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Mrs. Mckenzie Case Study

  1. Outline the disease, causes, incidence and risk factors. Discuss the impact of the selected disease on the patient and their family (450 words)

According to the case study, Mrs Sharon Mckenzie had a congestive cardiac failure. Congestive cardiac failure is a clinical syndrome that is highly complex in which the heart is unable to perform its circulatory function to meet the metabolic needs of the body. These metabolic needs include enough oxygen that is required to be pumped in the heart. The structural and functional alterations do not allow it to meet the desired efficiency (Mishra et al., 2018). These are the defects in myocardium that results in the impairment of the ejection of blood or the ventricular filling. The ventricles are the main pumping chambers changes in size and thickness that prevents it from either contracting or relaxing which in turn triggers fluid retention majorly in abdomen, lungs and legs. The causes for congestive cardiac failure are many but the most common is the reduced left ventricular myocardial function. The others include the dysfunction of myocardium, heart valve, endocardium, pericardium in combinations or alone (Inamdar & Inamdar, 2016). In congestive cardiac failure, either one or both the upper and lower ventricles do not get vacant completely which causes an increased pressure in atria and the veins thus leading to oedema that is fluid retention in lungs and kidney. This hampers the kidneys and lungs to operate normally and their normal function gets interfered. The failure of relaxation of ventricles causes the heart to fail. This leads to blood pooling under back-pressure (State of Victoria, 2018). Several other conditions by which a congestive cardiac failure can be caused are:

  1. Hypertension (high blood pressure)
  2. Congenital heart disease
  3. Myocarditis
  4. Heart valve disease
  5. Heart arrhythmia

Congestive cardiac failure prevalence is increasing and it has a global pandemic affecting 26 million people worldwide. The morbidity, mortality and the poor quality of life is increasing and still high despite of the therapies, treatment, medications and prevention techniques (Savarese & Lund, 2017).

The risk factors of the congestive cardiac failure are hypertension, obesity and diabetes that lead to cardiac failure through the metabolic dysfunction of myocardial, endothelial and oxidative stress ultimately leading to cardiac dysfunction and the remodeling of left ventricular (Dunaly et al., 2009).

The impact of the congestive cardiac failure on the patient and the family members would be very bad. According to a study, the patient and the family members face the most difficulty in the management of complex multiple medicines and the negotiation of multiple appointments (Fry at al., 2016). The important aspects of the lives of congestive cardiac failure patients are psychosocial and existential issues (Leeming et al., 2014). The patient with congestive cardiac failure has a very poor quality of life and they may get another attack anytime. They have to be very careful with their lifestyle and diet.

  1. Discuss three (3) common signs and symptoms of the selected disease and explain the underlying pathophysiology of each (350 words)

The three common signs and symptoms of the congestive cardiac failure and their underlying Pathophysiology are as follows:

Edema (Ankle swelling) -

Fluid collects in the ankles, thighs, legs and abdomen when the heart does not have enough power to pump the blood.

Pathophysiology- In heart failure, the series of neuro-humoral and humoral pathways is activated that promotes the impaired regulation of sodium excretion by the kidneys thus leading to water and sodium reabsoprtion. The decreased plasma oncotic pressure and the increased venous capillary pressure lead to the edema formation (Arrigo et al., 2016).

Shortness of breath (dyspnoea) -

One of the dominanat symptoms of congestive cardiac failure is dyspnoea. As the disease progresses, this increases ultimately leading to the difficulty in carrying out the daily activities. Pathophysiology – In congestive cardiac failure, the shortness of breath is caused by the reduced ability of the heart to vacant and to fill, thus producing the high pressures around the lungs in the blood vessels. The excessive increase of the ventilatory demand and the abnormal restrictive constraints on the expansion of tidal volume (VT) with the advancement of critical mechanical limitation of ventilation leads to the congestive cardiac failure (Laviolette & Laveneziana, 2014). The dysponea arises from the congestion in pulmonary as left ventricular dysfunction causes the decreased cardiac outpupt and the venous pressure increases. This finally leads to the fluid accumulation in lung alveoli thus reducing the ease of breathing and causing dyspnoea (Kupper et al., 2016).

Mild nausea and lack of appetite -

In congestive cardiac failure, it is the feeling of full or sick to the stomach. This is because of the heart’s inability to pump enough blood to the body parts. The digestive system receives less blood that is not enough blood to carry out a proper digestion. This causes discomfort in digestion thus making a patient feel lack of appetite and nausea (American heart association, 2019).


