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Case Study Analysis: Hypertension And Heart Failure

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Case Study Analysis: Hypertension And Heart Failure

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Case Study Analysis: Hypertension And Heart Failure

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Question:
Discuss about the Case Study Analysis of Hypertension and Heart Failure.
 
 
Answer:

1)      Why Hypertension leads to Heart Failure
Hypertension is a disease that affects the normal rate of the heartbeat to either more than 140 over 90 mmHg. Because of the increased speed of the heartbeat, the normal functioning of the body is affected because the heart struggles to maintain the body operations. A patient is confirmed to be suffering from hypertension after several tests of the blood pressure. If there are consistent results of strange/abnormal heartbeat rates, then the patient is said to be hypertensive. The human body should be subjected to different physical activities so that blood flow can be managed. Insufficient physical exercises lead to thickening of lipids in the arteries that makes the heart struggle to pump blood. Also, eating foodstuff that is rich in salt can expose an individual to this disease.
There are some long-term effects of hypertension that raises the chance of an individual being diagnosed with heart failure. For example, the vessels are narrowed, which makes it hard for the heart to effectively supply blood into the entire body. When a person is suffering high blood pressure, shortness of breathing is experienced, which means that the body will not be acquiring enough oxygen. Therefore, respiration system will be altered, and the lungs acquire droplets of water, which fully affects the breathing system causing pains in the chest. High blood pressure is related to enlarged heart size that reduces the ability of the heart to manage its pressure, thus leading to low blood pressure. Therefore, a higher chance of heart failure will be perceived because there will be no pressure to pump the blood through the artery to the body parts.
People with hypertension are prone to kidney diseases, thus affecting its functionality. The kidney is very crucial in the body because it cleanses the blood from the body parts back to the heart for oxygenation, thus making the cycle effective. If the kidney does not undertake such requirements, the blood will reach the heart while it is still contaminated thus reducing its profitability to the body. In cases where the blood not purified, it means that there are higher chances of the body parts failing because the blood supplied is not up to the expected standards. As a result of the kidney failure disease, the patient might also be exposed to heart failure disease that is characterised by low power for the blood-pumping activity (Cheriyan, McEniery, & Wilkinson, 2010).       
The brain of a person depends on oxygenated blood from the body just as the heart. In cases when the blood being pumped from the heart to other parts of the body is not nourishing, there are higher chances of some body parts failing. The brain is exposed to several critical diseases if it is not nourished by perfectly oxygenated blood from the heart. Stroke is among these diseases which make some of the brain cell to die. In such cases, one side of the body might be unresponsive, which might lead to heart failure. If the pressure of the blood is not controlled, the vessels connecting the heart and the brain can be weakened and destroyed, causing them to rupture, leak or narrow. Therefore, insufficient supply of the blood to the brain will lead to stroke and later heart failure.
 
2)      Pathophysiology of Heart Failure
The pathophysiologic processes that accompanies heart failure are complex because this is a disease that affects the entire body. The interactions and effects move from subcellular to the organs, thus affecting the normal functioning of the body in the body parts. The overwhelming of the adaptions for the networks leads to heart failure (Kitchens & Maze, 2016).
a)      Adaptations
There are some important adaptations of heart failure, and they are stated below: –

Death and regeneration of myocyte in alterations.
Activating the systems of Neurohormonal.
Sustenance of cardiac functionality through the use of Frank-Starling methodology.
Hypertrophy of myocardial with augmenting the mass of contractile tissue.

