1

NURSING CARE PLAN

Student Name: Kimberly Bundley Patient Initials: AS

Date submitted: September 29, 2011

Age/Sex: 86 Y Medical Diagnosis: CHF ANEMIA

Complete using your nursing textbooks. Underline the cause etiology and clinical manifestations that relate to your client. I. Etiology and Pathophysiology:

Heart failure develops when the heart doesn't function properly. The names "heart failure" and "congestive heart failure (CHF)" doesn't mean that the heart has actually "failed" or stopped but mean one or more chambers of the heart "fail" to keep up with the volume of blood flowing through them. Heart failure can be brought on by a variety of underlying diseases and health problems. (Black, 1974/2001). Heart failure may involve the left side, the right side or both sides of the heart. Each side has two chambers an atrium (upper chamber) and a ventricle (lower chamber). Heart failure occurs when any one of these four chambers is no longer able to keep up with the volume of blood flowing through it. Two types of heart dysfunction can lead to heart failure, including:

Systolic Heart Failure this is the most common cause of heart failure and occurs when the heart is weak and enlarged. The muscle of the left ventricle loses some of its ability to contract or shorten. In turn, it may not have the muscle power to pump the amount of oxygenated and nutrient-filled blood the body needs. Diastolic Failure the muscle becomes stiff and loses some of its ability to relax. As a result, the affected chamber has trouble filling with blood during the rest period that occurs between each heartbeat. Often the walls of the heart thicken, and the size of the left chamber may be normal or reduced.

The left side of the heart is crucial for normal heart function and is usually where heart failure begins. The left atrium receives oxygen-rich blood from the lungs and pumps it into the left ventricle, the heart's largest and strongest pump, which is responsible for supplying blood to the body. After it has circulated through the body, blood returns to the right atrium and then travels to the right ventricle, which pumps it into the lungs to be replenished with oxygen. When the right side loses pumping power, blood can back up in the veins attempting to return blood to the heart.

Right heart failure may occur alone but is usually a result of left-sided failure. When the left ventricle fails, fluid backs up in the lungs. In turn, pressure from excess fluid can damage the heart's right side as it works to pump blood into the lungs. Heart failure usually is a chronic, or long-term, condition that gradually gets worse. By the time most people notice and see a doctor about their symptoms, the heart has been "failing," little by little, for a long time. This is a good reason to have regular health checkups. During a routine physical examination, your doctor may detect signs of heart failure long before you experience symptoms. Heart failure rarely occurs suddenly except after a major heart attack, severe heart valve problem or period of seriously high blood pressure (Black, 1974/2001). II. Clinical Manifestations (Signs & Symptoms):

Breathlessness or Shortness of Breath (Dyspnea) when the heart begins to fail, blood backs up in the veins attempting to carry oxygenated blood from the lungs to the heart. As fluid pools in the lungs, it interferes with normal breathing. In turn, you may experience breathlessness during exercise or other activities. As the condition worsens, shortness of breath may occur when at rest or asleep. These periods of breathlessness may leave you feeling exhausted and anxious. Fatigue as heart failure becomes more severe, the heart is unable to pump the amount of blood required to meet all of the body's needs. To compensate, blood is diverted away from less-crucial areas, including the arms and legs, to supply the heart and brain. As a result, people with heart failure often feel weak (especially in their arms and legs), tired and have difficulty performing ordinary activities such as walking, climbing stairs or carrying groceries. Chronic Cough or Wheezing the fluid buildup in the lungs may result in a persistent cough or wheezing, that may produce phlegm (a thick, mucous-like substance) that may be tinged with blood. Rapid or Irregular Heartbeat the heart may speed up to compensate for its failing ability to adequately pump blood throughout the body. Patients may feel a fluttering in the heart (palpitations) or a heartbeat that seems irregular or out of rhythm. This often is described as a pounding or racing sensation in the chest. Lack of Appetite or Nausea when the liver and digestive system become congested them fails to receive a normal supply of blood. This can make you feel nauseous or full, even if you haven't eaten. Mental Confusion or Impaired Thinking Abnormal levels of certain substances, such as sodium, in the blood and reduced blood flow to the brain can cause memory loss or disorientation, which you may or may not be aware of. Fluid Buildup and Swelling because blood flow to the kidneys is restricted, the kidneys produce hormones that lead to salt and water retention. This causes swelling, also called edema, which occurs most often in the feet, ankles and legs. Rapid Weight Gain the fluid build-up throughout the body, may cause you to gain weight quickly.

These symptoms occur as the heart loses strength and the ability to pumped blood throughout the body. In turn, blood can back up and cause "congestion" in other body tissues, which is why heart failure sometimes is called "congestive." In addition, excess fluid may pool in the failing portion of the heart and the lungs. At the same time, the heart as well as other parts of the body attempt to adapt and make up for the deteriorating pumping ability. For example:

Heart Grows Larger the muscle mass of the heart grows in an attempt to increase its pumping power, which works for a while. The heart chambers also enlarge and stretch so they can hold a larger volume of blood. As the heart expands, the cells controlling its contractions also grow (Ignatavicius, Workman). Heart Pumps Faster in an attempt to circulate more blood throughout the body, the heart speeds up (Ignatavicius, Workman). Blood Vessels Narrow as less blood flows through the arteries and veins, blood pressure can drop to dangerously low levels. To compensate, the blood vessels become narrower, which keeps blood pressure higher, even as the heart loses power (Ignatavicius, Workman 2010). Blood Flow Is Diverted When the blood supply is no longer able to meet all of the body's needs, it is diverted away from less-crucial areas, such as the arms and legs, and given to the organs that are most important for survival, including the heart and brain. In turn, physical activity becomes more difficult as heart failure progresses (Ignatavicius, Workman 2010).

