Congested Cardiac Failure Health Assessment
Holistic Nursing Assessment of a Congestive Heart Failure Patient
Background and Initial Presentation
Many factors, both physical and psychological, impact the development of congestive heart failure (CHF). The prevalence of CHF in developed countries is 1-2% of the adult population overall and the sudden onset of life-threatening complications associated with the symptoms of CHF makes it especially dangerous (Blinderman et al. 2008). Given its immediate dangers, it is critical that a patient presenting with CHF receives a systematic and comprehensive assessment.
The initial stage of the holistic nursing assessment is the patient’s story. The nurse should initiate the interview by allowing the patient to introduce himself. This aspect of the patient interview allows him to provide unfiltered information that express his immediate concerns. The following patient background was acquired: 50-year-old man of Indian descent; 20-year Australian resident; owner of Indian restaurant; husband and father of three children.
These few details, while yet lacking specific medical relevance in determining the extent of his CHF complications, allow the nurse to make a number of inferences about the man’s health. His age does not place him in the category of the elderly and suggests that onset of his CHF symptoms may be relatively recent or based on genetic predispositions. Australia is a developed country and tentative conclusions may be drawn regarding the culture he is subjected to. Cardiovascular disease is the number one source of death in developed countries and special attention should therefore be placed on his dietary intake and exercise regimen. His family situation suggests that he exhibits psychosocial stability while the ownership of a popular Indian restaurant may be causing stress in his life. All these factors must be taken into account when proceeding with the assessment.
In the subjective assessment, the nurse must specifically characterize the cardio respiratory symptoms according to severity, location, duration, and time of onset. The nurse must also determine factors that aggravate or onset of the symptoms and factors that relieve them as well as a history of when the symptoms first began to appear (Jarvis 2009).
Shortness of breath (dyspnea) is the cardinal symptom of congestive heart failure. The Borg Scale may be used to assess the degree of dyspnea from 0 (none) to 10 (maximal). (Karapolat et al. 2008) Other evaluators include exercise tolerance. The nurse should question the patient how many stairs he is able to climb or what distance he is able to walk before he reaches a stage of exhaustion. Further considerations include any association with paroxysmal noctural dyspnea. The nurse should ask the patient whether he wakes frequently from acute dyspnea. The relation between dyspnea and posture is also important to consider.
A consistent cough may be a further indicator of CHF. The nurse should characterize the quality of the cough as dry, hacking, loose or productive and also record the severity and timing of the cough. Does the cough develop at night, with exercise, in cold air, outside or inside? A related symptom to the cough and one that can be simultaneously assessed is the sputum. The color, consistency and purulence of the sputum can provide further detail about the state of health of the presenting patient (Anon., 2010).
Occlusion of the heart muscle in CHF frequently produces chronic chest pain. This indicator is especially important to determine the progression of the disease. In the assessment, the nurse should pay special attention to the radiation, severity, timing and specific location of the pain. CHF tends to be localized in a specific part of the heart that has become congested and the radiation and location of the chest pain can help to determine the site of congestion. Chest pain may also be coupled to other symptoms such as faintness, shortness of breath and nausea.
Also related to the congestion of the heart and the ensuing difficulty of the muscle to function as an efficient pump, is the buildup of fluid throughout the body. This may produce areas of peripheral oedema visible on the body. This symptom is especially indicative and may be associated with leg cramps, tingling in the legs as well as the presence of varicose veins.
Other cardio respiratory symptoms common for CHF patients that should be considered as part of the nurse’s subjective assessment include cyanosis, pallor, wheezing, syncope, general fatigue, night sweats, palpitations, GI Reflux and weight loss (Anon., 2010).
The patient history provides the most transparent representation of the patient’s developing condition and offers the foundation for prescribing specific interventions. It must therefore be taken with special detail. According to a number of recent studies, patients with diabetes mellitus especially in combination with comorbid hypertension, cornonary artery disease, smoking, and left ventricular hypertrophy are at high risk of CHF (Held et al., 2007). These conditions present chronic stress for the heart and contribute to congestion in the heart muscle.
Important information that should be collected in the history includes previous admissions to a hospital and surgeries for a cardiac illness. Has the patient experienced a previous myocardial infarction, angina or coronary artery disease? Has he ever been diagnosed with cardiac murmurs or valvular heart disease? Important also to consider is the family history to determine genetic predispositions towards cardiovascular disease. The nurse should ask if anyone in the family has had a heart attack, particularly at a young age, and whether a family member has suffered a sudden death from cardiac disease.
In terms of personal history, the nurse should determine a body mass index (BMI) to test for obesity. This assessment should be combined with a nutritional status. A recent study suggests that an excessive intake of sodium can have detrimental effects on patients with CHF (Paterna et al., 2008). This may be of particular relevance considering the patient’s profession as an owner of a restaurant. The nurse might ask how often the patient dines at his restaurant. A history of smoking including usage per day and overall duration should be attained. The nurse should also determine the occupational environment of the patient and his frequency of exposure to stressful situations and irritating stimulants.
The most telling aspect of the medical history is the list of drugs prescribed to the patient. This provides insight into past complications that have required treatment. Beta-blockers, diuretics, steroids, antihistamines, and angiotensin-converting enzyme inhibitors all suggest previous cardiovascular disease (Anon., 2010).
Emotional, Mental and Spiritual Considerations
Holistic nursing addresses “the interrelationships of the bio-psycho-social-spiritual dimensions of the person” (Anon., 2002). For the specific patient, for example, his busy family life and management of his private business may be causing stress. Having lived in Australia for twenty years, he may be separated from his parents.
