HSNS373 Transitioning to Practice 1

Question 1: Signs of deterioration and whether the patient requires clinical review

Signs of deterioration

Deterioration or worsening heart failure emanates when the patient don’t respond to the onset therapy but progressively worsen. Its predictors include albumin, heart rate, respiratory rate, blood urea nitrogen, cholesterol, and systolic blood pressure (Clark, Cherif, McDonagh & squire, 2017). In its context, failure implies that the heart incapability to pump sufficient blood to encounter the body’s requirement. Typical repercussions of worsening heart failure include shortness of breath, fatigue as well as swelling in legs. According to Greene, Fonarow & Butler, 2020, in worsening case of heart failure, the patient usually encounter the following signs: extra swelling in the ankles or feet, shortness of breath that is not associated to exercise, waking up short of breath, increased fatigue, loss of appetite, sudden weight gain in a day, pain or swelling in the abdomen, trouble or discomfort breathing while lying flat, wheezing or coughing, as well as mental confusion.

As per the Bruce Reynolds case study, in his duration of hospitalization, did encounter deterioration signs of his heart failure. This included: swelling on his knees, speaking in short sentences as well as shortness of breath, increased work of intercostal recession, breathing and crackles at the lung bases, passage of urine, and warm to touch. This deterioration are caused by deterioration of blood pressure to high blood pleasure stage 2 from 178/104 mmHg to 180/102 mmHg, irregular heart rate worsening from 130 beats/min to 134 beats/ min, and respiratory rate 28 to 32 breaths per minute which are way above the normal rates. Escalating heart rate is connected with high-rise blood pressure, thus escalating the risk of hypertension which escalates the risk for heart failure for the patient.

 Clinical review

Use of vasodilators: Owing to the patient systolic dysfunction, therapy comprising ACE inhibitors will need to be initiated. Maximal doses are required to acquire the optimal benefaction from ACE inhibitor therapy (Harding, 2017).  This therefore will require an appropriate approach to by commencing with low doses as well as monitoring correctly but not automatically focusing on lower maximal doses. Initial dosages are enalapril, hydralazine, captopril, and lisinopril. While the dosages are being administered, the patient will require to be examined weekly with increment in dosage while at the same time monitoring blood pressure, creatinine, and supine as well as potassium levels. In case the ACE inhibitors cannot be tolerated due to deterioration in renal function or cough, isosorbide dinitrate as well hydralazine regime combination can be utilized.

Diuretics can be utilized owing to renal function age – associated deterioration, a loop diuretic like furosemide will be needed (Al-Khafaji, Patel & Hunter, 2016). Also digoxin will be required to curtail the symptoms severity. Owing to age – associated impairments in renal function of the patient, digoxin dosage will require to be adjusted as well as monitored correctly. In addition, the patient will require antihypertensive therapy owing to the persistent hypertension registered in him through adjuvant drug therapy (Zhong, 2016). Amlodipine as well as felodipine as the new established calcium antagonists are effective since they will only require to be administered once in a day. Agents like nitrates as well as hydralazine will also be beneficial to the patient.

Antiarrhythmic therapy will be effective for atrial fibrillation associated with an increment in heart failure severity of the patient (Lesuda, 2019). This is by administering amiodrone in low doses in consultation with cardiologist or physiologist if possible. Moreover anticoagulation can be utilized owing to systolic dysfunction as the patient had previous embolic episode.

Question 2: Succinct and accurate ISBAR handover in Verbal script format

Situation: “Hello Dr. Smith, this is Joseph. I was showering Bruce this morning and I wish to share with you what I observed. I noted Bruce had developed swelling on his knees in the last few days, short of breathe and speaking in shirt sentences, increased work of breathing, diaphoretic and passage of urine. I have checked out his edema, though nothing was documented. I feel this is issues that need your attention as soon as possible.”

Background: “I see Bruce Reynolds have been living in our community nursing home for the last 12 months. He was admitted due to decline in morbidity as well as heart failure. His situation is getting worse each and every day. On his medical history, he had an acute kidney failure due to heart failure.”

Assessment: “Bruce from the outlook view looks well, though from my observation, He is not good. I monitored his respiratory rate, heart resting rate and blood pressure and they have continued to escalate since he was admitted.”

Recommendation: “I perceive that we should put him under clinical review, subject him to medication, oxygen therapy, as well as oxygen therapy.”

Question 3: Immediate nursing management of the patient

Administration of oxygen therapy and medications

The symptomatic treatment medication for heart failure is stipulated by the physician, and the nurse’s role is to administer the prescribed medication. Nonetheless, the nurse is anticipated to have the pharmacological knowledge namely, the therapeutic as well as the medications so as to ensure patient progress in order to prevent treatment associated problem (Sepehrvand & Ezekowitz, 2016). If regulated without cautions, the treatment medication of heart failure can possess deadly effects and thus the nurse will be responsible for his/ her nursing exertions with contemplation to stipulated medications administration.

