Evaluating The Congestive Heart Failure Nursing Plan Nursing Essay

As defined by Phipp’s (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007) congestive heart failure occurs when, the myocardium of the heart is unable to uphold a sufficient cardiac output to meet the body’s metabolic needs. Heart failure can result from either systolic or diastolic dysfunction (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007). Assessment tools that will be used in the assessment of Mr. Toscana include, head to toe, physical, and systems assessments. A risk assessment will also be done on Mr. Toscana to insure that he is safe in hospital (Berman, A, Kozier, B, Erb, G.L, 2008,). As Mr. Toscana suffers from congestive heart failure a wide range of education and psychosocial support is available to help with his condition (Heart Foundation, 2010). A nursing care plan has been made to show four nursing diagnoses and interventions to reduce the impact of the diagnosis. These nursing diagnoses’s can be solved through a variety of diagnostic tests to make sure that every possible outcome is looked at (Berman, A, Kozier, B, Erb, G.L, 2008). Mr. Toscana is taking a few medications at the present time to manage his cardiac issues along with other medical conditions he suffers from, these medications are, Lasix, digoxin, aspirin, warfarin and perindopril. (Tiziani, A, 2010), (Better Health Channel, 2010)

PATHOPHYSIOLOGY OF CONGESTIVE CARDIAC FAILURE Both systolic and diastolic heart failure are second to myocardial injury. Progression of heart failure is highly dependent on the level of ventricular remodelling, this occurs after myocardial injury (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007). The changes in ventricle shape and dimension will cause a decrease in its effectiveness as a pump. An increase on diastolic pressure possibly will further change the shape of the left ventricle, thus resulting in papillary muscle rearrangement and mitral insufficiency. It is more common for congestive heart failure to begin in the left ventricular systolic dysfunction. Some of the common causes for decreased left ventricular stenosis include that of, CAD, systemic hypertension, and aortic stenosis. CAD by diminishing the oxygen supply to the myofibrils decreases contractility. Hypertension causes the left ventricle to contract more with more force to eject blood into the aorta. (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007) Over a period of time hypertrophy of the muscle fibres happens and an increase in myocardial oxygen consumption occurs. Aortic stenosis, the left ventricle must increase its pumping force to deliver blood through the tight valve. Heart failure will be the result when the hearts need of oxygen cannot be met and blood remains at the end of systole. (Mccance, K, Huether, S.E, Brashers, V.L, Rote, N.S, 2010,)

CLINICAL MANIFESTATIONS OF CONGESTIVE HEART FAILURE As stated in Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007, Page 814, ‘the clinical manifestations of heart failure occur secondary to elevated filing pressure and tissue hyperfusion’ Clinical manifestations of congestive heart failure can be broken down into the systems in which they affect the respiratory, cardiovascular, gastrointestinal systems and show effects in both cerebral and psychosocial. Clinical manifestations in respiratory are, dyspnoea, orthopnea, a persistent cough, crackles in the lungs. The cardiovascular system is affected by, the onset of angina, tachycardia, increase of systolic blood pressure and an increase in systolic blood pressure. Gastrointestinal clinical manifestations include that of, enlargement of the right upper quadrant of the abdomen, nausea and vomiting, pain in the epigastric region, anorexia and bloating. Confusion and restlessness can be seen as manifestations of cerebral, and anxiety is associated with manifestations to psychosocial. Generalised manifestations include oedema; either pitting or peripheral, weight gain and fatigue. (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007), (Mccance, K, Huether, S.E, Brashers, V.L, Rote, N.S, 2010,), (Better Health Channel, 2010)

