Posted: March 24th, 2022

Care needs concerns and treatment

 care needs, concerns and treatment strategies for Mrs. Margaret Cronin, an elderly patient admitted to HDU following assessment in DEM. This paper will first examine her necessities of care while determining the impact of all biopsychosocial and pathophysiological responses of the client. Given the melee of Margaret’s symptoms, along with her medical history — hypertension, pneumonia, and extreme anxiety — much of her care will have to be collaborative. This paper will examine the details of her collaborative care, including all diagnostic procedures and therapeutic interventions. With a patient suffering from these conditions including the immediate treatments she’s been prescribed — drug therapy, blood transfusion, and rigorous cardiorespiratory monitoring, and a saline IV — the nursing care priorities will have to be extremely detailed and well structured.

 

Preparing the bed area prior to the patient arrival was crucial, ensuring that all the proper supplies were ready for the patient’s entrance. For instance the indwelling catheter had to be prepared, the CVC so that CVP could be measured, all monitoring equipment had to be established and the tools needed to create the arterial line.

 

Assessment of the Client/Care Needs/Analysis of the impact of Biopsychosocial and Pathophysiological responses of the client

 

Margaret has heart failure: her body is retaining fluid, breathing is more laborious and her heart is not pumping as it should. The first assessment that needs to be done on Margaret is an airway assessment. One needs to determine if there are any obstructions or if her labored breathing is just a byproduct of her hypertension and coronary artery disease (Elliott, 2007). The assessment of Margaret’s airways are that they are patent, meaning open and unblocked.

 

The assessment of Margaret’s breathing is what needs to occur next and it was precisely what led to the usage of the Hudson mask. What also needs to occur is an assessment of whether or not Margaret is experiencing any abnormal breath sounds that are indicative of heart failure and/or pneumonia. Her breathing is at 26 per minute and she suffers from coughing episodes which she coughs up green phlegm and has difficulty catching her breath afterwards. Margaret’s circulation assessment is pink in colour and warm to the touch and with her blood pressure at 168/100 she’s at a high risk for hypertension. Her disability assessment demonstrates an altered level of consciousness, demonstrated by the way that Margaret keeps asking where she is. In regards to the environmental and exposure assessment, Margaret’s ECG demonstrates that an abnormality is present, based on the nonstandard reading (Guerrero, 2011). Margaret’s temperature is also raised (37.8) and is another manifestation of Margaret’s environment and exposure assessment. Checking Margaret’s skin for swelling or bruises or bloating would also be useful.

 

However, the assessment becomes deeper upon the arrival of Margaret’s daughter who explains both the fall and the bruises on Margaret’s back, which the head to toe assessment unveiled.

 

There needs to be a clear understanding of the biopsychosocial responses of the client and how they relate to the intimidating and confusing complications with her health. As one professional describes, clinicians need to understand that their relationship to the patient is also a form of medical treatment (Adler, 2007). The nurse needs to recognize that they are engaged in moment to moment mutual recognition of one another’s biopsychosocial states (Adler, 2007). Furthermore, “the introduction by either patient or physician of even small changes in their interactive process can lead to large changes in their biopsychosocial outcomes” (Adler, 2007). Finally allowing empathy to emerge can be viewed as a biospsychosocial relational process and is something which can also act as a guide toward ideal outcomes (Adler, 2007). Thus, in this case, it’s important to bear in mind the extreme emotional pain that Margaret must be enduring. She lost her husband of fifty years four months ago. This was a man that she spent almost her entire life with. The loss of her husband had to have been a devastating experience and one which is probably waging a negative impact on her mental and emotional health and no doubt negatively influencing her physical health.

