Case Study

Mr. P is a 76-year-old male with cardiomyopathy and congestive heart failure who has been hospitalized frequently to treat CHF symptoms. He has difficulty maintaining diet restrictions and managing his polypharmacy. He has 4+ pitting edema, moist crackles throughout lung fields, and labored breathing. He has no family other than his wife, who verbalizes sadness over his declining health and over her inability to get out of the house. She is overwhelmed with the stack of medical bills, as Mr. P always took care of the financial issues. Mr. P is despondent and asks why God has not taken him.

Question

Considering Mr. P's condition and circumstance, write an essay of 500-750 words that includes the following:

• Describe your approach to care.

• Recommend a treatment plan.

• Describe a method for providing both the patient and family with education and explain your rationale.

• Provide a teaching plan (avoid using terminology that the patient and family may not understand).

Case Study

The approach should include a combination of nutritional therapy as well as medication and other treatments. The home-based care program consisted of weekly home visits by a physician and a nurse. During visit, they have to assess the condition of patient, review of medications and made any necessary changes. Along with that, the needed laboratory tests were examined and the intravenous diuretics were administered. The patient compliance with the dosage regimen should also be determined on the basis of pill count which is followed by assessment of patient's physical status. Since, the patients had poor knowledge about the regimen or poor compliance he must need the additional intervention. Moreover, the information derived from the home visit must be provided to the patient's primary physicians. During initial visit, the nurse must educate and counsel the patients on the management and on behavioral techniques to enhance the compliance.

It must be followed by telephone calls every week for 6 weeks with continued counseling so that he must be adhered to the diet and drug regimen plan as well as the self-monitoring of symptoms (Grady, et al., 2000).

The treatment plan should include the airway management as it is the critical first step. It is required since the elderly with heart failure can promptly fatigue and may require the emergent intubation. The diuretics such as Furosemide should be used to decrease the venous congestion however, the use must be regulated as in the elderly, there is age-related decline in the renal function as well as the decreased circulating volume (Emergency Physicians Monthly). For pulmonary edema, the morphine and IV nitrates should be used. Moreover, the symptoms caused by fluid retention may be treated with diuretic followed by the weight monitoring. Additional treatments include the use of ACE inhibitor according to the tolerability, β-blockers, digoxin or spironolactone. The angiotensin antagonists are also used in patients in whom ACE inhibition is contraindicated (Gillespie, 2005).

The education and counseling of heart failure patient are the essential part of patient care. It may reduce the re-admission of these patients along with cost of care. The education can be provided through mailing the personalized educational materials in which main emphasis was done on self-care and the recommended health behaviors were promoted (Serxner, Miyaji, & Jeffords, 1998). The wife can be educated about the risk of contracting the disease. Along with that, the history of the wife should also be assessed to determine her risk of contracting the disease due to hypertension. Moreover, the overviews of associated symptoms, activity and exercise, dietary recommendations, and medications are taught to patient and his wife. The written materials and videotapes can also be used as the additional resource for patient education (Quaglietti, Atwood, Ackerman, & Froelicher, 2000).

The teaching plan may involve the following steps:

- Understanding the symptoms of heart failure is the primary topic to begin the teaching as many patients do not understand the term "heart failure". It must be explained clarifying the expected symptoms of heart failure and worsening failure.

- Watching a video regarding cardiomyopathy and heart failure in which the patient and his wife can watch the effects of the disease.

- Counseling related to dietary habits and recommendations as well as the activity and exercise.

- Patients should be taught the name and purpose of drugs used, their dosage, frequency, and the side effects if any. Moreover, a written medication schedule should be given to him to reduce the adverse affect of polypharmacy on his daily life, compliance, and drug interactions (Francis, 1998).

The main objective of education and counseling are to assist the patients to comply with the drug regimen, to maintain the clinical stability and function, and thereby improve the quality of life. These objectives can only be achieved if the patient and family are having knowledge about every aspect related to the condition and treatment and take active participation in the plan of care (Regan, 1990).

References:

- Grady, K. L., Dracup, K., Kennedy, G., Moser, D. K., Piano, M., Stevenson, L. W., et al. (2000). Team Management of Patients with Heart Failure. 102: 2443-2456. Retrieved from http://circ.ahajournals.org/content/102/19/2443.1.full

- Emergency Physicians Monthly. Geriatrics: Managing Congestive Heart Failure. Retrieved from http://epmonthly.com/article/geriatrics-managing-congestive-heart-failure/

- Gillespie, N. D. (2005). The diagnosis and management of chronic heart failure in the older patient. Br Med Bull 75-76 (1), 49-62.

- Serxner, S., Miyaji, M., & Jeffords, J. (1998). Congestive heart failure disease management: a patient education intervention. Congestive Heart Failure, 4, 23-28.

- Quaglietti, S. E., Atwood, J. E., Ackerman, L., & Froelicher, V. (2000). Management of the Patient With Congestive Heart Failure Using Outpatient, Home, and Palliative Care. Progress in Cardiovascular Diseases, 43 (3), 259-274.

- Francis, G. (1998). Approach to the patient with severe heart failure. In: Rose, E., Stevenson, L., eds. Management of End-Stage Heart Disease. Philadelphia, Pa: Lippincott-Raven; 39-52.

- Regan, T. J. (1990). Alcohol and the cardiovascular system. JAMA, 264, 377-381.