Jeanylyn Palad BSN IV-D Elective 2 1. What condition is the client probably suffering from?

The client is suffering from Congestive Heart Failure left sided. 2. What data in the clients history support the diagnosis?

July 6,2011

Basing on the situation, the client has a 6-year history of hypertension and coronary artery disease. This would indicate that the patient is at risk of developing CHF because hypertension causes overwork to the heart and coronary artery disease causes decreased blood flow to the heart muscle because the arteries that supply blood and oxygen to the heart become blocked by plaques, thus causing starvation for oxygen and nutrients. These caused the patients heart to fail to function properly and not pumped the blood properly to other parts of the body. 3. How does the above condition occur? In congestive heart failure, the heart's pumping power is weaker than normal. With this condition, blood moves through the heart and body at a slower rate, and pressure in the heart increases. As a result, the heart cannot pump enough oxygen and nutrients to meet the body's needs. CHF results from changes in systolic and diastolic function of the left ventricle. The heart fails when it cannot handle a normal blood volume or cannot tolerate a sudden expansion in the blood volume. To compensate, the chambers of the heart respond by stretching to hold more blood to pump through the body. This helps to keep the blood moving, but in time, the heart muscle walls weaken and are unable to pump as strongly. Causes of CHF 1. Volume overload: especially with left to right shunts that may cause the RV to hypertrophy in order to compensate for the additional blood volume. 2. Pressure overload: resulting from obstructive lesions such as valvular stenosis or coarctation of the aorta. 3. Decreased contractility: primarily factors that affect the contractility of the myocardium, such as cardiomyopathy or myocardial schema from severe anemia or asphyxia, low level of potassium, glucose, calcium or magnesium. 4. High cardiac output demands: in which the body s need for oxygenated blood exceeds the heart out put (even though the volume may be normal), such as in sepsis, hyperthyroidism and severe anemia. 4. What are the possible explanations of the conditions signs and symptoms? y y y y Shortness of breath- this is caused by a decrease in the lungs air volume (vital capacity) Fatigue inadequate cardiac output leads to hypoxic tissues and slowed removal of metabolic wastws, which in turn causes the client to tire easily Dizziness results in decrease cardiac output, causing inadequate brain perfusion Presence of dyspnea decrease in the lungs air volume (vital capacity) as air is displaced by blood or interstitial fluid. Also, pulmonary congestion eventually reduces the vital capacity of the lungs. With bilateral rales in the lower lobes results from increased left ventricular and left arterial pressure, which cause excessive accumulation of fluid in the interstitial and alveolar spaces

y y y y y

Irregular heart rate with a bounding pulse a compensatory effort of the heart to increase cardiac output Elevated Blood pressure due to coronary artery disease 4+ pitting edema of both ankles - blood flow to the kidneys is restricted, causing sodium and water retention. Blurred vision inadequate perfusion to the capillaries in the eyes Feel lightheaded results in decrease cardiac output, causing inadequate brain perfusion

5. List 3 nursing diagnosis including related factors that are appropriate for the client based on the history of current data. a. Decreased cardiac output related to impaired contractility increasing preload and afterload c. Impaired gas exchange related to presence of fluid in the alveoli secondary to elevated ventricular pressures b. Excess fluid volume related to reduced sodium and water retention 6. Prioritize the nursing interventions with 1 as the most important interventions, Include rationale for prioritization. Interventions __1___ Place client in Semi-Fowlers position Rationale

- positioning the patient will promote a patent airway by reducing pulmonary venous congestion (Airway) __2___ Assess breath sounds &breathing pattern - breathing pattern should be noted to know complications (Breathing) __3___ Assess capillary refill - to determine the perfusion of blood to distal parts/ peripheries (Circulation) __4___ Monitor urine output - to determine the circulatory volume __5___ Report laboratory results - to allow the physician to provide the patient with the proper treatment 7. What advise should you give to the client regarding her diet? y Reduce intake of foods high in sodium, diets with 2-4 g of sodium are usually prescribed. Choose foods that are low in salt, such as fresh meats, poultry, fish, dry and fresh legumes, eggs, milk and yogurt. Plain rice, pasta and oatmeal are good low-sodium choices. However, the sodium content can increase if salt or other high-sodium ingredients are added during their preparation. y Potassium supplements and dietary potassium are important. Advise the patient to take in foods rich in potassium y Do not restrict fluid intake instead limit it to 1000ml/day y Choose plenty of fresh fruits and vegetables. They contain only small amounts of salt. y Avoid caffeine , alcohol and smoking y Read food labels before buying packaged foods. Check the nutrition facts on the label for sodium content per serving. Find out the number of servings in the package. How does the sodium in each serving compare to the total sodium you can eat each day? Try to pick packaged foods with a sodium content less than 350 milligrams for each serving. It is also useful to check the list of ingredients. If salt or sodium is listed in the first five ingredients, it is too high in sodium.

8. What pharmacologic interventions would you expect for this client and what would be the implications for the clients health? y y y y y y y ACE inhibitors such as captopril, enalapril, lisinopril, and ramipril to open up blood vessels and decrease the work load of the heart Diuretics including hydrochlorothiazide, chlorthalidone, chlorothiazide, furosemide, torsemide, bumetanide, and spironolactone to help rid your body of fluid and salt (sodium) Digitalis glycosides to help the heart muscle to contract properly and help treat some heart rhythm disturbances Angiotensin receptor blockers (ARBs) such as losartan and candesartan for those who have side effects with ACE inhibitors Beta-blockers such as carvedilol and metoprolol, which may be helpful for some patients Venous vasodilator (nitroglycerin) reducing peripheral resistance decreaseas blood pressure, and the reduction in preload amy decrease he heart rate and pulmonary congestion Inotropes: IV inotropes are stimulants, such as dobutamine and milrinone, that increase the pumping ability of the heart. These are used as a temporary support of a very weak left ventricle that is not responding to standard CHF therapy. Potassium and magnesium supplements are often prescribed with diuretics to replace these minerals, which are excreted in urine.

9. What are the age-related considerations and complications would you teach this client as a part of the patients education? Modify daily activities and get enough rest to avoid stressing the heart Eat a heart-healthy diet that is low in sodium and fat Reduce stress Don't smoke and avoid exposure to second-hand smoke Don't drink alcohol or limit intake to no more than one drink two or three times a week Avoid or limit caffeine intake Lose weight Get regular exercise, which may include a physical rehabilitation program Weigh yourself daily, for a sudden increase may signal fluid build-up Keep track of symptoms and report any changes Have regular checkups to monitor the condition Complications that may arise: y y y y y Pulmonary edema Total failure of the heart to function (circulatory collapse) Abnormal heart rhythms -Atrial fibrillation, Left bundle-branch block, Ventricular tachycardia and ventricular fibrillation Impaired Kidney Function - Heart failure weakens the hearts ability to pump blood. This can affect other parts of the body including the kidneys (which in turn can lead to fluid build-up). Angina and Heart Attacks