AGED CARE
1.
Mrs. Chan is diagnosed as having congestive heart failure caused by excessive fluid overload and leading to foot edema and acute cellulites on the leg. Other than that, she also feels anxiety caused by frequent admission and decreased in physical mobility and uncertainty of the disease.
Congestive heart failure is a clinical syndrome in which the heart fails to maintain an adequate output, resulting in diminished blood flow to the tissues, and congestion in the pulmonary and/or the systemic circulation. The causes of congestive heart failure are diverse. Adverse consequences of the series of physiologic events that initially compensate for the reduced performance of the heart as a pump lead to the symptoms and signs of clinical congestive heart failure ( 2004).
Congestive heart failure can best be understood by first reviewing normal heart function. The amount of blood pumped per minute (the cardiac output), is controlled by an intricate balance of variables including stroke volume, heart rate, preload or inflow volume and pressure, myocardial contractility, afterload or systolic pressure, and the sequence of ventricular activation and contraction. Frank and Starling showed that cardiac stroke work is directly proportional to the length or degree of stretch of the myocardial fiber, and it is useful to describe cardiac function in terms of the ventricular function curve, the Frank-Starling relationship (2000).
The manifestations of heart failure range from sudden death, through cardiogenic shock, to chronic congestive heart failure depending upon the degree of circulatory inadequacy and the rapidity with which it develops. The manifestations include edema, particularly of the dependent portions of the body; a prolonged circulation time; hepatic enlargement (hepatomegaly); a sensation of shortness of breath and suffocation (dyspnea); and distention of the neck veins (2001).
A detailed clinical history is crucial and should address not only current signs and symptoms of heart failure but also signs and symptoms that point to a specific cause of the syndrome, such as coronary artery disease, hypertension or valvular heart disease. It is important to determine whether the patient has had a previous cardiac event, in particular a myocardial infarction (2000). Hypertension and a history of congestive heart failure are two clinical histories that could point out why Mrs. Chan has at present the condition.
Early diagnosis of heart failure is essential for successfully addressing underlying diseases or causes and, in some patients, preventing further myocardial dysfunction and clinical deterioration. However, initial diagnosis may be difficult because the presentations of heart failure can change from no symptoms to pulmonary edema with cardiogenic shock.
Mrs. Chan’s feeling of anxiety is understandable given her situation. Anxiety is uneasiness or uncertainty resulting from anticipating a threat or a danger (2004). On study examined the prevalence of anxiety and its impact on clinical outcomes in patients with congestive heart failure. Clinical implications of the study show that identifying congestive heart failure patients with moderate to high levels of anxiety, using a standard diagnostic tool, may be helpful in improving their long-term prognosis.
2.
Aging is a general physiologic process that is as yet poorly understood. Aging affects cells and the systems made up of them, as well as tissue components such as collagen, and numerous theories have been advanced to explain the phenomenon. In aging humans, there are declines in the circulating levels of some sex hormones, the adrenal androgen dehydroepiandrosterone and its sulfate, and growth hormone ( 2001).
The aging process affects all cells, organs and systems of the body. The earliest noticeable signs of the process are usually exhibited by the muscoloskeletal system; thinning and wrinkling of the skin, graying and/or loss of hair, loss of bone mass, increase in body fat, decrease in muscle mass and strength, and joint pains and stiffness that is worse in the morning. The sensory organs become less acute; reading glasses become necessary; the ear is unable to hear high pitch sounds: food tastes more bland; and the sense of smell becomes less discriminating.
The liver which is the major metabolic organ in the body show levels of activity drop in relation to aging. This decreased activity could result in slowed detoxification of some compounds and reduced excretion rates, which can result in higher effective circulating levels and longer half-lives (2005).
The reflexes become duller and motor responses get delayed. The deterioration of the heart and lungs manifest as increasing difficulty to perform strenuous activities; climbing stairs become an ordeal. All the other organs also weaken. They lose most of their reserve capacities and are unable to perform their assigned functions as efficiently. The immune system becomes less active and the person becomes more susceptible to infection (2004).
