Introduction:
A 42-year-old indigenous Australian male, named Reggie, residing near Blackall in Central Queensland, married with three children and the sole worker of his family, came with acute decompensation of heart failure. In this essay, we report a case of an adult man categorising it into two priority problems, for which we will discuss further interventions. The problems discussed in detail will be Pulmonary Edema and Venous Thromboembolism. Pulmonary edema will be managed by administration of Furosemide and Intra-aortic balloon pumping. Interventions in Venous Thromboembolism will be anti-coagulant therapy and the use of graduated compression stockings. In treating this critical case, the nurse has a significant role in monitoring and clinical reasoning to ensure improvement in Reggie’s health. The aforementioned interventions will help reduce edema of the alveoli, increasing cardiac output by reducing blood pressure, resolving stasis and promoting blood flow in the legs, which will lead to the healing of edema in the legs, which will cause a general improvement in the condition of the patient that threatens his life.
Body:
The patient presented with pain on inspiration. When examined, he had a high systolic blood pressure of 184, increased respiratory rate of 28 breaths per minute and coarse crackling sound on auscultation. Pulmonary Edema is a condition in which there is an accumulation of fluid in the parenchyma and the alveoli of the lungs. “It is due to either failure of the left ventricle of the heart to remove blood adequately from the pulmonary circulation, or an injury to the lung parenchyma or vasculature of the lung” (Arrigo, Parissis, Akiyama & Mebazaa, 2016; Thompson, Chambers & Liu, 2017). Hence, in this case, it would be known as Cardiogenic Pulmonary Edema, because Reggie is a patient of Acute Decompensated Heart Failure which is the rapid deterioration of earlier heart failure. The pathophysiology is best understood by the neuro-humoral pathway. “In the presence of cardiac dysfunction, several neuro-humoral pathways, including the sympathetic nervous system, the renin-angiotensin-aldosterone system and the arginine-vasopressin system, are activated to counter the negative effects of HF on oxygen delivery to the peripheral tissues. Neuro-humoral activation in HF leads to impaired regulation of sodium excretion through the kidneys which result in sodium and, secondarily, fluid accumulation” (Njist et al., 2015; Arrigo et al., 2016).
It is essential in Pulmonary Edema for the nurse to diagnose and start the treatment as early as possible in order to avoid any grave results. The most important intervention here is the administration of a diuretic, preferably loop diuretic, Furosemide. This is a Dependant (physician initiated) intervention. Responsibilities that a nurse has in the whole administration process of this drug are to “Monitor the urine output as well as other vital signs. Watch for a drop in blood pressure. If your patient is on a cardiac monitor, watch for any arrhythmias that could be caused by a shift in electrolytes. Monitor labwork: watch for changes in the BUN and Creatinine and also potassium and other electrolytes” (Wilson, 2017). It is important to listen to the heart and lung sounds since the patient has heart failure. In case multiple doses are being administered, the nurse should be careful to note any signs of dehydration and stop or decrease the drug immediately. It is also necessary for the nurse to make sure that a bathroom is nearby for the patient to go to whenever needed. If a urinary catheter is placed, he/she should make sure that does not leak or become kinked and also clean around the area in order to prevent any infection (Wilson, 2017). Furosemide helps relieve edema by increasing the output of urine. “Furosemide, sold under the brand name Lasix among others, is a medication used to treat fluid build-up due to heart failure, liver scarring, or kidney disease” (Still, Davis, Chilipko, Jenkosol & Norwood, 2013). Therefore, Furosemide will alleviate edema in the alveoli by acting on the kidney and increasing the output of urine, causing recovery and prevention of the pulmonary edematous condition that was causing Reggie to have coarse crackles, high systolic pressure and pain on inspiration. “Furosemide reduces preload by diuresis in 20-60 minutes” (Sovari, 2017).
