INTRODUCTION:

As a lecturer in a college of nursing, my role involves teaching and supervision of students in the clinical areas, to take part in the clinical teaching and to guide the students in the nursing care and education of the patients and families with the goal to achieve the best quality of nursing care. As a key member of the health care team, my cited client a 70 years old female, a known case of IHD and LVF made me realize that these patients demand good medical and continuous nursing attention not only during the hospitalization but need rehabilitative care as well.

CASE SUMMARY

A 70 years old female with known case of IHD with low EF 20%, DM with uncontrolled sugars, HTN, Bronchial asthma since 10-12 years, PTCA done in 2008 was admitted to the hospital with the following complaints:

Ø Breathlessness

Ø Chest pain

Ø Cough with expectorant

Ø Bilateral pedal edema

On Examination:

Ø B.P 150/90 mm of Hg

Ø Pulse: 100/ minute

Ø Respiration: 28/ minute

Ø O2 Saturation 70%

Ø CVS S1 S2+

Ø Abdomen soft and normal bowel sounds

Ø Random Blood Sugar 338 mg/dl

Investigations and the Reasons:

Ø Complete blood count: To assess general condition and infection

Ø ABG: To measure the oxygen and carbon dioxide levels in the blood

Ø Chest X-ray: For the assessment of heart size, pulmonary congestion and pericardial effusion.

Ø ECG : to assess cardiac function

Ø Cardiac Triage: Cardiac markers, specifically cardiac serum enzymes and troponin are important diagnostic criteria for IHD. The cardiac enzyme of primary importance is creatinine kinase (CK). When cardiac cells die, their cellular enzymes are released into circulation.

Ø 2 D Echo color Doppler study revealed Ischemic Cardiomyopathy, severely impaired L.V systolic function ( EF 0-20%), impaired RV systolic function, mild MR and TR, mild PH, congested IVC (PASP=40 mm of Hg) Patient went into CCF/Hypotension//Hypoxia/ AF/Cardiogenic shock and was put on ventilator.

Treatment and Management:

Ø Ventilator support

Ø Inj. Cordaron

Ø I.V Lasix 40 mg

Ø Tab. Atorvas 20mg

Ø Tab. Clopivas 75 mg

Ø Inj. Mixtard 24-0-12

Ø Inj. Actrapid 0-10-0

Ø Nebulization with Budecort BD

Ø Total fluid intake 1.2 L/day

Ø Salt Restricted Diet

Diuretics:

Diuretics are used in heart failure to mobilize edematous fluid, reduce pulmonary venous pressure and reduce preload. If excess extracellular fluid is excreted, blood volume returning to the heart can be reduced and cardiac function improved.²Diuretics act on the kidney by promoting excretion of sodium and water. Thiazide diuretics is the first choice in chronic CHF. They are useful in treating edema secondary to CHF and in controlling hypertension. Loop diuretics e.g. Furosemide (Lasix), is more commonly used in acute CHF.

Nutritional Therapy:

Diet education and weight management play an important role in controlling chronic CHF. Edema of chronic CHF requires dietary restriction of sodium. The Dietary Approach to Stop Hypertension (DASH) diet is effective as a first time therapy. The normal daily dietary intake of sodium ranges from 3-7 gm. For mild CHF 2gm sodium diet and for severe CHF sodium intake is restricted to 500-1000 mg.⁶ ll foods high in sodium is eliminated. Milk, cheese, bread, cereals, canned foods must be eliminated. In moderate to severe CHF and renal insufficiency fluid restrictions are implemented. Daily weight monitoring as well as weight reduction to be done to maintain fluid retention.

Cardiac Rehabilitation:

