessness can benefit in recognizing potential causes and building a collaborative plan of care.

Assess for feelings of apathy, hopelessness, and depression -  These moods may be an element of powerlessness.

Appraise the impact of powerlessness on the patient’s physical condition (e.g., appearance, oral intake, hygiene, sleep habits) -  Individuals may seem as though they are powerless to establish basic aspects of life and self-care activitieS

Listen actively to patient often -  This approach creates a supportive environment and sends a message of caring.