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Process Paper
Emily A. Dehnke
NURS 30040
Preofessor Troyer
November 24, 2010
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Process Paper
Client Profile
H.H. is an eighty-one year old female. She has been a resident of Altercare of Nobles Pond since October 3, 2009. She was
born on September 16th, 1929. She has many ongoing medical diagnoses and surgical history associated with those diagnoses. Her
first set of diagnoses and past surgeries have to do with her heart. She has hypertension, which is elevated blood pressure, and
congestive heart failure (CHF). CHF is primarily a physiological state (it is not a disease in itself) of older adults (>65 years old) and
is the leading cause of hospitalization in older people (Black & Hawks, 2005). It is caused by coronary artery disease, hypertensions,
heart attack, and cardiomyopathy (WebMD). It affects both men and women but mortality is higher in women. CHF means that the
heart can’t pump enough blood to meet the metabolic needs of the body; the heart can’t handle normal blood volume or a sudden
increase in blood volume with stress and exercise (decreased cardiac reserve) (Black & Hawks, 2005). Quite simply, it means that the
heart is not able to pump effectively. The performance of the heart is based on four components: how strong the heart muscle can
contract (contractility), the amount of blood in the ventricles at the end of diastole (preload), the pressure that needs to be overcome
for the left ventricle to pump blood out (afterload), and heart rate; if there are changes in any of these four components, heart failure
will ensue (Black & Hawks, 2005). When heart failure occurs, cardiac output is not sufficient to meet the demands of the body, so
compensatory mechanisms kick in such as ventricular dilation which increases the volume of the blood in the ventricle, increases
muscle stretch, and increases preload to increase the cardiac output (Black & Hawks, 2005). Another mechanism is increased
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sympathetic stimulation, which constricts arteries and veins, increases heart rate, and increases contractility to increase cardiac output
(Black & Hawks 2005). However, these compensatory mechanisms cannot sustain the heart forever; in fact, as a result the heart
muscle gets bigger and thicker (hypertrophy), the ventricle walls get thicker because they are tired and overworked, and the heart cells
change and die prematurely; overtime, all of these things lead to decreased heart function (Black & Hawks, 2005).
There are two types of heart failure: left heart failure and right heart failure. In left ventricular failure, the left ventricle cannot
keep up with its needed pumping action, so blood falls back and accumulates in the lungs. Not surprisingly, a lot of the symptoms of
LHF are respiratory0related such as dyspnea, orthopnea, Cheyne-Stokes respirations, fatigue, weakness, and pulmonary edema (Black
& Hawks, 2005). In right ventricular failure, the right ventricle can’t keep up with the blood pumping through it, so blood falls back
and accumulates throughout the body. Some symptoms of RHF are symmetrical peripheral edema (especially in feet and ankles),
jugular vein distension, and venous congestion of the organs of the body; all organs are affected by the congestion but liver and
gastrointestinal tract congestion causes discomfort and anorexia (Black & Hawks, 2005). The chart never mentioned which side of
heart failure H.H. had.
H.H. has a pacemaker to treat her CHF. Normally, a healthy heart has its own pacemaker, called the SA Node, that regulates
heart rate, but a heart with CHF does not beat regularly (WebMD, 2010). A pacemaker, which is a small device that sends electrical
impulses to the heart to keep the heart beating regularly, can fix an irregular heart beat such as in CHF (WebMD, 2010). A pacemaker
has two parts: the lead wires, which are placed through the veins and into the heart and the pulse generator, where the battery and tiny
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computer are located; the generator sends an electrical current through the leads to the heart to help regulate the heart rate (WebMD,
2010). Pacemakers are put right under the skin during a minor surgical procedure and the pacemaker can be felt under the skin
(WebMD, 2010). In a healthy heart, the heart’s right and left ventricles pump at the same time and in rhythm with the atrium, but in a
CHF heart, the ventricles don’t pump at the same time (WebMD, 2010). As a result, the left ventricle can’t pump as much blood out
to the body (WebMD, 2010). To keep the ventricles pumping together, a biventricular pacemaker is used in what is called cardiac
resynchronization therapy (CRT) (WebMD, 2010). This kind of pacemaker has three leads: one is placed in the right atrium, one is
placed in the right ventricle, and one is placed in the left ventricle (WebMD, 2010).
H.H.’s next set of diagnoses and surgeries deal with the thyroid gland. For some reason that is not mentioned in the chart,
H.H. has had a thyroidectomy. A thyroidectomy is the surgical removal of part or all of the thyroid gland; it is done to treat
hyperthyroidism, hypothyroid goiters, and thyroid cancer (Buckley & Schub, 2010). There are four types of thyroidectomies
classified by how much and what part of the thyroid is removed (Buckley & Schub, 2010). A lobectomy is when one lobe is removed,
a bilateral subtotal is when both lobes and the connecting part of the thyroid except for a small piece of the back of the thyroid is
removed, a near total is when the entire gland except for a small piece of the thyroid is removed, and a total is when the entire thyroid
gland is removed (Buckley & Schub, 2010). The specific type of H.H.’s thyroidectomy was not specified in the chart. After the
surgery, some complications may be excess sweating, excess fatigue, weight loss, nervousness, increased heart rate, hot flashes,
tremors, and menstrual irregularities (Buckley & Schub, 2010). A long-term complication of thyroidectomy is hypothyroidism, which
H.H. has, due to the absence of part or all of the functioning thyroid tissue.
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Hypothyroidism is a deficiency in thyroid hormone that causes slowing of the body’s metabolism; this slow metabolism leads
to decreased secretion of hydrochloric acid in the stomach, gastrointestinal motility, heart rate, body heat production, and consumption
of oxygen by the tissues (Black & Hawks, 2005). Also, the decreased thyroid hormone leads to an increase in serum cholesterol and
triglyceride levels that can increase risk for arteriosclerosis and coronary heart disease; this is the cause of H.?.’s
hypercholesterolemia, or high cholesterol levels (Black & Hawks, 2005). Some common signs and symptoms of hypothyroidism are
fatigue, dry skin, constipation, weight gain with no increase in food intake, increased sensitivity to cold, numbness, tingling, brittle
hair and nails, decreased pulse, forgetfulness, masked expression, increased sensitivity to sedatives, and thickened skin (Black &
Hawks, 2005). Extreme hypothyroidism is called myxedema coma and its mortality rate is almost 100%; myxedema coma symptoms
are respiratory depression and failure, sleep apnea, hypotension, lethargy, hypothermia, unconsciousness, and cardiovascular changes
due to extremely high cholesterol levels (Black & Hawks, 2005).
H.H.’s last set of diagnoses and past surgeries all deal with the lungs. H.H. has a history of pneumonia, with the most recent case
being right lower lung pneumonia. Pneumonia is an inflammatory process of the lung in response to a foreign antigen (Black &
Hawks, 2005). There are many causes of pneumonia such as bacteria, viruses, fungi, protozoa, aspiration of foods or fluids, or
inhalation of toxic chemicals, smoke, gas, or dust (Black & Hawks, 2005). Risk factors for pneumonia are older age, smoking, upper
respiratory infection, intubation, extended immobility, immunosuppressive therapy, malnutrition, dehydration, and chronic disease
(Black & Hawks, 2005). There are actually three types of pneumonia: segmental pneumonia involves one or more segments of the
lungs, lobar pneumonia involves one or more lobes of the lung, and bilateral pneumonia involves both lobes of the lung (Black &
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Hawks, 2005). Some signs and symptoms of pneumonia are fever, chills, sweats, pain with deep breathing and coughing, coughing up
blood and/or sputum, dyspnea, headache, and fatigue; pneumonia also results in increased interstitial and alveolar fluid (Black &
Hawks, 2005). Thanks to this extra fluid, infection, and inflammation of the lungs, pneumonia is often times the cause of pleural
effusion (WebMD, 2010). Pleural effusion is an abnormal amount of fluid around the lung, or in the pleural space (WebMD, 2010).