 

When it comes to the patient’s pathophysiological responses, it’s absolutely vital to understand how Margaret’s altered physiology impacts her clinical presentation. it’s important to keep in mind that this is a disease of cellular pathophysiology and not simply a hemodynamic disorder (Pratt, 1995). “The progression of compensated ventricular dysfunction to symptomatic heart failure is marked by the activation of vasoconstrictor hormones. Norepinephrine, renin-angiotensin-aldosterone, and arginine vasopressin are secreted in response to inadequate systemic perfusion” (Pratt, 1995). This can be so damaging because the heart is already failing and doesn’t need this added stress and burden. When the heart is under such stress and is experiencing a failure in functioning, the body makes up for it in the following ways: via a maintenance of systemic pressure by vasoconstriction, which leads to a redistribution of blood flow to vital organs as well as a re-establishment of cardiac output by bolstering the myocardial contractility and the heart rate by expanding the extracellular fluid volume (Colucci, 2012). Unfortunately when the human body makes these adaptations it creates an overwhelmed state of “the vasodilatory and natriuretic effects of natriuretic peptides, nitric oxide, prostaglandins, and bradykinin. Volume expansion is often effective because the heart can respond to an increase in venous return with an elevation in end — diastolic volume that results in a rise in stroke volume” (Colucci, 2012). Furthermore, a number of maladaptive consequences generally result because of this neurohumoral activation.

 

Collaborative Needs of the Patient: Diagnostic Procedures and Therapeutic Interventions

 

“The ICU team is a self-organizing, complex entity, that expands and contracts based on the needs of the moment” (Despins, 2009). While the degree of collaboration is going to fluctuate, the team in this case will consist of a bedside nurse, respiratory therapist and a physician (Despins, 2009). Thus, there needs to be a strong degree of communication, zero conflict between the care providers and a development of a contingency plan in case the patient in non-responsive. Nurses can be members of collaborative teams by their ability to re-socialize, being able to comprehend and articulate their roles as nurses, the knowledge and skills they can bestow on others, and their willingness to work on collaborative teams (Orchard, 2010). Fundamentally, Margaret needs a highly communicative team of clinicians who all work well together.

 

The diagnostic procedures and therapeutic interventions were described reasonably well in the case study. For example, blood pathology testing was ordered by the medical officer, as was a sputum sample. A CRX is also ordered as is a loading and maintenance dose of amiodarone. Based on the blood test results, the medical officer ordered dosages of resonium, frusemide, the patient’s standard medications, repeat ABGs, liver and thyroid exams, blood transfusion, oxygen. With a patient like Margaret, there needs to be a greater sense of collaborative care between all clinicians who are treating her and engaging with her in therapeutic interventions. For example, there needs to be a great level of cohesion and correspondence between Margaret’s general practitioner, her cardiologist, the medical officer, and the nurse practitioner. There needs to be a stronger and more cohesive identification of the management of reversible cardiac causes of heart failure (wa.gov.au, 2008). “Medication and symptom review, aiming to achieve target doses of heart failure medication such as ACE/ARB Inhibitors and Beta-Blockers in line with evidence-based guidelines and changing requirements for diuretic medication” (wa.gov.au, 2008). This needs to occur with a referral for investigation and a more comprehensive care management plan along with rehabilitation services (wa.gov.au, 2008).

 

Furthermore, there needs to be a stronger recognition of the comorbidities that are occurring with Margaret, such as the viral pneumonia and her issues with hypertension. “Comorbidities and baseline health status are therefore important when applying and establishing appropriate medications and dosages and choosing treatment for an older person” (Kraschnewski et al., 2006). The therapeutic interventions selected for Margaret do indicate that the collaborative care team was aware and at least trying to address her range of symptoms and the various co-existing conditions. Comorbidities are serious and can often be what lead to readmission or mortality rates for HF or CAD patients (Muzzarelli et al., 2010).

 

It’s also important to note that many of the therapeutic interventions appear to point to the physical and emotional frailty of Margaret, something that is common in elderly adults who are experiencing coronary artery disease (Kraschnewski et al., 2006). “Because frailty is a syndrome of impaired resistance to stressors, it is well suited to predict the elderly patient’s response to cardiovascular stress. One of the most promising clinical applications lies in using frailty to predict the elderly patient’s risk of mortality and morbidity in the setting of invasive cardiovascular procedures” (Afilalo, 2011). Margaret’s frailty is no doubt aggravated by her emotional state and is something which needs to be addressed by a strong collaboration of therapeutic strategies to reverse that development and to prevent adverse outcomes (Afilalo, 2011). There’s a need for both social support and the possibility of considering eventual coronary revascularization or valve replacement, or less invasive therapeutic options.

