Case Study On A Patient With Heart Failure
16 hours ago Tagged: heart failure heart. Mr. SB, 60-year-old male is a retiree and was admitted to the hospital accompanied by his daughter. He is 100kg at a height of 180cm so his calculated body mass index (BMI) was 30.9 indicating that he was overweight. When admitted, patient was complained of shortness of breath for 2 weeks and was worsening on the ... >> Go To The Portal
What is an end of shift report in nursing?
An end of shift report is a detailed record of a patient’s current medical status. It’s written by nurses who are finishing up their shifts and are then given to nurses who are beginning their next shifts.
What are the nursing interventions for a patient with heart failure?
Nursing interventions for a patient with HF focuses on management of the patient’s activities and fluid intake. Promoting activity tolerance. A total of 30 minutes of physical activity every day should be encouraged, and the nurse and the physician should collaborate to develop a schedule that promotes pacing and prioritization of activities.
What does a nurse know about heart failure on assessment?
On assessment, the nurse knows that a patient who reports no symptoms of heart failure at rest but is symptomatic with increased physical activity would have a heart failure classification of: 5. The diagnosis of heart failure is usually confirmed by:
How many nursing care plans are there for patients with heart failure?
Here are 18 nursing care plans (NCP) and nursing diagnoses for patients with Heart Failure: NOTE: This nursing care plan is recently updated with new content and a change in formatting. Nursing assessment and nursing interventions are listed in bold and followed by their specific rationale in the following line.
How do you write the end of a shift report?
Tips for an Effective End-of-Shift ReportUse Concise and Specific Language. ... Record Everything. ... Conduct Bedside Reporting as Often as Possible. ... Reserve Time to Answer Questions. ... Review Orders. ... Prioritize Organization. ... The PACE Format. ... Head to Toe.
What should a nurse shift report include?
It should include the patient's medical history, current medication, allergies, pain levels and pain management plan, and discharge instructions. Providing these sorts of details about your patient in your end of shift report decreases the risk of an oncoming nurse putting the patient in danger.
How do you write a nursing patient report?
How to write a nursing progress noteGather subjective evidence. After you record the date, time and both you and your patient's name, begin your nursing progress note by requesting information from the patient. ... Record objective information. ... Record your assessment. ... Detail a care plan. ... Include your interventions.
What is the nursing assessment for heart failure?
The nursing assessment for the patient with HF focuses on observing for the effectiveness of therapy and for the patient's ability to understand and implement self-management strategies. Assess the signs and symptoms such as dyspnea, shortness of breath, fatigue, and edema.
How do you write a patient report?
III. Patient case presentationDescribe the case in a narrative form.Provide patient demographics (age, sex, height, weight, race, occupation).Avoid patient identifiers (date of birth, initials).Describe the patient's complaint.List the patient's present illness.List the patient's medical history.More items...•
What is the SBAR format?
The SBAR (Situation-Background-Assessment-Recommendation) technique provides a framework for communication between members of the health care team about a patient's condition.
What is the format for report writing?
Report writing is a formal style of writing elaborately on a topic. The tone of a report and report writing format is always formal. The important section to focus on is the target audience. For example – report writing about a school event, report writing about a business case, etc.
How do you document a heart assessment?
Documentation of a basic, normal heart exam should look something along the lines of the following: The external chest is normal in appearance without lifts, heaves, or thrills. PMI is not visible and is palpated in the 5th intercostal space at the midclavicular line. Heart rate and rhythm are normal.
How do you assess a patient with heart failure?
AdvertisementBlood tests. Blood tests are done to look for signs of diseases that can affect the heart.Chest X-ray. ... Electrocardiogram (ECG). ... Echocardiogram. ... Stress test. ... Cardiac computerized tomography (CT) scan. ... Magnetic resonance imaging (MRI). ... Coronary angiogram.More items...•
How can the nurse best describe heart failure?
Heart failure (HF) or Congestive Heart Failure (CHF) is a physiologic state in which the heart cannot pump enough blood to meet the body's metabolic needs following any structural or functional impairment of ventricular filling or ejection of blood.
How old is Martha from A&E?
