Care Study on a patient suffering from Heart Failure

This care study will focus on a seventy eight year old gentleman, who I will call Mr James, which is a pseudonym to protect his identity as cited in clause 5 paragraph 5. 1 of the Nursing and Midwifery Council (NMC 2002). Mr James’s diagnosis is heart failure. I have chosen to focus on Mr James as he is the only long term patient that I have visited during my placement on the Intensive Care at Home. I have recognised that I must gain consent from Mr James to present my care study as cited in clause 3 paragraph 3. 3 of the NMC (NMC 2002).

The theoretical framework I have chosen to use is Roper, Logan, and Tierney’s nursing model (1996). This framework identified three major issues for Mr James; they include elimination due to his excessive oedema, which is being controlled by Furusemide, his breathing which is due to fluid retention, and the delicate issue of dying as this made him extremely anxious. Mr James is a retired married man who lives at home with his second wife. Both Mr and Mrs James have had previous marriages and have four children between them from their first relationships. Mr and Mrs James live comfortably in their detached house in an affluent area.

Mr James has always been a popular gentleman within his community and has been instrumental in forming a local bridge club. The aim of this care study is to ascertain whether or not the care that Mr James is receiving is the correct care i. e. the administration of intravenous Furusemide Mr James presented to his G. P with symptoms of tiredness, weakness, anxiety, breathlessness and a swollen abdomen. Due to his past medical history of a suspected undiagnosed myocardial infarction, his G. P referred him to a cardiologist for further investigations of his symptoms.

By referring Mr James to a cardiologist the G. P is acting in compliance with the National Standards Framework of Heart Failure (standard 11 2004). To present this care study I have used Roper, Logan and Tierney’s nursing model (1996). The following five key factors of this model will present the care that Mr James is receiving. Following Mr James’s appointment eighteen months ago with the cardiologist, he was diagnosed with heart failure, and due to the severity of his hearts ventricular damage he was told that two previous myocardial infarctions had been the cause of his heart failure.

His diagnosis was determined by having a twelve lead echocardiogram, an echocardiogram is a gold standard test to confirm a diagnosis of heart failure and establish its cause (DOH 2004). Heart failure presents as an abnormal Q wave on the trace (Jowett et al 1995). He also had a chest x-ray and cardiac enzyme blood tests. The Oxford Minidictionary for Nurses (2003:282) defines ‘heart failure’ as a condition in which the pumping action of either or both ventricles of the heart is inadequate.

This results in back pressure of blood, with congestion of the lungs, liver and oedema. It was ascertained that Mr James had in fact suffered two previous myocardial infarctions. Following his diagnosis it became necessary to introduce the following package of care to alleviate his symptoms as heart failure is not a curable disease it is a life limiting illness. However if Mr James did not receive his diuretic treatment, then he would inevitably become oedematous, putting more pressure on his heart which would result in his life being shortened.

Mr James’s heart failure could also be attributed to the ageing process, where according to the Merck Manual (Durrant 1999:12) ‘the maximum heart rate decreases’. Following his diagnosis from his cardiologist Mr James started his care regime in his own home this was achieved by a G. P referral to the Intensive Care at Home Team. After an initial assessment it was established that in fact Mr James’s main problems were those surrounding his elimination, breathing and his issues on dying. All the remaining activities of daily living were fairly well controlled due to him being at home, in his own environment.

Mr James has been treated effectively with intravenous Furusemide which is a loop diuretic; unfortunately he was unable to tolerate oral diuretics as they made him feel very nauseous. Loop diuretics are a group of diuretics that inhibit sodium and chloride in the ascending limb of the loop of Henle, but it increases the secretion of potassium in the distal tubule (Downie et al 2003). Initially a dose of 80mg of Furusemide per day (BNF 2003) was commenced via his midline catheter; this device is inserted into the patient’s arm twenty centimetres into their axilla to deliver drugs.

