Nursing Care of a Person with Altered Cardiovascular Function - Case Study Example

Nursing Care: Altered Cardiovascular Function Student’s Names Institutional Affiliation Nursing Care: Altered cardiovascular dysfunction Clinical Presentation Sylvie has a cardiovascular disorder that is linked to her Down ’s syndrome. The syndrome is associated with various cardiovascular anomalies including congenital heart anomalies such as septal defects, mitral valves anomalies and patent ductus arteriosus (Visootsak et al., 2011). From the shift handover report the patient is experiencing respiratory distress manifesting as dyspnoea, intercostal recession and nasal flaring (Leaver & Evans, 2007).. Expected findings on initial assessment include signs of discomfort and anxiety regarding the deterioration of her condition due to increasing difficulties in breathing and inability to perform some of her activities of daily living (Leaver & Evans, 2007). Her mucous membrane may appear blue due to the initial insufficient tissue oxygenation or hypoxia caused by a probable systematic-to-pulmonary shunt or a reversal of the shunt after surgery, a defect common in Down’s syndrome that allows the mixing of oxygenated and deoxygenated blood impairing oxygen delivery to the periphery (Chen, 2014).. The patient may also prefer sitting in a tripod position in an attempt to maximize the capacity of her lungs. In this position, the patient sits in a forward manner with her arms extended. It is a position assumed by most patients in respiratory distress to enhance the movement of air into the lungs by optimizing respiration through the use of accessory muscles of respiration (Bhatt et al., 2009). Swellings of the lower limbs is also another expected finding. The swelling is attributable to fluid accumulation in the extremities occasioned by an insufficient venous return leading to pooling of blood in the extremity (Simon, 2014). A scar is expected on her chest as a result of the previous heart surgery she has undergone. Nursing Priorities The three nursing priorities to be considered when attending to Sylvie would be to ensure that her airways patency is maintained and prevent further deterioration, ascertain that her breathing is not impaired and strategize to improve her breathing, and ensure that parameters relating to her circulation are maintained within normal limits. The prioritization follows the ABC rule where after anticipation of the patient’s problems, life-saving assessment and management measures on the airways are effected first before attending to life-threatening breathing and circulation problems (Lake, Moss & Duke, 2009; Thim, Krarup, Grove, Rohde & Lofgren, 2012). The assessment and management follows this system because the patient’s handover report shows she is still experiencing signs of respiratory distress and has findings of hypercapnea meaning that removal of carbondioxide is still inadequate. The inadequacy can be linked to a partially blocked airway, impaired ventilation or hypoperfusion due to impaired circulation (Thim et al., 2012). If it is ascertained that the airways are patent, the sufficiency of her breathing shall be confirmed and if there are no limitations in her breathing her circulation shall be assessed for any abnormalities. Nursing Management: Cardiac Function Assessment. Cardiac function assessment aids in identifying the cardiac status of the patient and inform any management measures that may be undertaken to restore normality in cardiac function. In addition, the monitoring of the patient’s cardiac status is aided by findings from the cardiac assessment. To assess Sylvie’s cardiac function, various assessment can be done. Vital signs assessment such as respiration and pulse rate, and blood pressure are appropriate indicators of cardiac function (Talley & O’Connor, 2014). Palpation is also one of the assessment technique that allows evaluation of various parameters such as normal and altered pounding and pulsation related to the heart’s beat (Talley & O’Conner, 2014). Capillary refill time is also u useful indicator of perfusion in the extremities that can be affected by cardiac function (Lewin & Maconochie, 2008). An increase in this time after repeated assessments may be indicative of impaired peripheral perfusion that could be related to a diminishing cardiac output requiring urgent attention (Lewin & Maconochie, 2008). Assessment and monitoring of jugular venous pressure shall be done to aid in the identification of any heart related abnormalities such as tricuspid stenosis or right heart failure in addition to recognising any hypovolemic states (Meyer, 2009). Since oedema can be a consequent of altered cardiac function, the patient's extremities shall be assessed and monitored to ascertain improvement in her oedematous state. Pitting oedema shall be determined using the bony part of the