Normally, only a little amount of watery fluid is present in the pleural space, allowing the lungs to move smoothly within the chest
cavity during breathing (WebMD, 2010). However, in pleural effusion, the increased fluid causes complications such as difficulty
breathing, cough, pain when breathing or coughing, fever, and shortness of breath (WebMD, 2010). Thoracentesis is used to remove
the excess pleural fluid from pleural effusions (Black & Hawks, 2005). It’s done by inserting a needle or plastic catheter through the
chest wall to drain the fluids; usually the fluids are sent to the lab to determine what is truly causing the pleural effusion (WebMD,
2010).
Functional Health Pattern Assessment
Include client’s admission date: 10/3/2010
Previous occupation: homemaker
Diet: NAS
Religion: Catholic
Activity: up as tolerated (with walker sometimes)
Allergies: Nickel Sulfate, NKDA
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Current meds: Levothyroxine (Synthroid), Ferrous Sulfate, Aspirin, Calcitriol, Nadolol (Corgard), Valsartan (Diovan), Fluticasone
(Flonase), Loratadine (Claritin), Acyclovir (Zoviraz), Bumetanide (Bumex), Albuterol Sulfactose, Digoxin (Linoxin), Vicodin,
Acetaminophen, Loperamide (Imodium), Albuterol Sulfate
Treatments: OT, PT, Up as tolerated, Walker, Wheelchair
Surgery: Pacemaker, Thoracentesis
Diagnostic test results: See Lab Interpretation Chart
Client Profile (summarize events leading to the day you cared for client): H.H. has lived in Altercare of Noble Pond since November
3, 2009. Her husband lived in Altercare before she did and knew she liked the facility. When she started to forget things and then
would have to ask her children to help her, she decided it was time to go to Altercare. She said “I felt like I was just getting down and
forgetful and I didn’t want my family to do stuff for me.” She said, “I didn’t want to be a burden on my family.” She has gone to the
hospital while at Altercare for pneumonia but has come back since then.
AREA OF HEALTH
SUBJECTIVE DATA
OBJECTIVE DATA
INDIRECT DATA
INTERPRETATION
*Identify source of
indirect data
(effective patterns or
barriers/potential
barriers)
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HEALTH/PERCEPTIO
N
HEALTH
MANAGEMENT
General Survey, perceived
health
& well-being, selfmanagement
“I feel so-so.”
“I feel better off than
most people my age.”
“Mentally I think I’m
fine.”
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H.H. has a slight mobility
impairment, but gets around
by herself. She sometimes
uses a walker and a
wheelchair if going out.
H.H. functioned
independently. She was very
pleasant to talk to and seemed
content with her life.
strategies, utilization of
preventative health
behaviors
and/or services.
H.H. has many ongoing &
recurrent diagnoses, the
most prevalent one being
CHF (Chart)
BUN: 24 (H)
HGB: 11.5 (L)
MCV: 107.8 (H)
V/S: 97.5 F, 62 HR, 16 Resp,
104/58 in LA, 91% Rm Air.
Pain: 2/10
PLT: 226 (H)
RBC: 3.48 (L)
BNP: 2162 (H
(Chart)
H.H. does have some
chronic and recurrent
medical problems, but
she seems very content
with his health and is a
very pleasant and kind
woman. The main
concern right now is her
CHF.
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NUTRITIONAL/
METABOLIC
Patterns of food and fluid
consumption,
Weight, skin turgor.
(Skin, Hair, Nails; Head
& Neck;
Mouth, Nose, Sinus;
swallowing, Ht., Wt)
“I eat what I feel
comfortable with.”
“I had 6 children so I
was always the last one
to eat, if I ate much at
all, so I just got into that
pattern.”
“I’m happy staying
around 100 pounds.”
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5’3” 100 lbs.
Pt. ate 50% of dinner.
Decreased appetite.
H.H. had elastic skin turgor
and was able to swallow pills
easily.
She is able to feed herself.
H.H. eats on average 50%
of her meals.
H.H. eats in her semiprivate room or the dining
room (Most often in
room).
H.H. often goes out to eat
with her family at her
favorite restaurants. H.H.
has hypothyroidism and
hypercholesterolemia(Cha
rt)
Synthroid, Aspirin,
calcitriol, claritan, bumex,
digoxin (Chart)
H.H. does not eat a lot,
which could put her at
risk for malnutrition.
She has
hypercholesterolemia
which should be
monitored. Also, she is
taking many meds that
could effect her
nutrition. Synthroid and
Claritin could cause
weight fluctuation.
Digoxin, calcitriol, and
aspirin could cause
anorexia. Bumex could
cause dehydration.
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ELIMINATION
Patterns of excretory
function &
Elimination of waste;
relevant labs,
Medications, impacting,
etc.
(Abdominal - bowel and
bladder)
“I’m regular and I go
when I have to without
any problems.”
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H.H. was able to walk to the
bathroom by herself. Her
abdomen was soft and
nontender. Hyperactive BS
x4. (I should have asked more
questions about when she used
the restroom such as: did she
you just void or have a bowel
movement? What did the
bowel movement look like?
How often do you usually
have a bowel movement?)
H.H. was not on a strict
I&O. (Chart)
Synthroid, ferrous sulfate,
aspirin, calcitriol, diovan,
bumex, digoxin, &
vicodin (Chart)
H.H.’s elimination
patterns were WNL for
her. It is important to
monitor her
medication’s side
effects dealing with
elimination: Synthroid
could cause cramps or
diarrhea. Ferrous sulfate
constipation, dark
stools, diarrhea,
epigastric pain, GI
bleed. Aspirin could
cause GI bleed,
epigastric distress, &
N/V. Calcitriol could
cause constipation &
abdominal pain. Diovan
could cause diarrhea.
Bumex could cause
dehydration. Digoxin
could cause N/V.
Vicodin could cause
constipation.
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ACTIVITY/EXERCISE
“I take care of myself.”
Patterns of exercise &
daily living,
“I walk with my
daughter every other
day and if she doesn’t
come, I walk by
myself.”
self-care activities include
major
body systems involved.
(Thoracic & Lung;
Cardiac;
Peripheral vascular;
Musculoskeletal,
vital signs)
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H.H. was able to move about
the room by herself without
any assistance. She did not
grimace or act like she was in
pain while moving around.
She functions independently.
Her hand grasps were strong
and equal. MAE. ROM
WNL. Uses walker to move
around sometimes and
wheelchair for when she goes
out.
H.H. was not a fall risk.
