A 68-year-old man named Das was rushed to the emergency room after complaining of shortness of breath and chest pain. Tests revealed he was experiencing worsening heart failure and volume overload. Heart failure is a condition in which the heart muscle cannot pump blood effectively to the rest of the body, and fluid builds up in the lungs, causing shortness of breath.
The RAAS system is central to the pathogenesis of heart failure. RAAS system activity is increased in patients with CHF, a mechanism that results in effects such as activation of the sympathetic nervous system and cardiac remodeling. In Das’s case, activation of the RAAS system regulated blood volume and promoted systemic vascular resistance. These mechanisms resulted in a persistent increase in his blood pressure and a hypertensive episode. The RAAS system increased oxygen, calcium and sodium ion levels, activated proteases and cell death, causing further heart damage. It also contributed to increased atherosclerosis, cardiovascular disease and hypertension (Craft et al., 2019).
Das’ shortness of breath may be due to blood and fluid buildup in his lungs preventing him from breathing effectively. Fluid accumulation in his lungs also blocked the airway bronchioles, causing wheezing (Brennan, 2018). The pleuritic chest pain on the right side may be due to the accumulation of fluid around Mr. Das’ lungs. Pleuritis is a condition in which the pleura, his two thin, large layers of tissue that help separate the lungs from the chest wall, become inflamed. This inflammation causes his two layers of the pleura to rub against each other. Under normal conditions, these layers slide over each other without friction, making breathing easier. Inflammation of the pleura caused Das to experience pain when breathing in and out (Craft et al., 2019). Edema or congestion may have stiffened Mr. Das’ lungs and increased his breathing and heart rate (Craft et al., 2019).
Excess fluid volume is a common sign of heart failure. Mr. Das showed signs of fluid overload indicated by the presence of bilateral paw edema, hypertension, and dyspnea. The etiology of hypertensive crisis is an increase in blood pressure due to increased fluid levels in the blood. Dyspnea may also result from excess fluid build-up in the lungs, limiting the ability to breathe. Fluid accumulation also affected Das’ ability to properly drain blood, causing venous congestion. This led to dilation of neck veins (Chaudhary et al., 2021). Edema is caused by leaking blood vessels, which can allow fluid to penetrate the surrounding tissues and cause swelling.
Mr. He was also sweaty. This etiology may be due to the increased effort of the heart to effectively pump blood to other parts of the body. However, the damage to the myocardium had caused his heart to overwork, so Mr. Das sweated profusely to lower his body temperature and maintain homeostasis. Cardiac enzymes, especially troponin, are normally present in the body in small amounts. Levels rise when the heart suddenly works harder than usual, indicating heart failure. Because of this, Mr. Das showed elevated troponin enzyme levels as his heart muscle was damaged and his heart was working harder than normal. Heart failure also affected renal function, causing decreased renal blood flow and increased levels of creatinine and blood urea nitrogen (Linton & Matteson, 2020).
A high priority nursing intervention for Mr. Das is to place him in a semi-rigid position. The procedure allows Mr. Das to breathe more effectively and reduces shortness of breath. This position can be achieved by laying Mr. Das on his back so that the head of his bed is at a 30-45 degree angle to him. Care must be taken to keep Mr. Das’s legs straight. This nursing procedure increases Das’s lung capacity by at least 10-15% of his, reduces shortness of breath, and also eliminates wheezing and crackling sounds. The half-bird pose also improves the range of motion of Das’s diaphragm muscles, improves gas exchange, and promotes lung expansion for easier breathing. The half-bird position maximizes the expansion of Mr. Das’ chest and improves oxygen levels (Chanif & Prastika, 2019).
Without this procedure, Das’ lung expansion could be compromised, causing pulmonary congestion, heart failure, and increased fatigue and weakness. Failure to reposition can worsen shortness of breath and lead to respiratory failure, which can be fatal (Chanif & Prastika, 2019).