 

Furthermore, one of the pillars of collaborative care that will need to be firmly established is the fostering of clear dialogue and a means for strong communication within the care management planning. For instance, there needs to be a clear decision and communication of all tests ordered and when the test results will be available. One of the most important aspects of this collaborative care will be the nursing interventions which can have significant impact on the patient’s health and stabilization (Allen, 2010). In fact, strategic nursing care can even minimize readmission rates of Margaret and other patients with comparable conditions (Chen et al., 2012).

 

Prioritize the Nursing Care Needs of Margaret

 

The prioritization of nursing interventions is essential, and the way in which a nurse determines this priority is going to be something unique and distinct. “Trials reviewed demonstrated a beneficial impact of nursing interventions for secondary prevention in patients with CAD or heart failure. However, the optimal combination of intervention components, including strategy, mode of delivery, frequency, and duration, remains unknown. Establishing consensus regarding outcome measures, inclusion of adequate, representative samples, along with cost-effectiveness analyses will promote translation and adoption of cost-effective nursing interventions” (Allen, 2010, p. 207).

 

The first priority is of course an ABCD assessment: this refers to airways, breathing, circulation, disability and (exposure). “First, life-threatening airway problems are assessed and treated; second, life-threatening breathing problems are assessed and treated; and so on. Using this structured approach, the aim is to quickly identify life-threatening problems and institute treatment to correct them” (Thim et al., 2012).

 

The next nursing priority would be determining any medication errors. In this particular case, one of the primary nursing priorities stems from the establishment that a conflict exists with the amioderone maintenance dose. So one of the top priorities remains as correcting this drug error immediately. One of the ways that this can occur is by turning off the medication until the order is correct and then reestablishing it once it has been revised. The preferred infusion site for amiodaron is via CVC but Margaret has no CVC at this point; the infusion has been commenced via IVC. As such, stopping for incorrect dose and restarting when dose corrected and CVC insitu would be ideal option. Placing monitor would be a subsequent nursing priority.

 

The next nursing priority would be the insertion of the indwelling catheter. This patient is in critical care and would thus require an indwelling catheter. For a patient with the conditions that Margaret has, accurate urine monitoring is absolutely essential (Foxley, 2011). The CVC would have to be inserted in order to measure the CVP; this can be done by connecting the CVC to a particular infusion set.

 

Establishing the arterial line placement is a frequent procedure for the management of patients in as serious a condition as Margaret. This type of measurement is so necessary because it’s more accurate than blood pressure and can more readily pinpoint changes in blood pressure and can allow for the removal of frequent blood gas samples (Peterson, 2012).

 

Another major consideration would be doing everything possible to relieve the patient’s pain. For instance, the patient would be instructed to speak to the nurse immediately as soon as chest pain occurs. The duty of the nurse would be to keep a strict eye on how the client reacts to the response and impact of medication, as well as the frequency, length, intensity and area where the client’s pain occurs. Another aspect of the nurse’s duty to observe is to look for and keep track of associated symptoms such as dyspnea, nausea and vomiting, heart palpitations, dizziness/vertigo along with a need to urinate. There would also be a priority of checking with the patient to evaluate any sensations of pain in the jaw, chin, neck, shoulder, back, arm or hand, particularly on the left side of her body. The nurse’s duty would be to keep the patient at rest during these episodes. Elevating the head of the bed is a necessity if Margaret continues to exhibit a shortness of breath. Monitoring Margaret for shortness of breath, along with her heart rate and rhythm is an immediate necessity. Implementing a pain rating scale to assess the patient’s perception of the level of pain that she is in could be useful in seeing if the medication for pain relief is at all effective (Moreau, 2003).