2. Discuss the pharmacodynamics & pharmacokinetics of one (1) common class of drug relevant to the chosen patient (300 words)

 a. This does not mean specific drugs but rather the class that these drugs belong to.

The one common class of drug that is relevant to the congestive cardiac failure is the ACE inhibitors. The ACE inhibitors are the Angiotensin- converting enzyme inhibitors that help patients with congestive cardiac failure. They are a type of vasodilator, a drug that functions by broadening the blood vessels that lowers the blood pressure, increases the blood flow and ultimately decreases the heart workload. Some of the examples of ACE inhibitors are captopril (Capoten), enalapril (Vasotec) and lisinopril (Zestril) (Mayo Foundation for Education and Research, 2019).

Pharmacokinetics of ACE inhibitors

All ACE inhibitors bind to the plasma protein and the tissues. The free drug is eliminated rapidly by the glomerular filteration in the kidney as compared to those that binds to tissue sites because the plasma concentration-time profile displays a long-lasting terminal phase of elimination. Captopril, the prototype of ACE inhibitor is both absorbed and eliminated rapidly. The later ACE inhibitor like Enalapril is an inactive pro-drug that requires de-esterification by carboxylesterase or the absorption to activate the acid form that is enalaprilat. It is rapidly and well absorbed that is 60%-70% through gastrointestinal tract. Cmax that is peak plasma concentration is attained after an hour of administration. The elimination half life is of about 2 hours (Gomez- Diez et al., 2014). Lisinopril is self active and an analogue of enaparil.

Pharmacodynamics of ACE inhibitors

All ACE inhibitor drugs inhibit the activity of ACE competitively to restrict the formation of the active angiotensin II from angiotensin I and active octapeptide from inactive decapeptide. This entire process takes place in blood and tissues of heart, adrenal gland, kidney and brain. A potent vasoconstrictor is Angiotensin II, it promotes aldosterone release and promotes the sympathetic activity and has various potential harmful effects on cardiovascular system. When rennin- angiotensin system is stimulated, the decrease in blood pressure secondary to vasodilation following ACE inhibition is maximum. When there is low or normal rennin-angiotensin system activity, ACE inhibitors lowers the blood pressure (BIHS, 2017).

3. In order of priority, develop a nursing care plan for your chosen patient who has just arrived on the ward from ED. Nursing care plan goals, interventions and rationales must relate to the first 8 hours post ward admission (500 words)

a. This can be done in the form of a table – each point needs to be appropriately referenced

The nursing plan for the congestive cardiac failure patient who has just arrived on the ward from ED will be inclusive of the interventions and rationales for the patient betterment. Mrs. McKenzie has complications such as shortness of breath, hypertension that is her blood pressure is too high, the values of vitals are higher than normal and so on. The main interventions taken by the RN will be the administration of oxygen therapy to mitigate the shortness of breath, the administration of medication to lower down the blood pressure and the third is to monitor the electrolyte imbalance to know the side effects if being caused by the diuretics.

The following interventions and rationale will be taken by the nurse:

Administration of oxygen -

Mrs. McKenzie has difficulty in breathing and has shortness of breath. Generally, the oxygen therapy is the first line of treatment for such patients. The doctor prescribes the oxygen therapy and its dosages but the nurse administers it.  The RN should regularly check of important vitals of patients with oxygen therapy like HR, BP, RR, level of consciousness and so on and monitor them. To monitor if the patient is getting the right amount of oxygen, the RN might do a quick vital check and a pulse oximeter check. The RN should be alert of target oxygen saturation, range of oxygen flow, indications, oxygen delivery device and the percentage of inspired oxygen (Mayhob, 2018). If oxygen therapy is given inappropriately, it may be fatal. It should be administered in safe and appropriate way. The right amount is necessary to prevent the oxygen toxicity in the patients.