The myocardial contractility is increased by norepinephrine released by the nerves of the cardiac. In cases when individual experiences acute heart failure, adaptive mechanisms that are used in maintaining the normal functioning of the heart might be destroyed, thus becoming ineffective. Myocyte hypertrophy, regeneration and death are the effects of increased stress of the walls of the cardiac. Therefore, if the functionality of the heart is affected, the output is altered leading to the provocation of neuroendocrine activation (Katz & Konstam, 2012).
b)      Ang II
Scientists have indicated that the effect of norepinephrine in cases of heart failure is the same as for Ang II. This compound is used to increase inotropy, reduce lusitropy and raise the level of afterload. All these processes lead to increased expenditure of energy for the heart. Also, Ang II has been used in the increment of myocyte of apoptosis. The myocardial function might be reduced progressively by And II as it balances the myocardial hypertrophy (Cheriyan, McEniery, & Wilkinson, 2010). Therefore, the volume and mass of myocardial are increased as the loss of myocyte activated, which in turn leads to further increment of the myocardial mass and volume. 
c)      Remodelling and Myocardial and Myocyte
In heart failure disease, the increased volume of myocardial is directly linked to the large myocytes that are always approaching the end of the cycle. Therefore, after they fall off, they add weight to the ventricles, thus creating unfavourable environs in the heart, thus affecting the progenitor cells that are supposed to replace the myocytes. The effectiveness of these cells reduces, which leads to acceleration of the heart failure because of the failed regeneration process. The myocardial remodelling is characterised by increased mass and volume of the heart and an increased rate of myocyte loss.
d)      Diastolic and Systolic Failure
When the stroke volume reduces, the chances of systolic and diastolic heart failure increases. Thereafter, chemo reflexes, central baroreflexes and peripherals are activated to manage the nerve traffic developed by the changes in the cardiac. Neurohormonal usually responds to the cases of reduced levels of stroke and this processes are clearly seen on people suffering from systolic heart failure. Some prognostic implication is identified when cardiac dysfunction is observed, which is correlated with plasma elevation. Norepinephrine is responsible for some abnormalities in a variety of signal transduction and reduction in the level of myocyte (Deedwania, 2012).
e)      Atrial Natriuretic Peptide (ANP) and Brain Natriuretic Peptide (BNP)
The BNP and ANP peptides are activated as a result of the expansion ventricular pressure and volume. Therefore, these peptides are released from the ventricles and atria for the BNP and ANP respectively. Natriuresis and vasodilation are supported by these peptides, and their effects are neutralised by reducing the pressures in the ventricles, thus reducing the pre and after load of the cardiac. Sodium reabsorption in the tubule is inhibited by BNP and at the same time, it produces arteriolar vasodilation. These volumes/levels of BNP and ANP increased when chronic heart failure is suffered. Therefore, Brain Natriuretic Peptide has very important therapeutic, prognostic and diagnostic implications (Kearney, 2008).
 
f)        Left Ventricle (LV) Stiffness
The left ventricle can increase in size if there is a combination of either the following: –

The increment in the pressure is filling the ventricle.
If a steeper pressure-volume curves for the ventricle is experienced.
If the distensibility of the ventricular decreases (Kitchens & Maze, 2016).

As a result of a failure in myocarditis or acute valvular regurgitation, there might be an increase in the pressure in ventricular up leading to steeper curve. The steeper ventricular curve results by; increased wall thickness and ventricular mass, myocardial ischemia, fibrosis of endomyocardial, and infiltrate disorders such as amyloidosis (Kaplan, Victor, & Kaplan, 2010).
g)      Left Ventricle Hypertrophy
Left Ventricle Hypertrophy is led by increased overload of pressure, which also occurs in hypertension, hypertrophic cardiomyopathy, and aortic stenosis. Therefore, the pressure-volume curve in diastolic is shifted to the left to a place along the axis (Nadar & Lip, 2009). Although the stiffness of the chamber may or may not be affected, the diastolic pressure is elevated in an abnormal manner. Increment if diastolic pressure leads to: –

Increased demand for oxygen for myocardial
Ventricle remodelling
Myocardial Ischemia
Maladaptive mechanisms are progressed eventually

h)      Arrhythmias
All forms of heart failure are imparted with significant burden by arrhythmias as dangerous rhythms are experienced in ischemic cardiomyopathy. Also, some of the arrhythmias contribute to the occurrence of heart failure condition. Life-threatening arrhythmias are the most significant among all the rhythms associated with heart failure. Myocardial hypertrophy, ventricular dilatation and myocardial fibrosis are the most common structural substrates in arrhythmias.
 