Her activity status is up as
tolerated. She has walked
to the bathroom to go to
the restroom since her
stay at Altercare. Her
ADL’s are all performed
by herself. She has given
her own baths in the
hospital. She has no
record of dyspnea on
exertion. (Chart)
She participates in beauty
shop weekly, bingo,
special events, music
programs, and euchre
(Chart)
H.H. has PT & OT.
She has albuterol ordered
scheduled and prn.
(Chart)
H.H. functions
independently. She is
able to participate in the
activities she enjoys.
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“I was married, but my
husband died last New
Year’s Eve. We did not
stay in the same room
when we were both her
(at Altercare). I had 6
children, but now only
have 5.”
We did not discuss sexual
relations or functioning.
H.H.’s husband died Dec
31, 2009 (Chart)
H.H. and I did not
discuss sexuality so no
conclusions can be
drawn regarding this
matter.
SLEEP/REST
“I’m a light sleeper.”
Patterns of sleep, rest,
relaxation,
“I try to take ½ hour
naps throughout the
day.”
When talking to H.H. about
her sleeping, she seemed
frustrated that her roommate
woke her up at night and she
couldn’t sleep very long.
(No information was
obtained from indirect
sources regarding
sleep/rest.)
H.H. has trouble
sleeping and seemed
very tired, so it is
important to monitor
her sleep. Also, a
roommate switch
should be considered
due to the
circumstances.
SEXUALITY/
REPRODUCTION
Satisfaction with present
level of
Interaction with sexual
partners
(Breast; Testes;
AbdominalGenitourinaryreproductive)
fatigue
(Appearance, behavior)
“After getting up at 5am
so many years after
having kids, I’m just
used to it. I thought
when they left I’d sleep
more but I don’t.”
“I would say I get 6 hrs
of broken sleep a night
because I’m a light
sleeper and my
roommate comes in late
H.H. tried to take a nap during
my clinical shift.
H.H. appeared very tired when
talking to her.
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because of dialysis.”
Patterns of thinking &
ways of
“I feel like I’m all there
mentally except for
forgetting normal
things.”
Perceiving environment,
orientation
“I can see fine with my
glasses.”
COGNITIVE/
PERCEPTUAL
Mentation, neuron status,
glasses,
Hearing aids, etc.
H.H. wears glasses. Her
hearing is WNL and she does
not have hearing aids. A&O
x3 during my shift. H.H.
could answer questions easily
and follow directions. Longterm & short-term memory
were intact.
H.H. has been A&O x3
during her entire stay at
Altercare. (Chart)
H.H. has no problems
with cognition.
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ROLE/RELATIONSHI
P
“My family does very
well with me.”
Patterns of engagement
with others,
“I play cards with a
woman my husband
used to play cards with.
We play cards with
Luane, Helen, Joanne,
and Baker.”
Ability to form &
maintain meaningful
Relationships, assumed
roles;
Family communication,
response,
involvement
Patterns of viewing &
valuing
Self; body image &
psychological
state
H.H. seemed to think the
world of her family. She said
nothing but good things about
them. When we spoke, we
mostly talked about her
family. H.H. also seemed to
really enjoy getting together to
play cards with her friends
because she spoke of it a
couple of times.
H.H. sees her family
almost everyday. Helen’s
family is not only
supportive and visit, but
they take her out. (Chart)
H.H. seems to have a
very good support
system in her family.
She seems to have fun
and meaningful
relationships in her life.
Widowed (Chart)
H.H. seemed to miss her
husband and kept his folded
flag (from the funeral) under
her TV stand. She had
pictures hung on her walls of
her family.
Visitation, occupation,
community
SELF-PERCEPTION/
SELF-CONCEPT
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“I’m not in anyone’s
hair and I don’t have to
depend on my family.”
“I’m happy with the
weight that I am.”
“Mentally I think I’m
fine.”
I observed H.H. being very
pleasant and happy overall. I
did not hear anything negative
from her. She seemed very
pleased that she was not a
burden to anyone because she
mentioned it a few times.
(No information was
obtained from indirect
sources relating to selfperception or selfconcept)
H.H. was an overall
happy woman who was
content with her current
situation in life.
Running head: PROCESS PAPER
COPING/STRESS
TOLERANCE
Stress tolerance,
behaviors, patterns
of coping with stressful
events &
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“The weather really
effects me. I don’t like
rain and then shine and
back & forth. It gets me
down. I like the snow
other than that.”
H.H. seemed happy overall.
However, she did seem very
tired. She showed no signs of
depression or anxiety.
H.H. has no past history
of depression or anxiety.
Her behavior since being
in the Altercare has been
appropriate. (Chart)
H.H. is coping fine with
her current situation in
life. It would be
beneficial to keep
allowing her to spend so
much time with her
family, especially
during the colder
months of the year.
“I am Roman Catholic. I
have great devotion to
the Blessed Virgin
Mary.”
H.H. talked about her faith a
couple of times. She had a
rosary and a picture of Mary
in her room.
H.H.’s faith is important
to her and she receives
weekly communion,
prayer with Eucharist
ministry, and visits with
Deacon Steve (Chart)
H.H. has faith in God
and is dedicated to her
Catholic faith AEB
prayer, rosary, attending
church, etc
level of effectiveness,
depression,
anxiety.
VALUE/BELIEF
Patterns of belief, values,
Perception of meaning of
life that
guide choices or decision;
includes
but is not limited to
religious beliefs
“My faith leads my
life.”
“There’s a mass held
here once a month and a
Eucharist minister
comes once a week for
mass.”
“I go to St. Michael’s
for special occasions.”
Religion: Catholic (Chart)
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Lab Interpretation
Lab Test
Result 1
Result 2
Normal Range
Interpretation
4/21/2010
5/25/2010
Na
139
141
136-145 mEq/L
WNL
Cl
105
103
98-107 mEq/L
WNL
Glucose
77
84
70-105 mg/dL
WNL
Creatinine
1.0
0.9
0.6-1.3 mg/dL
WNL
Electrolyte
Balance
13
13
4-18
WNL
K
4.4
3.6
3.5-5.1 mEq/L
WNL
CO2
25
28
22-29 mEq/L
WNL
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BUN
20 (H)
24 (H)
7-18 mg/dL
High: due to CHF; HTN; Age; Bumex; Corgard;
Diovan
Ca
8.6
8.7
8.4-10.2 mg/dL
WNL
HCT
37
36
35-47 mL/dL
WNL
HGB
11.9 (L)
11.5 (L)
12-16 gm/dL
Low: due to fluid overload due to CHF and/or
pneumonia; anemia; CHF
WBC
7.7
6.8
4.8-10.8 x103
WNL
MCV
101.4 (H)
107.8 (H)
80-100 gm/dL
High: due to Anemia; Hypothyroidism
PLT
195
226
130-140 x103
High: due to Anemia
RBC
3.34 (L)
3.48 (L)
4-5.5 x106
Low: due to fluid overload due to CHF and/or
pneumonia; HTN; hypothyroidism; decreased HGB
MCHC
31.9
33.7
31-37 gm/dL
WNL
RDW
14.4
14.3
11.5-14.5%
WNL
2162 (H)
<100 pg/mL
High: due to SEVERE CHF
BNP
Diagnostic Test Interpretation
Test
Chest X-Ray
Date and Clinical Indication
for Test
4/19/2010
Results
Comparing this study w/previous study of
3/26/2010 there has developed several small areas
Interpretation
Small areas of
Running head: PROCESS PAPER
Chest X-Ray
18
Cough, SOB
of inflammation infiltrate in the Right middle &
lower lung field. The left lung remains clear. There
is residue of cardiac surgery & moderate
cardiomegaly but no evidence of failure. The
pacemaker wires remain in good position.