A midline can remain in for six weeks, effectively this is a much less invasive method than that of a cannula that has to be renewed more frequently and can give peripheral irritation (Mallett et al 2000). Furusemide is the ideal drug, as diuretics will reduce his oedema therefore making him become less breathless (BNF 2003). Unfortunately Mr James was unable to tolerate this dose, he became nauseous, lost a considerable amount of weight, and also became dehydrated, it is therefore imperative that careful monitoring of patients receiving diuretics is maintained.

As a student nurse my task everyday was to record Mr James’s daily weight and blood pressure this is imperative so to ensure that the correct dosage is being administered. A daily weight reading will indicate if Mr James was becoming oedematous due to fluid retention and his blood pressure should not deviate too much from his baseline observations. Finding the correct dosage of a drug for a patient is a delicate balancing and juggling act when trying to maintain homeostasis. Consequently Mr James started a regime of 60mg of Furusemide daily.

Following a lengthy discussion one day during our visit he opened up to us explaining that although he found this dose more tolerable, he found that his quality of life was diminishing due to his constant micturition and tiredness that this dose bought him. We asked him to make sure to talk this over with his cardiologist on his next appointment. Following the appointment with his cardiologist he was prescribed a dose of 40mg of Furusemide to be given as a bolus one day and 80mg of Furusemide infused in 50mls of sodium chloride the following day.

Furusemide must be given in an infusion of saline as it has to be administered slowly to prevent renal failure it can also cause tinnitus (Madden 2000). By administering this regime of drugs, it provides Mr James a small amount of quality time with his family every other day, and also by addressing this, we are respecting Mr James’s role of identifying his preferences in his care as cited in clause 2 paragraph 2. 1 of the NMC Code of Professional Conduct (2002). We are also able to tailor his care to meet his personal needs.

At present Mr James’s condition is stable; however, if there was any deviation or deterioration in his condition he could be referred to his cardiologist or his heart failure nurse specialist, the nurse specialists educate patients about their condition and give timely management advice when their clinical status deteriorates. Their roles have shown to reduce hospital admissions (NHS Trust 2003). After visiting Mr James regularly during my placement, I found that both he and his wife began to open up to us; this was probably due to them gaining our trust.

Mr James declared to me that he has found his diagnosis to be a burden; this must be psychologically draining for him as he had always enjoyed an active social life, which unfortunately has become inhibited due to his daily treatment. He finds he can only go out if there are toilets close at hand as he needs to micturate frequently; therefore long car journeys are almost impossible. Holidays are also out of the question as he needs his daily intravenous drugs administering.

Mr James also told me that he can get very anxious at times he worries a great deal about his wife who had also suffered a myocardial infarction, ten years ago, but he was so thankful for being able to have his care at home by the Intensive Care at Home nurses as this enabled him to be with his wife and so lessen his anxiety. Mr James was lucky to be living in an area that incorporates an Intensive Care at Home team. The Intensive Care at Home team can provide care within the patient’s home, therefore enabling patient’s to return home quicker and free up many sought after hospital beds.

Figures released by the National Institute for Clinical Excellence (2003) estimates 900,000 people in the U. K have heart failure, therefore being able to facilitate care at home by an Intensive Care at Home team can be of great benefit to the National Health Service, this team of nurses can also help to facilitate independence for older people, which falls in line with the criteria set up by the National Service Framework Guidelines for Older People (2001). The Intensive Care at Home Team has recognised the need for Mrs James to have a break from time to time.

Mrs James is among an estimated 5. 7 million carers in Britain, of which 1. 9 million of these carers are looking after their spouse. In recent reforms ‘lay carers’ have become central to Government policy. The National Carers strategy states that ‘carers needs are diverse and the most common factors of support required are emotional, relief from isolation and receipt of reliable and satisfactory services and recognition of the role they are providing’ (Department of Health 2004).