 

Furthermore, since heart failure is one of the afflicting conditions, it’s absolutely possible that the doctor might prescribe Continuous Positive Airway Pressure (CPAP). “Standard medical treatment of CHF includes oxygen, diuretics, nitrates and morphine. Most patients respond to standard medical treatment; however some patients require NIV as a more aggressive intervention particularly for cardiac pulmonary edema” (Stoltzfus, 2006). This is where CPAP might be prescribed to Margaret. It is of course the physician’s duty to determine whether or not this measure is necessary for this particular patient in order to increase cardiac output (Stoltzfus, 2006). CPAP is another measure to keep the alveoli from collapsing; if used its yet another intervention that the nurse will need to monitor.

 

Meanwhile, the nurse needs to be constantly evaluating the effectiveness of the oxygen therapy to see if it is in fact increasing the oxygenation of the myocardial tissue so the consequential ischemia is prevented (coursewareobjects.com). All prescribed and revised medications need to be administered consistently to stop all pain, prevent new pain from occurring and to decrease the anxiety of the patient. Decreasing the anxiety of the patient is essential for the patient’s overall homeostasis as it will also decrease the fundamental workload of the cardiac system (coursewareobjects.com). Aside from monitoring the vital signs of the patient, consistently observing the patient’s cardiac rhythm and rate and all patterns in blood pressure are essential, along with keeping track of the patient’s hemodynamic parameters. Factors like the patient’s central venous pressure and pulmonary artery edge pressure can provide clear clues as to the state of hypotension and bradycardia, which may lead to hypoperfusion (coursewareobjects.com).

 

As already stated, aside from monitoring the patient’s vital signs to assess and establish baseline and ongoing changes, a nursing priority needs to be established which looks for cardiac dysrhythmias, such as disruptions of rhythm and conduction and to pinpoint and give treatment to substantial dysrhytmias. As alluded to earlier, the patient’s respiratory status needs to constantly be checked, not just to ascertain that the patient has adequate levels of oxygenation, but to see if there are indications of pulmonary edema (coursewareobjects.com).

 

Another consideration would involve how in critical care, the RN is responsible for documenting observations and fluid balance hourly. Any change in the client’s condition needs to be documented as it happens- this can occur by recording your observations either in the progress notes or on the observation charts at the bed site. Excess fluid volume, one must recall, is directly connected to the ineffective pumping mechanism of the heart as well as an increased preload, increased sodium and water retention, diminished organ perfusion, compromised regulatory mechanisms, diminished cardiac output, as well as bolstered ADH production (Comer, 2005). Thus, the nurse needs to be well acquainted with and check all signs of fluid retention. As already established, looking for signs of edema is important, as is the patient taking in more fluids than putting out, increased pulmonary artery pressures, increased blood pressures, increased heart rate, shortness of breath, dyspnea, wheezing, frothy white or pink sputum, hypoxia, cool/moist skin, altered electrolyte levels (Comer, 2005). These are all factors that the nurse needs to be prepared to deal with immediately as a hazardous sign of fluid retention. For instance one of the definitive ways to determine fluid intake vs. output, is to measure and document it. Margaret should still be kept hydrated with fluids and given a total of 2 liters per day, unless her attending physician has a problem with that.

 

Oxygen therapy is an effective means of dealing with such fluid retention, particularly when administered as prescribed. “Supplemental oxygen may be required to prevent hypoxia caused by increased cardiac pressures, fluid increases, and hypoventiliation. Depending on the severity of the condition, the patient may require varying amounts of oxygen supplementation to maintain adequate blood saturations, and mechanical ventilation may be required to ensure proper oxygenation” (Comer, 2005, p. 42). Thus, this excerpt clearly demonstrates why it was so necessary to engage in aggressive oxygenation of Margaret.

 

Another nursing priority which needs to occur is the auscultation of the lungs for the presence of crackles (rales) and other noises made by the breath (Comer, 2005). Watching the patient for signs like dyspnea or nocturnal dyspnea is important because these symptoms could indicate pulmonary edema as a result of cardiac decompensation and pulmonary congestion (Comer, 2005). Symptoms of pulmonary edema generally reflect left-sided heart failure; right-sided heart failure may have a more gradual onset and manifestation, but many of these symptoms (dyspnea and the debilitating cough) can be very difficult to abolish. Another factor of checking the patient carefully for edema is to check regularly to see if there is a distention of the jugular vein, something which can also points to congestive failure and fluid excess (Comer, 2005). The nurses also has the duty to check in on the patient regularly and address any sudden complaints which could indicate pulmonary edema or pulmonary embolus such as experiencing air hunger or complaining about a distinct feeling of suffocation or doom (Comer, 2005).