5/4/2010
Comparing this study w/the previous study of
4/19/2010 the small areas of the inflammatory
infiltrate on the right middle and lower lung field
have cleared. There are rather dense fibrotic
changes throughout the lung fields but no evidence
of any acute inflammatory disease at this time.
There is moderate cardiomegaly but no evidence of
failure. The pacemaker wires are in good position.
Follow-up Pneumonia
pneumonia on the right.
No active disease.
Moderate cardiomegaly
Medication Profile
Scheduled Medications
Drug Name
Drug Action/
Normal Dose
Major side
(generic/trade name)
Purpose
Range
Effects
Generic: Levothyroxine
-replacement in
hypothyroidism
to restore
normal
hormone
PO: 0.125 mg/d
Nervousness, h/a,
insomnia, irritability,
arrhythmia, angina
pectoris, hypotension,
tachycardia, cramps,
Brand: Synthroid
Order: 0.125 mg PO qd
Nursing Considerations
-assess apical HR & BP prior to &
during therapy
-monitor thyroid function tests
-assess for overdose: hyperthyroidism:
Running head: PROCESS PAPER
Classification:
hormone, thyroid
preparation
balance
Generic: Ferrous
Sulfate
-prevent/treat
iron-deficiency
anemia
Brand:
19
PO: 120-240 mg/d
in 2-4 div. doses (23 mg/kg/d)
diarrhea, vomiting,
diaphoresis,
hyperthyroidism,
menstrual irregularities,
heat intolerance, weight
loss
S/S tachycardia, chest pain,
nervousness, insomnia, tremors,
diaphoresis, weight loss
Constipation, dark
stools, diarrhea,
epigastric pain, GI
bleed
-give with meals
Order: 325 mg PO BID
Brand: Bayer
Order:81 mg PO qd
Classification:
antipyretic, nonopioid
analgesic, salicylate
-asses bowel function
-monitor HGB, HCT prior to & q3 wks
during 1st 2 months of treatment
Classification:
antianemic, iron
supplements
Generic: Aspirin
-assess nutrition
-monitor for overdose: stomach pain,
fever, N/V, diarrhea, bluish lips,
drowsiness, weakness, tachycardia, etc.
-decrease pain,
reduce
inflammation,
reduce fever,
decrease
incidence of
heart attacks
PO: 80-325 mg qd
Tinnitus, GI bleed,
dyspepsia, epigastric
distress, N/V,
abdominal pain,
anorexia,
hepatotoxicity, anemia,
hemolysis, increased
bleeding
-assess pain, fever
-may cause increase AST, ALT
-monitor serum salicylate levels
periodically
-monitor bleeding!
-monitor for overdose: h/a, tinnitus,
hyperventilation, agitation, mental
confusion, etc.
Running head: PROCESS PAPER
Generic: Calcitriol
Brand: Vitamin D3
Order: 0.25 mcg PO qd
Classification: fatsoluble vitamin
-treat
hypercalcemia
in
hypothyroidism
(PO only)
20
PO: 0.25 mcg/d
h/a, dizziness, malaise,
dyspnea, abdominal
pain, anorexia,
constipation, dry mouth
-assess for Vit D deficiency before &
during
-assess for bone pain & weakness
before & during
-observe for hypocalcemia: parasthesia,
muscle twitching, colic, cardiac
arrhythmias, Trousseau’s sign
-treat/prevent
vit D & Ca
deficiency
-draw serum Ca & P 2x/wk initially;
monitor monthly at least during therapy
-may cause increased cholesterol levels
Generic: Nadolol
Brand: Corgard
Order: 80 mg PO qd
-decrease HR &
BP
-manage angina
pectoris
PO: 40 mg qd
initially, can
increased by 4080mg/d (up to
320mg/d)
Fatigue, weakness,
anxiety, depression,
dizziness, drowsiness,
insomnia, erectile
dysfunction
Classification:
antianginal,
antihypertensive, betablocker
Generic: Valsartan
Brand:Diovan
-monitor BP & HR
-I/O, daily weight
-may cause increase BUN, K,
triglyceride levels
-may cause increase blood glucose
levels
-monitor for overdose: bradycardia,
severe dizziness, fainting, drowsiness,
seizure, dyspnea, bluish nails or palms
-decrease
BP/treat
hypertension
PO: HTN- 80-160
mg/d
CHF: 40 mg 2x/d
Dizziness, anxiety,
depression, insomnia,
weakness, hypotension,
chest pain, edema,
-hold if systolic <110
-monitor BP & HR
Running head: PROCESS PAPER
Order: 40 mg PO qd
Classification:
antihypertensive,
angiotensin II receptor
antagonist
-decrease heart
death &
hospitalization
due to CHF in
CHF patients
21
(patient may be
taking lesser
amount because
hypertension is
being treated with
other medications
too)
abominal pain, diarrhea
-daily weight
-may increase serum K, BUN, &
creatinine
-may increase AST, ALT, & bilirubin
-may increase uric acid
-may decrease slightly HCT, HGB
Generic: Fluticasone
Brand: Flonase
-decrease nonallergic rhinitis
symptoms
Order: 50 mcg/spray
Nasal Spray: 50
mcg/spray (number
of sprays depends
on symptoms)
1 spray into each nostril
qd
Dizziness, h/q,
epistaxis, nasal
irritation & burning,
nasal congestion,
sneezing, teary eyes,
cough, bronchspasm,
dry mouth
Classification:
antiasthmatic,
corticosteroid
(inhalation)
Generic: Loratadine
Brand: Claritin
Order: 10 mg PO qd
Classification:
antihistamine
-relieve
seasonal
allergies
-decrease
symptoms of
allergic
PO: 10 mg qd
Confusion, paradoxical
excitation, blurred
vision, dry mouth, GI
upset, rash,
photosensitivity,
weight gain
-monitor symptoms: nasal stuffiness,
nasal discharge, sneezing
-periodically monitor adrenal function
-pts on long-term use should have
periodic otolaryngologic exams to
monitor nasal mucosa & passages for
infxn or ulceration
-asses allergy symptoms
-assess lung sounds
-maintain fluid intake 1500-2000 mL/d
-may cause false negative result of
allergy skin testing
Running head: PROCESS PAPER
22
reactions
Generic: Bumetanide
Brand: Bumex
Order: 1 mg PO BID
Classification: loop
diuretic
-decreases
edema due to
heart failure,
hepatic disease,
or renal
impairment
PO: 0.5-2 mg/d
given in 1-2 doses
(max: 10 mg/d)
Dehydration,
hypochloremia,
hypokalemia,
hypomagnesemia,
hyponatremia,
hypovolemia,
metabolic alkalosis
-assess fluid status
-monitor BP & HR
-in geriatric patients: diuretic use is
associated with increased risk for falls
-may decrease serum Na, K, Ca, Mg
-may increase BUN, serum glucose,
creatinine, & uric acid levels
Generic: Albuterol
Sulfactose
Brand:
Order: Inhale 2.5 mg/3
mL (0.083% solution)
TID
-bronchodilates
-treats asthma,
COPD,
bronchospasm
Inhalation: initial
dose not exceed 2
mg 3-4 times/d,
may increase
carefully up to 32
mg/d
Nervousness,
restlessness, tremor,
h/a, chest pain,
palpitations, angina,
arrhythmias, HTN
PO: for geriatric
patients, dose
should not exceed
0.125 mg (except
when treating A.