thumb, and its severity noted on a five-point scale (Simon, 2014). Changes in the severity shall aid in monitoring changes in cardiac function. Arteries shall also be palpated to assess pulses. The apical heart rate shall be palpated routinely for a full minute noting the regularity, rhythm and rate of the pulse. The radial pulse shall also be assessed in the same way noting any palpable difference between the left and the right side. The pulse readings signify the heart’s beat and are salient in identifying and monitoring normal and abnormal heart rates such as tachycardia (Talley & O’Connor, 2014). Changes in pulse readings are essential cardiac function monitoring parameters. Auscultation shall also be significant especially in assessing heart sounds and identifying any murmurs (Joanna, 2007). The latter may be heard if the patient has septal defects or valvular defects. Presence of S3 heart sounds may be indicative of a low cardiac output (Joanna, 2007).The timing, radiation, location and characteristic of murmurs shall be noted including any accompanying features such respiration. Nursing Management: Cardiac Workload Reduction Among the nursing strategies applicable for Sylvie to reduce cardiac workload include provision and facilitation of a quiet and comfortable environment free of activities or events that may enhance commotion and destruct the patient's piece. In addition, the number of family, friends or visitors in the patient's environment should be limited. These measures help to enhance patient relaxation and limit sympathetic stimulation (Delui, Yari, Khouyinezhad, Amini & Bayazi, 2013). By avoiding or limiting sympathetic stimulation, sympathetic excitation of the peripheral vascular system is limited thereby restricting sympathetic induced peripheral vasoconstriction (Delui et al., 2013). A reduction in the latter in turn reduces afterload in addition to lessening sympathetic stimulation of the heart via beta receptors. Utilization of relaxation techniques such as vision activities and manual imagination shall also help in stress alleviation, limit sympathetic activity and enhance patient calm (Delui et al., 2013). The patient’s legs shall be elevated when in a sleeping or resting position or when in a sitting position. Elevation of the lower limbs enhances movement of venous blood fortified by gravitational forces reducing accumulation of fluids in the extremities thereby aid in relieving peripheral oedema (Vincent, 2008). Any medication due for administration shall be timely administered. The administration includes titration of the doses within the prescribed parameters while ensuring the body is adequately perfused. The drugs include ACE inhibitors and diuretics that can reduce peripheral vascular resistance and lower the afterload, and beta blockers that limit sympathetic excitation of the heart reducing myocardial oxygen demand (Vincent, 2008). Monitoring of urine output hourly shall ensure that renal perfusion is maintained and that the kidney is adequately responding to the effects of diuretics and ACE inhibitors. Among possible changes that would signify an alteration in her condition include a decrease in weight that would indicate a subsiding oedema, a decrease in her heart beat would also mean an improvement in cardiac function or that the patient is responsive to therapeutic and nursing care. Decreasing oxygen saturation readings below normal may signify a deteriorating cardiac function, hypoventilation or need for more oxygen therapy (Pluddermann, Thompson & price, 2011). Moreover, diminishing symptoms of respiratory distress such as intercostal recession and nasal flaring would be a positive indicator of a stabilizing condition. Medication Management Patients with Down’s syndrome have significant cardiac abnormalities that predispose them to atrial fibrillation and even heart failure (Visootsak et al., 2011). Sylvie is an example of such a patient who has manifestations of cardiac dysfunction hence the reason she is on medication such as cardiac glycosides, ACE inhibitors and diuretics. Cardiac glycosides such as digoxin can increase myocardial contractility by enhancing calcium influx into myocardial cells after inhibition of myocardial Na/K ATPase (Acharya, Mehta & Vekariya, 2012). Therefore, it enhances inotropic activity of the heart thereby sustaining a failing heart. Furthermore, its ability to suppress conduction in the AV node enables it to control atrial fibrillation common in such patients. Diuretics are useful in relieving fluid accumulation or oedema related to decreased cardiac output (Chen, 2014). They effect this by enhancing fluid loss in the kidney. Decreased peripheral fluid is significant in reducing cardiac afterload thereby preserving myocardial activity. ACE inhibitors such as enalapril inhibits formation of angiotensin II from angiotensin I. Angiotensin II