Medication administration -

Mrs. McKenzie has been prescribed various medicines for high blood pressure, congestive cardiac failure and edema. She forgets to take all her medicines sometimes. It is the nurses’ responsibility to make sure that the patient adheres to the routine and decide the route of administration for the patient. The medications of heart failure can have lethal effects on the patient if they are administered without discretions (Amakali, 2015). One-third errors are made during the administration phase of medication delivery (Durhman, 2015). The medication should be administered via the proper route, with efficacy and regularly. The patient and the family members should be educated by RN about the regime of medication and its route, volume and the side effects to reduce the rates of medication errors (Marynaik, 2018). After giving the medication therapy, a patient should be monitored and if the RN finds any kind of discomfort then the doctor should be immediately informed.

Serum level monitoring -

The sodium, potassium, bicarbonate and chloride levels are monitored because this enables the electrolyte monitor imbalance. Since the patient is administered with diuretics, the monitoring of electrolytes is necessary (Doenges et al., 2016). This monitoring will help to know if the patient is facing any side effects of the diuretics that are being prescribed and administered. Electrolyte imbalance also known as hypokalaemia is monitored.


Amakali, K. 2015. Clinical care for the patient with heart failure a nursing care perspective.Cardiovascular Pharmacology, (4)2, 3-5.
American Heart Association. (2019). Warning signs of heart failure. Retrieved from https//www.heart.org/en/health-topics/heart-failure/warning-signs-of-heart-failureArrigo, M., Parissis, J. T., Akiyama, E., amp Mebazaa, A. (2016). Understanding acute heart failure pathophysiology and diagnosis.European Heart Journal Supplements,18(suppl_G), G11-G18.
BIHS. (2017). Angiotensin converting enzyme (ACE) inhibitors. Retrieved from https//bihsoc.org/wp-content/uploads/2017/11/Angiotensin-Converting-Enzyme-Final-2017.pdfDurham, B. 2015. The nurses role in medication safety. Nursing 2017, 45(4), 1-4.
Dunlay, S. M., Weston, S. A., Jacobsen, S. J., amp Roger, V. L. (2009). Risk factors for heart failure a population-based case-control study.The American Journal of Medicine,122(11), 1023-1028.
Fry, M., McLachlan, S., Purdy, S., Sanders, T., Kadam, U. T., amp Chew-Graham, C. A. (2016). The implications of living with heart failure the impact on everyday life, family support, co-morbidities and access to healthcare a secondary qualitative analysis.BMC Family Practice,17(1), 139.
Gmez-Dez, M., Muoz, A., Caballero, J. M. S., Riber, C., Castejn, F., amp Serrano-Rodrguez, J. M. (2014). Pharmacokinetics and pharmacodynamics of enalapril and its active metabolite, enalaprilat, at four different doses in healthy horses.Research in Veterinary Science,97(1), 105-110.
Inamdar, A., amp Inamdar, A. (2016). Heart failure diagnosis, management and utilization.Journal of Clinical Medicine,5(7), 62.
Kupper, N., Bonhof, C., Westerhuis, B., Widdershoven, J., amp Denollet, J. (2016). Determinants of dyspnea in chronic heart failure.Journal of Cardiac Failure,22(3), 201-209.
Leeming, A., Murray, S. A., amp Kendall, M. (2014). The impact of advanced heart failure on social, psychological and existential aspects and personhood.European Journal of Cardiovascular Nursing,13(2), 162-167.
Laviolette, L., amp Laveneziana, P. (2014). Dyspnoea a multidimensional and multidisciplinary approach.European Respiratory Journal,43(6), 1750-1762.
Mahob M.M. (2018). Nurses knowledge, practice and barriers affecting a safe administration of oxygen therapy. IOSR Journal Of Nursing And Health Science, 7(3), 42-51.
Marynaik K. 2018. How to avoid medication errors in nursing. Retrieved from https//www.rn.com/nursing-news/nurses-role-in-medication-error-prevention/Mayo Foundation for Education and Research. (2019). Heart Failure. Retrieved from https//www.mayoclinic.org/diseases-conditions/heart-failure/diagnosis-treatment/drc-20373148Mishra, S., Mohan, J. C., Nair, T., Chopra, V. K., Harikrishnan, S., Guha, S., amp Chandra, K. S. (2018). Management protocols for chronic heart failure in India.Indian Heart Journal,70(1), 105-127.
Savarese, G., amp Lund, L. H. (2017). Global public health burden of heart failure.Cardiac Failure Review,3(1), 7.
State of Victoria. (2018). Congestive heart failure (CHF). Retrieved from https//www.betterhealth.vic.gov.au/health/conditionsandtreatments/congestive-heart-failure-chf


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