NURSING ASSESSMENT OF MR. TOSCANA For Mr. Toscana a variety of nursing assessments will be done upon admission. As well as the usual monitoring of vital signs, assessments such as, head to toe, physical and systems assessments, need to be completed. A head to toe assessment will be performed to give a detail initial assessment studying the whole body to see if there is any other factors that may cause harm or pain, in a head to toe assessment circulatory problems, pressure areas, existing wounds, can all be seen as well as gaining an in depth assessment of the skin. A physical assessment will be done on Mr. Toscana will also be performed, a physical assessment includes, inspection; which is the visual inspection of a person, palpation; the examination done by touch, auscultation; a form of examination by listening to the sounds made by the body (heart, lung and bowel), percussion; the examination done by tapping, percussion is done to listen for abnormal sounds and detect issue (Berman, A, Kozier, B, Erb, G.L, 2008,). A systems assessment of Mr. Toscana will be beneficial because, along with the other forms of assessment a systems will be able to give a base mark of where he is, a systems assessment covers, central nervous (CNS), cardiovascular (CVS) assesses, respiratory (RESP), gastrointestinal (GIT), renal (RENAL), skin integrity (SKIN), and psychosocial (PSYCH). Together these forms assessment will provide a detailed amount of information to create a nursing care plan for Mr. Toscana, including interventions that need to be made, and things to implement to further his recovery and aid in his discharge. (Berman, A, Kozier, B, Erb, G.L, 2008,).

NURSING CARE PLAN Please refer to appendices one for full nursing care plan. (Berman, A, Kozier, B, Erb, G.L, 2008,). (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007), (Heart Foundation, 2010), (Holmesglen, 2009), (Better Health Channel, 2010)

DIAGNOSTIC TESTS For Mr. Toscana there are a number of diagnostic tests that will help with the assessment, management and detection of underlying issues. Tests that can be performed on Mr. Toscana are as follows, a chest X-ray to see if there are any problems with his lungs, or vascular congestion, or congestion of the liver (this can suggest right sided failure) (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007), a full blood test including electrolytes, an ECG to check the rhythm of the heart, and determine the causes for Mr. Toscana’s symptoms. The use of urine analysis to see if infection is present, function of kidneys, traces of blood in relation to fluid build up. The combination of these tests will provide a baseline for assessment, guide the nursing care, and rule out all other possible causes of the symptoms that Mr. Toscana has presented with. (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007)

RISK ASSESMENT From the history of Mr. Toscana a risk assessment can be done. Assessments such as falls, and pressure care. A falls risk assessment will be done on Mr. Toscana to determine the risk he is of falling, and if further measures need to be implemented to insure that he is safe while in hospital, a suitable framework for a falls risk is the FRAT tool, (Falls Risk Assessment Tool), (Department Of Human Services Victoria, 2005) a FRAT tool will show the level of risk that Mr. Toscana is, and risk factors. A pressure area risk check can be done by using the Braden risk assessment tool (Berman, A, Kozier, B, Erb, G.L, 2008,), (South Australia Health, Date Unknown). this will help minimise the risk of Mr. Toscana developing pressure areas where possible. Things at home can also be deemed a risk, things such as; not being compliant with his medications can lead to poor health, and stress can all affect his general wellbeing and lead to further the progression of medical conditions.

EDUCATION AND PSYCHOSOCIAL SUPPORT For Mr. Toscana education is a must, education about the maintenance of his congestive heart failure, about the importance of taking medication on a regular basis. How to manage the affects of his congestive cardiac failure, and avoid the effects, support for Mr. Toscana is also imperative to aid in his recovery things such as providing strategies to minimise the health problems, referral to a social worker to help with issues that are affecting him at home. Support groups set up by the heart foundation of Victoria will help with the emotional issues related to having this condition. (Heart Foundation, 2010) The importance of education and psychosocial support will be seen through less medical admissions or problems, increased quality of life and will give Mr. Toscana the ability to be able to deal with small problems before they grow into something much bigger. (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007) , (Berman, A, Kozier, B, Erb, G.L, 2008,) (Better Health Channel, 2010)

