Complex Health Issues Cardiac Case Scenario

Synopsis of the case

The patient, Mathew Cottrell, is a 56-year-old male who was presented to the Emergency department due to chest tightness and increased shortness of breath. He was handed over to Ward 3B Cardiology after being administered tests, where results showed hypertension and heart failure. All these, paired with being overweight and having a medical history of Idiopathic Dilated Cardiomyopathy NYHA class II, necessitated him being admitted to the hospital for further medical care. This illness has advanced stages that have produced complications that might ultimately result in heart failure and other cardiovascular problems.

The patient was identified to have three main health issues which are relevant to the case study. The identified health issues are:

1.Risk of impaired oxygenation due to bilateral lobe congestion as well as worsening heart failure

Due to bilateral lobe congestion, the patient's heart chambers swell and lose their ability to contract; as a result, there is a significant risk of death.  This is as a result of acute heart failure given the imbalance between the exchange of oxygen and carbon dioxide in the lungs (Iqbal & Gupta, 2022). Acute heart failure can present suddenly and dramatically, as in the case of flash pulmonary edema, or it can present gradually, with symptoms worsening over a duration until a critical decompensating threshold is reached (King & Goldstein, 2022). For patients who have a history of prior heart failure, hypotension frequently has a distinct cause which thus categorises the impaired oxygenation as a health issue.

2.Risk of fluid imbalance

The age of the patient indicates that there is a danger of fluid imbalance. The elderly are more prone to water overload and hyponatremia because they have a decreased ability to eliminate a water burden. Additionally, aging-related neuroendocrine alterations impact the equilibrium of fluid and electrolytes. Variations in fluid balance brought on by aging are partially caused by changes in the amounts of these hormones (Iantorno, 2020). The hypothalamic supraoptic and paraventricular nuclei create the peptide hormone.

3.Risk of progressive effects with alcohol withdrawal

Alcohol withdrawal has been demonstrated to rank among the patient's health problems. Regularly consuming too much alcohol and having high blood pressure are related. High blood pressure (hypertension) gradually strains the heart muscle over time, leading to cardiovascular disease (CVD), which increases the risk of heart attack and stroke. Furthermore, excessive alcohol use may result in heart failure (Schultheiss et al., 2019). This is because it aggravates cardiomyopathy, a disorder that affects the heart muscle. This damage is caused by parts of the heart expanding and enlarging. As a result, the heart muscle weakens, making it less capable of adequately pumping blood.

Rationale for order of prioritisation

The prioritisation for the patient’s issues is ranked from 1 to 3 where 1 represents the highest ranking while 3 represent the lowest prioritisation ranking.

Priority 1 Impaired Oxygenation due to bilateral lobe congestion

Impaired oxygenation mixed with heart failure is a growing public health problem and is now the most common cause of hospitalizations and mortality among older patients. The increasing prevalence of impaired oxygenation in heart failure in the patient is most likely primary and its intervention would reduce the risk of death of the patient (Iqbal & Gupta, 2022). The bilateral congestion experienced by the patient will lead to changes in oxygen to carbon dioxide ratio, which will result in impaired gas exchange (King & Goldstein, 2022). In addition, given the patient's cardiac impairments, the back strain on the capillaries supplying oxygenated blood to the heart will cause the narrowing of the pulmonary circulation and flooding of the alveoli with blood (Britannica, 2022). This as a health issue is of high prioritisation given its mortality risk. 

Priority 2 fluid Imbalance

The heart becomes less effective in pumping blood-rich oxygen to the rest of the body due to heart failure. The result is an accumulation of fluid in the body. Due to a fast rise in filling pressures, fluid overload occurs extremely quickly, and a precipitating condition, such as uncontrolled hypertension, is frequently identified (Azzam et al., 2017). As a result, the fluid build-up brought on by the imbalance is a secondary reason why the patient was admitted to the hospital. Additionally, patients with heart failure often experience congestion brought on by fluid imbalance over a lengthy period. Patients may also be "acutely" overweight (Azzam et al., 2017). The health risk of fluid imbalance of a medium should thus be given priority because of the extended time before adverse effects on the patient. 