 

Another aspect of fluid management is that the diuretics given to Margaret need to be properly managed; for instance while the diuretics increase the urine flow, which is good, they could also have a negative impact on the patient’s ability to absorb sodium and chloride in the renal tabules (Comer, 2005). While diuretics can be necessary and effective, there’s also a clear risk of electrolyte imbalance, along with decreased renal function: “Electrolytes, especially sodium, potassium, and magnesium, may be decreased and cause complications and organ dysfunction” (Comer, 2005). Thus, as a nurse one needs to look for signs of potential electrolyte imbalance, such as progressive lethargy, mental confusion, muscle cramping and other typical signs of a danger electrolyte imbalance.

 

In order to effectively engage in anxiety reduction, one needs to monitor the patient for verbal and nonverbal signs of anxiety; pinpoint when the level of anxiety adjusts and thus expands the need for more oxygen (coursewareobjects.com). Each approach with the patient needs to be both calm ad soothing and the nurse needs to be prepared in how to teach the patient the use of a relaxation technique, such as breathing and imagery techniques to help bolster self-control (coursewareobjects.com). The nurse should speak with the patient’s daughter and attempt to determine if other family members can visit in order to provide Margaret with the highest level of support possible. This is so incredibly vital given Margaret’s remark to the nurse to just let her die, given how much she misses her husband. Margaret needs to feel loved and supported and cared about; it is still just four months since her husband died. It would also be worthwhile for the nurse in charge of care to look into forms of psychological interventions, as those have been known to be effective for CHD patients (Whalley et al., 2011). In fact, such psychosocial interventions could even be beneficial for members of Margaret’s family (Madan et al., 2012).

 

In fact, it’s entirely possible that some of Margaret’s condition is caused by something known as “broken heart syndrome.” “Broken heart syndrome is a temporary heart condition brought on by stressful situations, such as the death of a loved one. People with broken heart syndrome may have sudden chest pain or think they’re having a heart attack. These broken heart syndrome symptoms may be brought on by the heart’s reaction to a surge of stress hormones. In broken heart syndrome, a part of your heart temporarily enlarges and doesn’t pump well, while the remainder of the heart functions normally or with even more forceful contractions” (Mayoclinc, 2013). While it would be naive to attribute all of Margaret’s symptoms to this condition, it would be dismissive and incorrect to assume that the death of her husband wasn’t having some impact on her health. Most likely, the death of Margaret’s husband is having a significant impact on her health and is doing much to exacerbate her condition. The best way to combat this issue is to help her feel as loved and as supported as possible. Furthermore, it would be worthwhile to try and deconstruct any damaging beliefs Margaret has about her illness, as that can impact her recovery as well, as studies have shown (Goulding, 2010).

 

The nurse can help to facilitate this with her caring activities, but the presence of Margaret’s family will do a tremendous amount. In fact, the nurse should even feel free to help Margaret by engaging in alternative therapies, such as music therapy or aroma therapy or other sensory therapies. “Unrelieved anxiety can produce an increase in sympathetic nervous system activity leading to an increase in cardiac workload. Nursing interventions using music therapy or sensory information among patients with coronary artery disease has resulted in anxiety reduction” (Taylor-Piliae & Chair, 2002).

 

Another way in which the nurse can alleviate some of the stress and anxiety that Margaret is facing is by providing factual info about the diagnosis, treatment and prognosis of the disease. While some of this information is bound to be shocking and complicated, it will help to decrease the fear of the unknown, which is significant. This is true even if the doctor decides she is a candidate for surgery; telling her the risks involved for her condition is a fact and a necessity (van Diepen, 2011). Finally, the nurse needs to be prepared to educate and brief the patient when discharge does eventually happen on ways to self-treat symptoms and engage in preventative care; this too can reduce anxiety (Moser et al., 2012).