MEDICATIONS Mr. Toscana is taking a number of medications including, warfarin and digoxin. The action of Digoxin is, it increase the myocardial contraction force in the failing heart, decreases conductivity of the heart in particular the A-V node, increase on vagal activity this results in the slowing of the sinoatrial nodal rate, increases myocardial excitability this can result in ectopic beats this happens mostly through high doses of digoxin, oral digoxin effective in an approximate time frame of 1 hour, maximal effect is reached between four and six hours. The use of digoxin for Mr. Toscana is, to treat his congestive heart failure. Digoxin may produce a false ST-T wave change on an ECG if tested during exercise. Digoxin can cause the following adverse effects, gastrointestinal issues including, anorexia, nausea, vomiting, diarrhoea, and pain in the abdomen. Cardiovascular effects, ectopic beats, bradycardia, heart block. Tachycardia (ventricular). The adverse effect of toxicity is a decrease on appetite, nausea, vomiting, diarrhoea, severe stomach pains, weakness and tiredness, a slow and irregular heartbeat, blurred vision, drowsiness, mental depression or confusion, fainting and headaches. Nursing points/precautions which should be followed are that the tablet should never be halved; neither IM nor SC routes are recommended due to unpredictable absorption, because prolonged or intense pain and necrosis of the muscle to the client (Intramuscular), severe irritation may occur when given via a subcutaneous injection. A rapid IV administration should be avoided as it may cause hypertension and vasoconstriction. The action of warfarin is a suppressant of vitamin-K dependant synthesis of prothrombin in the liver, this prevents the extension of a clot that is already established of the formation of a new one, warfarin has an anticoagulant effect that is produced after 36-72 hours and can persist for between 4 and 5 days after the discontinuation of therapy. The use of warfarin is, as a prevention and management of the following, deep vein thrombosis (DVT) or pulmonary embolism, thromboembolism in atrial fibrillation, and can be used as an adjunct to therapy for coronary occlusion. For Mr. Toscana there is no relevant interaction with this drug. The adverse effects of warfarin are fatal or non fatal bleeding, nausea, vomiting, diarrhoea, alopecia, fever, hypersensitivity reaction, an overdose is seen by bleeding from the gums and haematuria, in rare cases skin necrosis is also seen. Some of the nursing points and precautions with warfarin are, that all intramuscular injections be avoided, and subcutaneous injection sites should be closely monitored for haematoma, make sure that the does is given the same time daily to Mr. Toscana, observation for the early signs of overdose things such bleeding especially important from the gums.( Tiziani, A, 2010)

CONCLUSION Through a range of assessments, diagnostic testing, education and the development of a nursing care plan Mr. Toscana’s condition should improve as well as his general wellbeing. Goals set out in the care plan will be achieved by interventions put in place insuring a quicker recovery for Mr. Toscana. Education is particularly important for Mr. Toscana’s medication regime, support strategies will help with the improvement of overall health and wellbeing.

As defined by Phipp’s (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007) congestive heart failure occurs when, the myocardium of the heart is unable to uphold a sufficient cardiac output to meet the body’s metabolic needs. Heart failure can result from either systolic or diastolic dysfunction (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007). Assessment tools that will be used in the assessment of Mr. Toscana include, head to toe, physical, and systems assessments. A risk assessment will also be done on Mr. Toscana to insure that he is safe in hospital (Berman, A, Kozier, B, Erb, G.L, 2008,). As Mr. Toscana suffers from congestive heart failure a wide range of education and psychosocial support is available to help with his condition (Heart Foundation, 2010). A nursing care plan has been made to show four nursing diagnoses and interventions to reduce the impact of the diagnosis. These nursing diagnoses’s can be solved through a variety of diagnostic tests to make sure that every possible outcome is looked at (Berman, A, Kozier, B, Erb, G.L, 2008). Mr. Toscana is taking a few medications at the present time to manage his cardiac issues along with other medical conditions he suffers from, these medications are, Lasix, digoxin, aspirin, warfarin and perindopril. (Tiziani, A, 2010), (Better Health Channel, 2010)

