Answer 1: CHF Overview, Causes, Incidence, and Risk Factors

Outline of the disease

Congestive heart failure is termed as a severe, chronic and progressive condition of heart in which, due to which the heart muscles becomes unable to contract and relax properly, therefore decreasing the ability of the heart to maintain its systolic and diastolic motion (Herr et al., 2016). This eventually causes the heart ventricles to pump inefficiently and increases the complication associated with pumping of blood. While understanding the heart anatomy it is noted that within the four chambers, within which the ventricle chambers are responsible for pumping of blood from heart to the bodily organs and tissues (Russo et al., 2014). In congestive heart syndrome, due to the inability of the heart muscles around the ventricles, enough blood does not reach to the bodily organs. In such situation, organs such as liver, kidney, heart and abdomen starts accumulating bodily fluid in their smooth muscle coverings due to which they become bloated and swollen (Herr et al., 2016). This leads to shortness of breath in affected individuals, leading to congestive heart failure.  In the case study, the congestive heart failure associated condition of Mrs. Sharon McKenzie (77) has been mentioned who is facing symptoms of cold feet, swollen ankle, shortness of breath and others, indicating towards congestive heart failure.

Causes, incidence and risk factors

As per Crowley et al. (2017), the primary cause of congestive heart failure is weakened heart muscle that makes the heart ventricles disable to pump enough blood to the different organs and tissues of the body. Further, as per McMurray et al. (2014), cardiomyopathy related condition, in which blood line becomes infected with virus and bacteria, performing exercise after having a history of myocardial infarction, aging and Further, in the case study of Mrs. Sharon McKenzie, it was mentioned that the patient had an myocardial infarction condition 12 years ago due to which she had a risk factor for developing congestive heart failure which was also mentioned in the research article by Frangogiannis (2014), that patients with myocardial infarction could develop congestive heart failure if they do not follow the preventive measures and keep on performing heavy and strenuous activities. On the other hand, due to accumulation of plaque and fatty deposits in the wall of heart blood vessels, risk factor of developing CHF increases (Ziaeian & Fonarow, 2016). 

The Australian Institute of Health and Welfare under the government of Australia mentioned the incidence of CHF in the country however, clearly mentioned of no national data of the incidence (Australian Institute of Health and Welfare, 2019). As per the government, all the data related to CHF has been obtained through the international bodies and they estimate of 300,000 people affected with CHF in Australia. Further, they also reported of 30,000 new cases registered in Australian healthcare facilities every year. Majority of the population affected with this disorder are above the age of 45 (Australian Institute of Health and Welfare, 2019).

Answer 2: CHF Symptoms and Pathophysiology

Further, risk factor associated to this condition is increased blood pressure, hypertension, pulmonary embolism and rheumatic fever. Besides this as per Herr et al. (2016) past occurrence of myocardial infarction could lead to congestive heart failure in 70% of the cases. Moreover, exercise, gap in diet, anemic condition, bacterial or viral infection as well as increased fat consumption could also increase the risk of congestive heart failure in patient, as it was seen in the case of Mrs. McKenzie (Frangogiannis, 2014).

The effect of this health condition would impact the patient and her husband by decreasing their quality of life. Due to the health condition, it would increase the financial burden on the patient and her husband as with increasing complication, the cost of medication would also increase. Hence, they both would suffer from mental and financial complications (Kanter et al., 2014). Further, due to mental trauma, the husband of Mrs. Sharon McKenzie would also suffer from healthcare complications, thereby deteriorating their personal life balance. Therefore, due to Basaraba and Barry (2015), the patient and the families would suffer from mental and physical trauma.

Signs and symptoms of CHF and associated pathophysiology

The common signs and symptoms associated with this disease which were also observed in case of Mrs. Sharon McKenzie are shortness of breath, elevated respiratory rate and increased blood pressure. As per Thibodeau et al. (2014), it is one of the crucial symptom of CHF in which all the smooth muscles around the lungs, heart and upper body organs increases their lipid accumulation, due to which people feel heavy in their lungs (Thibodeau et al., 2014). In the case study it was seen that Sharon McKenzie was unable to move within her house and despite of her previous case of myocardial infarction, she used to go for walk with her husband. Hence, it was associated with her shortness of breath.

