NUR241 Task One Assessment Information

This report discusses the pathophysiology of chronic heart failure and the nursing assessment process for diagnosis and care plan. It includes interventions and evaluation for better patient outcomes.

Task one: Assessment
information

Table of Contents
INTRODUCTION...........................................................................................................................1
MAIN BODY...................................................................................................................................1
Pathophysiology of heart failure............................................................................................1
Application of the nursing assessment process......................................................................3
CONCLUSION................................................................................................................................5
REFERENCES................................................................................................................................7

INTRODUCTION
Nursing assessment is defined as the gathering of information which is related about the
patient that carry the physiological, psychological, sociological and their spiritual status which is
licensed by the registered nurse. In addition, nursing assessment also used to state about the set
of cation which is taken within the nursing process. the section of the nursing assessment is
usually associated with the delegation of the certified nurse’s aides which may show the impact
for the understanding of patient (Díaz and et. al., 2020). Therefore, the nursing process are
usually divided into the five step which may include the assessment phase, diagnosis phase,
planning phase, implementing phase and evaluation phase. In this, the nursing assessment is
important in order to determine the need with the unique need and concern with each patient as
well as any potential that show the aspect of barrier in order to provide the term of care that may
affect the compliance and show the outcome. In this report, the discussion is based on patient
who is facing the issue of chronic heart failure, with this, the pathophysiology, nursing diagnosis
and their assessment are applied (Gabriel-Costa, 2018).
MAIN BODY
Pathophysiology of heart failure
Heart failure is also known as congestive heart failure which is usually occur when the heart
muscle does not pump blood in the such a way which help to provide the way which can restrict
the flow of oxygen. In addition, the blood often backs up and fluid up in the lungs that causing
the shortness of breath due to the arising condition which is shows the aspect of hypoxia. In
addition, the certain heart condition such as narrowing of the arteries in the heart which is may
defined as the coronary heart disease or hypertension (Sarhene and et. al., 2019). Moreover, they
show the impact which is related with the heart which is weak or stiff to fill and pump blood in
the proper ways. In addition, the pathophysiology usually shows some of the context that is
cardiac dysfunction that precipitate the change in vascular functions, blood volume and
neurohumoral status. usually, the change is usually serve as the mechanism which help to
maintain the cardiac output that is primarily defined as the Frank starling mechanism and the
arterial pressure which show the impact of systematic vasoconstriction. In addition, these change
are usually arising in month or year that can be worsen with the cardiac functions (Hohendanner
and et. al., 2018).
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Cardiac functions: The change which is analyse with the cardiac function with the heart failure
are due to lower cardiac activity or output. These are usually occurring due to the decrease in
stroke volume that is usually due to the systolic dysfunction, diastolic function or the
combination of both which may show their impact on the function of heart. The systolic
dysfunction which show the outcome from the loss of intrinsic inotropic that is also report as
contractility that can be cause by the alteration in the signal transduction mechanism that is
usually show the responsibility towards the regulation of inotropy. The systolic dysfunction
which is also show the aspect which is outcome of loss of viable, contracting muscle as show
their occurrence that follow the concept acute myocardial infarction (Mialet-Perez and et. al.,
2018).
The diastolic dysfunction is usually referring as the ventricle which is become complaint
that is stiffer which is usually impair during the ventricular filling. The lower filling of the
ventricle shows the outcome in the less ejection of blood. In addition, the blood systolic and
diastolic dysfunction are usually show the impact which is higher ventricular end diastolic
pressure that help to serve the compensate mechanism which is utilise the Frank starling
mechanism in order to augment with the stroke volume. In other type of heart failure, the
ventricle dilates on the anatomical basis which help to normalise the pre load pressure which is
accommodated to enhance the filled volume (Rangaswami and et. al., 2019).