 

Summary

 

Thus, given Margaret’s medical history and emotional history there’s a serious and significant reason to be concerned. The bulk of her care is dependent on well-orchestrated, targeted interventions which focus on collaborative work of clinicians. Much of the nurse’s duty involves administering the therapies chosen by the doctor to alleviate her symptoms of pain and to reduce the fluid in her body. The nurse has the utmost responsibility to ensure that all vital signs are constantly monitored along with other reactions of the body to ensure that Margaret stays safe and stays on the road to recovery. The nurse is also a tremendously instrumental person involved in supporting the patient, making the patient feel cared for and looked after. The nurse can be a truly powerful figure in instilling hope and making the patient feel less alone in the world, an impact which can have a truly meaningful effect on her health.

 

References

 

Adler, H.M. (n.d.). Toward a biopsychosocial understanding of the patient — physician relationship: An emerging dialogue. (2007). J Gen Intern Med,22(2), 280 — 285.

 

Afilala, J. (n.d.). Frailty in patients with cardiovascular disease: Why, when, and how to measure. (2011). Curr Cardiovasc Risk Rep, 5(5), 467 — 472.

 

Allen, J.K. (2010). Randomized trials of nursing interventions for secondary prevention in patients with coronary artery disease and heart failure: Systematic review.

 

Journal of Cardiovascular Nursing,25(3), 207-220.

 

Chen, J . (n.d.). Skilled nursing facility referral and hospital readmission rates after heart failure or myocardial infarction . (2012). The American Journal of Medicine, 125(1), 100.e1 — 100.e9.

 

Colucci, W.S. (2013). Pathophysiology of heart failure: Neurohumoral adaptations.

 

Retrieved from http://www.uptodate.com/contents/pathophysiology-of-heart-failure-neurohumoral-adaptations

 

Comer, S. (2005). Delmar’s critical care: Nursing care plans. Clifton Park: Thomson

 

Delmar Learning

 

Coursewareobjects.com. (n.d.). Patient with acute coronary syndrome. Retrieved from http://www.coursewareobjects.com/objects/evolve/E2/book_pages/lewismedsurg / pdfs/nursing_care_plans.pdf

 

Despins, L.A. (2009). Patient safety and collaboration.Critical Care Nurse, 29(2), 85-92.

 

Elliott, D. (2007). Acccn’s critical care nursing. Chatswood: Elsevier Saunders.

 

Foxley, S. (2011). Indwelling urinary catheters. Indwelling Urinary Catheters, 20(9),

 

564-570.

 

Goulding, L. (n.d.). Randomized controlled trials of interventions to change maladaptive illness beliefs in people with coronary heart disease: systematic review.

 

(2010). Journal of Advanced Nursing,66(5), 946-961.

 

Guerrero, C.B. (2011). Critical care transport. Sudbury: Jones and Bartlett.

 

Kraschnewski, J., & Alexander, K.P. (n.d.). Coronary artery disease later in life .

 

(2006). Chronic Conditions Later in Life, 17-22.

 

Madan, S.K. (n.d.). Psychosocial concerns and interventions for patients and their identified support givers to help cope with acute manifestations of advanced coronary artery diseases. (2012).

 

Mayoclincstaff. (2011, February 10). Risk factors. Retrieved from http://www.mayoclinic.com/health/broken-heart-syndrome/DS01135/DSECTION=risk-factors

 

Moreau, D. (2003). Eldercare strategies: Expert care plans for the older adult.

 

Philadelphia: Lippincott, Williams and Wilkins.

 

Moser, D.K. (n.d.). The impact on anxiety and perceived control of a short one-on-one nursing intervention designed to decrease treatment seeking delay in people with coronary heart disease. (2012). Eur J. Cardiovasc Nursing, 11(2), 160-167.

 

Muzzarelli, S. (n.d.). Predictors of early readmission or death in elderly patients with heart failure. (2010). American Heart Journal, 160, 308-14.