The advantages of this intervention include reduction of edema, and drop in high blood pressure, which would further prevent strokes, heart attacks and kidney problems. (WebMD) The disadvantages of this drug intervention comprise of dizziness, headache, vision problems, dehydration, muscle cramps, itching/rash, stomach pain, diarrhea, constipation, jaundice, and clay coloured stools. There are several adverse effects of the drug that are caused by its interaction with other drugs such as Sucralfate, Cyclosporine, various antibiotics, cardiac and hypertension medications, laxatives, salicylates, etc (Lasix Oral, n.d.). A lactating mother should avoid it as it has the ability to pass into breast milk. It is also reported to delay the production of breast milk (Cunha, 2018).
Intra-aortic balloon pumping (IABP) is aggressive form care in cardiogenic shock patients. “Regardless of the cause, when the cardiogenic shock is recognised in the early stages, the IABP may decrease the high mortality rate significantly” (Cunha, 2018). It is a collaborative intervention. “An intra-aortic balloon pump is a short-term catheter solution to help the heart pump blood. IABPs are used to increase blood flow through the coronary arteries and reduce the heart’s workload by decreasing the afterload” (Intra-Aortic Balloon Pump, n.d.). The patient’s femoral artery is where the IABP, which is a pumping chamber, is inserted from. It is then passed into the abdominal aorta ultimately reaching the descending thoracic aorta. At the start of diastole, the balloon inflates, while the aortic valve closes, to expand the coronary artery. As the aortic valve opens again, deflation occurs. Therefore, the workload of the left ventricle is consequently decreased as there is a reduction in the intra-aortic fluid volume. It is important to note that the balloon should inflate at the accurate time in the cycle. The nurse must have all the facts and information about the intervention so as to direct patients to the normal cardiac status. The patients should be given a thorough neurologic examination, to make sure they are aware of their orientation. It is the nurse’s responsibility to help the patient comprehend every aspect of his treatment. Inappropriate conversations should be made away from the patient where he is not able to hear them. The nurse should keep the incisions clean and dry. To aid the patient in turning, coughing and deep-breathing is imperative to prevent any complications. To avoid the risk of thrombus formation, all the pulses must be taken at every hour, along with the temperature. This intervention is suitable for the patient because it can increase the oxygen perfusion of the myocardial tissue and cardiac output by 40%. This intervention will assist in the reduction of pulmonary edema that is caused by the inability of the heart to pump blood, backing up of blood and increase in blood pressure. “IABP is the most frequently used and has saved countless patients with advanced heart disease over the past 50 years” (Jiang et al., 2017).
Intra-aortic balloon pumping is imperative to assist cardiac function in heart failure patients. It is also used as a temporary procedure for anyone waiting for a transplant. “Various studies have shown that as many as a quarter of patients may encounter bleeding at the IABP’s access site” (Senecal, 2015). A Ruptured aorta is a very serious complication of the procedure. There could be an occlusion of the femoral artery (where the catheter is inserted) causing blockage of blood flow to other parts of the body. Hematomas could form under the groin skin. There is also kidney failure reported as a complication of this procedure from a few patients (Senecal, 2015). “Major vascular complications, including limb and mesenteric ischemia as well as bleeding and hemorrhage, have been associated with IABP” (de Jong et al., 2017).
Types of evaluation data comprise of Primary sources, and Secondary sources. The edema in the patient’s lungs was greatly reduced. An absence of coarse crackles on auscultation was noticed. Breath sounds were normal. He stopped experiencing any pain on inspiration.
The patient presented with fatigue and weight gain. When examined, bilateral pitting edema of both legs was seen. Venous Thromboembolism (VTE) consists of Deep Vein Thrombosis and Pulmonary Embolism (Yu-Fen et al., 2018). It is the formation of a blood clot deep in the legs (DVT) which travels and embeds in the lungs, forming pulmonary embolism (Uhlig et al., 2016). The three conditions inclining towards VTE are Hypercoagulability, Stasis and Endothelial damage (Lasix Oral, n.d.). In this case, it occurs due to stasis of blood which is a factor of heart failure.
