Medical Diagnosis of Congestive Heart Failure

Medical Diagnosis of Congestive Heart Failure
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Medical Diagnosis of Congestive Heart Failure
Diagnosis Congestive heart failure occurs when the heart cannot pump enough oxygen-rich blood to other parts of the body. Essentially, it is a chronic progressive condition in which the heart's muscle cannot pump enough blood to meet physical requirements sufficiently. In the United States, over 6.2 million adults have congestive heart failure. According to the CDC (2020), congestive heart failure was mentioned in 378,800 death certificates in 2018. Among these victims was a close relative, which makes this topic vital because it has personal implications for my expectations of the public health system. Therefore, the current document is a process paper focusing on right-sided heart failure.
Case Presentation
Mark is a 46 years old African American construction supervisor. He arrives at the health facility complaining of shortness of breath, a general feeling of fatigue and weakness, and tightness in the chest. The chief complaint is that Mark was experiencing a persistent cough and wheezing coupled with pink blood-tinged mucus in the past few days, including the day of arrival. On his arrival (18th October 2021) at the health facility, Mark could not walk because of fatigue and weakness, and his speech was slurred. He struggled to lift a hand and to shift his face.
Right-sided congestive heart failure occurs in the right ventricle chamber of the heart. The right ventricle is responsible for pumping the blood to the lungs, where oxygen is collected. There are several causes of right-sided heart failure. Among them is the presence of left-sided heart failure. Left-sided heart failure is the commonest of all congestive heart failures. It occurs in the left ventricle: a heart chamber whose responsibility is to pump blood to the rest of the body organs except the lungs. When the left ventricle cannot pump sufficient blood out of the heart, the blood backs up into the lungs leading to a buildup of fluids and shortness of breath. The accumulation of blood in the lungs stresses the right ventricle leading to right-sided heart failure. Thus, the shortness of breath, a feeling of weakness and fatigue, persistent cough, wheezing, and pink blood-tinged mucus may indicate a possible congestive heart failure. Other causes of heart failure include underlying issues like hypertension, coronary diseases, and a previous heart attack.
Mark also reported having stopped working out in the past year due to weakness and a rapid increase in weight. Other signs and symptoms of heart failure shown by the patient include swelling in the legs, feet, and ankles, a rapid and irregular heartbeat. The swelling in the feet and ankles coupled with the rapid gain in weight may suggest fluid buildup in the body. Mark also reported experiencing low or no appetite in recent months, which contradicted his rapid gain in weight. Mark's medical records also show that he is diagnosed with hypertension and currently manages the condition with prescriptions. However, Mark's current medical records did not establish a previous heart attack or a coronary disease.
Mark works out regularly (except since weakness and fatigue manifested) and eats healthy by avoiding fast food. He smokes and drinks beer occasionally. He relies on subsidized housing in San Francisco and lives with his wife and three children. His medical records indicate diagnosis and treatment of hypertension and recommendations to desist alcohol and tobacco. Marks' BMI was 26.0 kg/M2 with a heartbeat rate of 96 beats per minute in the most recent medical assessment.
Nursing Process
Assessment
Subjective data refers to the information gathered from the patient or conversation from the patient's next of kin. In this case, both Mark and his wife reported on the feeling of weakness, fatigue, and shortness of breath. While the subjective data does not necessarily support conclusions that Mark is dealing with a heart attack, it provides the first point of view that it could be a heart attack. On the other hand, objective data refers to the information that can be measured using any of the five human senses. In the case of Mark, objective data included the swelling of the feet, ankles, and legs. The persistent cough and wheezing, and the pink blood-tinged mucus. These are objective data because they can be observed through sight. Further, the patient's past medical history provides another form of objective data. Mark is already diagnosed with hypertension and has been asked to stop smoking and drinking. Combined with the subjective data, the objective data provides further evidence that Mark could be suffering from a possible heart attack.
Mark's medical history is also a source of vital objective data. Essential information from the chart was his BMI and rate of heartbeat and the past diagnoses and treatment of hypertension. The BMI is important because it shows that Mark's weight might impact his rate of heartbeat. The heartbeat rate is vital because it suggests that Mark's heart is working above the normal rate of a healthy adult of his age. Further, the hypertensions diagnosis may reveal an underlying issue leading to the patient's current predicaments. Based on this information, several aspects of my education enable me to formulate the possible connection to heart failure. For instance, the clinical nursing practice was vital in predicting Mark's possibility of having a heart attack. According to Zeng, Zhu, and Zhao (2016), clinical practice in nursing refers to the comprehensive ability to effectively perform safe nursing interventions and practices based on attitudes, skills, professional values, and knowledge acquired through education and work experience. These clinical abilities are critical for nurses in making diagnosis and care decisions.
Diagnosis
According to Cavalcanti and Pereira (2014), nurses who take care of patients with heart failure experience difficulties interpreting symptoms and signals that manifest as a result of heart failure-related pathophysiological processes. Standards of nursing diagnosis, like NANDA-I, are supposed to reduce the difficulties faced by nurses. Nursing diagnosis is the clinical analysis of individual patients and their relatives (da Silva Alves Souza et al., 2017). Concerning cardiovascular functions, NANDA-I provides three descriptors that are key for the nursing diagnosis of congestive heart failure. These include decreased cardiac output, fatigue, and activity intolerance (Pereira & Flores, 2016). The three descriptors form part of the diagnosis in the current paper.
In this case, information was provided by both Mark and his wife. Mark's primary physical diagnosis that suggests heart failure includes shortness of breath, a feeling of fatigue and weakness, tightness in the chest, and bloodstains in the mucus. Other physically visible information includes swelling of the legs, ankles, and feet. Further, the sudden increase in weight reported by the patient besides loss of appetite and inability to work out were significant contributions to th...