Section one The client
The client (Mr Parker) has recently been diagnosed with chronic heart failure. When addressing the clinical reasoning cues the client stated he experiences breathlessness. Breathlessness has been associated with Cardiac ischemia but is common in acute and chronic conditions (Slater, Abshire & Davidson, 2018). Part of my clinical assessment includes assessing a client’s respiration rate and pulse oximetry. The client’s respiration rate has been recorded as 24, which is considered abnormal and actually considered critically unwell (Walker, 2016). Pulse oximetry is used to assess the client’s oxygen saturation. The oxygen saturations have been recorded at 92 per cent which is above the acceptable rate of 89 per cent (Walker, 2016). Since breathlessness is a common problem proper clinical assessment can lead to a diagnosis. Breathlessness may be an indicator of acute myocardial infarction, heart failure or valvular heart disease (Slater, Abshire ; Davidson, 2018).
Manual pulse palpation is an important assessment to ascertain if the heart rhythm is irregular or regular. Research confirms that manual pulse checking is useful for detecting atrial fibrillation which can initiate the necessity of doing an Electrocardiogram (ECG) and contribute to commencing treatment early and improving client outcomes (Nicholson, 2014). ECG is important in identifying causes of potential heart failure. Heart diseases such as left bundle branch block, hypertrophy of left atrium, acute or previous myocardial infarction can be detected which may warrant further investigation (King, Kingery ; Casey, 2012). Mr Parker’s heart rate is 118 beats per minute which is concerning, an abnormal resting heart rate greater than 100 warrants further investigation regarding the tachycardia (Nicholson, 2014).
Regarding heart auscultation when a heart sound caused by abrupt deceleration of the left ventricle occurs when the rate of filling exceeds the compliance and signifies both the left atrium pressure and left ventricle dysfunction. The displaced apex heartbeat suggests left ventricle remodelling and relates to raised left ventricular end diastolic mass and volume with a decrease in the ventricle ejection. A raised jugular venous pressure 3rd beat sound and displacement of the apex beat are specific and increase the likelihood of heart failure (Elder, Japp & Verghese, 2016).
Blood pressure is another important assessment for Heart failure particularly when clients are hypotensive, this has been suggested to raise the risk of adverse outcomes. A decrease in systolic blood pressure during the 24 hours was linked with renal impairment and adverse outcomes at 30 and 180 days (Cotter et al, 2018).
Medications section 3
Frusemide is classified as a Loop diuretic, which is used to control oedema across clinical fields. Diuretics are used to stop sodium reabsorption in allocated renal tubules which result in raised urinary sodium and water excretion. Loop diuretics have a ceiling dose and for clients, with congestive heart failure, the limit is 80mg, which is what the client has been prescribed (Oh & Han, 2015). The major side effects associated with this medication are hypovolemia, electrolyte imbalances and ototoxicity. These side effects are more pronounced in people taking non-steroidal anti-inflammatory drugs. The bioavailability can be enhanced if it is taken before meals because food can disrupt its absorption (Oh & Han, 2015).
Digoxin toxicity can occur with long-term therapy as well as after an overdose. Toxicity may cause anorexia, vomiting, nausea and fatal arrhythmias which is a significant issue for Mr Parker who has congestive heart failure. Careful monitoring of the client is required on the medication. Another issue is the dosage which is too high, the recommended range for the serum concentration is 0.5-0.9 nanogram/ml due to the fact that there is evidence of better outcomes at lower concentrations (Pincus, 2016). As a nurse, I would ask contact the doctor with my concerns regarding potential adverse reactions and wait for further instruction.
Lastly, the client was prescribed with Ramipril an ace inhibitor for the treatment of hypertension. However his current blood pressure of 102/84 is not considered hypertensive, in advanced heart failure client may have irreversible hypotension due to a damaged cardiovascular system (Doenges, Moorhouse & Murr, 2014). Ramipril is an ace inhibitor that may cause orthostatic hypotension which should be explained to Mr Parker It is crucial that Mr Parker understand the importance of postural physiology as well as potential factors that may aggravate this particularly as this may impact on his occupation
(Ricci, De Caterina & Fedorowski, 2015).
Question 4 Physical activity
When assessing a client’s cardiovascular health there is a strong correlation between a persons lifestyle and cardiovascular health. An important clue in my assessment of the client was that he was unable to attend his rehab program due to the distance it took him. It has been estimated that cardiac rehabilitation rates in rural areas are as low as 10 to 30 per cent. Cardiac rehabilitation rates are associated with improved secondary prevention rates where care may be required for the rest of a person life (Hamilton, Mills, McRae ; Thompson,2018).