The most frequent stipulation medications for a heart failure illness patient are:

• Digitalis, e.g. digoxine: For ameliorating heart muscles contractions as well as cardiac output.
• Diuretics, e.g. Furosemide: To augment the excess fluid eradication from the body in order to intercept systematic edema. In that aspect, the nurse will have already examined the patient concerning side effects associated to each of the medications.
• Angiotensin Converting Enzyme inhibitors (ACE inhibitor): To intercept the Angiotensin conversion, thus intercepting fluid and salt reabsorption by Aldosterone. It empowers these therapeutic impacts by slowing down the heart rate pace, and therefore as a result preserves the heart rhythms. The nurses should administer the patient’s purse pattern as the medication can cause him to establish heart arrest as well as bradycardia (Schulman, Ikizler & Hakim, 2015).
• Furosemide: To strengthen the excess fluid eradication from the body via urination and thus ameliorate kidneys flush out. The wanted therapeutic effect aligns with significant electrolytes loss particularly potassium as well as sodium. Sodium loss prospects hypovolemia as well as dehydration, while potassium loss subjects the patient at a danger for arrhythmia, besides the hitherto heart. Provided the anticipated side effects associated to this medication, the nurse need to evaluate the patient for the dehydration signs, like mucosa, dry skin as well as thread pulse and low blood pressure. Likewise, the patient need to be observed  for the imbalanced serum potassium signs like grumbling muscle cramps, palpitations as well as arrhythmias evidences.
  
  

On top of these medications, the patient will require to be orchestrated oxygen to make certain adequate saturation. In that aspect, care need to be taken in order to circumvent oxygen overflow so as to intercept the lungs hyperinflation as well as emphysema risk. Nasal cannula utilization for oxygen therapy warrant adequate ventilation while reducing the suffocation sensations that could be prompted by the oxygen masks.

Patients diet modification

Diet plays a vital role in health maintenance for patient having heart failure (Gardner, Omeara & Jardine, 2016). The patient requires altering his diet to fall in with the thriving rule of fat free, low salt formula. Consequently, the nurse needs to provide the nurse with meals that are fat free as well as salt free. Salt free diet lessens the fluid reservation which locates a load on the languishing heart as well as fat free diet lessens the ischemic heart illness risk. The food need to be soft produced so as to lessen the mechanical digestion efforts of hard foodstuff, which establishes energy demand, yet in the patient constituting an arbitrated body metabolism.

Small rationing of meals is advocated. Large meals situate heart pressure, therefore escalating the workload. The nurse is required to advice the patient to perpetuate a semi – fowler position subsequent to every meal so as to lessen heart pressure. In addition, the nurse requires offering patient with caloric food in order to supplement his energy. Vitamin rich food requires to be provided to ameliorate the immunity of the patient since his immunity is low due to low body metabolism.

Question 4: Ongoing management of the case and integration of relevant members of the interdisciplinary committee

This establishes interdisciplinary care plans that are established by various medical specialties and disciplines representatives, each concentrating on the patient’s condition, treatment objectives, as well as mechanisms of ameliorating outcomes (Lenihan & Sawyer, 2017). This type care arrangement escalates communication efficacy among the healthcare staff, constructing sense of teamwork and collaboration as well as straightening the overall care picture that the patient requires. This will decline the overall length of stay of the patient despite of diagnosis, curtail hospital – acquired conditions appraisal not connected to the original diagnosis as well as lessening healthcare – associated expenditures.

References:

Al-Khafaji, N., Patel, M., & Hunter, C. (2016). Ultrafiltration Versus Intravenous Diuretics for Treatment of Acute Decompensated Heart Failure Versus Intravenous Diuretics for Treatment of Acute Decompensated Heart Failure. Journal of Cardiac Failure, 22(8), S61. https://doi.org/10.1016/j.cardfail.2016.06.185

Clark, A. L., Cherif, M., McDonagh, T. A., & Squire, I. B. (2017). In-hospital worsening heart failure: a clinically relevant endpoint? ESC Heart Failure, 5(1), 9–18. https://doi.org/10.1002/ehf2.12195

GARDNER, R., OMEARA, E., & JARDINE, A. (2016). 607 Renal dysfunction, as measured by the Modification of Diet in Renal Disease (MDRD) equations, and outcome in patients with advanced heart failure. European Journal of Heart Failure Supplements, 5(1), 140–141. https://doi.org/10.1016/s1567-4215(06)80404-2

Greene, S. J., Fonarow, G. C., & Butler, J. (2020). Risk Profiles in Heart Failure. Circulation: Heart Failure, 13(6). https://doi.org/10.1161/circheartfailure.120.007132

Harding, S. A. (2017). The role of vasodilators in the prevention and treatment of no-reflow following percutaneous coronary intervention. Heart, 92(9), 1191–1193. https://doi.org/10.1136/hrt.2006.088427

Lenihan, D. J., & Sawyer, D. B. (2017). Heart Disease in Cancer Patients: A Burgeoning Field Where Optimizing Patient Care Is Requiring Interdisciplinary Collaborations. Heart Failure Clinics, 7(3), xxi–xxiii. https://doi.org/10.1016/j.hfc.2011.04.001

Lesuda, N. (2018).  InPharma, 201(1), 11–11. https://doi.org/10.1007/bf03301989

Schulman, G., Ikizler, T. A., & Hakim, R. (2015). Angiotensin-Converting Enzyme Inhibitors and Hemodialysis Membranes. Seminars in Dialysis, 12(1), S-88-S-91. https://doi.org/10.1046/j.1525-139x.1999.90209.x

Sepehrvand, N., & Ezekowitz, J. A. (2016). Oxygen Therapy in Patients With Acute Heart Failure. JACC: Heart Failure, 4(10), 783–790. https://doi.org/10.1016/j.jchf.2016.03.026

Zhong, Y. (2016). Adjuvant systemic drug therapy and recurrence of hepatocellular carcinoma following curative resection. Drug Discoveries & Therapeutics. https://doi.org/10.5582/ddt.2013.v7.4.164

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