Priority 3 Risk of adverse effects from alcohol Withdrawal

The patient’s drinking could lead to heart tissue damage even before concerning symptoms arise, but this risk is reduced since its moderate. However, during the withdrawal process, the individual may have growing cardiac difficulties in various ways (News, 2019). It is possible that discontinuation will induce metabolic issues (Lucena et al., 2018). These metabolic problems might eventually cause the heart to stop working entirely. Additionally, he is highly likely to experience alcoholic cardiomyopathy, the long-term use of alcohol leads to hear failure (Alshahrani et al., 2021). The occurrence of acute alcohol withdrawal (AW) in the patient may further deteriorate his health if not mitigated accordingly. This is because seizures may occur in certain individuals, and their severity may worsen with consecutive AW episodes.

Nurse’s role in addressing the patient’s health issues

The nurse's job will be to assist staff in setting treatment priorities depending on the urgency and seriousness of a patient's condition where NSW health policies, A-G algorithm assessment and National Safety and Quality Health Service (NSQHS) standards will be incorporated (Strazzieri-Pulido et al., 2018).

Issue 1: Impaired Oxygenation

In this case, the assessment to be followed as a standard of care will be of an A-G algorithm. The assessment will cover airway, breathing, circulation, disability, exposure, further data, and goals to explain and determine the patient's risk of deterioration (Cathala, 2020). Additionally, the main goal of the intervention will be to reduce the patient's breathing related to the interchange of carbon dioxide and oxygen (Gil Wayne, 2022). Given the severity of the patient's illness, a vibratory PEP treatment will be used (Koutoukidis & Stainton, 2020). An arterial blood gas will also be used to monitor oxygen and carbon dioxide levels in the blood in more detail (ABG) (King & Goldstein, 2022). To help the patient make an accurate diagnosis and track the efficacy of medical therapy, the nurse must evaluate the patient's vital signs and breathing patterns (Gil Wayne, 2022). This will require a full blood count, urea, electrolytes, creatinine, and arterial blood gas to be assessed. 

Issue 2: Fluid Imbalance

In individuals with heart failure, fluid overload congestion is a frequent clinical symptom linked to negative outcomes. As such, in this case, the National Safety and Quality Health Service standards shall be adhered to, specifically, the recognizing and responding to acute deterioration standard (NSW Government, 2020). This will promptly ensure that the patient's deterioration is recognized and intervention is taken (NSW Government, 2020). An essential part of nursing care to determine hydration status should be the nurse keeping track of patients' fluid intake and output (Ackley et al., 2019). Fluid imbalance reports, therefore, show how future audits might be used to encourage better practice in strengthening the patient's healthcare (Yang et al., 2019). The patient's fluid should also be restricted to 1.5 liters daily, where a strict fluid balance will be implemented. This will allow the nurse to easily monitor the patient's daily weight, which integrates the application of quality improvement systems per the clinical governance standard.

Issue 3: Alcohol withdrawal

In this scenario, a policy directive for recognizing and managing deteriorating patients will be followed. The recommendation is a reaction to and appropriate treatment for the patient's deteriorating psychological and physical condition (Health Care, 2017). To assess and monitor patient deterioration as part of the local deteriorating patient safety net system, a nurse must adhere to conventional diagnostic tools and endorsed local patient care pathways, including the NSW health standard observation charts, given the increased risk of reduced cardiac output caused by the patient's alcohol use (Health Care, 2017). Therefore, tests such as the Glasgow Coma Scale (GCS) for the extent of consciousness and the Alcohol Withdrawal Scale (AWS) are needed in the patient's care plan (Strazzieri-Pulido et al., 2018). In addition to prescription beta-blockers and ACE inhibitors, treatment options may include lowering salt consumption (Wolf et al., 2020). Furthermore, the nurse should monitor the patient's heart rate and rhythm to note any abnormalities or dysrhythmias (Clinic, 2021). This is necessary given how the person's electrolytes change and become unbalanced (News, 2019).

References

Ackley, B., Ladwig, G., Flynn Makic, M., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing Diagnosis Handbook E-Book. Mosby.