 

Orchard, C.A. (2010). Persistent isolationist or collaborator?.Journal of Nursing

 

Management, (18), 248-257.

 

Peterson, K.J. (2012). Measuring central venous pressure.Critical Care Nurse, 32(3), 62-

 

69.

 

Pratt, N.G. (n.d.). Pathophysiology of heart failure: neuroendocrine response.

 

(1995). Critical Care Nurse, 18(1), 22-31.

 

Stoltzfus, S. (n.d.). The role of non-invasive ventilation. (2006). Dimensions of the Critical Care Nurse, 25(2), 66-70.

 

Taylor-Piliaea, R.E., & Chair, S.Y. (n.d.). The effect of nursing interventions utilizing music therapy or sensory information on chinese patients’ anxiety prior to cardiac catheterization: A pilot study. (2002). Eur J. Cardiovasc Nurs, 1(3), 203-211.

 

Thim, T., Krarup, N.H.V., & Grove, E.L. (2012). Initial assessment and treatment with the airway, breathing, circulation, disability, exposure (abcde) approach.Int J. Gen

 

Medicine, 5, 117 — 121.

 

Van Depien, S., Bakal, J.A., & McAlister, F.A. (n.d.). Mortality and readmission of patients with heart failure, atrial fibrillation, or coronary artery disease undergoing noncardiac surgery. (2011).

 

Wa.gov.au. (2008, August). Cardiovascular health network. Retrieved from http://www.healthnetworks.health.wa.gov.au/modelsofcare/docs/Heart_Failure_M

 

odel_of_Care.pdf

 

Whalley, B., Rees, K., & Davies, P. (n.d.). Psychological interventions for coronary heart disease. (2011).Cochrane Database of Systematic Reviews, (8), CD002902.

---

Get Professional Assignment Help Cheaply

Are you busy and do not have time to handle your assignment? Are you scared that your paper will not make the grade? Do you have responsibilities that may hinder you from turning in your assignment on time? Are you tired and can barely handle your assignment? Are your grades inconsistent?

Whichever your reason is, it is valid! You can get professional academic help from our service at affordable rates. We have a team of professional academic writers who can handle all your assignments.

Why Choose Our Academic Writing Service?

• Plagiarism free papers
• Timely delivery
• Any deadline
• Skilled, Experienced Native English Writers
• Subject-relevant academic writer
• Adherence to paper instructions
• Ability to tackle bulk assignments
• Reasonable prices
• 24/7 Customer Support
• Get superb grades consistently

 

Online Academic Help With Different Subjects

Literature

Students barely have time to read. We got you! Have your literature essay or book review written without having the hassle of reading the book. You can get your literature paper custom-written for you by our literature specialists.

Finance

Do you struggle with finance? No need to torture yourself if finance is not your cup of tea. You can order your finance paper from our academic writing service and get 100% original work from competent finance experts.

Computer science

Computer science is a tough subject. Fortunately, our computer science experts are up to the match. No need to stress and have sleepless nights. Our academic writers will tackle all your computer science assignments and deliver them on time. Let us handle all your python, java, ruby, JavaScript, php , C+ assignments!

Psychology

While psychology may be an interesting subject, you may lack sufficient time to handle your assignments. Don’t despair; by using our academic writing service, you can be assured of perfect grades. Moreover, your grades will be consistent.

Engineering

Engineering is quite a demanding subject. Students face a lot of pressure and barely have enough time to do what they love to do. Our academic writing service got you covered! Our engineering specialists follow the paper instructions and ensure timely delivery of the paper.

Nursing

In the nursing course, you may have difficulties with literature reviews, annotated bibliographies, critical essays, and other assignments. Our nursing assignment writers will offer you professional nursing paper help at low prices.

Sociology

Truth be told, sociology papers can be quite exhausting. Our academic writing service relieves you of fatigue, pressure, and stress. You can relax and have peace of mind as our academic writers handle your sociology assignment.

Business

We take pride in having some of the best business writers in the industry. Our business writers have a lot of experience in the field. They are reliable, and you can be assured of a high-grade paper. They are able to handle business papers of any subject, length, deadline, and difficulty!