Neurohumoral status: The neurohumoral responses are usually occur during the context of heart
failure. These were majorly including the activation of the sympathetic nerve and the renin
angiotensin system and the enhanced release of the anti-diuretic hormone which is also known as
vasopressin. The effect of such as responses is secreting the arterial vasoconstriction in order to
maintain the arterial pressure, venous constriction that enhance the venous response and
enhanced blood volume in order to enhance ventricular filling. In general, these neurohumoral
responses are usually analyse as the compensatory mechanism but they can also show the
aggravate heart failure which help to enhance the ventricular afterload that depress the stroke
volume and enhance the preload in order to show the systematic congestion and oedema which is
usually occur shown within the case study (Pfeffer, Shah and Borlaug, 2019). Mrs Yindi
Burarrwanga is also dealing with the causes of oedema which may create complication with the
patient in such a way which affect the cardiac output. In addition, it is important in order to
understand the pathophysiology of the heart failure because it serves as the rationale for the
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proper therapeutic intervention. The symptoms which is analyse within the chronic heart failure
are usually show the evidence which is related with the heart where the heart used to lose their
ability in order to pump the blood in the effective way. The derive outcome are usually show the
aspect where the blood back can up in legs, ankles and feet that causing the issue of oedema
(Palaskas and et. al., 2020).
Application of the nursing assessment process
There is need to provide nursing care which can be effective and allow to get better and
effective response towards taking care and providing better nursing process which provide better
patient outcomes. Here, it is needed to includes the nursing assessment, nursing diagnosis, plan,
intervention, evaluation (Immonen et. al., (2019)).
Nursing assessment
Auscultate apical pulse, asses heart rate- Here, tachycardia refers to the early sign of
heart failure. Here, increase in the heart rate can lead to create high impact on individual body
which is first response to reduce the cardiac output. This can response as favourable output on
cardiac but over time, it can be harmful and may lead to crate worsen heart failure. It is important
to take control over the appropriate heart rate which are associated with effective clinical
outcomes along with including reduced mortality and hospitalisation.
Note heart sounds- There is need to get note about the sound of heart which include the
ventricular gallop that can be heard during auscultation. This can have caused due to entering of
large fluid volume in the ventricle at beginning of diastole. Here, s1 and s2 may get weak due to
decreased pumping action.
Assess rhythm along with dysrhythmias when telemetry is available- Here, both
ventricular and atrial dysrhythmias can be common. Fibrosis, myocardial stretch and chamber
dilation can lead to overall electrical paths to heart. Atrial fibrillation can be common in patient
and can occur in increased heart failure (Basu et. al., (2020)).
Assess for palpitations or irregular heartbreak- Here, palpitation can lead due to
dysrhythmias secondary which can lead to risk of chronic heart failure. Here, AF is one of the
most common dysrhythmia in heart failure. This can also be the compensatory mechanism which
can lead to failing heart and lead to lack of flow with fast or irregular heartbeat.
Palate peripheral pulses- This can lead to create decreased cardiac output which may
include the reflection in diminished radial, dorsalis pedis, popliteal and post tibial pulses. There
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is marked diminution and can lead to peripheral pulse which are associated with indicating
severely depressed stroked volume. Here pulses may be irregular to palpation and beat can
alternating with weak beat (Nakagawa et. al., (2019)).
Monitor blood pressure- This one can be effective nursing assessment where nursing staff
should ensure about the blood pressure. This can allow to ensure the severity of heart failure
which can also include effectiveness of the response towards the elevated blood pressure. This
can be increased due to systemic vascular resistance. Here, blood pressure can be often used for
determining the intervention which can be effective in dealing with better result. This can include
the chronic heart failure. Here, blood pressure works as parameter which can help to determine
the excess dosage of pharmacological response towards the chronic heart failure.
Monitoring urine output, concentrated urine and noting decreasing output- Here,
nursing staff need to perform some test which can includes the monitoring of urine output. This
can enable nursing staff to get about the effective response of drug and help to evaluate the renal
perfusion. Here, individual patient may develop diuretic resistance which can result in decreased
in urinary output x(Nakagawa et. al., (2019)).
Nursing diagnosis
There is need for the nursing diagnosis which may include different diagnosis that should
have performed by the nursing staff which are discussed further.
 Physical examination
 Blood test
 Chest X-ray, CT scan
 Electrocardiogram
 Stress test
 Myocardial biopsy
Nursing care plan
There is need to make some nursing care plan which can be effective and allow to get better
and effective health outcomes (Leilah et. al., (2019)). These nursing care plan may include-
 Decreased cardiac output
 Activity intolerance
 Excess fluid volume
 Risk for impaired skin integrity
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 Acute plan
 Hyperthermia
 Impaired gas exchange
 Fear
 Anxiety powerlessness
Intervention
There is various nursing intervention that are effective and allow to get better care about
the patient health. In this, there are some of the intervention may include providing restful
environment and encouraging periods for rest and sleep which can assist activity, encouraging
rest, providing quite environment, assist patient in assuming high Fowler’s position and others.