Fatigue, h/a, weakness,
bradycardia, anorexia,
N/V, arrhythmias,
blurred vision
-assess lung sounds, HR & BP before
& during
-monitor pulmonary function tests
-may decrease serum K with nebulizer
or higher-than-recommended doses
Classification:
bronchodilator,
adrenergic
Generic: Digoxin
Brand: Linoxin
Order: 0.125 mg PO qd
Classification:
-treat CHF, Afib
-increase CO &
slow HR
-monitor apical pulse for 1 min before
giving (must be >60 to give)
-I/O, daily weight
-for geriatric patient: digoxin has been
Running head: PROCESS PAPER
23
antiarrhythmis,
inotropic, digitalis
glycosides
fib)
associated with increased risk of falls
-therapeutic digoxin levels are 0.5-2
mg/mL (draw levels before next dose)
-geriatric patients are more at risk for
toxic effects of digoxin so monitor for
OD: abdominal pain, anorexia, N/V,
visual disturbance, bradycardia
Generic: Hydrocodone
(Acetaminophen)
Brand: Vicodin
schedule III
Order: 2.5 mg
hydrocodone/500 mg
acetaminopen PO qhs (at
bedtime)
-decrease pain
-suppress cough
PO: 2.5-10 mg q3-6
hrs
Confusion, dizziness,
sedation, hypotension,
bradycardia,
constipation, dyspepsia,
N
-do not exceed 4g/d of acetaminophen
-assess BP, HR, & Resp before &
during
-assess bowel function routinely
-assess pain location, type, intensity
-antidote: narcan
Classification:
antitussive, opioid
analgesis, opioid
agonist/nonopioid
analgesic combinations
(Deglin & Vallerand, 2007) (Key, Hayes, & McCuistion, 2006)
PRN Medications
Running head: PROCESS PAPER
24
Drug Name
Drug Action/
Normal Dose
Major side
(generic/trade name)
Purpose
Range
Effects
-decrease pain
PO: 325-640 mg
q4-6h
Neutropenia,
hepatotoxicity,
leucopenia, rash,
hepatic failure, renal
failure (with high
doses)
Generic:
Acetaminophen
-decrease fever
Brand: Tylenol
Order: 650 mg PO q4h
prn
Classification:
antipyretic, nonopioid
analgesic
Generic: Loperamide
Brand: Imodium
-relieve
diarrhea (for
loose stools)
Classification:
antidiarrheal
Brand:
-do not exceed 4g/d of acetaminophen
-assess pain location, type, intensity
-assess fever
-increased LDH, AST, ALT, bilirubin,
& prothrombin time indicate
hepatotoxicity
Antidote: acetadote
Order: 2 mg PO QID
Generic: Albuterol
Sulfate
Nursing Considerations
-see “albuterol”
info above
PO: 4 mg initially,
then 2 mg after
each loose stool;
maintenance dose is
usually 4-8 mg/d in
div. doses
Drowsiness, dizziness,
constipation,
abdominal pain or
discomfort or
distension, dry mouth,
N/V
-see “albuterol”
info above
-see “albuterol” info
above
-do not exceed 16 mg/d for Rx
-assess frequency & consistency of
stools & bowel sounds before & during
-assess for fluid & electrolyte balance
& skin for turgor & dehydration
-see “albuterol” info above
Running head: PROCESS PAPER
25
Order: Inhale 2.5 mg/3
mL (0.083% solution)
q4h prn
Classification:
bronchodilator,
adrenergic
Generic: Hydrocodone
(Acetaminophen)
-decrease pain
(specifically
joint pain)
-see above
“Vicodin” info
-see above “Vicodin”
info
Brand: Vicodin
schedule III
Order: 2.5 mg
hydrocodone/500 mg
acetaminopen PO q6h
prn
Classification:
antitussive, opioid
analgesis, opioid
agonist/nonopioid
analgesic combinations
(Deglin & Vallerand, 2007) (Key, Hayes, & McCuistion, 2006)
Concept Map
-see above “Vicodin” info
Medications
Student Name Emily Dehnke_ Client Initials _H.H._ Date _11/24/2010_
Lab Values/Diagnostic Test Results
Age _81__ Gender _F__ Room # _306-2_ Admit Date __10/3/2009__
BUN: 24 (H)
CODE Status __DNR-CC__ Allergies ______Nickel Sulfate, NKDA_____
HGB: 11.5 (L)
-Levothyroxine
(Synthroid)
Running
head:
PROCESS PAPER
-Ferrous Sulfate
-Aspirin
26
Diet __NAS__ Activity _Up as tolerated_ Braden Score _18__
PLT: 226 (H)
-Calcitriol
Admitting Diagnoses/Chief Complaint
-Nadolol (Corgard)
Congestive Heart Failure
-Valsartan (Diovan)
-Fluticasone (Flonase)
MCV: 107.8 (H)
Congestive Heart Failure (CHF)
Physical Assessment Data
RBC: 3.48 (L)
BNP: 2162 (H)
*All other labs were WNL
-Loratadine (Claritin)
-Acyclovir (Zoviraz)
-Bumetanide (Bumex)
-Albuterol Sulfactose
-Digoxin (Linoxin)
-Vicodin
-Acetaminophen
-Loperamide (Imodium)
-Albuterol Sulfate
IV Sites/Fluids/Rate: None
Past Medical /Surgical History
-CHF
Patient did not have an IV
-Hypertension
-Pacemaker
-Thyroidectomy
5’3” 100 lbs. V/S: 97.5 F, 62 HR, 16 Resp, 104/58 in LA, 91%
Rm Air. Pain: 2/10
Chest X-Ray (most recent):
A&Ox3. PERRLA. Pt. has glasses. Hearing WNL. No hearing
devices present. Mucous membranes pink, moist. Lips pink,
moist. Tongue moist, intact. Teeth natural. Facial expression
WNL, symmetrical. Skin warm, dry, smooth.
moderate cardiomegaly
No sign of pneumonia;
Resp. rhythm reg. & non-labored. BSx4, soft ś tenderness
Pt. ate 50% of dinner. Decreased appetite.
Heart sounds clear & WNL, Apical pulse 65. Pacemaker
present.
Hand grasps strong & equal, MAE, ROM WNL. Dorsalis
Pedis +2, Posterior Tibial +2. Cap refill <3 sec.
Treatments
PT
OT
Functions independently. Walks to bathroom by seld.
Sometimes uses walker. Uses wheelchair when going out
Up as tolerated
Walker
Wheelchair
-Hypercholesterolemia
-Hypothyroidism
-Recurrent Right Pleural Effusion
-Thoracentesis x3
Running head: PROCESS PAPER
27
Nursing Care Plan
Nursing Diagnosis 1: Decreased Cardiac Output
(CO) r/t heart failure AEB…
-CHF
-Pacemaker
Chest X-ray: cardiomegaly
Nursing Diagnosis 2: Risk for Imbalanced
Nutrtion: Less than body requirements r/t
decreased appetite AEB…
Nursing Diagnosis 3: Risk for Ineffective sleep
pattern r/t frequent awakenings AEB…
-Light sleeper
-5’3” 100 pounds
-decreased appetite
-Roommate comes back from dialysis late &
wakes H.H. up
-POX 91%
-“I had 6 children so I was always the last one to -Tired
eat, if I ate much at all, so I just got into that
-Averages 6 hrs of broken sleep per night
pattern”
-HTN
-“I’m happy staying around 100 pounds.”