Digestion becomes less effective the person is unable to tolerate many foodstuffs and becomes susceptible to malnutrition. Females go into menopause and lose their ability to reproduce. Males retain their reproductive capacity but develop erectile and/or other sexual dysfunctions.
The elimination of toxicants and their metabolites is affected by age-related changes in hepatic function, described above, and by decreased kidney function. A decrease in the rate of renal clearance results in an increase in the elimination half-life of a compound. Renal changes observed with age include a decrease in mass of the kidneys, a reduction in the size and number of nephrons, a decrease in renal blood flow, and reductions in glomerular filtration rate, renal plasma flow, and tubular function. In addition, the alterations in pulmonary function that affect absorption of gases and volatile compounds also will affect their excretion through the pulmonary route. There is also evidence that bile flow and biliary transport is reduced with aging, thus reducing excretion through that route ( 2005).
Another potential area of concern is changes in the blood-brain barrier with aging, resulting in increased permeability of the cerebral microvasculature to toxicants that could result in neurodegenerative disease. Most data currently indicate that there are no significant changes in permeability with normal aging. Diseases often associated with aging, however, such as diabetes, hypertension, and cerebral ischemic events, may compromise this barrier function. This may be important in understanding the environmental etiology of conditions such as Parkinsonism, which has been linked to exposure to some compounds that ordinarily show limited penetration of the blood-brain barrier ( 2005).
Major physiologic changes occur with aging of the heart. Heart functions begin to slow down with age. The aging process reduces the heart muscle strength. So its pumping power declines, and the maximal heart rate also decreases. When the amount of blood pumped by the heart in a minute declines, systolic blood pressure tends to rise. The left ventricular wall thickens, systolic function decreases, and heart rate response to exercise is blunted. Maximal oxygen consumption declines, left ventricular filling declines, cardiac output remains normal or declines and the cardiothoracic ratio increases (1998).
There are some common problems associated with the heart as an effect of the aging process. One of these is atherosclerosis. Arteriosclerosis is the hardening or clogging of the arteries due to excessive build up of fat and cholesterol known as plaque. Fatty plaque deposits inside the blood vessels cause it to narrow and can totally block blood vessels and also cause the valves that control the direction of blood flow to thicken and become stiff. Arteriosclerosis in turn is the underlying cause of most cardiovascular diseases (2001).
With aging, the heart has to work harder due to decreased blood supply ( 2001). Greater force is necessary to push blood through narrowed vessels due to plaque build up. So high blood pressure develops and this buildup and shortage of oxygenated blood over time, leads to heart attacks. In a heart attack, a part of the heart muscle becomes starved for oxygen and dies.
Congestive heart failure, that which Mrs. Chan experienced, is also very common in the aging population. In people older than 75, heart failure occurs 10 times more often than in younger adults (1998).
3.
The assessment of heart function involves a review of signs and symptoms from the medical history, pulse assessment, and direct examination of the heart. A patient who has signs and symptoms of cardiac problems may be suffering a life-threatening condition requiring immediate attention.
When such is the case, health care professionals should act quickly and decide on the portions of examination that are absolutely necessary for the patient. When the patient’s condition is stable, a more thorough assessment can reveal baseline heart function and any risks for heart disease.
To establish the diagnosis of congestive heart failure, a physical examination should be performed which should include exam for jugular venous distention, cardiac auscultation, pulmonary exam and peripheral edema. Jugular venous distention and bilateral leg edema are both observed in Mrs. Chan, clearly indicating a possible congestive heart failure.
Initial diagnostic tests to confirm the diagnosis includes an echocardiogram performed for patients with symptoms highly suggestive of congestive heart failure due to the lack of sensitivity of physical findings in some patients with congestive heart failure. Patients with mild symptoms such as fatigue or peripheral edema should only undergo echocardiography if there are physical or radiologic findings suggestive of heart failure. The constellation of the patient’s symptoms and the findings from a physical examination, chest radiograph, and echocardiogram clearly establish a diagnosis of congestive heart failure (2003).