III. Treatment and Nursing Management:

Monitor me&O q 4 hr (more or less frequently depending on the clients status). Clients weight daily. Assess for presence of peripheral edema. Assess jugular vein distention, hepatomegaly, and abdominal pain. Assess vital signs and mental status. Auscultation for abnormal heart and breath sounds. Administer diuretic therapy as ordered and evaluate effectiveness of the therapy.

IV:

Diagnostic Studies/Lab analysis: Clients Results Yellow Cloudy 1.014 Normal Negative Normal Results Clear, yellow Clear 1.001-1.035 Negative Negative Reason Kidney Function

Test Urinalysis Color Clarity Spec Gravity Glucose Bili

Ketone Blood pH Protein WBC RBC Bacteria Hematology WBC RBC Hgb Hct PLT General Chemistry Sodium Potassium Chloride CO2 AGAP Creatinine Glucose

Negative Small 5.5 30 >182 24 Many

Negative Negative 4.6-8.0 Negative Negative </=5 None

5.7 3.64 6.1 22.0 256

3.8 - 10.8 3.9 - 5.2 Female: 12 - 15.6 Female: 35 - 46% 150,000 - 450,000

Monitor Blood Levels and Infection Check digoxin therapeutic levels

126 3.4 85 33 8 1.32 84

137-145 mEq/L 3.6-5.0 mEq/L 98 108 mmol/L. 23-29 mEq/L 8 to 16 mEq/L 0.8 to 1.4 mg/dL. 70 to 99 mg/dL

Monitor Fluid and Electrolytes. Side effects of digoxin.

Therapeutic Drug Monitoring Digoxin

<0.1

For CHF

Diagnostic test: Chest X-rayDepicts enlarged cardiac silhouette, pulmonary edema venous congestion and interstitial edema **If your clients values are outside the normal range, identify possible reasons. Discharge Planning and Client Teaching

NURSING CARE PLAN Growth and Development According to Erickson

Stage: Psychosocial Stage 8 - Integrity vs. Despair

Eriksons last stage (8) involves much reflection. As older adults, some can look back with a feeling of integrity, which would give a sense of contentment and fulfillment because of the meaningful life led and the valuable contributions to society. Others may have a sense of despair; reflecting upon their experiences and failures (Edelman & Mandle, 2006). AS is an 86 y/o divorced female who lives with her children. AS express concerns that she is no longer able to do things independently. She denies tobacco abuse. She has one daughter; and often reflects on how her husband was the only man that has, or will, ever see her naked! She spoke often of her vested interested in roller skating and roller derby in earlier days. The patient displays an abundant amount of integrity, appearing to be very proud of her at this place in time. She can perform some ADLs independently, and ecstatically boasts of not wanting to depend on anyone. However, in our conversing, I learned that her daughter and other family members do a lot for the patient. The daughter takes her to her doctors appointments, to the grocery store, and, too, is directly involved with any outings that AS arranges. I would say this is the despair part for the patient. She knows that because of her age, and physical condition, she cannot do it all; she needs just a little bit of help at times. It seems to sadden her just to know that she does need help and she cant do everything by herself. Nonetheless, her despair, does not at all, take away from his integrity. Powerlessness can be experienced by people suffering from a chronic debilitating illness, as well as by attempting health promotion thus correctly identifying the

actual and perceived problem essential to providing appropriate support measures. Underlying

disease process limits her to do daily ADLs and her current admission status has delayed her ability to reason with her health. List nursing actions to assist your client in meeting their growth and developmental. 1. Encourage the client to discuss their feelings about the current health status. 2. Suggest to the client and family to consider joining different types of senior groups. 3. Suggest to the client and family to engage in some type of exercise regime that's age and health related to health status. 4. Discuss the benefits of their complying with current medication regime.

IV:

List in priority order all relevant nursing diagnoses for your patient.

1. Fluid volume excess R/T: compromised regulatory mechanism secondary to congestive heart failure AEB crackles in bases bilaterally, peripheral edema 3+ bilaterally, oliguria, 3 lb. weight gain in 2 days. 2. Decreased Cardiac output R/T Heart Failure AEB Altered electrical conduction. 3. Impaired gas exchange R/T fluid present in the lungs air present in the pleural space, decreased functional lung tissue AEB crackles all over the lung field and chest X-Ray 4. Risk of activity intolerance R/T fluid in lungs AEB SOB on exertion. 5. Risk for anxiety R/T decreased cardiac output AEB client being restless, increase in heart rate and respiration rate.