Martha is a 60-year-old lady who is admitted to accident and emergency (A&E) with breathlessness – her respiratory rate is 40 per minute and her oxygen saturation is 89%. On admission, her pulse is 175 beats per minute (bpm) and irregular. Her blood pressure is 90/50 mmHg. Martha is put on high-flow oxygen, a continuous cardiac monitor, hourly observation of vital signs and an intravenous cannula is inserted. Martha is administered intravenous digoxin and furosemide in A&E and is catheterised to enable accurate fluid balance. Martha is married with three grown-up children and smokes 20 cigarettes a day. Martha is then transferred to a medical ward with a cardiac specialty.
Why is Martha unable to eat?
Martha is very distressed but knows where she is and why. She is unable to eat or drink at the moment due to her breathlessness. She is a life-long smoker. She lives with her husband in a third-floor flat with a lift. She still works part time as a cleaner for a local company.
Why is Martha at risk of fluid overload?
Due to her cardiac failure, Martha is at risk of fluid overloadTo ensure that Martha receives adequate fluids and nutritionTo prevent complications of dehydrationTo ensure that there is effective communication within the multidisciplinary team.
Is Martha on oxygen?
Martha is breathless and on oxygen therapy 35% via the mask. She has peripheral oedema and is fluid overloaded. Furosemide is being administered intravenously. She is on stage 2 (see Fig. 13.1) of the heart failure care plan but is not receiving glyceryl trinitrate (GTN) due to hypotension.
Can Martha smoke in hospital?
6. Problem: Martha is a life-long smoker and cannot smoke in hospital.
Who wrote the heart failure care plan?
The heart failure care plan (Fig. 13.1) has been written by a senior charge nurse for coronary care, Rafael Ripoll, and outlines care for the four stages of heart failure. The case history for Martha will then guide you through the assessment, nursing action and evaluation of a patient with heart failure.
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What are the goals of nursing care plan for patients with heart failure?
Nursing care plan goals for patients with heart failure includes support to improve heart pump function by various nursing interventions, prevention, and identification of complications, and providing a teaching plan for lifestyle modifications. Nursing interventions include promoting activity and reducing fatigue to relieve the symptoms of fluid overload.
What is Heart Failure?
Heart failure (HF) or Congestive Heart Failure (CHF) is a physiologic state in which the heart cannot pump enough blood to meet the body’s metabolic needs following any structural or functional impairment of ventricular filling or ejection of blood.
What is the drug of choice for patients with severe heart failure?
Loop diuretics [furosemide (Lasix), ethacrynic acid (Edecrin)] promote fluid loss even when GFR is low, in contrast with thiazides. Loop diuretics are the drug of choice for patients with severe heart failure (Felker, 2012). Other than hypokalemia, loop diuretics can also cause severe hypotension due to excessive fluid volume loss.
What is the mainstay of HF treatment?
Vasodilators are the mainstay of treatment in HF and are used to increase cardiac output, reducing circulating volume (venodilators) and decreasing SVR, thereby reducing ventricular workload. Note: Parenteral vasodilators (Nitroprusside) are reserved for patients with severe HF or those unable to take oral medications.
What is congestive heart failure?
Because heart failure causes vascular congestion, it is often called congestive heart failure, although most cardiac specialists no longer use it. Other terms used to denote heart failure include chronic heart failure, cardiac decompensation, cardiac insufficiency, and ventricular failure.
Why is my BP elevated with HF?
Monitor BP. In early, moderate, or chronic HF, BP may be elevated because of increased SVR. In advanced HF, the body may no longer be able to compensate, and profound hypotension may occur.
How many diagnoses are there in a nursing care plan?
This nursing care plan guide contains 18 nursing diagnoses and some priority aspects of clinical care for patients with heart failure. Learn about the nursing interventions and assessment cues for heart failure, including the goals, defining characteristics, and related factors for each nursing diagnosis.
What is Heart Failure?
Heart failure, also known as congestive heart failure, is recognized as a clinical syndrome characterized by signs and symptoms of fluid overload or of inadequate tissue perfusion.
How to prevent heart failure?