Statistics

We boast of having some of the most experienced statistics experts in the industry. Our statistics experts have diverse skills, expertise, and knowledge to handle any kind of assignment. They have access to all kinds of software to get your assignment done.

Law

Writing a law essay may prove to be an insurmountable obstacle, especially when you need to know the peculiarities of the legislative framework. Take advantage of our top-notch law specialists and get superb grades and 100% satisfaction.

What discipline/subjects do you deal in?

We have highlighted some of the most popular subjects we handle above. Those are just a tip of the iceberg. We deal in all academic disciplines since our writers are as diverse. They have been drawn from across all disciplines, and orders are assigned to those writers believed to be the best in the field. In a nutshell, there is no task we cannot handle; all you need to do is place your order with us. As long as your instructions are clear, just trust we shall deliver irrespective of the discipline.

Are your writers competent enough to handle my paper?

Our essay writers are graduates with bachelor's, masters, Ph.D., and doctorate degrees in various subjects. The minimum requirement to be an essay writer with our essay writing service is to have a college degree. All our academic writers have a minimum of two years of academic writing. We have a stringent recruitment process to ensure that we get only the most competent essay writers in the industry. We also ensure that the writers are handsomely compensated for their value. The majority of our writers are native English speakers. As such, the fluency of language and grammar is impeccable.

What if I don’t like the paper?

There is a very low likelihood that you won’t like the paper.

Reasons being:

• When assigning your order, we match the paper’s discipline with the writer’s field/specialization. Since all our writers are graduates, we match the paper’s subject with the field the writer studied. For instance, if it’s a nursing paper, only a nursing graduate and writer will handle it. Furthermore, all our writers have academic writing experience and top-notch research skills.
• We have a quality assurance that reviews the paper before it gets to you. As such, we ensure that you get a paper that meets the required standard and will most definitely make the grade.

In the event that you don’t like your paper:

• The writer will revise the paper up to your pleasing. You have unlimited revisions. You simply need to highlight what specifically you don’t like about the paper, and the writer will make the amendments. The paper will be revised until you are satisfied. Revisions are free of charge
• We will have a different writer write the paper from scratch.
• Last resort, if the above does not work, we will refund your money.

Will the professor find out I didn’t write the paper myself?

Not at all. All papers are written from scratch. There is no way your tutor or instructor will realize that you did not write the paper yourself. In fact, we recommend using our assignment help services for consistent results.

What if the paper is plagiarized?

We check all papers for plagiarism before we submit them. We use powerful plagiarism checking software such as SafeAssign, LopesWrite, and Turnitin. We also upload the plagiarism report so that you can review it. We understand that plagiarism is academic suicide. We would not take the risk of submitting plagiarized work and jeopardize your academic journey. Furthermore, we do not sell or use prewritten papers, and each paper is written from scratch.

When will I get my paper?

You determine when you get the paper by setting the deadline when placing the order. All papers are delivered within the deadline. We are well aware that we operate in a time-sensitive industry. As such, we have laid out strategies to ensure that the client receives the paper on time and they never miss the deadline. We understand that papers that are submitted late have some points deducted. We do not want you to miss any points due to late submission. We work on beating deadlines by huge margins in order to ensure that you have ample time to review the paper before you submit it.

Will anyone find out that I used your services?

We have a privacy and confidentiality policy that guides our work. We NEVER share any customer information with third parties. Noone will ever know that you used our assignment help services. It’s only between you and us. We are bound by our policies to protect the customer’s identity and information. All your information, such as your names, phone number, email, order information, and so on, are protected. We have robust security systems that ensure that your data is protected. Hacking our systems is close to impossible, and it has never happened.

How our Assignment  Help Service Works

1.      Place an order

You fill all the paper instructions in the order form. Make sure you include all the helpful materials so that our academic writers can deliver the perfect paper. It will also help to eliminate unnecessary revisions.

2.      Pay for the order

Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.

3.      Track the progress

You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.

4.      Download the paper

The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.

PLACE THIS ORDER OR A SIMILAR ORDER WITH US TODAY AND GET A PERFECT SCORE!!!

---