Analyzing an Aspect of Nursing Care Based on a Provided Profile of a Patient - Essay Example

of the Nursing of the Concerned 14 May Analysing a Chosen Aspect of Nursing Care Based On a Provided Profile of a Patient Introduction A 77 year old male patient with past history of myocardial infarction (MI), left ventricular failure, COPD, duodenal ulcer and peripheral vascular disease was admitted with an acute presentation of stroke. Out of these multiple pathologies, left ventricular failure (LVF) deserves special attention. The underlying pathophysiology of LVF, management and nursing interventions have been discussed. Chosen aspect of care Admission of an elderly patient with multiple comorbidities to the hospital necessitates a thorough evaluation of all the systems, disease optimisation, discharge, follow up, and rehabilitation. Although, the patient has multiple system involvement, given the recent history of myocardial infarction and resulting LVF, heart failure is likely to be the leading cause of hospital readmission in this case. LVF, when coexisting with COPD, makes pharmacological treatment challenging (Padeletti, Jelic and LeJemtel, 2008). This disease is likely to impact and overshadow the management and prognosis of all other associated conditions. Limitation of functional capacity due to LVF is a serious hindrance for the patient to seek treatment for other associated conditions and participate in a rehabilitation program for stroke, peripheral vascular disease and COPD. Acute decompensation of LVF can occur because of treatment non-compliance, infection or poor nutritional status and can be fatal. Thus, nurses play an important role in preventing acute decompensation and rehospitalisation. Heart failure patients generally have a poor prognosis and a reduced quality of life (Gould, 2002). However, because of advances in treatment and dedicated heart failure programs, the prognosis of the condition has improved with the 6 month mortality rate declining from 26% in 1995 to 14% in 2005(Mehta, et al., 2009). Concurrently, hospitalization rates are increasing. An elderly patient with multiple comorbidities, multiple medications and reduced quality of life is the typical profile of a patient with heart failure. In this patient, MI, LVF, COPD, peripheral vascular disease as well as duodenal ulcer have common risk factors of age, smoking and atherosclerosis. Pathophysiology of left ventricular failure Left ventricular failure may be defined as the inability of left side of the heart to pump enough blood to meet the metabolic needs of the body. Coronary artery disease leading to myocardial infarction is the most common cause of left sided heart failure (NICE, 2010, Gould 2002). MI impairs myocardial contraction and hence, reduces its efficiency to pump blood. Severity of the infarction is proportional to the severity of LVF. Other common causes of left ventricular failure include hypertension, cardiomyopathy and valvular heart disease. Positive history of smoking, peripheral vascular disease and age, point towards atherosclerosis and resulting MI as the cause of LVF in this patient. COPD also causes heart failure which is mainly right sided. However, it can also precipitate LVF (Paudel, et al., 2008). LVF, in turn, can cause right heart failure by increasing pulmonary vascular resistance (pulmonary hypertension). Signs and symptoms As the ability of the left ventricle to pump blood in the forward direction is impaired, symptoms result from pulmonary vascular congestion and inadequate cardiac output. Pulmonary congestion affects gas exchange in the alveoli and causes dyspnea, orthopnoea, cough, dizziness, confusion, syncope, fatigue, and decreased functional capacity and exercise tolerance (Buckler, 2009). New York Heart Association (NYHA) grading is a useful tool for grading the severity of LVF that should be used. Physical examination reveals tachypnea, gallop rhythm and features of pulmonary oedema, such as crepitations over lung fields, predominantly at the base. Respiratory distress and production of pink frothy sputum is present in decompensated cases, along with decreased oxygen saturation and cyanosis. Common tests and investigations A patient with history and physical examination suggestive of LVF should be referred to a cardiologist. Laboratory tests that are performed in a LVF patient are haemogram, serum electrolytes, renal and liver function tests and urine analysis. Levels of natriuretic peptides (e.g. BNP) in the serum are very specific for heart failure and have a prognostic value (Buckler, 2009). Imaging studies include chest X-ray and echocardiography. Chest X-ray may show cardiomegaly, Kerley lines, vascular redistribution and pulmonary oedema. The most important diagnostic test for LVF is transthoracic 2D Doppler echocardiography. It allows the assessment of left ventricular function and ejection fraction. Various algorithms use a combination of clinical and investigational parameters is for diagnosis of LVF. Nursing interventions for left ventricular failure