Congestive heart failure

Answer

1. • • • Congestive Heart Failure

         Introduction

                     Heart failure is described as a complex clinical syndrome, which results from structural or functional heart disorder that impairs ejection of blood or ventricular filling; thus, systemic circulation fails to meet the systemic needs. Symptoms of heart failure include decreased exercise tolerance, dyspnea, and fluid retention. Fluid retention is associated with peripheral or pulmonary edema (Malik, Brito, & Chhabra, 2020). Caring for congestive heart failure patients should be holistic in approach and include patient education to improve outcomes.

         Epidemiology

                     About 5.1 million people in the United States clinical present with heart failure. The prevalence of heart failure continues to increase. More than 650,000 new cases of heart failure are diagnosed annually particularly in persons who are more than 65 years of age (Malik et al., 2020). Black men present with the highest rate of incidence of the disease compared to White men. The prevalence of the disease among non-Hispanic Black females and males is 3.8% and 4.5%, respectively, versus 1.8% and 2.7% in non-Hispanic White females and males, respectively (Malik et al., 2020). Mortality is about 50% within 5 years of diagnosis.  The 5-year survival for heart failure stage A, B, C and D is 97%, 96%, 75%, and 20%, respectively (Malik et al., 2020).Prevalence of heart failure is greater than 37.7 million globally. Medical costs for caring of patients in the United States are projected to rise from $20.9 billion in 2012 to staggering $53.1 billion by 2030 (Ziaeian & Fonarow, 2016).

         Background

                      Congestive heart failure can be caused by disorders of the myocardium, endocardium, pericardium, vessels, heart valves or metabolic disorders. The most common cause of systolic dysfunction includes coronary heart disease, idiopathic dilated cardiomyopathy, valvular disease, hypertension and coronary heart disease (Malik et al., 2020).  Obesity, hypertension, diabetes mellitus, hyperlipidemia, and coronary artery disease are highly prevalent in congestive heart failure patients with preserved ejection function. Hypertension is a major cause of congestive heart failure with preserved ejection fraction. Besides, conditions such as restrictive cardiomyopathy and hypertrophic obstructive cardiomyopathy are associated with significant level of diastolic dysfunction resulting in heart failure with preserved ejection fraction (Malik et al., 2020). Causes of high-output failure include hyperthyroidism, atrioventricular fistulas, pregnancy, beriberi, anemia, multiple myeloma, carcinoid syndrome, polycythemia vera, and Paget disease of bone (Malik et al., 2020).

                     Common causes of decompensation in a stable patient with congestive with congestive heart failure include sudden changes in weather, lack of physical activity, inappropriate reduction in medications, and excess intake of sodium in the diet. Other important cause of decmpensation includes excess intake of water, emotional crisis, and prolonged physical activity (Malik et al., 2020). Congestive heart failure manifests with numerous symptoms that impairs quality of life. Symptoms include fatigue, dyspnea, fluid retention, and poor exercise tolerance (Ziaeian & Fonarow, 2016).

         Pathophysiology

                     Adaptive mechanisms aimed at maintaining sufficient overall contractile performance of the heart at the normal range becomes maladaptive in the long run. Primary myocardial response to chronically elevated wall-stress is myocyte hypertrophy, due to regeneration and apoptosis (Malik et al., 2020). The process of myocyte hypertrophy results in wall remodeling with reduced cardiac output, leading to a cascade of vascular mechanism and neurohumoral mechanism. Clinical presentations such as decreased renal perfusion and carotid baroreceptor stimulation results in activation of renin-angiotensin-aldosterone system and sympathetic nervous system. Activation of the renin-angiotensin-aldosterone system leads to elevation of the afterload, vasoconstriction, and hemodynamic alterations, elevated preload. Activation of the sympathetic nervous system leads to inotropy and elevated heart rate, resulting to myocardial toxicity (Malik et al., 2020).

                     B-type natriuretic peptide and atrial natriuretic peptide are released from the ventricles and atria in response to volume expansion or heart chamber pressure. These peptides promote vasodilation and natriuresis. Besides, B-type natriuretic peptide inhibits sodium reabsorption in the proximal convoluted tubule. It also suppresses aldosterone release and suppresses renin (Malik et al., 2020). In patients with congestive heart failure with preserved ejection fraction, there is increased ventricle stiffness and impaired relaxation, leading to dysfunction in diastolic filling of the left ventricle. Patients with left ventricular hypertrophy manifest with a shift of the diastolic-pressure-volume curve to the left resulting in an increase of diastolic pressures that in turn results in increased oxygen demand, increased energy expenditure, and myocardial ischemia. All these mechanisms results in worsening of the left ventricular function and negative remodeling; thus, causing symptoms of heart failure (Malik et al., 2020).  Symptoms of congestive heart failure due to excess fluid accumulation include orthopnea, dyspnea, pain from hepatic congestion, abdominal distention from ascites, and edema. Weakness and fatigue that is most pronounced with physical exertion indicates congestive heart failure due to reduction in cardiac output (Malik et al., 2020).

