Cardiovascular and vital signs assessment

The nursing assessment in this patient should include cardiovascular, respiratory, and fluid assessment. The cardiovascular examination should include measurement of vital signs since they are the best predictors of patient deterioration (Elliott & Coventry, 2012).

Cardiovascular and vital signs assessment

The cardiovascular examination is carried out using the inspection, palpation, and auscultation techniques (Glynn, Drake, & Hutchison, 2012). The general examination on inspection will include assessment for stigmata of heart failure including ascites, weak rapid pulse, tachycardia, low blood pressure, distended neck veins, and weakness. Palpation should be done to note for any cardiac abnormalities such as apex deviation. The heart sounds should be assessed for any murmurs or accentuation of the heart sounds (Glynn et al., 2012).

The patient David has a tachycardia of 118 bpm, a tachypnoea of 24, a low oxygen saturation of 92% and a normal blood pressure of 102/84. This is due to sympathetic compensation in cardiogenic shock (Brunner, 2010). Monitoring of these vitals in David’s case is important as it shows clinical improvement or deterioration (Critchley, Lee, & Ho, 2010). It also shows escalation points for intervention (Hands et al., 2013).

Respiratory assessment

Heart failure affects the respiratory system in predictable ways. The assessment that includes inspection, palpation, percussion, and auscultation should be done to pick out signs of heart failure in this system (Glynn et al., 2012). Heart failure causes pulmonary edema that may manifest as wheezing, coughing with sputum production, basal crepitation, increased respiratory rate, and cyanosis. The patient has an increased respiratory rate of 24 breaths per minute. the monitoring of respiratory symptoms is an important aspect of the assessment as worsening symptoms means worsening pulmonary pathology and hypoxia (Brunner, 2010).

Fluid assessment

Heart failure lead to salt and water retention and a characteristic fluid overload status. Fluid volume assessment should therefore be carried out to reduce the risk of worsening fluid status in this patient (Kim, Susan, Scott, & Heddwen, 2010). This is done by assessing for signs of fluid overload such as peripheral circulation, pulses, distended vasculature, ascites, pulmonary edema, pedal edema and anasarca (Glynn et al., 2012). The patient’s fluid intake should be noted and the urine output monitored. Daily weighing should be done to assess changes in fluid status.

Medication management

Digoxin 62.5mcg PO daily

This is a cardiac glycoside with a positive inotropic effect on the heart. Its mechanism of action is inhibition of the sodium-potassium pump causing an increase in intracellular calcium and increasing cardiac myocyte contractility (Katzung, Masters, & Trevor, 2012). This positive ionotropic effect translates to improved cardiac output and perfusion which is beneficial in heart failure (Ambrosy et al., 2014).

Respiratory assessment

Nursing responsibility in digoxin use is to make sure dose titration, administration and side effects are monitored. David should be warned about this drug toxicity and encouraged to verbalize any effects he sees. The side effects present as blurred vision, delirium, abdominal pain, nausea, vomiting and confusion (Katzung et al., 2012). This can be avoided by strict prescription and maintenance of low serum concentration of the drug. This toxicity is worse in renal impairment and in dehydration hence maintenance of adequate rehydration is key in digoxin therapy.

Furosemide 40mg PO twice daily

Furosemide is a diuretic, specifically a loop diuretic (Thomson et al., 2010).  It acts by inhibiting the sodium-potassium-chloride cotransporter in the kidney causing an increase in water and sodium excretion. This is the reason for its indication in the treatment of David’s fluid retention and fluid overload associated with his heart failure (Thomson et al., 2010). Nursing monitoring of therapy should include monitoring of fluid intake and urine output. Those with a drug allergy to furosemide should not be administered this drug as it could be rapidly fatal. Another important nursing action is patient education and monitoring for side effects of the drug which includes hearing loss, dizziness, fatigue, and bleeding (Katzung et al., 2012). This drug is contraindicated in those with liver disease or renal failure which the nurse should be aware of.

Ramipril 5mg PO twice daily.

Ramipril is an angiotensin-converting enzyme inhibitor with a role in heart failure and hypertension. It inhibits the conversion of angiotensin I to angiotensin II. Angiotensin II is a potent vasoconstrictor hence this drug essentially causes vasoconstriction, improving blood pressure and organ perfusion (Katzung et al., 2012). It is contraindicated in those with an allergy to it, liver disease and renal failure. Nursing responsibility includes monitoring of blood pressure to assess for therapeutic effect and to monitor for the side effects, of note being hypotension. Nursing education involves making the patient aware of side effects such as tachycardia, nausea, vomiting, diarrhea, dizziness and weakness and to vocalize any reactions.