PATHOPHYSIOLOGY OF CONGESTIVE CARDIAC FAILURE Both systolic and diastolic heart failure are second to myocardial injury. Progression of heart failure is highly dependent on the level of ventricular remodelling, this occurs after myocardial injury (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007). The changes in ventricle shape and dimension will cause a decrease in its effectiveness as a pump. An increase on diastolic pressure possibly will further change the shape of the left ventricle, thus resulting in papillary muscle rearrangement and mitral insufficiency. It is more common for congestive heart failure to begin in the left ventricular systolic dysfunction. Some of the common causes for decreased left ventricular stenosis include that of, CAD, systemic hypertension, and aortic stenosis. CAD by diminishing the oxygen supply to the myofibrils decreases contractility. Hypertension causes the left ventricle to contract more with more force to eject blood into the aorta. (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007) Over a period of time hypertrophy of the muscle fibres happens and an increase in myocardial oxygen consumption occurs. Aortic stenosis, the left ventricle must increase its pumping force to deliver blood through the tight valve. Heart failure will be the result when the hearts need of oxygen cannot be met and blood remains at the end of systole. (Mccance, K, Huether, S.E, Brashers, V.L, Rote, N.S, 2010,)

CLINICAL MANIFESTATIONS OF CONGESTIVE HEART FAILURE As stated in Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007, Page 814, ‘the clinical manifestations of heart failure occur secondary to elevated filing pressure and tissue hyperfusion’ Clinical manifestations of congestive heart failure can be broken down into the systems in which they affect the respiratory, cardiovascular, gastrointestinal systems and show effects in both cerebral and psychosocial. Clinical manifestations in respiratory are, dyspnoea, orthopnea, a persistent cough, crackles in the lungs. The cardiovascular system is affected by, the onset of angina, tachycardia, increase of systolic blood pressure and an increase in systolic blood pressure. Gastrointestinal clinical manifestations include that of, enlargement of the right upper quadrant of the abdomen, nausea and vomiting, pain in the epigastric region, anorexia and bloating. Confusion and restlessness can be seen as manifestations of cerebral, and anxiety is associated with manifestations to psychosocial. Generalised manifestations include oedema; either pitting or peripheral, weight gain and fatigue. (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007), (Mccance, K, Huether, S.E, Brashers, V.L, Rote, N.S, 2010,), (Better Health Channel, 2010)

NURSING ASSESSMENT OF MR. TOSCANA For Mr. Toscana a variety of nursing assessments will be done upon admission. As well as the usual monitoring of vital signs, assessments such as, head to toe, physical and systems assessments, need to be completed. A head to toe assessment will be performed to give a detail initial assessment studying the whole body to see if there is any other factors that may cause harm or pain, in a head to toe assessment circulatory problems, pressure areas, existing wounds, can all be seen as well as gaining an in depth assessment of the skin. A physical assessment will be done on Mr. Toscana will also be performed, a physical assessment includes, inspection; which is the visual inspection of a person, palpation; the examination done by touch, auscultation; a form of examination by listening to the sounds made by the body (heart, lung and bowel), percussion; the examination done by tapping, percussion is done to listen for abnormal sounds and detect issue (Berman, A, Kozier, B, Erb, G.L, 2008,). A systems assessment of Mr. Toscana will be beneficial because, along with the other forms of assessment a systems will be able to give a base mark of where he is, a systems assessment covers, central nervous (CNS), cardiovascular (CVS) assesses, respiratory (RESP), gastrointestinal (GIT), renal (RENAL), skin integrity (SKIN), and psychosocial (PSYCH). Together these forms assessment will provide a detailed amount of information to create a nursing care plan for Mr. Toscana, including interventions that need to be made, and things to implement to further his recovery and aid in his discharge. (Berman, A, Kozier, B, Erb, G.L, 2008,).