Prevention of heart failure mainly lies in lifestyle management. Healthy diet. Avoiding intake of fatty and salty foods greatly improves the cardiovascular health of an individual. Engaging in cardiovascular exercises thrice a week could keep the cardiovascular system up and running smoothly. Smoking cessation.
What is left sided heart failure?
Left-Sided Heart Failure. Left-sided heart failure or left ventricular failure have different manifestations with right-sided heart failure. Pulmonary congestion occurs when the left ventricle cannot effectively pump blood out of the ventricle into the aorta and the systemic circulation.
What happens when the right ventricle fails?
Right-Sided Heart Failure. When the right ventricle fails, congestion in the peripheral tissues and the viscera predominates. The right side of the heart cannot eject blood and cannot accommodate all the blood that normally returns to it from the venous circulation.
What causes HF in the heart?
Coronary artery disease. Atherosclerosis of the coronary arteries is the primary cause of HF, and coronary artery disease is found in more than 60% of the patients with HF. Ischemia. Ischemia deprives heart cells of oxygen and leads to acidosis from the accumulation of lactic acid. Cardiomyopathy.
What is the most common cause of hospitalization for people over 75?
B: Heart failure is the most frequent cause of hospitalization for people older than 75 years old. A: Angina pectoris also occurs among people more than 75 years of age but it is not the most frequent cause of hospitalization.
What is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients?
Heart failure is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients.
What is the cause of heart failure?
It results when there is a delay in ventricular filling and a reduction in the ejection of blood amount. The common cause of congestive heart failure is an impairment in myocardial function.
How to prevent readmission in hospital?
Early recognition of symptoms can prevent readmission of the patient in the hospital. The patient can consult a doctor or nurse through telephone.
What is a congestive heart failure?
Congestive Heart Failure or CHF is a severe circulatory congestion due to decreased myocardial contractility, which results in the heart’s inability to pump sufficient blood to meet the body’s needs. About 80% of CHF cases occur before 1 year of age.
What is the best medicine for heart failure?
Digoxin is the medication of choice to treat heart failure. Options A, C, and D: Diltiazem (calcium channel blocker) and propranolol and metoprolol (beta blockers) have a negative inotropic effect and would worsen the failing heart. Question 60.
What causes left ventricular failure?
Left ventricular failure occurs when the left ventricle in unable to pump blood into systemic circulation. Pressure increases in the left atrium and pulmonary veins; then the lungs become congested with blood, causing elevated pulmonary pressure and pulmonary edema.
What happens when cardiac muscle hypertrophies cause decreased ventricular compliance?
Increased muscle mass impedes oxygenation of the heart muscle, which leads to decreased contraction force and heart failure.
Why is heart failure most commonly associated with cardiomyopathy?
Because the structure and function of the heart muscle is affected, heart failure most commonly occurs in clients with cardiomyopathy. Option C: MI results from prolonged myocardial ischemia due to reduced blood flow through one of the coronary arteries.
What causes a high cardiac output?
High cardiac output demands occur when the body’s need for oxygen exceeds the heart’s output s seen in sepsis and hyperthyroidism.
What is HF in the heart?
Question 66 Explanation: HF is a result of structural and functional abnormalities of the heart tissue muscle. The heart muscle becomes weak and does not adequately pump the blood out of the chambers. As a result, blood pools in the left ventricle and backs up into the left atrium, and eventually into the lungs.
What is end of shift report?
An end-of-shift report allows nurses to understand where their patients stand in regard to recovery by providing a picture of a patient’s improvement or decline over the last several hours.
Why is it important to have a detailed end of shift report?
Because understanding the personal needs of individual patients is a vital part of providing proper care, it’s important that each nurse is provided with a detailed end-of-shift report at the beginning of each new shift.
What is bedside reporting?
Reviewing the end-of-shift report directly with the patient, his or her accompanying family members and the incoming nurse is often referred to by medical staff as bedside reporting. When possible, bedside reporting is typically the first thing done as a nurse arrives for a shift. This conversation provides the opportunity for all parties to ask any questions they may have before getting to work, and it also allows the patient to be actively involved in his or her own care.
What to keep in mind when making an end of shift report?
When making an end-of-shift report, there are several key things nurses must keep in mind aside from just including a patient’s necessary medical information. The following are ways you can create more thorough and adequate end-of-shift reports for your relieving nurses.