Mr Parker’s diagnosis of chronic heart failure has some serious implications for his life with a marked reduction in his capacity for exercise which may have detrimental effects on his quality of life, activities of daily living and also mortality. While survival after diagnosis has improved it still has a poor prognosis with 30 to 40 per cent of people dying within a year. (Sagar et al, 2015) Obviously when commencing the program with a client such as Mr Parker one should start slowly and build up a tolerance to the exercise which will, in turn, inspire confidence regarding their cardiovascular health and their prognosis. However in order for this to occur exercise must be emphasized as playing a significant role in his rehabilitation, not just acute care. Any pertinent clinical issues should be addressed by his physicians such as tachycardia or chest discomfort and the client should be referred to the emergency department (Conti, Conti & Plasschaert, J. (2018).
Identify-It is highly important to identify the client’s name and date of birth when greeting the client. Also, identify the title and role of staff to hand over too.
Situation- The client David Parker has been admitted with an acute coronary syndrome.
The electrocardiogram he had whilst in the emergency ward reveals he had changes in the ST segment and the serum troponin levels indicate a positive value.
Background- The client has recently been diagnosed with having chronic heart failure by his cardiologist. His medical history includes type 2 diabetes (diet controlled), hypertension and hypercholesterolemia. The client is currently taking frusemide 40 mg orally twice daily, digoxin 62.5mcg orally and ramipril. He is also on 1000mg fluid restriction per day. He was admitted a month ago with myocardial infarction. He recovered initially and was referred to a cardiac rehabilitation program which he was unable to attend due to work commitments. David experiences breathlessness, which is not relieved by rest and frequently, experiences fatigue. The client is a smoker and smokes ten cigarettes for stress relief. He states his appetite has decreased recently and he experiences nausea.
Assessment (Vital signs) 36.5 temperature, heart rate -118 beats per minute, blood pressure 102/84, and oxygen saturations 92 percent on room air.
Recommendations-Please monitor Mr Parker for further deterioration of his vital signs over the next eight hour period and cardiac condition. Please review clients digoxin with prescribing doctor within the next shift or as soon as possible as a matter of urgency.
Conti, C. R., Conti, J. B., ; Plasschaert, J. (2018). Development of a Cardiovascular Rehabilitation Program: Focus on Exercise. Cardiovascular Innovations and Applications, 3(2), 233-235.
Cotter, G., Metra, M., Davison, B. A., Jondeau, G., Cleland, J. G., Bourge, R. C., … ; van Veldhuisen, D. J. (2018). Systolic blood pressure reduction during the first 24 h in acute heart failure admission: friend or foe?. European journal of heart failure, 20(2), 317-322.
Doenges, M. E., Moorhouse, M. F., ; Murr, A. C. (2014). Nursing care plans: guidelines for individualizing client care across the life span. FA Davis.
Elder, A., Japp, A., ; Verghese, A. (2016). How valuable is physical examination of the cardiovascular system?. BMJ: British Medical Journal (Online), 354.
Hamilton, S., Mills, B., McRae, S., ; Thompson, S. (2018). Evidence to service gap: cardiac rehabilitation and secondary prevention in rural and remote Western Australia. BMC health services research, 18(1), 64.
King, M., Kingery, J., ; CASEY, M. B. (2012). Diagnosis and evaluation of heart failure. heart failure, 100(21), 23.
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Nicholson, C. (2014). Advanced cardiac examination: the arterial pulse. Nursing Standard, 28(47).
Oh, S. W., ; Han, S. Y. (2015). Loop diuretics in clinical practice. Electrolytes ; Blood Pressure, 13(1), 17-21.
Pincus, M. (2016). Management of digoxin toxicity. Australian Prescriber, 39(1), 18.
Ricci, F., De Caterina, R., ; Fedorowski, A. (2015). Orthostatic hypotension: epidemiology, prognosis, and treatment. Journal of the American college of cardiology, 66(7), 848-860.
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.
Slater, T., Abshire, M., ; Davidson, P. (2018). Assessment of breathlessness: A critical dimension of identifying cardiovascular disease. Australian Nursing and Midwifery Journal, 25(9), 36.
Walker, J. (2016). Assessing respiratory rate and function in the community. Journal Of Community Nursing, 30(5), 50-54.