NURSING CARE PLAN Please refer to appendices one for full nursing care plan. (Berman, A, Kozier, B, Erb, G.L, 2008,). (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007), (Heart Foundation, 2010), (Holmesglen, 2009), (Better Health Channel, 2010)

DIAGNOSTIC TESTS For Mr. Toscana there are a number of diagnostic tests that will help with the assessment, management and detection of underlying issues. Tests that can be performed on Mr. Toscana are as follows, a chest X-ray to see if there are any problems with his lungs, or vascular congestion, or congestion of the liver (this can suggest right sided failure) (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007), a full blood test including electrolytes, an ECG to check the rhythm of the heart, and determine the causes for Mr. Toscana’s symptoms. The use of urine analysis to see if infection is present, function of kidneys, traces of blood in relation to fluid build up. The combination of these tests will provide a baseline for assessment, guide the nursing care, and rule out all other possible causes of the symptoms that Mr. Toscana has presented with. (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007)

RISK ASSESMENT From the history of Mr. Toscana a risk assessment can be done. Assessments such as falls, and pressure care. A falls risk assessment will be done on Mr. Toscana to determine the risk he is of falling, and if further measures need to be implemented to insure that he is safe while in hospital, a suitable framework for a falls risk is the FRAT tool, (Falls Risk Assessment Tool), (Department Of Human Services Victoria, 2005) a FRAT tool will show the level of risk that Mr. Toscana is, and risk factors. A pressure area risk check can be done by using the Braden risk assessment tool (Berman, A, Kozier, B, Erb, G.L, 2008,), (South Australia Health, Date Unknown). this will help minimise the risk of Mr. Toscana developing pressure areas where possible. Things at home can also be deemed a risk, things such as; not being compliant with his medications can lead to poor health, and stress can all affect his general wellbeing and lead to further the progression of medical conditions.

EDUCATION AND PSYCHOSOCIAL SUPPORT For Mr. Toscana education is a must, education about the maintenance of his congestive heart failure, about the importance of taking medication on a regular basis. How to manage the affects of his congestive cardiac failure, and avoid the effects, support for Mr. Toscana is also imperative to aid in his recovery things such as providing strategies to minimise the health problems, referral to a social worker to help with issues that are affecting him at home. Support groups set up by the heart foundation of Victoria will help with the emotional issues related to having this condition. (Heart Foundation, 2010) The importance of education and psychosocial support will be seen through less medical admissions or problems, increased quality of life and will give Mr. Toscana the ability to be able to deal with small problems before they grow into something much bigger. (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007) , (Berman, A, Kozier, B, Erb, G.L, 2008,) (Better Health Channel, 2010)

MEDICATIONS Mr. Toscana is taking a number of medications including, warfarin and digoxin. The action of Digoxin is, it increase the myocardial contraction force in the failing heart, decreases conductivity of the heart in particular the A-V node, increase on vagal activity this results in the slowing of the sinoatrial nodal rate, increases myocardial excitability this can result in ectopic beats this happens mostly through high doses of digoxin, oral digoxin effective in an approximate time frame of 1 hour, maximal effect is reached between four and six hours. The use of digoxin for Mr. Toscana is, to treat his congestive heart failure. Digoxin may produce a false ST-T wave change on an ECG if tested during exercise. Digoxin can cause the following adverse effects, gastrointestinal issues including, anorexia, nausea, vomiting, diarrhoea, and pain in the abdomen. Cardiovascular effects, ectopic beats, bradycardia, heart block. Tachycardia (ventricular). The adverse effect of toxicity is a decrease on appetite, nausea, vomiting, diarrhoea, severe stomach pains, weakness and tiredness, a slow and irregular heartbeat, blurred vision, drowsiness, mental depression or confusion, fainting and headaches. Nursing points/precautions which should be followed are that the tablet should never be halved; neither IM nor SC routes are recommended due to unpredictable absorption, because prolonged or intense pain and necrosis of the muscle to the client (Intramuscular), severe irritation may occur when given via a subcutaneous injection. A rapid IV administration should be avoided as it may cause hypertension and vasoconstriction. The action of warfarin is a suppressant of vitamin-K dependant synthesis of prothrombin in the liver, this prevents the extension of a clot that is already established of the formation of a new one, warfarin has an anticoagulant effect that is produced after 36-72 hours and can persist for between 4 and 5 days after the discontinuation of therapy. The use of warfarin is, as a prevention and management of the following, deep vein thrombosis (DVT) or pulmonary embolism, thromboembolism in atrial fibrillation, and can be used as an adjunct to therapy for coronary occlusion. For Mr. Toscana there is no relevant interaction with this drug. The adverse effects of warfarin are fatal or non fatal bleeding, nausea, vomiting, diarrhoea, alopecia, fever, hypersensitivity reaction, an overdose is seen by bleeding from the gums and haematuria, in rare cases skin necrosis is also seen. Some of the nursing points and precautions with warfarin are, that all intramuscular injections be avoided, and subcutaneous injection sites should be closely monitored for haematoma, make sure that the does is given the same time daily to Mr. Toscana, observation for the early signs of overdose things such bleeding especially important from the gums.( Tiziani, A, 2010)