What does "Pace" mean in a report?
PACE is an acronym standing for Patient, Actions, Changes and Evaluation, all of which serve as sections in the report.
Do ICU nurses have to give special orders?
To ensure a patient receives the proper care, nurses should include special orders on each end-of-shift report and take time to review them directly with the incoming nurse.
Do nurses have to report before each shift?
Even when bedside reporting is not done before each shift, many nurses have questions regarding the end-of-shift report. It’s important to optimize the time the next nurse and the patient spend together to ensure their questions get answered and that all details of the end-of-shift report are clarified. When it comes to taking the next steps in caring for a patient, nurses are more likely to be effective when they’ve had all of their concerns addressed.
When is the end of shift report for nursing?
Making an Effective and Professional Nursing End-of-Shift Report. July 22, 2021. December 19, 2019. Creating a proper end-of-shift report is a crucial part of ensuring patient safety and a smooth transition from the outgoing shift of nurses to the incoming one. While it’s definitely enticing to zip out of work as quickly as possible ...
What to do when admitted for heart failure?
If a patient is admitted for heart failure, keep a note of their breathing and put that in your report, especially if there are any inexplicable changes. Address Medication. In your report, make sure to indicate what medications the patient is receiving, how much of it, and how it is introduced. Be clear and specific and don’t forget to include ...
What to write in a pain report?
Don’t forget to write down the time of the last dose to avoid giving the patient too much analgesic.
When to notify a nurse of a patient's health history?
Once you’ve addressed the patient’s health history, it’s a good time to notify the oncoming nurse of any recent abnormalities you’ve noticed in the patient during your shift. For example, any wounds or lesions should be indicated, especially what type of dressing is being used and when that dressing was last changed.
What are social issues in nursing?
These kinds of issues could be homelessness, transportation issues, lack of home support, or a history of drug abuse.
What should you focus on in a patient history?
Instead of starting immediately with a patient’s history, you should focus on important information that will influence everything that happens next. You should address any allergies present, the code status of the patient, and identify other members of the patient’s medical team, if applicable.
What is the end of shift report for oncoming nurses?
An end of shift report is a detailed record of a patient’s current medical status. It’s written by nurses who are finishing up their shifts and are then given to nurses who are beginning their next shifts. It should include the patient’s medical history, current medication, allergies, pain levels and pain management plan, and discharge instructions. Providing these sorts of details about your patient in your end of shift report decreases the risk of an oncoming nurse putting the patient in danger.
What should be included in an end of shift report?
It should include the patient’s medical history, current medication, allergies, pain levels and pain management plan, and discharge instructions. Providing these sorts of details about your patient in your end of shift report decreases the risk of an oncoming nurse putting the patient in danger.
What if you are the oncoming nurse?
If you are the oncoming nurse, the best way to receive a report is to be punctual and focused. If you are late, it shortens the window of time that the departing nurse can report on patients.
Why is it important to hand off patients?
Engaging with a patient and their families during a handoff with an oncoming nurse ensures a safe and effective transfer between shifts. It also gives nurses more time with the patients to answer questions and take care of any needs they may have.
Why don't you give every detail on a patient?
There are some areas you don’t need to give every detail on because they are either not relevant to the admitting diagnosis or something the oncoming nurse can easily look up . Using too much time on one patient will reduce the amount of time you have to give a report on the next patient.
How long does a nurse brain report take?
The amount of time you have for each patient's report depends on where you work and the nurse to patient ratio, but it's usually around 5 minutes per patient. Your Nurse's Brain can function as a nursing handoff report template. If you have kept track of this information using your Nurse’s Brain, it’s easy to quickly transfer ...
Why is handoff important in nursing?
Giving a focused, efficient report is an important communication skill in nursing. Others will respect the care and organization you put in--which can improve your nursing relationships with coworkers. Giving a good report builds trust, ensures continuity of care, and improves patient safety.
May Be Related to
May Be Evidenced by
- The common data cues that could serve as defining characteristics or part of your “as evidenced by” in your diagnostic statement. 1. Increased heart rate (tachycardia), dysrhythmias, ECG changes 2. Changes in BP (hypotension/hypertension) 3. Extra heart sounds (S3, S4) 4. Decreased urineoutput (oliguria) 5. Diminished peripheral pulses 6. Cool, ash...