Understandably, acute decompensation of LVF is managed in an inpatient setting. For chronic heart failure patients, the trend of nurse-led outpatient care is being increasingly followed to reduce hospitalization and financial burden, and improve the outcome and quality of life (Timmins, 2005). In both inpatient and outpatient settings, evidence exists that nurses play a leading role in the multidisciplinary management of LVF, and readmission rates are reduced in cases where nurses are actively involved (Blue, et al., 2001; Davidson, et al., 2001). These interventions are chiefly concerned with disease management, risk factor reduction and cardiac rehabilitation (Bakan and Akyol, 2008; Allen and Dennison, 2010). Even though, nursing interventions in heart failure patients showed improvement in parameters such as blood pressure, lipid profile, smoking cessation, exercise and nutrition status, more evidence is required to establish cost effectiveness of these interventions (Allen and Dennison, 2010). Furthermore, nurses as part of the palliative care team, can apply the palliative care strategies of symptom alleviation and improvement of the quality of life of this patient (Bekelman, 2008). No surgical management is immediately anticipated in this patient, but nurses are actively involved in surgical management such as ventricular assist device placement and cardiac transplant, in patients of heart failure (Deaton and Grady, 2004). Although, nursing interventions cover all aspects of LVF management, some of the important interventions as applicable to the patient’s profile which will satisfy the holistic needs of the patient are discussed below. Multidisciplinary team approach Interventions delivered with a multidisciplinary approach, involving patient education, nutrition advice and home visit, in the management of heart failure had demonstrated reduced admission rates as early as 1995 (Rich, et al., 1995). Subsequently, a systematic review of randomized trials concluded that this approach reduces mortality and hospitalizations and is cost saving (McAlister, et al., 2004), and this led to newer recommendations (NICE, 2010). Members of this multidisciplinary team in the management of LVF patient under discussion should be clinician, specialist heart failure nurse, dietician, physiotherapist, occupational therapist and social worker. Out of these members, nurses are primarily responsible for integrating the care extended by the other team members. Their role is in clinical management of the disease, patient education, nutrition, and physical and social rehabilitation. Medical management and principles of nursing Drugs that are usually employed in the management of LVF are ACE inhibitors, beta blockers, aldosterone antagonists, diuretics, digoxin and vasodilators. The patient is taking ramipril (ACE inhibitor), frusemide (diuretic) and GTN (vasodilator) spray for LVF and aspirin, clopidogrel, amiodarone, simvastatin as other cardiac medication. Offering both beta blockers and ACE inhibitors should be a key priority in treatment of left ventricular systolic dysfunction, especially if it is coexisting with peripheral vascular disease and COPD without reversibility (NICE, 2010). Rest of the drugs are then administered in a patient who is still symptomatic. Nurses are involved in administering medication, reviewing and assessing the need for change, reinforcing patient’s compliance and self management activities and educating patient about drug dosages, dosing schedule as well as side effects. This intervention is aimed at maximising the use of effective therapy. Other aspects of clinical management which entail nurse participation are monitoring and identifying the problems which warrant action. Heart failure specialist nurses monitor several parameters namely, signs and symptoms including functional capacity and cardiovascular status, fluid intake and output, nutrition and cognitive status (Davidson, et al., 2005). Any deviations from normal or a worsening trend should be reported to the cardiologist and management plan modified accordingly. Additionally, nurses can reinforce health promoting behaviours such as exercise, smoking cessation, low salt intake etc. as applicable in LVF patient. Intervention such as home visits and telephonic support by heart failure nurses provides support to patient and family members (Davidson, et al., 2005). Intervention regarding malnutrition Poor appetite caused by the disease process itself, as well as multiple drugs intake is a part of the symptom profile of a LVF patient. Combined with impaired mobility, it can result in malnutrition and cardiac cachexia. Simple nursing interventions such as observing and correcting patient’s eating habits, oral hygiene and salt restriction have been shown to prevent malnutrition and improve the nutrition status of the patient. Nurses work in conjunction with dietician and oral hygienist or dentist to achieve this aim (Jacobsson, Pihl-Lindgren and Fridlund, 2001). Psychological and socio-cultural factors An elderly