CONCLUSION Through a range of assessments, diagnostic testing, education and the development of a nursing care plan Mr. Toscana’s condition should improve as well as his general wellbeing. Goals set out in the care plan will be achieved by interventions put in place insuring a quicker recovery for Mr. Toscana. Education is particularly important for Mr. Toscana’s medication regime, support strategies will help with the improvement of overall health and wellbeing.

As defined by Phipp’s (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007) congestive heart failure occurs when, the myocardium of the heart is unable to uphold a sufficient cardiac output to meet the body’s metabolic needs. Heart failure can result from either systolic or diastolic dysfunction (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007). Assessment tools that will be used in the assessment of Mr. Toscana include, head to toe, physical, and systems assessments. A risk assessment will also be done on Mr. Toscana to insure that he is safe in hospital (Berman, A, Kozier, B, Erb, G.L, 2008,). As Mr. Toscana suffers from congestive heart failure a wide range of education and psychosocial support is available to help with his condition (Heart Foundation, 2010). A nursing care plan has been made to show four nursing diagnoses and interventions to reduce the impact of the diagnosis. These nursing diagnoses’s can be solved through a variety of diagnostic tests to make sure that every possible outcome is looked at (Berman, A, Kozier, B, Erb, G.L, 2008). Mr. Toscana is taking a few medications at the present time to manage his cardiac issues along with other medical conditions he suffers from, these medications are, Lasix, digoxin, aspirin, warfarin and perindopril. (Tiziani, A, 2010), (Better Health Channel, 2010)

PATHOPHYSIOLOGY OF CONGESTIVE CARDIAC FAILURE Both systolic and diastolic heart failure are second to myocardial injury. Progression of heart failure is highly dependent on the level of ventricular remodelling, this occurs after myocardial injury (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007). The changes in ventricle shape and dimension will cause a decrease in its effectiveness as a pump. An increase on diastolic pressure possibly will further change the shape of the left ventricle, thus resulting in papillary muscle rearrangement and mitral insufficiency. It is more common for congestive heart failure to begin in the left ventricular systolic dysfunction. Some of the common causes for decreased left ventricular stenosis include that of, CAD, systemic hypertension, and aortic stenosis. CAD by diminishing the oxygen supply to the myofibrils decreases contractility. Hypertension causes the left ventricle to contract more with more force to eject blood into the aorta. (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007) Over a period of time hypertrophy of the muscle fibres happens and an increase in myocardial oxygen consumption occurs. Aortic stenosis, the left ventricle must increase its pumping force to deliver blood through the tight valve. Heart failure will be the result when the hearts need of oxygen cannot be met and blood remains at the end of systole. (Mccance, K, Huether, S.E, Brashers, V.L, Rote, N.S, 2010,)