Desired Goals and Outcomes
- Common goals and expected outcomes: 1. Patient will demonstrate adequate cardiac output as evidenced by vital signs within acceptable limits, dysrhythmias absent/controlled, and no symptoms of failure (e.g., hemodynamic parameters within acceptable limits, urinary output adequate). 2. Patient will report decreased episodes of dyspnea, angina. 3. Patient will participat…
Nursing Assessment and Rationales
- The following is a nursing assessment guide for heart failure nursing care plans. 1. Auscultate apical pulse, assess heart rate. Tachycardia is an early sign of heart failure. An increase in heart rate is the body’s first response to compensate for reduced cardiac output (CO). Initially, this compensatory response has a favorable effect on cardiac output, but over time, persistent tachy…
Nursing Interventions and Rationales
- Here are the nursing interventions for this heart failure nursing care plan. 1. Give oxygen as indicated by the patient’s symptoms, oxygen saturation, and ABGs. Supplemental oxygen increases oxygen availability to the myocardium and can help relieve symptoms of hypoxemia, ischemia, and subsequent activity intolerance(Giordano, 2005; Haque et al., 1996). The need is b…
What Is Heart Failure?
Pathophysiology
- Heart failure results from a variety of cardiovascular conditions, including chronic hypertension, coronary artery disease, and valvular disease. 1. As HF develops, the body activates neurohormonal compensatory mechanisms. 2. Systolic HFresults in decreased blood volume being ejected from the ventricle. 3. The sympathetic nervous system is then stimulated to releas…
Statistics
- Just like coronary artery disease, the incidence of HF increases with age. 1. More than 5 million people in the United States have HF. 2. There are 550, 000 casesof HF diagnosed each year according to the American Heart Association. 3. HF is most common among people older than 75 years of age. 4. HF is now considered epidemicin the United States. 5. HF is the most common r…
Incidences
- Heart failure can affect both women and men, although the mortality is higher among women. 1. There are also racial differences; at all ages death rates are higher in African American than in non-Hispanic whites. 2. Heart failure is primarily a disease of older adults, affecting 6% to 10% of those older than 65. 3. It is also the leading cause of hospitalization in older people.
Causes
- Systemic diseases are usually one of the most common causes of heart failure. 1. Coronary artery disease. Atherosclerosis of the coronary arteries is the primary cause of HF, and coronary artery disease is found in more than 60% of the patients with HF. 2. Ischemia. Ischemia deprives heart cells of oxygen and leads to acidosisfrom the accumulation ...
Clinical Manifestations
- The clinical manifestations produced y the different types of HF are similar and therefore do not assist in differentiating the types of HF. The signs and symptoms can be related to the ventricle affected.
Prevention
- Prevention of heart failure mainly lies in lifestyle management. 1. Healthy diet.Avoiding intake of fatty and salty foods greatly improves the cardiovascular health of an individual. 2. Engaging in cardiovascular exercises thrice a week could keep the cardiovascular systemup and running smoothly. 3. Smoking cessation. Nicotine causes vasoconstrictionthat increases the pressure al…
Complications
- Many potential problems associated with HF therapy relate to the use of diuretics. 1. Hypokalemia. Excessive and repeated dieresis can lead to hypokalemia. 2. Hyperkalemia. Hyperkalemia may occur with the use of ACE inhibitors, ARBs, or spironolactone. 3. Prolonged diuretic therapy might lead to hyponatremia and result in disorientation, fatigue, apprehension, w…
Assessment and Diagnostic Findings
- HF may go undetected until the patient presents with signs and symptoms of pulmonary and peripheral edema. 1. ECG:Ventricular or atrial hypertrophy, axis deviation, ischemia, and damage patterns may be present. Dysrhythmias, e.g., tachycardia, atrial fibrillation, conduction delays, especially left bundle branch block, frequent premature ventricular contractions (PVCs) may be …
Medical Management
- The overall goals of management of HF are to relieve patient symptoms, to improve functional status and quality of life, and to extend survival.
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