On the other hand, CHF is associated with his heart muscles inability to pump appropriate amount of blood to the body organs and tissues (Peacock et al., 2014). In such situation, the heart muscles work harder to pump blood to the entire body, and hence, put extra strain to the blood vessels. Hence, the blood pressure in the blood vessel increases in CHF condition. Further, due to increased pressure, blood vessels require increased systolic and diastolic motion so that the increased oxygen demands (Peacock et al., 2014). Therefore, it was seen in this case study of Mrs. Sharon McKenzie that due to these pathophysiological changes she was suffering for increased blood pressure and elevated heart rate.

Answer 3: Pharmacodynamics of Loop Diuretics

The third symptom, associated with CHF is swollen ankle and cold feet, and as per Thibodeau et al. (2014), external and internal factors are associated with it. In is seen that due to the heart muscles inability of pumping blood, all the smooth muscles, and tissues of the body starts accumulating fluid around them. As Basaraba and Barry (2015) mentioned that majority of the arm, legs and ankle tissues accumulates fluid around them primarily, due to which, cold feet and swelling of the ankles are seen and hence, the patient in the case study also showed the symptoms of CHF (Basaraba & Barry, 2015). 

The class of drug which was chosen in the case study was Loop diuretic which is used by healthcare professionals to decrease the amount of sodium consumption so that the fluid accumulated around the organs could be decreased (Ellison & Felker, 2017). This drug was effective in decreasing the fluid accumulation so that the congestive heart related shortness of breath could be treated.

Pharmacodynamics

As per Louizos et al. (2014), the pharmacodynamics associated with the Loop diuretics works along with the nephron and the distal exchange site. The primary role of this drug is seen with ascending limb of the Henley’s loop and shows complex effect on the renal circulation. Due to the action of this drug, the blood flow is diverted from the juxta medullary to the outer cortex. Further, it was also seen that by acting on the nephron, it decreases the absorption of sodium and other ions due to which the fluid accumulated in the soft tissues of the organs starts decreasing (Cox & Lenihan, 2014). 

Pharmacokinetics

While discussing the pharmacokinetics of the loop diuretic class of drugs, the absorption, metabolism, distribution, biotransformation and elimination from the body should be discussed (Louizos et al., 2014). As per Cox and Lenihan (2014), oral absorption of the drug is 65% and hence the absorption is incomplete from this oral route. The half life of the drug is 90 minutes and it is the form of carboxylic acid, which in the presence of gastric juices in the intestine acts properly. Due to these, facts in its optimum pH 5.0, it is active for four hours inside the body. Distribution of this drug inside the body is mainly through plasma proteins and through the plasma albumin the biotransformation of this drug takes place in smaller amount (Louizos et al., 2014). The excretion of this drug occurs via urinal route

Answer 4: Nursing Care Plan for Patients with CHF during First 8 Hours Post Ward Admission

The care plan developed for Mrs. Sharon McKenzie is as follows:

The goals of the care plan would be:

• Decreasing the accumulated fluid from the bodily organs of the patient and decreasing the accumulated fluid from the ankles so that congestion of heart could be decreased and shortness of breath could be decreased.
• The increased respiratory rate and elevated blood pressure so that the strain from the heart muscles and blood vessels could be reduced and the damage associated with it could be eliminated.
• The third goal of the nursing intervention would be addressing the shortness of breath in the patient so that her increased discomfort and breathlessness could be treated.

To achieve the first goal, patient would be provided with loop diuretic drugs so that increased sodium consumption could be treated and the accumulated fats could be decreased (Pellicori, Kaur & Clark, 2015). Further, this would help to monitor the fluid intake and excretion so that through this the fluid intake of the patient could be increased or decreased. Further, the patient’s water output could be assessed and the resulting dehydration could be avoided. As per Pellicori, Kaur and Clark (2015), this would be effective intervention as diuretic medications are helpful in decreasing the excessive fluid intake and monitoring this process would help to decrease the risk factor of dehydration.
 

To achieve the second goal, the Brain natriuretic peptide production of the heart would be monitored so that the stress on the heart muscle could be understood (Gordan, Gwathmey & Xie, 2015). Further, the patient would be provided with medication to control the respiratory rate, heart rhythm and pressure so that excessive pressure from the patient’s heart could be reduced. The rationale for this intervention would be associated with the research of Gordan, Gwathmey and Xie (2015), which mentions that BNP production helps to understand the excessive pressure of the body and hence, it should be included in the care plan of the patients suffering from congestive heart failure.