CLINICAL MANIFESTATIONS OF CONGESTIVE HEART FAILURE As stated in Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007, Page 814, ‘the clinical manifestations of heart failure occur secondary to elevated filing pressure and tissue hyperfusion’ Clinical manifestations of congestive heart failure can be broken down into the systems in which they affect the respiratory, cardiovascular, gastrointestinal systems and show effects in both cerebral and psychosocial. Clinical manifestations in respiratory are, dyspnoea, orthopnea, a persistent cough, crackles in the lungs. The cardiovascular system is affected by, the onset of angina, tachycardia, increase of systolic blood pressure and an increase in systolic blood pressure. Gastrointestinal clinical manifestations include that of, enlargement of the right upper quadrant of the abdomen, nausea and vomiting, pain in the epigastric region, anorexia and bloating. Confusion and restlessness can be seen as manifestations of cerebral, and anxiety is associated with manifestations to psychosocial. Generalised manifestations include oedema; either pitting or peripheral, weight gain and fatigue. (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007), (Mccance, K, Huether, S.E, Brashers, V.L, Rote, N.S, 2010,), (Better Health Channel, 2010)

NURSING ASSESSMENT OF MR. TOSCANA For Mr. Toscana a variety of nursing assessments will be done upon admission. As well as the usual monitoring of vital signs, assessments such as, head to toe, physical and systems assessments, need to be completed. A head to toe assessment will be performed to give a detail initial assessment studying the whole body to see if there is any other factors that may cause harm or pain, in a head to toe assessment circulatory problems, pressure areas, existing wounds, can all be seen as well as gaining an in depth assessment of the skin. A physical assessment will be done on Mr. Toscana will also be performed, a physical assessment includes, inspection; which is the visual inspection of a person, palpation; the examination done by touch, auscultation; a form of examination by listening to the sounds made by the body (heart, lung and bowel), percussion; the examination done by tapping, percussion is done to listen for abnormal sounds and detect issue (Berman, A, Kozier, B, Erb, G.L, 2008,). A systems assessment of Mr. Toscana will be beneficial because, along with the other forms of assessment a systems will be able to give a base mark of where he is, a systems assessment covers, central nervous (CNS), cardiovascular (CVS) assesses, respiratory (RESP), gastrointestinal (GIT), renal (RENAL), skin integrity (SKIN), and psychosocial (PSYCH). Together these forms assessment will provide a detailed amount of information to create a nursing care plan for Mr. Toscana, including interventions that need to be made, and things to implement to further his recovery and aid in his discharge. (Berman, A, Kozier, B, Erb, G.L, 2008,).

NURSING CARE PLAN Please refer to appendices one for full nursing care plan. (Berman, A, Kozier, B, Erb, G.L, 2008,). (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007), (Heart Foundation, 2010), (Holmesglen, 2009), (Better Health Channel, 2010)

DIAGNOSTIC TESTS For Mr. Toscana there are a number of diagnostic tests that will help with the assessment, management and detection of underlying issues. Tests that can be performed on Mr. Toscana are as follows, a chest X-ray to see if there are any problems with his lungs, or vascular congestion, or congestion of the liver (this can suggest right sided failure) (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007), a full blood test including electrolytes, an ECG to check the rhythm of the heart, and determine the causes for Mr. Toscana’s symptoms. The use of urine analysis to see if infection is present, function of kidneys, traces of blood in relation to fluid build up. The combination of these tests will provide a baseline for assessment, guide the nursing care, and rule out all other possible causes of the symptoms that Mr. Toscana has presented with. (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007)

RISK ASSESMENT From the history of Mr. Toscana a risk assessment can be done. Assessments such as falls, and pressure care. A falls risk assessment will be done on Mr. Toscana to determine the risk he is of falling, and if further measures need to be implemented to insure that he is safe while in hospital, a suitable framework for a falls risk is the FRAT tool, (Falls Risk Assessment Tool), (Department Of Human Services Victoria, 2005) a FRAT tool will show the level of risk that Mr. Toscana is, and risk factors. A pressure area risk check can be done by using the Braden risk assessment tool (Berman, A, Kozier, B, Erb, G.L, 2008,), (South Australia Health, Date Unknown). this will help minimise the risk of Mr. Toscana developing pressure areas where possible. Things at home can also be deemed a risk, things such as; not being compliant with his medications can lead to poor health, and stress can all affect his general wellbeing and lead to further the progression of medical conditions.