The performance of a 12-lead electrocardiogram (ECG) is essential in the evaluation of a patient with congestive heart failure. Evidence of myocardial infarction or conduction abnormalities such as left bundle-branch block and other abnormalities serve to heighten the suspicion of left ventricular systolic dysfunction.
An ECG evaluation also is needed to role out arrhythmias that can worsen symptoms of congestive heart failure or predict potential complications such as sudden cardiac death. Since atrial tachyarrhythmias such as atrial fibrillation with uncontrolled ventricular response may be the sole cause of congestive heart failure and left ventricular dysfunction, the early identification of this arrhythmia is crucial (2003).
Patients with a confirmed diagnosis of congestive heart failure should have the following tests performed to screen for the underlying causes of the heart failure: ECG, CBC, UA, serum creatinine, serum albumin, and echocardiogram. If the patient has an atrial fibrillation or flutter or is over 65 years old, a T4 or TSH should also be obtained.
A newer tool being used in the diagnosis and assessment of CHF is the measurement of blood levels of B-type natriuretic peptide (BNP). BNP is a peptide that is secreted by the left ventricle in response to stretch and can be used to differentiate dyspnea due to congestive heart failure from that caused by COPD, obesity, or other chronic illnesses. The patient presented, however, has fairly classic signs and symptoms of congestive heart failure, so a BNP level would predictably be elevated and would add little to the diagnosis. On the other hand, a BNP level at the time of this patient’s initial presentation would likely have allowed for an earlier diagnosis (2003).
The management of heart failure is based on its physiologic concepts. Therapy includes rest, oxygenation, measures to improve myocardial contractility, correction of arrhythmias, diuresis, sodium restriction, and reduction of afterload if possible. Even in the most urgent situation, the cause of the heart failure must be determined, any correctable conditions searched for, and contributing factors eliminated (2003).
Robust clinical trials have demonstrated the benefits of therapy with various [beta]-blockers in patients with congestive heart failure. Bisoprolol, long-acting metoprolol, and carvedilol have all been shown to improve survival and to decrease hospitalizations for heart failure. In the instance of severe congestive heart failure, only carvedilol thus far has been demonstrated to improve survival and is also well-tolerated. Although several small trials have demonstrated differences among patient responses to these agents, a large, randomized direct comparison trial demonstrating the superiority of one over another has not yet been completed (2003).
For a patient with congestive heart failure, left ventricular dysfunction, the same approach to the initial medical management should be taken. The consideration of surgical revascularization, however, should be undertaken soon after the patient presents, especially if the patient has chest pain or objective evidence of ischemia. The assessment of myocardial viability using the noninvasive techniques described above is important, particularly since the patient’s risk of surgery is usually quite high. If extensive myocardial scarring were found with little evidence of viability, surgical or mechanical revascularization would be inadvisable.
If the expected improvement does not occur and the patient’s symptoms worsen, other therapies, including transplantation should be considered. If Mrs. Chan’s ECG findings demonstrate a marked intraventricular conduction delay, cardiac resynchronization with a biventricular pacing device may be beneficial. Should transplantation prove to be the only viable option, evaluation for any concomitant diseases that would preclude transplantation (eg, cancer and severe renal dysfunction) should be undertaken. The decision regarding listing the patient for cardiac transplantation can be facilitated by an assessment of a patient’s exercise-induced maximal oxygen uptake.
A peak oxygen uptake of < 14 mL/kg/min (or < 50% of predicted normal values) or the need for continuous therapy with IV inotropic agents generally identifies the need for transplantation. The placement of an implantable left ventricular assist device is sometimes needed as a “bridge” to cardiac transplantation for a patient who requires a greater degree of hemodynamic support (2003).
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