                     Subacute and acute presentations, in a matter of days to weeks, is characterized by shortness of breath with exertion and/or at rest, paroxysmal nocturnal dyspnea, orthopnea, and right upper-quadrant discomfort as a result of acute hepatic congestion (Malik et al., 2020). Palpitations, without or with lightheadedness, can occur in patients who develop ventricular or atrial tachyarrhythmias. Chronic clinical presentations may vary since anorexia, fatigue, peripheral edema, and abdominal distension may be more pronounced than dyspnea. Anorexia is secondary to factors such as bowel edema, nausea induced by hepatic congestion, and poor perfusion of the splanchnic circulation (Malik et al., 2020). Late stages of congestive heart failure manifest with signs such as pedal edema, tachycardia, abnormal lung sounds, increased jugular venous pressure, and S3 gallop (Inamdar & Inamdar, 2016).

         Prognosis

                     Congestive heart failure is a serious medical condition that is associated with high mortality rate. Mortality rate at 1 year is 22%, while mortality rate for patients who have had the disease for 5 years is 43%. Patients with advanced New York Heart Failure classification report highest mortality rate (Malik et al., 2020). Clinical values including systolic blood pressure <115 mmHg, serum urea >15 mmol/L, SERUM creatinine >2.72 mg/dL, left ventricular ejection fraction <45%, and N-terminal pro-brain natriuretic peptide >986 pg/mL are key predictors of high risk of mortality (Inamdar & Inamdar, 2016). Heart failure that is characterized by systolic dysfunction has mortality rate of 50% over 5 years. Heart failure patients require repeated admissions over the years (Malik et al., 2020).

         Current Trends in Care/Treatment

         Pharmacotherapy

                     Beta-blockers, diuretics, angiotensin receptor blockers, angiotensin converting enzyme inhibitors, hydralazine plus nitrate, angiotensin receptor neprilysin inhibitor, aldosterone antagonists, and digoxin are used in management and improvement of symptoms. Angiotensin receptor neprilysin inhibitor should not be administered within 36 hours of administration of a dose of angiotensin converting enzyme inhibitors (Malik et al., 2020). Diuretics include potassium sparing drugs, loop diuretics, and thiazides, which are administered to reduce edema by reducing venous pressure and blood volume (Inamdar & Inamdar, 2016).

         Device Therapy

                     Implantable cardioverter-defibrillator is indicated form secondary and primary prevention of sudden cardiac death. Patents with prolonged QRS duration, reduced left ventricular ejection fraction, and with a sinus rhythm can be managed with cardiac resynchronization therapy with bi-ventricular pacing to improve survival and symptoms. Patients who can be managed with cardiac resynchronization therapy implantation can also be managed with an implantable cardioverter-defibrillator; or receive a combination of the two devices (Malik et al., 2020). Cardiac transplant or a ventricular assist device is reserved for patients with severe disease regardless of all measures (Malik et al., 2020).

         Cultural Sensitive Care

                     Congestive heart failure patients from the African-American community with New York Heart Association functional classification III to IV congestive heart failure and left ventricular ejection fraction <40%, regardless of medical therapy (angiotensin converting enzyme inhibitors, beta-blocker, angiotensin II receptor blockers, diuretics, and aldosterone), should be administered hydralazine plus oral nitrate (Malik et al., 2020). African-Americans reports with highest incidence rates of heart failure, Hispanic and Whites reports with intermediate rates, while Chinese-Americans manifest with lowest incidence rates (Ziaeian & Fonarow, 2016). 

         Relevance of Jean Watson’s Theory of Human Caring

                     Dr. Jean Watson developed the Theory of Human Caring that focuses on how nurses care for their patients as well as how caring advancements into better plans so as to promote wellness and health. The other goal is to restore health and prevent illness. The aims are compatible with the goals of treating a congestive heart failure patient. According to Jean Watson’s Theory of Human Caring a disease such as congestive heart failure can be cured; however, the illness may remain since, without caring, health will not be attained. Caring is considered as the essence of nursing and depicts responsiveness between the nurse and the person; the nurse co-participates with the person being provided with care (Gonzalo, 2019). Constant reviews of the nurses’ caring behavior and patient satisfaction help to advance the quality of nursing (Pajnkihar, Štiglic, & Vrbnjak, 2017). Caring should be central to improvement of patient’s experience as endorse Watson’s theory of human caring. Caring includes care about and care for clients. Patient education is necessary for health promotion in patients with congestive heart failure (Pajnkihar, Štiglic, & Vrbnjak, 2017).