EDUCATION AND PSYCHOSOCIAL SUPPORT For Mr. Toscana education is a must, education about the maintenance of his congestive heart failure, about the importance of taking medication on a regular basis. How to manage the affects of his congestive cardiac failure, and avoid the effects, support for Mr. Toscana is also imperative to aid in his recovery things such as providing strategies to minimise the health problems, referral to a social worker to help with issues that are affecting him at home. Support groups set up by the heart foundation of Victoria will help with the emotional issues related to having this condition. (Heart Foundation, 2010) The importance of education and psychosocial support will be seen through less medical admissions or problems, increased quality of life and will give Mr. Toscana the ability to be able to deal with small problems before they grow into something much bigger. (Monahan, F, Sands, J, Neighbours, M, Marek, J.F, 2007) , (Berman, A, Kozier, B, Erb, G.L, 2008,) (Better Health Channel, 2010)

MEDICATIONS Mr. Toscana is taking a number of medications including, warfarin and digoxin. The action of Digoxin is, it increase the myocardial contraction force in the failing heart, decreases conductivity of the heart in particular the A-V node, increase on vagal activity this results in the slowing of the sinoatrial nodal rate, increases myocardial excitability this can result in ectopic beats this happens mostly through high doses of digoxin, oral digoxin effective in an approximate time frame of 1 hour, maximal effect is reached between four and six hours. The use of digoxin for Mr. Toscana is, to treat his congestive heart failure. Digoxin may produce a false ST-T wave change on an ECG if tested during exercise. Digoxin can cause the following adverse effects, gastrointestinal issues including, anorexia, nausea, vomiting, diarrhoea, and pain in the abdomen. Cardiovascular effects, ectopic beats, bradycardia, heart block. Tachycardia (ventricular). The adverse effect of toxicity is a decrease on appetite, nausea, vomiting, diarrhoea, severe stomach pains, weakness and tiredness, a slow and irregular heartbeat, blurred vision, drowsiness, mental depression or confusion, fainting and headaches. Nursing points/precautions which should be followed are that the tablet should never be halved; neither IM nor SC routes are recommended due to unpredictable absorption, because prolonged or intense pain and necrosis of the muscle to the client (Intramuscular), severe irritation may occur when given via a subcutaneous injection. A rapid IV administration should be avoided as it may cause hypertension and vasoconstriction. The action of warfarin is a suppressant of vitamin-K dependant synthesis of prothrombin in the liver, this prevents the extension of a clot that is already established of the formation of a new one, warfarin has an anticoagulant effect that is produced after 36-72 hours and can persist for between 4 and 5 days after the discontinuation of therapy. The use of warfarin is, as a prevention and management of the following, deep vein thrombosis (DVT) or pulmonary embolism, thromboembolism in atrial fibrillation, and can be used as an adjunct to therapy for coronary occlusion. For Mr. Toscana there is no relevant interaction with this drug. The adverse effects of warfarin are fatal or non fatal bleeding, nausea, vomiting, diarrhoea, alopecia, fever, hypersensitivity reaction, an overdose is seen by bleeding from the gums and haematuria, in rare cases skin necrosis is also seen. Some of the nursing points and precautions with warfarin are, that all intramuscular injections be avoided, and subcutaneous injection sites should be closely monitored for haematoma, make sure that the does is given the same time daily to Mr. Toscana, observation for the early signs of overdose things such bleeding especially important from the gums.( Tiziani, A, 2010)

CONCLUSION Through a range of assessments, diagnostic testing, education and the development of a nursing care plan Mr. Toscana’s condition should improve as well as his general wellbeing. Goals set out in the care plan will be achieved by interventions put in place insuring a quicker recovery for Mr. Toscana. Education is particularly important for Mr. Toscana’s medication regime, support strategies will help with the improvement of overall health and wellbeing.