-Extremely elevated BNP
-hypercholesterolemia
-“After getting up at 5am so many years after
having kids, I’m just used to it. I thought when
they left I’d sleep more but I don’t.”
- Synthroid, Aspirin, calcitriol, claritan, bumex,
digoxin
Outcomes: Two Patient-centered goals
Outcomes: Two Patient-centered goals
Outcomes: Two Patient-centered goals
Short-term: The pt. will exhibit adequate CO by
regular heart rhythms and rate, BP, resp., and
output during my shift.
Short-term: The pt. will ingest at least 50% of
each meal during my shift.
Short-term: Pt. will report feeling rested during
my shift
Long-term: Pt. will ingest 50% of all meals and
not lose more than 5 pounds.
Long-term: Pt. will exhibit improved sleep
patterns AEB sleeping 6-7 hrs at one time.
Interventions w/Rationale
Interventions w/Rationale
Interventions w/Rationale
1. Assess V/S qd.
1. Explain need for adequate consumption of
1. Ask pt. if she is feeling rested every morning
Long-term: The pt. will exhibit adequate CO by
regular heart rhythms and rate, BP, resp., and
output consistently while living at Altercare.
Running head: PROCESS PAPER
28
-Hypotension could indicate decreased CO.
Tachycardia can increase heart and oxygen
demands. Irregular heart rhythms can
compromise CO.
proper nutrients prn
after pt. wakes up.
-clients ċ greater nutritional knowledge
generally choose healthier diets
-The single most important criterion for
adequacy of sleep & rest is the client’s
statement
2. Monitor I/O and weigh qd
2. Explain how inadequate nutrient intake can
harm pt. prn
-If intake is greater than output, client may not
be able to clear the fluids which would cause
fluid overload. Excess fluid puts extra work on
the heart
3. Assess for change in mental status qd.
-decreased nutrition greatly increases risk for
infection & delays surgical wound healing
3. Manage pain efficiently at all times
-pain can be a reason why a pt. doesn’t eat
2. Position client to maximize comfort each
time you leave the client.
-Comfort is essential for ensuring sleep.
3. Offer massage, relaxation techniques,
relaxing music, etc.
-Change in mental status can indicate
decreased cerebral/tissue perfusion and hypoxia.
4. Ask pt. about her food preferences prn
-These techniques promote relaxation and
sleep.
4. Asses peripheral pulses qd.
-Pt. more likely to eat when she has food she
enjoys
4. Consult with physician about possible need
for sleeping aides such a medications
-Weak peripheral pulses are often found in
clients with decreased CO.
5. Encourage pt. to drink fluids prn
5. Ensure that patient is following her NAS diet.
-an important part of nutrition is hydration and
fluid balance
-Sometimes a sleep aid is beneficial to a
client who is having trouble getting adequate
sleep, especially if the patient has trouble
staying asleep.
-Reducing sodium consumption helps prevent
fluid retention in the lungs, ankles, and abdomen,
which can make breathing and walking harder
5. Ensure quiet, comfortable, and relaxing
environment by turning down lights,
minimizing noise, closing the door, etc.
6. Encourage safe and mild exercise.
-With a doctor's OK, mild activities like
walking, swimming, and biking are beneficial for
a CHF patient.
-decreases anxiety and increases mood and
relaxation of patient
6. Consult with nursing home director about
possibly moving roommate to a different room
who’s current occupant is not as light of a
Running head: PROCESS PAPER
29
sleeper.
-It is important to create and maintain an
environment that encourages sleep.
EBP Citation:
EBP Citation:
EBP Citation:
Black, J., & Hawks, J.H. (2005). Medical
surgical nursing: clinical management for
positive outcomes. (7th Ed) St. Louis, MO:
Elsevier Saunders.
Black, J., & Hawks, J.H. (2005). Medical
surgical nursing: clinical management for
positive outcomes. (7th Ed) St. Louis, MO:
Elsevier Saunders.
Black, J., & Hawks, J.H. (2005). Medical
surgical nursing: clinical management for
positive outcomes. (7th Ed) St. Louis, MO:
Elsevier Saunders.
Carpenito-Moyet, L.J. (2006). Nursing diagnosis: Carpenito-Moyet, L.J. (2006). Nursing
application to clinical practice. (11th Ed.)
diagnosis: application to clinical practice. (11th
Philadelphia, PA: Lippincott.
Ed.) Philadelphia, PA: Lippincott.
Carpenito-Moyet, L.J. (2006). Nursing
diagnosis: application to clinical practice. (11th
Ed.) Philadelphia, PA: Lippincott.
Craven, R., & Hirnle, C.J. (2009). Fundamentals
of nursing: human health and function. (6th Ed.)
Philadelphia, PA: Lippincott.
Craven, R., & Hirnle, C.J. (2009).
Fundamentals of nursing: human health and
function. (6th Ed.) Philadelphia, PA: Lippincott.
Craven, R., & Hirnle, C.J. (2009).
Fundamentals of nursing: human health and
function. (6th Ed.) Philadelphia, PA: Lippincott.
Evaluation:
Evaluation:
Evaluation:
Short-term: Goal met. H.H.’s V/S were WNL
for her. Will continue to monitor
Short-term: Goal met. H.H. ate 50% of dinner.
Will continue to monitor
Short-term: Goal not met. H.H. did not report
feeling rested during my shift. Will continue to
monitor.
Long-term: Goal not able to be evaluated at
time of shift. Will continue to monitor.
Long-term: Goal not able to be evaluated at
time of shift. Will continue to monitor.
Kotz, D. (2009, December). Six smart ways to
treat heart failure. U.S. News and World Report,
146(11). 55-59. Retrieved from Academic Search
Complete.
Long-term: Goal not able to be evaluated at
time of shift. Will continue to monitor.
Running head: PROCESS PAPER
30
Reference
Black, J.M., & Hawks, J.H. (2005). Medical-Surgical nursing: clinical management for positive outcomes. Philadelphia, PA: Elseveir
Saunders.
Buckley, L.L, & Schub, T. (2010). Thyroidectomy. Cinahl Information Systems. 7(31-32) Retrieved from Cinahl Plus with full text
database.
Carpenito-Moyet, L.J. (2006). Nursing diagnosis: application to clinical practice. (11th Ed.) Philadelphia, PA: Lippincott.
Craven, R, & Hirnle, C. (2009). Fundamentals of nursing. Philadelpia, PA: Lippincott Williams and Wilkins.
Deglin, J.H., and Vallerand, A.H. (Eds.) (2007). Davis’s drug guide for nurses. Philadelphia, PA: F. A. Davis Company.
Kee, J.L., Hayes, E.R., & McCuistion, L.E. (Eds.) (2006). Pharmacology: a nursing process approach. St. Louis, MO: Saunders
Elsevier.