3)      Rationale of the Treatment
According to the doctor’s prescriptions, it was important for the 64-year-old female patient to undertake some medicine that would help her recover from the state of breathlessness. This is a critical condition that could not be handled through outpatient health services, and that is the reason she was sent to the medical ward. The doctors decision was triggered by the results obtained after the testing the blood pressure that was found to be 156/96 mmHg, the heartbeat pulse at 128 bpm and a shallow respiration rate. These results show that the patient was suffering hypertension, and there were high chances that she had a heart attack.
The patient has problems in breathing because of the affected cardiac functionality, and that is the reason behind the Ventolin 5mg medication, which helps in regulating the respiratory rate for asthmatic individuals. However, this disease did not help her, but it led to severe tremors ad anxiety, which worsened the situation. Intravenous (IV) therapy was used in cooling the situation and neutralising the effect of Ventolin into the body of the patient. The reaction observes after Ventolin was initiated into the body of the patient indicated that the health problem was not as a results lung disease. The next medical test was electrocardiogram, which shows that there was abnormal heart rhythm. Later, a chest indicated that there were some traces of fluid in the lung fields (Díez, 2014).
Arterial Blood Gases (ABG) test was conducted to test the acidity of the blood from the artery and obtain the levels of oxygen (O2) and carbon dioxide (CO2). According to the results obtained, the pH indicated that the blood was alkaline because the value obtained was above the normal range of values. The pressure of oxygen was found to be at a good pressure value but carbon dioxide values obtained was above the normal range which is between 35-45 mmHg. When the pressure of CO2 is perceived to be above 45 mmHg, it means that the gas is not able to move out of the body efficiently. Therefore, an intervention to accelerate the movement of CO2 out of the body is supposed to be used to balance the volumes to sustainable values. The bicarbonate values were within a manageable range although it was unable to maintain the pH of the blood. The oximetry reading shown that the patient needed 85% of 3 litres oxygen through the nasal prongs.     
After the patient was referred to the medical ward, there some medicines that were prescribed based on the medical tests undertaken and results undertaken. The doctor stated that the patient needed to be put in oxygen machine at 3 litres/minute through the nasal prongs. This would make her respiratory system managed effectively by providing sufficient flow of oxygen. The methyldopa 250 mg prescribed by the doctors was aimed at reducing the arterial pressure because the patient was diagnosed with a heart attack caused by hypertension condition. Also, physiotens (moxonidine) is a drug that is used to reduce/moderate the blood pressure, and this makes it an antihypertensive medicine. In this case, moxonidine is the component stimulates imidazoline receptors found in the brain, thus reducing the rate of sending signals blood vessels that make them narrow and contract (Semigran & Shin, 2013).
Plendil (felodipine) is also another medicine that was prescribed by the doctor for the 64-year-old patient. This medicine in categorised in a group of drugs that are known as calcium channel blockers (Matt Vera, 2013). It helps the blood vessels to relax/widen, thus reducing the workload on the heart by making the pumping process easier. Therefore, the blood pressure will be automatically lowered and perfectly managed. Karvia medicine was also used as an antihypertensive drug that, which is prescribed to be used by adults whose hypertension condition has no known/obvious cause. It is supposed to be used once in the morning to maintain the blood pressure and treat kidney disease if perceived. Karvezide 300 mg/25 mg is used by individuals who suffer hypertension just as the patient in this case. Its core use is the treatment of high blood pressure, and it contains a combination of hydrochlorothiazide and irbesartan (Hosenpud & Greenberg, 2013).
In the next morning, the patient was feeling much better after the use of the drugs prescribed by the doctor. Her wellness was fully supported by the oxygen provided, and whenever the supply was disconnected, she was unable to breathe. She was then assessed by the cardiologist, and Lasix 40 mg drug was ordered for the start and then to be continued every morning. The cardiologist stated that the patient suffered heart failure, and it was probably because of hypertension condition that she has had for many years. Use of Lasix (furosemide) 40 mg was aimed at reducing the excessive fluids in the lungs so that the respiratory system could be enhanced (MacGregor & Kaplan, 2010). Therefore, the shortness of breath and hypertension could be managed effectively. The excessive fluids in the body are lost through urination when furosemide is taken. Lasix 40 mg dosage helped the patient’s respiratory system by clearing the excessive fluids in the lungs. Therefore, in the next morning, she confessed that she was feeling much better, and her lungs felt good and free. 
 