Patient education

Physical activity guidelines

Physical inactivity and a sedentary lifestyle are among the major modifiable risk factors for cardiovascular disease (Piepoli et al., 2011). Following heart failure which presents with dyspnea and activity intolerance, it may appear that exercise is contraindicated in heart failure. On the contrary, guidelines released in 2016 by the European society of cardiology recommend exercise training as it reduces functional capacity and symptoms and is associated with reduced hospitalization due to heart failure (Piepoli et al., 2011). No universal modalities have been agreed on and the recommendation is the use of individualized plans with reference to the clinical situation and personal preference. It is also recommended to do so in a supervised program (Piepoli et al., 2011).

Fluid assessment

David education should be carried out in a friendly environment t to enhance understanding. A teach- back method should be used to enhance understanding (Tamura-Lis, 2013). In this method, David is taught these guidelines and asked to teach them back to the nurse. In effective understanding, most of the principles should emerge from the teach back. Since he has a history of non- adherence to recommendations after his initial myocardial infarction, this evaluation is important to prevent recurrence (White, Garbez, Carroll, Brinker, & Howie-Esquivel, 2013). Use of multiple media formats such as pamphlets and videos are recommended. Further evaluation can be done using cross-questions about physical activity guidelines.

ISBAR Handover

Introduction/ Identify

My name is —– a registered nurse handing over Mr. David Parker. He is a patient admitted through our cardiology clinic under DR.——.

Situation

He was received in the ward fairly unstable today with dyspnea at rest from the cardiology clinic with a diagnosis of chronic heart failure.

Background

He had been diagnosed a few months earlier with myocardial infarction under our care and discharged through a heart failure program. He is, however, reported to be non-compliant to the program and does not follow diet restriction as he refuses low-fat food prepared by his wife. He is still a smoker and drinks alcohol. His medication currently includes Digoxin 62.5mcg PO daily, Furosemide 40mg PO twice daily and Ramipril 5mg PO twice daily.

Assessment

He is dyspneic at rest with a cough and fatigue. His vitals were as follows: respiratory rate of 24 breaths per minute, blood pressure of 102/84, heart rate of 118, oxygen saturation of 92% and a temperature of 36.5⁰c.

Recommendation/plan

As requested by the Doctor, put the patient on 1000 ml fluid restriction. A recommended fluid chart should be started. He was prescribed Ramipril, furosemide and digoxin. Monitor this drug therapy and ensure compliance. There is a risk of further deterioration. Monitor vital signs as indicated. 

References

Ambrosy, A. P., Butler, J., Ahmed, A., Vaduganathan, M., Van Veldhuisen, D. J., Colucci, W. S., & Gheorghiade, M. (2014). The use of digoxin in patients with worsening chronic heart failure: reconsidering an old drug to reduce hospital admissions. Journal of the American College of Cardiology, 63(18), 1823-1832.

Brunner, L. S. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing (Vol. 1). Lippincott Williams & Wilkins.

Critchley, L. A., Lee, A., & Ho, A. M. H. (2010). A critical review of the ability of continuous cardiac output monitors to measure trends in cardiac output. Anesthesia & Analgesia, 111(5), 1180-1192.

Elliott, M., & Coventry, A. (2012). Critical care: the eight vital signs of patient monitoring. British Journal of Nursing, 21(10), 621-625.

Glynn, M., Drake, W. M., & Hutchison, R. (2012). Hutchison’s clinical methods: an integrated approach to clinical practice. Edinburgh: W.B. Saunders

Hands, C., Reid, E., Meredith, P., Smith, G. B., Prytherch, D. R., Schmidt, P. E., & Featherstone, P. I. (2013). Patterns in the recording of vital signs and early warning scores: compliance with a clinical escalation protocol. BMJ Qual Saf, 2013.

Katzung, B. G., Masters, S. B., & Trevor, A. J. (2012). Basic and Clinical Pharmacology (LANGE Basic Science). McGraw-Hill Education

Kim, E. B., Susan, M. B., Scott, B., & Heddwen, L. B. (2010). Ganong’s review of medical physiology.

Piepoli, M. F., Conraads, V., Corra, U., Dickstein, K., Francis, D. P., Jaarsma, T., … & Anker, S. D. (2011). Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation. European journal of heart failure, 13(4), 347-357.

Tamura-Lis, W. (2013). Teach-back for quality education and patient safety. Urologic Nursing, 33(6), 267.

Thomson, M. R., Nappi, J. M., Dunn, S. P., Hollis, I. B., Rodgers, J. E., & Van Bakel, A. B. (2010). Continuous versus intermittent infusion of furosemide in acute decompensated heart failure. Journal of cardiac failure, 16(3), 188-193.

White, M., Garbez, R., Carroll, M., Brinker, E., & Howie-Esquivel, J. (2013). Is “teach-back” associated with knowledge retention and hospital readmission in hospitalized heart failure patients?. Journal of Cardiovascular Nursing, 28(2), 137-146.