Cardiac rehabilitation is the restoration of a person to an optimal state of function of six areas: physiologic, psychologic, mental, spiritual, economic and vocational. Patients may recover but may not attain psychologic well - being because of misconception about the illness. Cardiovascular diseases are the major cause of death which kills almost 10 times more women than breast cancer and more deaths in women than men. Cardiovascular disease (CVD) has assumed epidemic proportion in India. Atherosclerosis in Indians has been shown to occur prematurely, that is, at least a decade or two earlier than their counterparts in developed countries.⁵Returning to work and resuming all activities have been outcome measure of cardiac rehabilitation and are important in terms of the cost effectiveness of cardiac care and rehabilitation. In cardiac rehabilitation the nurse and the patient must consider that ischemic heart disease is a chronic disease. It will not be cured nor will it disappear by itself. Therefore basic changes in life style must be made to promote recovery and health.⁵In Cardiac patients control of diabetes is highly recommended because high glucose levels accelerate atherosclerosis and DM has been found to be most single powerful predictor of IHD in women. Women with DM have five times the risk for developing IHD than nondiabetic women.¹Second major cause in CAD is hypertension. Physical inactivity is a third major modifiable risk factor. CAD is greater among persons who have diabetes even those with well controlled blood glucose levels. The incidence of cardiac disease is increased in older adults and is the leading cause of death in older persons. Activity performance, endurance and ability to tolerate stress can be improved in the older adults with physical training. Congestive Heart Failure (CHF) is a complication that occurs when the pumping power of the heart has diminished. It is characterized by ventricular dysfunction, reduced exercise tolerance, diminished quality of life and shortened life expectancy. It is a defect in the ability of the ventricles to pump. The left ventricle loses its ability to generate enough pressure to eject blood forward through the high pressure aorta. The hall mark of systolic dysfunction is a decrease in the left ventricular ejection fraction (EF).⁴ Left sided failure (LVF) results from LV dysfunction which causes blood to back up through the left atrium and into the pulmonary veins. The increased pulmonary pressure causes fluid extravasation from the pulmonary capillary bed into the interstitial and then the alveoli which is manifested as pulmonary congestion and edema.⁴Cardiogenic shock occurs when inadequate oxygen to the tissues because of severe left ventricular failure (LVF). It requires aggressive management of arrhythmias, IABP and use of vasoactive drugs to prevent complications such as ARF.³The nurse can play a major role in teaching health promoting behaviors to the person at risk for CAD. The nurse caring for the older adults with IHD must be aware of the physiologic changes that occur in the cardiovascular system. So it is important that nurses should be included in a cardiac rehabilitation program.

Nursing Management:

Following measures were taken during the Angina attack

Ø Administered oxygen

Ø Checked the vital signs

Ø ECG taken

Ø Pain relief with a nitrate followed by analgesic administered

Ø Auscultation of heart sounds done

Ø Given semi-fowler’s position to the patient

Ø Assured the patient to reduce the anxiety

AMBULATORY AND HOME CARE:

The time spent in providing daily care is an ideal teaching period. Patient is cautioned to avoid exposures to extremes of weather and advised not to eat large, heavy meals. After a heavy meal adequate rest is planned for 1-2 hours because blood is shunted to the GI tract to aid digestion and absorption. So

· Taught the patient and care takers about diets that are low in sodium and reduced in saturated fats

· Maintaining an ideal weight is important because it increases the myocardial workload

· To follow regular exercise program

· Explained the patient and others the proper use of nitroglycerin

· Counseled to assess the psycho logic adjustment of the patient

Collaborative Care:

In person with CHF, oxygen saturation of blood is reduced because the blood is not adequately oxygenated in the lungs. Administration of oxygen improves saturation and meets the needs of tissue oxygen. Thus oxygen therapy helps relieve dyspnea and fatigue. ABG (arterial blood gases) or pulse oximetry is used to monitor the oxygen therapy. A patient with severe CHF requires bed rest with limited activity. Physical and emotional rest allows the patient to conserve energy and decreases the need for oxygen therapy.

CONCLUSION:

Ischemic Heart Disease (IHD) and DM with uncontrolled sugars have been the leading cause of mortality and morbidity, in all age groups of the country. So we need to equip our population to identify the important risk factors like obesity, physical inactivity, stress and consumption of fatty foods to halt the progress of this deadly disease. Our every single effort in this direction are like drops of water saved for the future.³

REFERENCES:

1. American Heart Association: 2002 heart and stroke facts statistics, Dallas, 2002

2. Chyan D: Diabetes and CHD : a time for action, Critical Care Nurse 21:10,2001

3. American Heart Association: WWW. Americanheart.org (Nov 29,2002)

4. Carelock J, Clark AP: Heart failure: pathophysiologic mechanism, Am J Nurs 101:26,2001

5. Lewis Heitkemper Dirksen: Medical-Surgical Nursing: Assessment and Management of Clinical Problems, 6^th edition – 2004

6. World Health Organization: WWW.who.org

Received on 05.04.2016 Modified on 30.04.2016

Asian J. Nur. Edu. and Research.2017; 7(1): 123-125.

DOI: 10.5958/2349-2996.2017.00025.8