4)      Nursing Interventions
a)      Nutrition
This nursing intervention will be aimed at educating/informing the patient or her family members how they should manage the nutrition to enable the patient manage hypertension and heart failure effectively. The approach of this nursing plan will be connected to the avoidance of imbalanced diet/nutrition. Also, other cultural preferences and other activities to be undertaken towards nutrition will be included in the plan. It has been evidenced that skinfold for the triceps should not be more than 25mm for women and 15mm for men. Therefore, the patient or the family members will be advised to manage the diet to avoid obesity. The most effective and functional eating patterns for the patient will be advised to manage the body to desirable weight. An appropriate exercise system can be initiated for the patient to ensure that the respiratory system is enhanced (Michael Felker, 2010).
The patient suffering heart failure should ensure that all cases that can lead to obesity are avoided because when an individual gains more weight, the blood pressure is perceived to raise. The patient or the carers should understand the direct relationship between hypertension and obesity. Their understanding prompts them to focus on exercises and weight loss because reducing weight will replace the use of the drug for therapy. Instruction are important to help the patient choose effective diets such as prioritising on fruits, low-fat foods, vegetable and avoid feeding on foodstuff with saturated fats. It is important to avoid cholesterol and fats to prevent atherogenesis.  Elimination of drug therapy can be reduced or replaced by using dietary approaches to stop hypertension (Mann & Felker, 2014).
b)      Decreased Cardiac Output
There are several chances of experiencing decreased cardiac output for a person suffering hypertension or heart failure. The resistance of the vascular might be increased, suffering from ventricular rigidity myocardial ischemia (Rnao, 2009). It will be desired or effective for the patient to engage in activities which are perceived to reduce BP or cardiac workload. The blood pressure should also be managed within the acceptable or manageable range. Also, it will good for the patient if the cardiac rhythm is successfully maintained and engage in stress management activities. The stress level of a patient should be assessed to identify the best method to be used in reducing it to a manageable point (Stewart & Blue, 2008).
Based on laboratory report, a registered nurse can identify the factors that are contributing to the reduction of cardiac output. Some other factors such as skin colour and moisture can be identified to check the level of hypertension, thus paving a way for an effective method of control. The nurse will also advise the patient on the best ways to manage cardiac output. Also, the response of the medical interventions implemented will also be monitored and evaluated so that their effectiveness can be maintained (Bulechek, Butcher, Dochterman, & Wagner, 2013).
c)      Coping Effectively
A registered nurse is to focus on coping with different changes experienced when the heart failure condition is suffered. They should be advised to cope with exercises that help in managing the condition. For instance, a person who was used to little or no exercise might experience muscle fatigue after engaging in various physical activities advised by the doctor. Based on this nursing plan, the impossible coping behaviours should be identified so that alternatives evaluated (Nanda, 2012). Individual stressing agents should be determined and their potential effect evaluated. The capability of coping to the strategies will also be accessed by the nurse, thus showing the level of willingness to the treatment approach. It is normal that a person will try hard to fit in a medical intervention plan if it is perceived to help in a treatment process (Michael Felker, 2010).
The patient is advised to focus on priorities of life, thus being able to undertint the current situation and effect on future life. Therefore, the patient will be assisted in planning for necessary changes in lifestyle, thus being helped to cope and fit perfectly. The patient should make life changes that are realistic and able to make her powerful and encourage in life. The patient should be informed that a lot physical and psychological changes will be experienced (“Heart failure: management”, 2014). Therefore, it will be advisable to be ready for changes such as impaired concentration, fatigue, irritability among others. The negative thoughts perceived by the patient about the dangers connected with the condition should be replaced with positive ideas through encouragements.
 