patient, who has multiple health problems and is living alone, is likely to have psychological issues of concern such as anxiety, fear, depression, worthlessness, financial worries and feeling of isolation. Thus, providing reassurance and support, and addressing the psychological and spiritual needs of the patient are a part of nursing care. Mutual goal setting in which nurse and patient work together to identify and achieve client-determined goals is one of the nursing interventions that have been shown to improve mental health and quality of life of patients. Supportive-educative nursing technique targets self care management behaviour by involving patients in the decision making process (Scott, Setter-Kline and Britton, 2004). Law and ethics When a patient is found collapsed or has cognitive dysfunction and no family members or relatives are immediately accessible, information about the patient’s clinical history as well as consent for treatment and procedures is not available. This creates challenges for the health care team in context of legal and ethical issues. In this case, law dictates that life saving measures can be administered without obtaining the consent. However, every effort should be subsequently made to respect patient’s as well as family members’ wishes. As the patient expresses desire to be discharged home, his wishes should be respected and in view of his requiring assistance while mobilising, nurse should liaison with occupational therapy and physiotherapy professionals and aid in rehabilitation. Department of Health’s consent related advice can guide in case of impaired decision making capacity of patients (NICE, 2010). Appropriate health promotion/patient teaching It is important to ensure that patient understands his condition and receives advice about his medication, nutrition and diet, salt intake, daily weighing and weight reduction, exercise and smoking (Vickers and Rigby, 2007). Patient’s knowledge should be assessed in terms of whether he knows which activities are likely to aid in management of his condition and which are likely to worsen it. Nurses contribute to and encourage self care behaviour of the patient. Although, symptoms of confusion and disorientation which were initially present, resolved at the time of discharge, presence of cognitive impairment has been shown to increase the risk of rehospitalisation and poor treatment compliance (Ekman, Fagerberg and Skoog, 2001). The goals should be adherence to the treatment and adoption of a lifestyle that prevents the exacerbation of an acute event. These goals can be achieved by education, guidance and support. Also, it is important that the advice is reviewed periodically and evaluated for appropriateness. Discharge planning Prior to discharge, heart failure nurse should coordinate with the ward nurse to obtain all the case specific details. A record of patient’s symptom profile at discharge, dyspnoea grade, physical examination findings, blood tests and medications is to be kept and first home visit should be scheduled (Vickers and Rigby, 2007). As the patient lives alone and is refusing institutionalised care, the nurse should assess the deficits that are likely to be present in the area of self care. Telephonic support should be provided to the patient. The time for which the patient is being rehabilitated in the ward prior to discharge, should be utilised by the nurse to help the patient in achieving his maximum potential. Patient should be counselled that diet management, personal hygiene and social interaction issues will be complicated by living alone at home (Timmins, 2005). Acute LVF scenario If the patient decompensates and presents with acute respiratory distress, he should be managed in the cardiac care unit till the condition is stabilised. Life-saving measures include supplemental oxygen therapy, propped up position, diuretics and opioids for the management of pulmonary oedema. ACE inhibitors, nitrates and psychological support measures should be accordingly administered. Oxygen saturation should be maintained and patient’s vital parameters including cardiac, respiratory and mental status should be continuously monitored. Maximum rest should be provided to the patient (Timmins, 2005). Conclusion LVF is a complex clinical entity predominantly seen in elder adults and which frequently coexists with multiple pathologies. Heart failure has an impact on all aspects of a patient’s life such as physical wellness in terms of organ and body system function, psychology, nutrition, mobility and quality of life. Nursing intervention aimed at management of these aspects in a LVF patient mandate an organized and multidisciplinary approach, taking into consideration social, legal and ethical issues. Reference List Allen, J.K. and Dennison, C.R., 2010. Randomized trials of nursing interventions for secondary prevention in patients with coronary artery disease and heart failure: Systematic Review. Journal of Cardiovascular Nursing, 25(3), pp.207-220. 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