The major intervention in a patient with the risk of VTE is the management with Heparin and Warfarin as VTE Prophylaxis. These are anticoagulant agents. It is an independent nursing intervention. “Anticoagulant therapy prevents further clot deposition and allows the patient’s natural fibrinolytic mechanisms to lyse the existing clot” (De Palo, 2019). Moderate-risk patients (40-60 years) are ought to be given Heparin, preferably low-dose unfractionated heparin or low molecular-weight heparin (De Palo, 2019). A nurse should have a comprehensive knowledge of the condition to be able to perform efficiently in its prevention. “Lack of knowledge about VTE is an important barrier to effective nursing performance” (Yu-Fen et al., 2018).
As important is the administration of the drugs is, monitoring of the patient holds equal importance. It is essential to monitor a patient that is being given heparin prophylaxis to look for any signs of VTE in addition to bleeding and thrombocytopenia which are the side effects of the drug. Signs include pain, tenderness, edema and discolouration of the lower limbs (Senecal, 2015). This intervention is appropriate for the patient because since he shows signs of edema in his legs, this drug will help resolve the stasis causing the blood flow to move in its proper direction, which would lead to the reduction of the edema, diminishing any risk of DVT or PE.
Heparin has a short half-life allowing easy dose adjustments and an immediate effect. Moreover, it is a natural agent. It causes magnificent effects on the clotting cascade. Warfarin has a longer half-life and exceptional bioavailability, as it works for a longer period of time (Brown, Wilkerson & Love, 2015). Bleeding (thrombocytopenia), Bruising or bluish discolouration of the skin and mild itching of the feet can be seen as side effects (Unfried, 2017).
Graduated compression stockings are special stockings that endorse blood flow in legs. It is an Independent intervention. “It also demonstrated that GCS probably reduce the risk of developing DVT in the thighs (proximal DVT, moderate-quality evidence) and PE (low-quality evidence)” (Sachdeva, Dalton & Lees, 2018). They work by compression therapy to decrease venous pressure and prevent venous disorders like edema, phlebitis, and thrombosis. “By squeezing the leg tissues and walls of the veins, compression stockings can help blood in the veins return to the heart. They can also improve the flow of the fluid (called lymph) that bathes the cells in the legs” (Barone, 2016). The nurse’s responsibilities in this intervention are to assess the size of the stockings properly with a measuring tape, to educate the patient about the pros and cons of it. The nurse should also remember to remove the stockings and examine the patient’s skin after every 12 hours (Wade, Paton & Woolacott, 2017). “Graduated compression stockings exert the greatest degree of compression at the ankle, and the level of compression gradually decreases up the garment” (Lim & Davies, 2014). It is appropriate for the patient because it works by decreasing the diameter of distended veins and increasing the velocity of venous blood flow and maintaining valve efficacy. This intervention will resolve the oedematous condition of the legs of the patient while preventing VTE.
Their advantages include the fact that they are a conservative method of treating venous disorders. They decrease pain and discomfort associated with the underlying venous disorder. They also aid in the reduction of bruising and clot formation (Webb, Walter, Overby, Hall & Griffin, 2019). They may cause skin irritation if they are worn for long periods of time (Nall, 2018).
Conclusion
After these interventions, the patient was active, and the previously noted exhaustion was gone. Bilateral pitting edema of legs was managed, and the swelling was diminished to a great degree. The patient also lost significant weight.
Since the
patient was in a serious condition of acute decompensated heart failure
presenting with symptoms that directed towards the risk of pulmonary edema and
venous thromboembolism, it
was imperative to use interventions whose benefits outweigh the risks. They included:
administration of Furosemide, insertion of Intra-aortic balloon pump,
administration of Heparin and Warfarin, and provision of graduated compression
stockings (Still et al., 2013). These interventions aided in the
reduction of edema from the alveoli, increasing the cardiac output by reduction
of blood pressure, resolution of stasis, and promotion of blood flow in the
legs leading to the cure of edema in legs, causing an overall improvement in
the patient’s life-threatening condition
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