The third intervention to achieve the nursing care goals would be providing the patient with corticosteroids so that the airway smooth muscles could be relieved and patient could breathe freely. Further, this would help the lungs to accumulate enough oxygen to meet the patient’s body (Louizos et al., 2014). Inclusion of anticoagulants in the medication of the patient is also important so that blood clots of the blood vessels could be assessed and treated to remove any blockage from patient’s blood vessels. Researcher Frangogiannis (2014) also believes that inclusion of corticosteroids and anticoagulants are helpful in treating patients and their congestive heart failure and help to reduce their discomfort and focus on primary intervention to overcome their disorder.   

References

Australian Institute of Health and Welfare (2019). Heart failure. . . what of the future?, Summary – Australian Institute of Health and Welfare. [online] Australian Institute of Health and Welfare. Available at: https://www.aihw.gov.au/reports/heart-stroke-vascular-diseases/heart-failure-future/contents/summary [Accessed 22 Mar. 2019].

Basaraba, J. E., & Barry, A. R. (2015). Pharmacotherapy of heart failure with preserved ejection fraction. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 35(4), 351-360.

Cox, Z. L., & Lenihan, D. J. (2014). Loop Diuretic Resistance in Heart Failure: Resistance Etiology–Based Strategies to Restoring Diuretic Efficacy. Journal of cardiac failure, 20(8), 611-622.

Crowley, M. J., Diamantidis, C. J., McDuffie, J. R., Cameron, C. B., Stanifer, J. W., Mock, C. K., … & Williams, J. W. (2017). Clinical outcomes of metformin use in populations with chronic kidney disease, congestive heart failure, or chronic liver disease: a systematic review. Annals of internal medicine, 166(3), 191-200. 

Ellison, D. H., & Felker, G. M. (2017). Diuretic treatment in heart failure. New England Journal of Medicine, 377(20), 1964-1975.

Frangogiannis, N. G. (2014). The inflammatory response in myocardial injury, repair, and remodelling. Nature Reviews Cardiology, 11(5), 255. 

Gordan, R., Gwathmey, J. K., & Xie, L. H. (2015). Autonomic and endocrine control of cardiovascular function. World journal of cardiology, 7(4), 204.

Herr, J. K., Salyer, J., Lyon, D. E., Goodloe, L., Schubert, C., & Clement, D. G. (2014). Heart failure symptom relationships: a systematic review. Journal of Cardiovascular Nursing, 29(5), 416-422. 

Kanter, C., D’Agostino, N. M., Daniels, M., Stone, A., & Edelstein, K. (2014). Together and apart: providing psychosocial support for patients and families living with brain tumors. Supportive Care in Cancer, 22(1), 43-52.

Louizos, C., Yáñez, J. A., Forrest, L., & Davies, N. M. (2014). Understanding the hysteresis loop conundrum in pharmacokinetic/pharmacodynamic relationships. Journal of pharmacy & pharmaceutical sciences: a publication of the Canadian Society for Pharmaceutical Sciences, Societe canadienne des sciences pharmaceutiques, 17(1), 34.

McMurray, J. J., Packer, M., Desai, A. S., Gong, J., Lefkowitz, M. P., Rizkala, A. R., … & Zile, M. R. (2014). Angiotensin–neprilysin inhibition versus enalapril in heart failure. New England Journal of Medicine, 371(11), 993-1004. 

Peacock, W. F., Chandra, A., Char, D., Collins, S., Der Sahakian, G., Ding, L., … & Hu, M. Y. (2014). Clevidipine in acute heart failure: results of the a study of blood pressure control in acute heart failure—a pilot study (PRONTO). American heart journal, 167(4), 529-536.

Pellicori, P., Kaur, K., & Clark, A. L. (2015). Fluid management in patients with chronic heart failure. Cardiac Failure Review, 1(2), 90.

Russo, G., Cioffi, G., Gori, S., Tuccia, F., Boccardi, L., Khoury, G., … & Tarantini, L. (2014). Role of hypertension on new onset congestive heart failure in patients receiving trastuzumab therapy for breast cancer. Journal of cardiovascular medicine, 15(2), 141-146. 

Thibodeau, J. T., Turer, A. T., Gualano, S. K., Ayers, C. R., Velez-Martinez, M., Mishkin, J. D., … & Drazner, M. H. (2014). Characterization of a novel symptom of advanced heart failure: bendopnea. JACC: Heart Failure, 2(1), 24-31.

Ziaeian, B., & Fonarow, G. C. (2016). Epidemiology and aetiology of heart failure. Nature Reviews Cardiology, 13(6), 368.