Legislation has been introduced which aims to ensure that carers are able to take up opportunities, which people without such responsibilities take for granted, through the Equal Opportunities Act (Department of Health 2004). Addressing this, the Intensive Care at Home Team have been able to facilitate respite care for Mr James in the local palliative care unit close to their home, this enables Mrs James to travel up to the North of the country to stay with her sons and their families.

Mr James has found that this respite care has also been of some benefit to him, as he has received excellent care and attention from the palliative care team. Mr James told me that his illness has altered his stance in life, it has changed his perspectives, where he had always been independent, he was now reliant on others, he had always been very adventurous, but now was very cautious, and to a certain extent his heart failure has changed his personality.

Although he claimed he was not terribly religious, he told me he had asked god on many occasions for help, not just for him but also his family, following this comment I gently probed him a little, it became apparent to me that spirituality is a totally individual subject to us all and as a nurse I must be aware of this and try to become a good listener, whilst remaining completely non-judgemental (Narayanasamy 2001). It wasn’t too long before Mr

James quite openly broached the subject of death, he spoke of his initial denial of his diagnosis, and his anger at how the heart failure had changed every aspect of his life, and also how his loss of independence had been his greatest fear, his bargaining with god in his prayers, made me realise that all his thoughts had been all the elements contained in the Kubler-Ross framework of bereavement (1969). It was apparent that being so reliant on his family and friends and obviously a medical team, left Mr James suffering from low self-esteem and a degree of loss of status.

Mr James had been a civil servant before his retirement, his profession had given him status, and his wife had said that he had always been a very proud man. Mr James had been instrumental in forming many social gatherings; he has many friends and still can enjoy playing bridge at the weekend. Mr and Mrs James enjoy still being able to socialise with friends this lifts their spirits. Mr and Mrs James live in a large detached house in an affluent area, by being cared for at home Mr James can enjoy the superb views surrounding his home, and take short walks in their garden and in nearby parks.

If Mr James was unable to receive his care at home he would have to be in hospital, where he would be less likely to have the opportunity to take short walks in the countryside, walking is one of the recommended exercises for heart failure patients as stated by the British Heart Foundation (1999). There is far less pollution in an area in the country, to that in a city, so consequently Mr James has less chance of pollution exacerbating his symptoms. Mr James would also be at risk of contracting a hospital acquired infection if he were in hospital.

The most common types of hospital acquired infections are urinary tract infections and chest infections but also the so-called ‘superbug’ methicillin-resistant staphylococcus aureus (MRSA). The latest audit commission report (National Audit Office, 2004) shows that there is an increase in MRSA cases, it has increased from 7,250 in 2001-2002 to 7,647 in 2003-2004. Mr James had revealed to me that he was of a ‘good financial status’. He said that he and his wife live quite comfortably.

Both Mr and Mrs James can afford to run a car; this enables Mr James to attend hospital appointments every fortnight. Without his own transport Mr James would be entitled to hospital transport as he is retired (age concern 2004), but it would mean he would probably have to wait around in draughty corridors possibly for sometime, causing him distress as he finds that getting cold exacerbates his symptoms. Mr James can also afford to heat his house sufficiently, which can obviously prevent him getting cold. Being of retirement age Mr James would be entitled to free prescriptions (age concern 2004).

Being able to afford good food is also important; Mr James always makes sure that he has a well balanced diet. Following the discussion with Mr James it became apparent that both Mr and Mrs James can lead a financially independent life, this is important for providing Mr James with a sense of identity, as his role of main provider. To conclude, I feel that Mr James’s package of care is the most effective for him, as it has been tailored to meet his needs; his drug regime of intravenous Furusemide is obviously effective, as his condition has remained stable throughout my placement.

Evidence shows that due to the alleviating of his symptoms his condition has remained stable throughout my placement. Consequently this has enabled Mr James to proceed in maintaining a fairly good quality of life, thanks to the constant follow up care, the monitoring of his symptoms and his daily regime of intravenous Furusemide. However I have been made aware that his condition could deteriorate at anytime.