Here, providing restful environment can be effective and allow to get better and effective
response towards the patient care. This can be effective in reducing the unnecessary disturbance
that are reduce the workload and allow to get better care about the oxygen damage. This is
effective and provide high response towards the improvement in patient health (Lewandowska et.
al., (2021)).
Encouraging rest can also help in dealing with providing better physical rest which are
associated with maintaining improved cardiac contraction efficiency along with deceased
myocardial oxygen demand.
Evaluation
After providing all the nursing assessment, diagnosis and using intervention can help to
provide better result which are associated with taking care of patient health. This can be effective
and provide better health outcomes to individual which can provide better result. Through
applying these it can help in patient to get better care and their improved health (Haavisto et. al.,
(2019)).
CONCLUSION
From the above discussion, it can have concluded that there is high impact of chronic heart
failure which can lead to risk of life. There is need to understanding about the pathophysiology
which can be effective to get ensure about the causes and impact of leading change in individual
health. In this, there is discussion about the pathophysiology of edema which can lead to chronic
heart failure. There is also discussion about the nursing intervention which may include the
nursing assessment, nursing diagnosis, care plan, intervention and others.
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REFERENCES
Books and Journals
Basu, S., Harris, A., Mason, S., & Norman, J. (2020). A longitudinal assessment of occupational
stress in Emergency Department Nursing Staff. Journal of nursing management, 28(1),
167-174.
Díaz and et. al., 2020. Neuroinflammation in heart failure: new insights for an old disease. The
Journal of physiology, 598(1), pp.33-59.
Gabriel-Costa, D., 2018. The pathophysiology of myocardial infarction-induced heart
failure. Pathophysiology, 25(4), pp.277-284.
Haavisto, E., Hupli, M., Hahtela, N., Heikkilä, A., Huovila, P., Moisio, E. L., ... & Talman, K.
(2019). Structure and content of a new entrance exam to select undergraduate nursing
students. International journal of nursing education scholarship, 16(1).
Hohendanner and et. al., 2018. Pathophysiological and therapeutic implications in patients with
atrial fibrillation and heart failure. Heart failure reviews, 23(1), pp.27-36.
Immonen, K., Oikarainen, A., Tomietto, M., Kääriäinen, M., Tuomikoski, A. M., Kaučič, B.
M., ... & Mikkonen, K. (2019). Assessment of nursing students' competence in clinical
practice: a systematic review of reviews. International Journal of Nursing Studies, 100,
103414.
Leilah, M. A. G., Attia, N., Shebl, A. M., & Mansour, H. E. (2019). Developing Nursing
Standards for Maintaining Fluid and Electrolyte Balance for Critically Ill Patients in
Intensive Care Units. Journal of intensive and critical care, 5(1), 0-0.
Lewandowska, A., Stróżyk, P. M., Kabała, M., & Kozieł, D. (2021). An assessment of
knowledge on the protection of personal data among nursing staff. Pomeranian Journal
of Life Sciences, 67(2), 48-54.
Mialet-Perez and et. al., 2018. Monoamine oxidase-A, serotonin and norepinephrine: synergistic
players in cardiac physiology and pathology. Journal of Neural Transmission, 125(11),
pp.1627-1634.
Nakagawa, K., & Matsuo, K. (2019). Assessment of oral function and proper diet level for frail
elderly individuals in nursing homes using chewing training food. The journal of
nutrition, health & aging, 23(5), 483-489.
Palaskas and et. al., 2020. Immune checkpoint inhibitor myocarditis: pathophysiological
characteristics, diagnosis, and treatment. Journal of the American Heart Association, 9(2),
p.e013757.
Pfeffer, M.A., Shah, A.M. and Borlaug, B.A., 2019. Heart failure with preserved ejection
fraction in perspective. Circulation research, 124(11), pp.1598-1617.
Rangaswami and et. al., 2019. Cardiorenal syndrome: classification, pathophysiology, diagnosis,
and treatment strategies: a scientific statement from the American Heart
Association. Circulation, 139(16), pp.e840-e878.
Sarhene and et. al., 2019. Biomarkers in heart failure: the past, current and future. Heart failure
reviews, 24(6), pp.867-903.
Online
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