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Congestive Heart Failure
Everyone loses pumping ability in their heart as they age. The serious case of heart failure develops when other health conditions cause the heart to work harder or become damaged due to increased stress. Heart failure is usually a chronic disease. It gradually tends to become worse. By the time someone is diagnosed with it, the heart has most likely begun to lose pumping capacity for quits some time. Nearly five million Americans are living with heart failure and 550,000 new cases are diagnosed each year. This paper will discuss what heart failure is, and what nursing interventions may be of help to patients who suffer from this disease. My grandmother was recently diagnosed with congestive heart failure. By interviewing her and performing a brief assessment, I hope to recognize a few nursing diagnoses and some interventions that may make her disease more bearable.
Heart failure can involve the right side of the heart, the left side, or both. Heart failure usually affects the left side first. Each side of the heart is made up of two chambers the atrium and the ventricle. If either of these chambers loses their ability to keep up with the amount of blood flow then heart failure occurs.
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Left - sided failure involves the left (lower) ventricle. The left ventricle pumps oxygenated blood to the rest of the body. This chamber is the largest and is essential for everyday function. Systolic failure is a condition that arises when the left ventricle loses its ability to contract. Diastolic failure is if the ventricle loses its ability to relax. Relaxing allows the heart to fill with blood during the resting period between beats. Pulmonary edema occurs when fluid leaks into the lungs due to the backing up of blood in the left chamber. Fluid will also build up in the tissues of the body when blood flow slows down because of the heart’s decreasing ability to pump. This excess fluid or congestion is where the term congestive heart failure comes from.
Right - sided failure is often a result of left - sided failure. When the left side fails, increased fluid pressure develops in the lungs and damages the heart’s right side. When pumping power is lost in the right side, blood backs up in the veins causing swelling in the legs and ankles.
The heart tries to make up for loss of pumping capacity in three ways enlarging, developing more muscle mass, and pumping faster. By enlarging, the heart contracts more strongly and pumps more blood. When the contracting cells of the heart increase in size, an increase in muscle mass also occurs. Pumping faster helps to increase the heart’s output.
The body also does other things to help compensate for the loss in power in the heart. Blood vessels narrow to keep the blood pressure up. The body diverts the majority of the blood to the heart and the brain. Eventually the heart can’t keep up and the person will suffer from fatigue, breathing problems or various other symptoms such as coughing, wheezing, loss of appetite, nausea, confusion, or increased heart rate. Factors such as smoking, being overweight, having a diet high in fat and cholesterol, and not exercising can contribute to heart failure.
After reviewing medical journals related to my topic, I discovered that many physicians and nurses think that congestive heart failure is frequently found in patients with sleep disorders. Recent studies have shown a presence of sleep apnea in many patients with congestive heart failure (CHF). Treatments such as continuous positive airway pressure (CPAP) can significantly reduce the symptoms of both CHF and sleep apnea.
Research suggests that many of these patients cannot perform such basic activities as correctly defining their illness or identifying their medications. “To provide the kind of care these patients need, we have to move beyond the four walls of the hospital . . . when we can expand our care to include home health care and teaching (patients) about things such as proper diet, monitoring their symptoms and correctly taking their medications, we can perhaps reduce re-hospitalization for congestive heart failure”(Hoyt 1).
According to an article from The American College of Physicians (CHEST) magazine, “congestive heart failure currently affects 1.5 to .0% of the population and is associated with excessive morbidity and mortality. It is the only major cardiovascular disease that is increasing in prevalence and incidence, due to the aging population, reduction in acute cardiovascular mortality, and relatively ineffective treatment for CHF.” Despite major progressions in treatment, prognosis remains grim. CHF has now emerged as the leading cause of hospitalization in patients 65 years old and older. In the United States, there is an ongoing search for a more cost efficient and effective therapy. This is due to the annual direct costs of treatment for CHF patients being somewhere in the neighborhood of $0 to $40 billion. One promising approach to this problem is the diagnosis and specific treatment of sleep-related breathing disorders in patients with CHF. Patient care is provided by the coordinated efforts of heart failure cardiologists, cardiothoracic surgeons who specialize in heart transplantation and support devices, and nurses and nurse practitioners highly skilled and trained in the care of patients with heart failure.