Kotz, D. (2009, December). Six smart ways to treat heart failure. U.S. News and World Report, 146(11). 55-59. Retrieved from
Academic Search Complete.
WebMD. 2010. WebMD. Retrieved from http://www.webmd.com
Running head: PROCESS PAPER
31
Thyroidectomy
Description
Thyroidectomy, the removal of all or part of the thyroid gland, is most frequently performed to treat hyperthyroidism or hypothyroid goiters and to remove benign or malignant
thyroid neoplasms. There are four basic types of thyroidectomies: removal of one lobe of the thyroid (lobectomy); removal of both lobes of the thyroid and the isthmus with the
exception of a small posterior remnant (bilateral subtotal); removal of the entire thyroid gland with the exception of a small remnant located on the side contralateral to the
pathology (near total); and complete removal of the entire thyroid (total). Total thyroidectomy is the preferred procedure for Graves’ disease and multi-nodular goiter.
A recently developed endoscopic technique called minimally invasive video-assisted thyroidectomy (MIVAT) involves endoscopic dissection and removal of the thyroid gland and
has the advantage of superior cosmetic results, shortened hospitalization, and reduced postoperative discomfort. In cases of thyroid cancer or large lesions extending into
surrounding structures, more extensive surgeries such as lymph node dissection, modified radical neck dissection, and/or median sternotomy may be required.
Description of Operative Procedures
Lobectomy With or Without Isthmectomy
Removal of one lobe of the thyroid and the thyroid isthmus if necessary••
Bilateral Subtotal Thyroidectomy
Part of the thyroid is excised. This is performed for benign conditions and some low-grade ••malignancies. There is reduced danger of accidental parathyroid removal
Near Total Thyroidectomy
Removal of the entire thyroid gland except for a small remnant contralateral to the pathology••
Total Thyroidectomy
After an incision is made in the front of the neck (i.e., sternal notch), the muscles are cut and retracted. The thyroid’s blood supply is clamped, the thyroid is cut free,
removed, and a drain is placed. In some cases, some normal thyroid tissue, particularly the isthmus (a small band of tissue), may be left intact. In cancer, lymph nodes
may also be removed. The muscles and skin are sutured or clipped. Sutures or clips are removed 2–10 days after surgery
Minimally Invasive Video-Assisted Thyroidectomy (MIVAT)
The neck is extended and a small (2.5 cm) incision is made. A videoendoscope with surgical ••tools is inserted into the incision to visualize the thyroid and adjacent
structures and to complete thyroidectomy procedures
Potential Complications
Thyroidectomy performed by an experienced surgeon carries a complication rate of < 1%. Complications may result from the surgery itself or from secondary metabolic
disturbances. Hypocalcemia is the most common complication after thyroidectomy (2–53% of patients experience temporary hypocalcemia and 0.4–14% experience permanent
hypocalcemia) due to damage to the parathyroid. The risk for hypocalcemia is significantly reduced with near total thyroidectomy compared with total thyroidectomy. Other
potential complications of thyroidectomy include infection (< 1–2%), hemorrhage (0.3–1%), airway obstruction, laryngeal nerve damage (which may result in vocal dysfunction),
and metabolic disturbances such as thyrotoxicosis (i.e., thyroid storm).
Outcomes
Short-term outcomes include excessive fatigue and sweating, weight loss, nervousness, tachycardia, feeling hot, tremors, and menstrual irregularities. Thyroid replacement
medication (e.g., levothyroxine) is usually required after surgery; calcium supplementation is needed with parathyroid damage.
Assessment
Laboratory Tests That May Be Ordered
Running head: PROCESS PAPER
32
Serum thyroid function studies reveal elevated levels of free thyroxin (T4), free triiodothyronine ••(T3), and free thyroxine index (FTI) and suppressed levels of thyroidstimulating hormone (TSH) in hyperthyroidism
Thyroid antibody testing for the presence of thyroid antibodies (as in Graves’ disease)••
Other Diagnostic Tests/Studies That May Be Ordered
Thyroid scans using I-131 (radioactive iodine) reveal increased thyroid uptake of the radioisotope••
Thyroid ultrasound examination with fine-needle aspiration to investigate thyroid nodules••
EKG for heart arrhythmias••
CT or MRI scans of the orbits of the eyes to rule out other causes of exophthalmos••
Preoperative Treatment Goals
Provide Symptomatic Relief and Preoperative Support
Assess all physiologic systems and review laboratory/diagnostic study results for details of thyroid status; immediately report abnormalities and ••treat, as ordered
Assess for pain and other discomfort; provide symptomatic relief, as ordered••
Follow facility pre- and postsurgical protocols to prepare patient for surgery••
Reinforce pre- and postsurgical education; ensure completion of facility informed consent documents••
Postoperative Treatment Goals
Provide Prescribed Treatment and Reduce Risk of Complications
Closely monitor for postsurgical complications (e.g., excessive bleeding, infection, voice hoarseness, hypoparathyroidism); provide symptomatic ••relief of pain, nausea,
or other discomfort, as ordered
Monitor the pitch and tone of the patient’s voice postoperatively every 1–2 hours to detect hoarseness due to possible recurrent laryngeal nerve damage. Discourage
excessive talking to prevent vocal cord edema
Administer prescribed thyroid hormone replacement, calcium supplements (e.g., calcium carbonate), antiemetics (e.g., droperidol), analgesics (e.g., acetaminophen alone
or with codeine), antihypertensives (e.g., nadolol), and prophylactic antibiotics
Maintain a clear liquid diet; provide good skin care, keeping the skin and wound incision clean and dry from drainage—if ordered, apply a thin ••layer of topical antibiotic
ointment
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33
Promote Emotional Well-Being and Relieve Anxiety
Assess patient’s anxiety level and coping ability; provide emotional support, educate, and encourage discussion about thyroid pathophysiology, potential surgical
complications, treatment risks and benefits, and individualized prognosis
Request referral to a mental health clinician or member of the clergy, as appropriate, for anxiety regarding need for lifetime medical follow-up and medications
Food for Thought
Total thyroidectomy is the preferred procedure for bilateral multinodular goiters, with preservation of the recurrent laryngeal nerves and the 4parathyroid glands
Oxygen, suction, and tracheostomy equipment should be available for emergency situations4
MIVAT operating times tend to be significantly longer than in conventional thyroidectomy4
Ultrasonic thyroidectomy is as effective as conventional thyroidectomy and is a shorter procedure 4
Thyroidectomy appears to be as safe in older patients (> 65 years) as in younger patients (21–35 years); (Seybt et al., 2009)
Red Flags
Monitor postoperatively for potentially life-threatening signs of thyrotoxicosis, including significant tachycardia, hyperpyrexia, heart failure, 4neurologic compromise, and
gastroenterologic and hepatic dysfunction
What Do I Need to Tell the Patient/Patient’s Family?