is a natural vasoconstrictor hence a decrease in its concentration in blood lessens vasoconstriction decreasing afterload and cardiac workload (Izzo Jr & Weir, 2011). In addition, its inhibition limits the secretion of water-retaining hormones such as antidiuretic and aldosterone that act via the kidney to enhance water retention (Izzo Jr & Weir, 2011). When administering these medications, caution should be taken to prevent the occurrence of their side-effects. If the patient has history of any previous hypersensitivity reaction to the drugs, caution should be taken to avoid re-administration of the same drug. Digoxin has a narrow therapeutic index meaning that toxic doses are very close to therapeutic doses. Therefore, its administration should be cautiously done to limit toxicity (Acharya, Mehta & Vekariya, 2012). ACE inhibitors such as enalapril should not be used in case the patient conceives due to the risk of fetal injury. Co-administration of ACE inhibitors and diuretics may increase hypotensive risk, hence the need to monitor blood pressure periodically (Chen, 2014; Izzo Jr & Weir, 2011). Preparation for Discharge Patient education is salient in enhancing prognosis of cardiac dysfunction such as in Sylvie's case. One area of education shall regard compliance and adherence to medication. The medication prescribed for Sylvie are mean to support the activity of her heart and reduce the workload of the heart to preserve heart function. It is paramount that she takes them at the right time, in the right dose and via the appropriate route (Elliot & Liu, 2010). Drugs such as cardiac glycosides if taken inappropriately may easily lead to toxicity due to their narrow therapeutic index. Sylvie'realtives should be familiar with their supportive role in managing her medications including reminding her where necessary. Home care and support shall be significant to Sylvie. She quickly fatigues; therefore, she shall need support from her family members in performing some of her activities of daily living. The latter include shopping, cooking, and transportation during appointment days. The significance of such support is to enable the patient not to be overwhelmed by physical activities that may aggravate her condition or even precipitate a cardiac arrest (Leaver & Evans, 2007). Ethics and Legal Practices Ethical principles are applied in everyday nursing practice in making justifiable moral decisions. The cardiac specialist did not involve Sylvie when directly conversing with her parents. Sylvie is excluded in the conversation against her right to autonomy. Regard for a person’s autonomy is encompassed in the ethical principle of autonomy that requires that the patient be involved and engaged when making decisions related to her management or treatment (Lindberg, Fagerstrom, Sivberg & Willman, 2014). Sylvie has the right to understand the care that is been administered to her. She should be aware of the procedures of the care, why she has to receive a given care, alternative options of care available, the benefits of the kind of medical or nursing care, any shortcomings associated with the care that is to be administered (Fagerstrom, Sivberg & Willman, 2014). By understanding such kind of information relating to their care, Sylvie shall be empowered and be capable to make an informed decision whether to accept or refuse the administration of any prescribed form of care. A registered nurse shall be expected to provide necessary resources including reading materials and patient education to impart knowledge to the patient. Information provided shall include details about Down’s syndrome and the condition’s implications to her health. Explanation of the link between her current cardiovascular dysfunction and the syndrome shall also be explained in addition to educating her on the management and treatment options. The nurse shall also ensure that the patient understands the information or education provided by asking her to verbalize content of information regarding the care to be provided. After the nurse is satisfied that the patient understands her condition and the care to be provided, the patient's consent shall be sought before decisions affiliated to her care are made (Entwistle, Carter, Cribb & McCaffery, 2010). (Entwistle, V., Carter, S.M., Cribb, A. & McCaffery, K, 2010) References Acharya, T.A., Mehta, D.S. & Vekariya, R.S. (2012). Digoxin toxicity: Crucial to diagnose. International Journal of Basic & Clinical Pharmacology, 1(1), 39-40. Bhatt, S.P., Guleria, R., Luqman-Arafath, T.K., Gupta, A.K., Mohan, A., Nanda, S. & Stoltzfus, J.C. (2009). Effect of tripod position on objective parameters respiratory parameter function in stable chronic obstructive pulmonary disease. The Indian Journal of Chest Disease and Allied Sciences, 51(2), 83-89. Chen, H. (2014). 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