Furosemide is a diuretic that increases the secretion of sodium ions along with water by the kidneys by inhibiting the reabsorption of sodium ions from the distal tubules, proximal tubules and Henle’s loop. This effect of furosemide is achieved through inhibition of the Na-K-Cl cotransporter, which causes excessive ion secretion. Das was prescribed the drug to manage fluid overload by helping the body excrete excess sodium and water in the urine (Brown et al., 2020).
Nursing considerations regarding this drug include monitoring Mr. Das’ fluid intake and output, urine output, weight and electrolyte levels, as well as his BGL and renal function. The drug should be given in the morning to avoid nocturia. The expected clinical response is volume restoration with increased urine output. Continued clinical observation includes monitoring his clinical condition and looking for signs of deterioration. Mr. Das should be tested for developing oliguria and electrolyte imbalances (Bullock & Manias, 2017).
Glyceryl trinitrate (GTN) is a drug that relaxes vascular smooth muscle and dilates peripheral arteries and veins. It converts aldehyde dehydrogenase to nitric oxide, causing activation of guanylate cyclase and synthesis of cyclic guanosine 3′,5′-monophosphate (cGMP). Protein kinase-dependent phosphorylation and dephosphorylation of myosin light chain is stimulated by cGMP, resulting in vascular relaxation and thereby improved blood flow. The drug was given to Das to reduce strain on his heart, which should reduce chest pain and lower blood pressure (Rees, 2020).
GTN nursing considerations include timely monitoring of blood pressure, heart rate, gastrointestinal function, and assessment of its mucosa. Expected clinical responses to Das following her GTN administration are vasodilation, lower blood pressure, and less chest pain and shortness of breath. Clinical observations that should be continued include monitoring blood pressure, oxygen saturation, heart rhythm and rate, fluid intake and excretion.
Brennan, E. J. (2018). Chronic heart failure nursing: integrated multidisciplinary care. British Journal of Nursing, 27(12), 681-688. https://doi.org/10.12968/bjon.2018.27.12.681
Brown, A., Westley, K., Robson, J., Armstrong, L., Matthews, I., Runnett, C., … & Thomas, H. (2020). Furosemide in end-stage heart failure: community subcutaneous infusions. BMJ Supportive & Palliative Care. https://dx.doi.org/10.1136/bmjspcare-2019-002158
Bullock, S., & Manias, E. (2017). Fundamentals of pharmacology. Pearson Higher Education AU. https://books.google.co.in/books?hl=en&lr=&id=ODjiBAAAQBAJ&oi=fnd&pg=PP1&dq=fundamentals+of+pharmacology+bullock&ots=WKdgMhFf6Q&sig=3sAA8viJTQTof4r7AOxCJUqjIXw&redir_esc=y#v=onepage&q=fundamentals%20of%20pharmacology%20bullock&f=false
Chanif, C., & Prastika, D. (2019). Position of Fowler and Semi-fowler to Reduce of Shortness of Breath (Dyspnea) Level While Undergoing Nebulizer Therapy. South East Asia Nursing Research, 1(1), 14.
Chaudhary, R., Sukhi, A., Simon, M. A., Villanueva, F. S., & Pacella, J. J. (2021). Role of Internal Jugular Venous Ultrasound in suspected or confirmed Heart Failure: A Systematic Review. Journal of cardiac failure. https://doi.org/10.1016/j.cardfail.2021.08.009
Craft, J., Gordon, C., Huether, S. E., McCance, K. L., & Brashers, V. L. (2019). Understanding Pathophysiology 3e Australia New Zealand. Elsevier Health Sciences.
Linton, A. D., & Matteson, M. A. (2020). Medical-Surgical Nursing E-Book. Elsevier Health Sciences. https://books.google.co.in/books?hl=en&lr=&id=DA-IDwAAQBAJ&oi=fnd&pg=PP1&dq=medical+surgical+nursing+linton&ots=7H8-KSkCWM&sig=RPGflXkFBjGv1n3pCZNNvoQ9img&redir_esc=y#v=onepage&q=medical%20surgical%20nursing%20linton&f=false
Rees, S. (2020). GLYCERYL TRINITRATE. Journal of Prescribing Practice, 2(7), 372-373. https://doi.org/10.12968/jprp.2020.2.7.372
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