Avoid taking aspirin postoperatively as it may pose risk for bleeding, decrease protein binding of thyroid hormones and lead to increased levels of 4T3 and T4
Follow up closely with the clinician. Promptly report the following signs/symptoms: numbness or tingling around the lips or extremities; twitching 4or spasms; fever; chills;
incision site redness, swelling, bleeding, or discharge; cough; dyspnea; and severe fatigue, pain, nausea, or vomiting
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34
Six Smart Ways to Treat Heart Failure
It isn't only patients who need to do the right thing. Doctors could improve, too
Heart failure at 45? Meet Robert Jones. His heart, severely weakened as a result of uncontrolled high blood pressure and diabetes, has landed him in the hospital
nine times over the past three years and forced the Cheshire, Mass., mechanic to retire 18 months ago. Because his heart has to work harder to pump blood, he
could have a heart attack, his kidneys could fail, or fluid could build up in his lungs if he isn't faithful to a slew of medications and a low-sodium diet. His resolve
got a boost last June from telemedicine. A device in his house monitors his weight, pulse, and blood pressure and transmits the telltale numbers every morning by
phone to a nurse, who calls Jones within an hour if they're out of whack. "Since I've had the machine, I haven't been back to the hospital," he says. "That's pretty
good."
Jones is fortunate. Many of the 5.7 million Americans with congestive heart failure (the formal name) face diminished quality of life, years of hospitalizations, and
possible early death because their doctors don't follow best practices that can help overcome the gradual loss of function that defines CHF. The initial damage to
the heart may be caused by a heart attack, years of smoking, or a valve defect resulting from high blood pressure or a condition such as Jones's diabetes. Over
time, as the heart pumps harder to overcome its dwindling power, the walls often thicken and enlarge, and the pumping chambers may lose their vital
synchronization.
New drugs, procedures, and technologies can slow the decline. Get With the Guidelines software from the American Heart Association, for example, lets doctors
feed in information about a patient and get recommendations for medications, dietary restrictions, and possibly a pacemaker to prevent abnormal heart rhythms
and fluid retention. The program could reduce deaths and rehospitalizations by more than 20 percent, yet fewer than 1 in 10 of the nation's roughly 5,000
hospitals has signed up. And even at hospitals that supposedly were following the guidelines, only one third of 12,565 heart failure patients who might have
benefited from fluid-eliminating diuretic medications received them, according to a recent Cleveland Clinic study.
Hence heart failure remains the No. 1 cause of hospitalizations and deaths in those over 65, and a recent study in the New England Journal of Medicine found that
more than 25 percent of discharged patients are back in the hospital within a month. "We can take the failure out of heart failure," says AHA President Clyde
Yancy, "if we use all of the available treatment strategies to the best of our abilities."
Running head: PROCESS PAPER
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Hospitals can find that challenging. Berkshire Medical Center in Pittsfield, Mass., where Jones gets his care, adopted the guidelines in 2005, but readmissions
didn't drop. In 2007, the hospital invested $350,000 a year, about $1,200 per CHF patient, in a program that provides outpatients like Jones with home
monitoring--including the telemedicine device and home visits by a nurse--free if insurance won't foot the bill. Now readmission rates are at 17 percent, down
from 27 percent two years ago. A review study published in October in the Journal of the American College of Cardiology found that remotely monitored CHF
patients had lower death rates as well.
While health reform may change the landscape, most insurance companies currently do not reimburse hospitals or patients for the kind of care Berkshire provides.
Thus, CHF patients can't assume their care will be equally thorough and enlightened. It is largely up to them and to their families to recognize the warning signs
and take charge of their conditions.
Here are six ways to help yourself or a family member follow the principles of the AHA guidelines:
1.
Get diagnosed ASAP. Investigating possible signs of CHF early--shortness of breath, fatigue, and difficulty with physical activity are a few--can prevent
irreversible damage. Regular blood pressure checks are a good idea, since uncontrolled high blood pressure, which can lead to heart failure, doesn't
always have symptoms. Besides reviewing the usual medical history, physical, and blood tests, a physician looking for evidence of CHF may order a chest
X-ray to check for fluid in the lungs and an echocardiogram or other type of imaging to measure the heart's ejection fraction, or pumping ability. Imaging
also will reveal synchronization problems, or dyssynchrony, which is common among heart failure patients.
2.
Get effective drugs. An ejection fraction below 40 percent calls for medications such as ACE inhibitors (to dilate blood vessels), beta blockers (to lower
blood pressure and prevent arrhythmias), and diuretics (to flush out excess fluid), according to the AHA guidelines. Gregg Fonarow, a professor of
cardiovascular medicine at UCLA School of Medicine who chaired the AHA guidelines committee, says these drugs are "absolutely critical." Their use, he
says, could determine "whether patients will die or be rehospitalized" within the few months that follow. African-American patients should be offered
hydralazine nitrate, which dilates veins and arteries; that alone cuts the risk of death in this population by 43 percent. According to Fonarow, less than 1
in 5 African-Americans who qualify for this treatment receives it.
Women need to be especially vigilant--studies show that they are less likely than men to be given guideline-indicated therapies, although current AHA guidelines
recommend the same medications for both genders. Part of the reason that women are treated differently is that research on treating women with CHF lags
behind research on men, says cardiologist Nieca Goldberg, director of the Women's Heart Center at New York University Medical Center.
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3. Consider a pacemaker. A pacemaker helps reset the heart's electrical system so that all parts work as well as possible and in sync. One pacemaker approach
is cardiac resynchronization therapy, or CRT, recommended in the AHA guidelines along with medication for those with dyssynchrony and an ejection fraction of
35 percent or less. The $25,000-to-$40,000 procedure has been shown to lower the risk of dying from CHF by one third over several years and to reduce the
likelihood of rehospitalization by about half.
Yet a study published last year in the journal Circulation found that only 12 percent of hospitalized CHF patients had had a pacemaker implanted before being
discharged. "I'd estimate that only about one third of patients who need CRT are actually getting it," says study author Adrian Hernandez, an assistant professor
of medicine at Duke University School of Medicine.
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4. Manage related conditions. Nearly half of CHF patients have symptoms such as shortness of breath but have a normal ejection fraction. These
patients, who are more likely to be female or elderly, often have the conditions that classic heart failure patients do--such as high blood pressure,
diabetes, kidney disease, a heart rhythm disorder, and coronary artery disease--but their symptoms are caused by stiffening of the heart muscle, which
can be seen with a Doppler echocardiogram. The strategy for such patients, says Yancy, is to bring these conditions under control.
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5. Cut way back on salt. Reducing sodium consumption helps prevent fluid retention in the lungs, ankles, and abdomen, which can make breathing
and walking harder. The AHA recommends a daily limit of 2,000 milligrams, which is about a teaspoon. Sources include not only the usual suspects, like
salt and pickles, but also sports drinks, soup mixes, and even nonprescription medications like Alka-Seltzer. (A single dose has 1,100 mg.) A good way to
tell if you're getting too much salt? Weigh yourself every day, says Fonarow. If you gain more than 2 or 3 pounds, cut back on sodium, or ask if you need
a higher dose of diuretics.

6. Exercise, but safely. While it isn't clear that exercise reduces deaths or hospitalizations, some recent studies suggest that it can temper CHF
symptoms like fatigue--if done with care. Overexertion can be dangerous. Training with heavy weights, for instance, is out, says Fonarow. With a doctor's
OK, mild activities like walking, swimming, and biking are usually fine (and cheap or free). Jones makes a point of biking 2 miles a day around his
neighborhood and trying not to slip up at the supermarket. A visiting nurse comes every week to peruse his refrigerator and ask about his exercise
habits. "If I'm bad," he says, "my nurse yells and tells me I'm bad"--and he resolves to try harder.