References
Bulechek, G., Butcher, H., Dochterman, J., & Wagner, C. (2013). Nursing Interventions Classification (NIC). Amsterdam: Elsevier Health Sciences.
Cheriyan, J., McEniery, C., & Wilkinson, I. (2010). Hypertension. Oxford: Oxford University Press.
Deedwania, P. (2012). Heart failure. Philadelphia, PA: Saunders.
Díez, J. (2014). Arterial Hypertension in Patients with Heart Failure. Heart Failure Clinics, 10(2), 233-242. https://dx.doi.org/10.1016/j.hfc.2013.12.004
Heart failure: management. (2014). Clinical Pharmacist. https://dx.doi.org/10.1211/cp.2014.11138784
Hosenpud, J. & Greenberg, B. (2013). Congestive heart failure (3rd Ed.). New York: Springer-Verlag.
Kaplan, N., Victor, R., & Kaplan, N. (2010). Kaplan’s clinical hypertension. Philadelphia: Wollters Kluwer Health/Lippincott Williams & Wilkins.
Katz, A. & Konstam, M. (2012). Heart Failure. Lippincott Williams & Wilkins.
Kearney, M. (2008). Chronic heart failure. Oxford: Oxford University Press.
Kitchens, J. & Maze, L. (2016). Heart Failure. Elsevier Health Sciences.
MacGregor, G. & Kaplan, N. (2010). Hypertension. Abingdon: Health Press.
Mann, D. & Felker, G. (2014). Heart failure. Elsevier Health Sciences.
Matt Vera, R. (2013). 6 Hypertension Nursing Care Plans – Nurseslabs. Nurseslabs. Retrieved 28 July 2016, from https://nurseslabs.com/6-hypertension-htn-nursing-care-plans/
Michael Felker, G. (2010). Diuretic Management in Heart Failure. Congestive Heart Failure, 16, S68-S72. https://dx.doi.org/10.1111/j.1751-7133.2010.00172.x
Nadar, S. & Lip, G. (2009). Oxford Cardiology Library: Hypertension. Oxford University Press, Incorporated.
Nanda, (2012). Nanda Nursing Interventions: 4 Nursing Diagnosis Interventions for Hypertension. Nanda-nursinginterventions.blogspot.co.ke. Retrieved 28 July 2016, from https://nanda-nursinginterventions.blogspot.co.ke/2012/05/4-nursing-diagnosis-interventions-for.html
Nicholson, C. (2007). Heart failure. Chichester, West Sussex: John Wiley & Sons.
O’Connor, C. (2014). Heart Failure: Where the Paths Cross. JACC: Heart Failure, 2(4), 427. https://dx.doi.org/10.1016/j.jchf.2014.05.001
Rnao, (2009). Nursing Management of Hypertension | Registered Nurses’ Association of Ontario. Rnao.ca. Retrieved 28 July 2016, from https://rnao.ca/bpg/guidelines/nursing-management-hypertension
Royal Pharmaceutical Society, (2014). Acute heart failure. The Pharmaceutical Journal. https://dx.doi.org/10.1211/pj.2014.11138556
RuDusky, B. (2015). Heart Failure and Comorbidities. JACC: Heart Failure, 3(12), 1003. https://dx.doi.org/10.1016/j.jchf.2015.09.008
Semigran, M. & Shin, J. (2013). Heart failure. Boca Raton: CRC Press.
Shin, J. & Semigran, M. (2010). Heart Failure and Pulmonary Hypertension. Heart Failure Clinics, 6(2), 215-222. https://dx.doi.org/10.1016/j.hfc.2009.11.007
Stewart, S. & Blue, L. (2008). Improving outcomes in chronic heart failure. London: BMJ.

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