          

         Table 1: Nursing Care Plan

         NURSING DIAGNOSIS (NANDA APPROVED)	EXPECTED OUTCOME (Measurable Goal)	NURSING INTERVENTIONS  (What do you plan to do?)	RATIONALE (Why are you doing this?)
         Decreased cardiac out	·         Normal heart rate and rhythm by two months under treatment (Wayne, 2019). ·         Patient demonstrates sufficient cardiac out as evidenced by pulse rate and blood pressure as well as rhythm within the normal range for the patient; ability to tolerate physical exertion without symptoms of syncope, dyspnea, or chest pain and strong peripheral pulses by a period of 6 months after commencement of treatment (Wayne, 2019). ·         Patient explains precautions and actions for to take for cardiac disease after two weeks of patient education (Wayne, 2019). ·         Patient demonstrates dry skin, warm skin, and eupnea with absence of pulmonary crackles by two months of treatment (Wayne, 2019).	·         Record volume of intake and output. In acutely ill patients, hourly measurement of urine output is necessary so as to detect decreased urine output (Wayne, 2019). ·         Limit sodium intake and fluid intake in patients with increased preload (Wayne, 2019).       ·         Auscultation of heart sounds. Record rhythm, heart rate, presence of S3 and S4, and lung sounds.	·         Reduced cardiac output contributes to reduced perfusion of the kidneys, which results in decreased urine output (Wayne, 2019).   ·          Sodium and fluid restriction results in decreased extracellular fluid volume as well as reduced demands on the heart (Wayne, 2019). ·         New onset of fine crackles in lung bases, tachycardia, and a gallop rhythm demonstrates onset of heart failure. In case the patient develops pulmonary edema it will lead to severe dyspnea and course crackles on inspiration (Wayne, 2019).
         Ineffective tissue perfusion	·         Display vital signs within the acceptable range, no symptoms of failure, or dysrhythmias/controlled (Vera, 2020). ·         Patient will demonstrate behaviors that indicate improved circulation (Vera, 2020).	·         Assess the patient for pain intensity using a pain rating scale, for precipitating factors and location of pain (Vera, 2020). ·         Assess response to medications every five minutes (Vera, 2020).             ·         Monitor vital signs, particularly blood pressure and pulse, every five minutes until pain subsides (Vera, 2020).	·         Ti identify precipitating factors, intensity, and location of pain to assist with accurate diagnosis (Vera, 2020). ·         Assessment of the response determines the effectiveness of the medications and to determine if further interventions are required (Vera, 2020). ·         Elevated blood pressure and tachycardia often occur with angina and reflects mechanisms of compensation secondary to sympathetic nervous-stimulation (Vera, 2020).
         Deficient knowledge	·         Help the patient identify the relationship between ongoing treatment plans and medications to prevention of complications and recurrent episodes within two weeks of hospitalization (Vera, 2020). ·         Help the client to initiate necessary behavioral or lifestyle changes within a period of 6 months. ·         Help the client to identify own risk/stress factors and various techniques for handling them within a period of 2 weeks of hospitalization (Vera, 2020).	·         Review medications, side effects, and purpose of medications. Provide both written and oral instructions (Vera, 2020).                         ·         Recommend taking of diuretics early in the morning (Vera, 2020).       ·         Provide opportunities for the client to discuss concerns, ask questions, and make necessary lifestyle changes (Vera, 2020).	·         Understanding importance of prompt reporting of medication side effects and therapeutic needs can help to prevent occurrence of drug-associated complications. Anxiety may hinder the patient from developing an understanding of details hence written notes may be referred by the patient later (Vera, 2020). ·         The rationale is to provide sufficient time for diuretics to impart their action so as to prevent interruption of sleep (Vera, 2020). ·         Debilitating and chronicity nature of heart failure often drain supportive capacity and coping abilities of both care providers and the patient, leading to depression (Vera, 2020).

          

          

          

Answer

Assessing Risk and Reward

The Nissan Motor Company is one of the leading automobile makers in the world. The Japanese carmaker has primarily enjoyed a successful run, allowing it to enter various regional and international markets such as the United States. However, the changing business environment was not favorable to the company in 2019. Notably, the cooperation recorded losses amounting to 7.8%. The experience pushed the management into making tough decisions, requiring almost all of its North American workforce to go for unpaid leaves.

In late 2019, the company announced that the decline in sales necessitated a two-day unpaid leave for the North American workers. The stated days for the vacation were January 2 and 3^rd    (Chicago Tribune, 2019).  Notably, this move was a crucial decision for the company because of its conflicting impacts. Whereas on the positive side, it could help the firm minimize expenses, it threatened to affect the public perception of the company regarding employee welfare.

The rewards for the decision involved cutting expenses by not paying the workers on leave, which eventually would translate into reduced expenses. Another reward was that the decision could allow the company to optimize performance by evaluating employee performances then developing new milestones. However, on the low side, the company risked affecting its public image and brand name, especially in the North American market. As per Chakravorti (2010), the way an organization treats its employees influences the firm's public perception. Thus, Nissan risked eliciting a negative public perception. With a distorted public image, the company could fail to revive its declining sales.

I would have advised the management of Nissan to utilize the Predictive Analytic perspective in determining the right decision to take. Ideally, the approach tries to predict what might happen in the future if particular decisions or actions are undertaken at the moment (Traymbak & Aggarwal, 2019). Looking at the situation at Nissan, the company needed to develop a goal such as increasing sales. After that, they would have made decisions aimed at realizing the set goal. In this regard, the predicted outcome could give the management an overview of whether more risks existed or significant rewards could be realized.

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