Congestive heart failure is treated by finding and removing the cause. Medicines usually given are
• Digoxin - to slow and strengthen the pumping of the heart muscle.
• Diuretics - to remove extra fluid from the body tissue.
• Captopril - enlarges the blood vessels and lowers blood pressure.
Hospital admission and readmission for congestive heart failure are both common and expensive. This could soon be prevented by new drug treatments and new therapy programs. In addition to reducing admissions, these treatments also improve the quality of life for CHF patients. Angiotensin - converting enzyme (ACE) inhibitors are a frequently used drug in patients who can tolerate them. Angiotensin class II receptor blocking agents offer an option to patients who cannot tolerate these drugs. Research has also shown that treatment with spironlactone will improve mortality and readmission rates. An exercise program should also be put into effect.
Other important information regarding a nurse’s role in helping the patient with CHF is early diagnosis. As common as it is, its diagnosis is often missed. It is estimated that heart failure is correctly identified initially in only 50% of the cases each year. A detailed clinical history is crucial to identifying the problem. Signs and symptoms of heart failure as well as signs and symptoms of other diseases which may be the underlying cause need to be noted. The patient should be questioned to see if they have a past history of cardiac events such as a myocardial infarction. An electrocardiograph and a chest radiograph should also be taken.
My plan of care for my grandmother included educating her on her new diagnosis. I also planned on establishing an exercising program directed and helping her to plan a healthy diet. She already follows a fairly healthy diet with little or no salt and very small amounts of fat and cholesterol. The patient has a past history of hypertension, which she controls with medication. There is no past history of elevated cholesterol, triglycerides, heart murmurs, congenital heart disease, rheumatic fever, recurrent tonsillitis, or anemia. Patient stopped smoking 0 years ago. When she did smoke, she smoked 1- packs a day for 15 years. Patient claims to consume alcoholic drinks once every two to three months. There is no family cardiac history. On my initial assessment, she appeared to be content and in no distress. She was alert and oriented to person, time, and place. Her skin was pink, warm, and intact. She had no signs of cyanosis or cachexia. At rest, she seemed slightly dyspneic. Patient is 56 and weighs approximately 150 lbs. Her respirations were 0, and her blood pressure was 14/86. No lower extremity edema was present. At the time of assessment, no chest pain, cough, or fatigue was present. In conclusion, the following diagnoses were discovered
• Alteration in tissue perfusion related to interruption in flow
• Decreased cardiac output related to reduction in stroke volume
My desired outcomes with the patient to care for the alteration in tissue perfusion include maintaining a normal blood pressure within the patient’s range. The extremities will stay warm with the absence of pallor and cyanosis. Peripheral pulses should be palpable and patient should remain free of edema. I related to the patient to report any signs of diminished tissue perfusion such as decreased blood pressure, restlessness, confusion, slow capillary refill, or oliguria. Ways to maintain adequate tissue perfusion include administering IV fluids, antimicrobial agents, and vasopressors. To treat the patient with decreased cardiac output, once again blood pressure should remain normal. Apical pulse rates should remain between 60-100 beats per minute and be regular. Respirations should be unlabored and there should be an absence of dizziness and syncope. Other nursing actions to help the patient should be to raise the head of the bead to facilitate the heart’s pumping. Meals should be smaller and more frequent. Avoid extreme hot or cold temperatures and avoid people who are obviously sick.
The most important responsibility for a nurse caring for a patient with a new disease such as my grandmother should be to educate them on the disease and how to handle side effects and symptoms. Many patients will be in and out of the hospital periodically, so they may need support devices to deal with the frequent hospitalizations. Being away from family and the comforts of home and normal everyday life can be stressing and quite upsetting to many people. Sometimes when support from family is not possible because of distance and busy schedules, nurses are the only interaction a patient has that is meaningful.
In conclusion, congestive heart failure has reached epidemic proportions. Clinical trials of investigative congestive heart failure drugs may soon make CHF decrease rapidly in society. The secret to helping patients with CHF is early diagnosis. Treating the underlying problem is also of great significance. This may help prevent future unneeded hospitalizations.
The role nurses play in treating patients with CHF is that of educator and supporter. Nurses have to alert patients of signs and symptoms that will help the patient to control their CHF. They must also be there for the patient in times of distress and confusion.
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