Emotional health patterns that should be considered include the patient’s response to stress. Different situations should be presented to which the patient describes his emotional response. It should be determined whether the patient spends more time being angry, lonely, depressed, sad, agitated, calm, or fearful. Depression has been directly linked to the development of CHF and is extremely relevant in the assessment (Smith et al., 2009). Further, the nurse should determine the state of his relationship to his wife, his children, and his parents and his response to disputes that arise within these relationships.
Mental health patterns can be determined by assessing the amount of change the patient is currently experiencing in his life, the way he responds to change, his dietary and exercise habits, his work prioritizations, and his perception of his ability to cope with challenges in his life.
The third component of the assessment consists of the patient’s spiritual health patterns. Questions concerning religion and beliefs, the value of life, and en evaluation of the patient’s perceptions of love, fear, hope, and death should be included in the assessment.
Objective / Physical Assessment
The Framingham Criteria is a commonly used diagnostic system for heart failure (McKee et al., 1971). The diagnosis of CHF requires the confirmation of one major physical symptoms and two minor correlates. The major symptoms include acute pulmonary edema, jugular vein distension, weight loss of more than 4.5 kg in 5 days and paroxysmal nocturnal dyspnea. Minor correlates include tachycardia of more than 120 beats per minute, nocturnal caugh, dyspnea on ordinary exertion and pleural effusion. The physical examination performed by the nurse should therefore be geared towards the determination of these symptoms.
The nurse should first measure primary vital signs. These include temperature, pulse, respiratory rate, blood pressure and oxygen saturation in the blood. The pulse and blood pressure can be especially indicative for this patient because they provide information on the efficiency of blood perfusion through the body. According to the Framingham Criteria, extreme tachycardia is one component of the CHF diagnosis. The nurse should therefore check for the presence, the rate, rhythm, amplitude and equivalence of both central and peripheral pulses. Synchrony of the radial and femoral pulses as well as comparative amplitude gives information about the location of heart damage. If the pulses present weaker on the left side, it may be reasonable to infer that the patient has left side heart damage. Evident diaphoresis would further support the CHF diagnosis.
The nurse should then concentrate her physical examination on the heart itself. Ausculation of the heart should be performed carefully with a stethoscope. In performing the assessment, the nurse should listen to normal heart sounds first before trying to identify murmurs on the patient (Anon., 2010). The aortic, pulmonic, tricuspid and mitral valves should be ausculated to identify the rate and rhythm of any murmurs or other irregularities.
While these primary assessments help to provide a general view of the patient’s symptoms, the real severity of CHF is measured according to the left ventricular ejection fraction (LVEF). This measures the fraction of blood that is pumped out of the left ventricle of the heart and determines the degree of congestion (Karapolat et al., 2008). This measurement can be determined by performing a transthoracic echocardiography. A normal ejection fraction lies between 50 — 70%. One below 40% is defiend as systolic heart failure (Dickstein et al., 2008). While this is not part of the nurse’s responsibility, she may propose the procedure to the attending physician.
Holistic Nursing Considerations
In a holistic nursing assessment, the nurse should function as an integrater. She must balance the patient’s self-evaluation of his ailments and guide him to finding the source of his pain. At the same time, she must make physical assessments to make a diagnosis of the patient’s symptoms. While the nurse applies tools of Western Medicine, he or she should also consider alternative modalities as part of her evaluation. Given his different cultural background, it is necessary to consistently explain the medical evaluation and be open to traditional remedial practices offered by the patient himself. In the holistic domain, the nurse should gather the information with a sense of interrelatedness and an understanding of the cumulative effect of disparate factors on the patient’s health.
1. Blinderman CD, Homel P, Billings JA, Portenoy RK, Tennstedt SL, 2008. Symptom Distress and Quality of Life in Patients with Advanced Congestive Heart Failure. Journal of Pain and Symptom Management, 35(6), pp.594-603.
2. Jarvis, C, 2009. Physical examination and health assessment: First Canadian Edition. Toronto, Ont: Elsevier Canada.
3. Karapolat et al., 2008. Effect of dyspnea and clinical variables on the quality of life and functional capacity in patients with chronic obstructive pulmonary disease and congestive heart failure. Chinese Medical Journal, 121(7), pp592-596.
4. Adult Cardio-Respiratory Assessment. Adapted from First Nations and Inuit Health Branch, 2006. Clinical Practice Guidelines for Nurses in Primary Care. CRNBC Janurary 2010/Pub. 780.
5. Held et al., 2007. Glucose Levels Predict Hospitalization for Congestive Heart Failure in Patients at High Cardiovascular Risk. Circulation Journal of the American Heart Association. 115, pp.1371-1375.
6. Paterna, Salatore et al., 2008. Normal-sodium diet compared with low-sodium diet in compensated congestive heart failure: is sodium an old enemy or a new friend? Clinical Science, 114, pp.221-230.
7. McKee PA, Castelli WP, McNamara PM, Kannel WB, 1971. The natural history of congestive heart failure: the Framingham study. New England Journal of Medicine, 285(26), pp.1441 — 6.
8. Dickstein K, Cohen-Solal A, Filippatos G, et al., 2008. “ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM).” European Heart Journal, 29(19), pp.2388 — 442.
9. Smith et al., 2009. Elevated Depression Symptoms Predict Long-Term Cardiovascular Mortality in Patients with Atrial Fibrillation and Heart Failure: Circulation Journal of the American Heart Association, 120, pp.134-140.
10. American Holistic Nurses’ Association. What is Holistic Nursing? Available at: http://www.ahna.org/about/whatis.html. Accessed October 16, 2002.
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