Azzam, Z., Kinaneh, S., Bahouth, F., Ismael-Badarneh, R., Khoury, E., & Abassi, Z. (2017). Involvement of Cytokines in the Pathogenesis of Salt and Water Imbalance in Congestive Heart Failure. Frontiers In Immunology, 8. https://doi.org/10.3389/fimmu.2017.00716

Britannica. (2022). lung congestion | medical condition. Encyclopedia Britannica. https://www.britannica.com/science/lung-congestion.

Clinic, C. (2021). Alcoholic Cardiomyopathy: Causes, Symptoms and Treatment. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/21994-alcoholic-cardiomyopathy#:~:text=Alcoholic%20cardiomyopathy%20is%20a%20condition%20where%20consuming%20too%20much%20alcohol,as%20well%20as%20it%20should.

Cathala, X. (2020). Performing an A-G patient assessment: a step-by-step guide | Nursing Times. Nursing Times. https://www.nursingtimes.net/clinical-archive/assessment-skills/performing-an-a-g-patient-assessment-a-step-by-step-guide-06-01-2020/.

Gil Wayne, R. (2022). Impaired Gas Exchange Nursing Care Plan. Nurseslabs. https://nurseslabs.com/impaired-gas-exchange/.

Health Care, A. (2017). National Safety and Quality Health Service Standards [Ebook] (2nd ed.). Australian Commission on Safety and Quality in Health Care. https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf.

Iantorno, M. (2020). Heart failure - fluids and diuretics: MedlinePlus Medical Encyclopedia. Medlineplus.gov. https://medlineplus.gov/ency/patientinstructions/000112.htm.

Iqbal, M., & Gupta, M. (2022). Cardiogenic Pulmonary Edema. Ncbi.nlm.nih.gov. https://www.ncbi.nlm.nih.gov/books/NBK544260/.

King, K., & Goldstein, S. (2022). Congestive Heart Failure And Pulmonary Edema. Ncbi.nlm.nih.gov. https://www.ncbi.nlm.nih.gov/books/NBK554557/.

Koutoukidis, G., & Stainton, K. (2020). Tabbner's nursing care.

Lucena, A., Magro, C., Proença, M., Pires, A., Moraes, V., & Aliti, G. (2018). Validação de intervenções e atividades de enfermagem para pacientes em terapia hemodialítica. Revista Gaúcha De Enfermagem, 38(3). https://doi.org/10.1590/1983-1447.2017.03.66789

News, A. (2019). Heavy drinking may cause heart damage before symptoms appear. www.heart.org. https://www.heart.org/en/news/2019/12/18/heavy-drinking-may-cause-heart-damage-before-symptoms-appear#:~:text=Heavy%20drinking%20could%20lead%20to,%2C%20arrhythmias%2C%20stroke%20and%20death.

NSW Government. (2020). Recognition and management of patients who are deteriorating [Ebook]. https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2020_018.pdf.

Schultheiss, H., Fairweather, D., Caforio, A., Escher, F., Hershberger, R., & Lipshultz, S. et al. (2019). Dilated cardiomyopathy. Nature Reviews Disease Primers, 5(1). https://doi.org/10.1038/s41572-019-0084-1

Strazzieri-Pulido, K., S. González, C., Nogueira, P., Padilha, K., & G. Santos, V. (2018). Pressure injuries in critical patients: Incidence, patient-associated factors, and nursing workload. Journal Of Nursing Management, 27(2), 301-310. https://doi.org/10.1111/jonm.12671

Wolf, C., Curry, A., Nacht, J., & Simpson, S. (2020). Management of Alcohol Withdrawal in the Emergency Department: Current Perspectives. Open Access Emergency Medicine, Volume 12, 53-65. https://doi.org/10.2147/oaem.s235288

Wright, C., Norman, R., Varhol, R., Davis, J., Wilson-Taylor, E., Dorigo, J., & Robinson, S. (2018). Exploring the costs and effectiveness of the Drug and Alcohol Withdrawal Network: a home-based alcohol and other drug withdrawal service. Australian Journal Of Primary Health, 24(5), 385. https://doi.org/10.1071/py17110

Yang, S., Mu, P., Wu, H., & Curia, M. (2019). Fluid balance monitoring in congestive heart failure patients in hospital. JBI Database of Systematic Reviews and Implementation Reports, 17(10), 2202-2211. https://doi.org/10.11124/jbisrir-2017-004021