Mrs. L opens the door in answer to my knocking, welcoming me into her sunlit home. Big band music subtly floats into the room via the adjacent kitchen. I'm immediately struck by Mrs. L's glow: her skin is beautiful, belying her 80-plus years. She smiles easily and engages me eagerly. She appears fit and moves about gracefully.
At first, I'm not sure this patient referral was appropriate. You see, I'm at Mrs. L's home today because I'm conducting a pilot study on readiness for discharge in patients with chronic obstructive pulmonary disease and heart failure. But Mrs. L seems so healthy, I wonder to myself if she's really chronically ill with heart failure. As it turns out, I'm not the only person in Mrs. L's life who has been fooled by her vitality and strength.
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MI to heart failure
Mrs. L and her husband shared more than 50 years together, which she describes as “the best.” They enjoyed their large family and after years of hard work, entertained and relaxed with friends and family at their lake home. After her husband's death 12 years ago, Mrs. L immersed herself in her children and grandchildren's lives. She was active with gardening, sewing, and socializing with friends. In fact, Mrs. L's progression to heart failure started soon after her husband's death as she was planning a weekend craft fair excursion with one of her daughters.
Mrs. L awoke to nausea and abdominal pain the morning she was to depart for her daughter's home. She decided to take it easy that day, and when her symptoms didn't resolve, she called her daughter and cancelled their plans. Thinking she must have the flu, Mrs. L retired early in hopes of sleeping off her symptoms. She awoke the next morning feeling better, not entirely, but well enough to make the drive and renew her plans. However, as she neared her daughter's home, the abdominal pain came back with a vengeance. She began sweating profusely and became very nauseous.
Upon arrival to her destination, Mrs. L informed her son-in-law, “I think I'm having a heart attack.” He reassured her that it must have been the traffic that had her upset and feeling off-kilter. Fortunately, Mrs. L's daughter arrived home from her work as an RN. She listened to her mother's symptoms, insisted she take an aspirin, and drove her directly to the ED.
Her daughter knew that women, and especially those with diabetes like her mother, present with atypical symptoms when they're experiencing a myocardial infarction (MI). Abdominal pain, nausea, and fatigue are common in these individuals, rather than the classic radiating chest pain. That evening, the cardiologist informed Mrs. L that she had not one, but two MIs. She underwent angioplasty and stenting that night.
After her diagnosis, Mrs. L was placed on an angiotensin-converting enzyme (ACE) inhibitor, aspirin, and furosemide. She was also given instructions to weigh herself daily, assess her oxygen saturation, and manage her diabetes with diet, exercise, and an oral hypoglycemic (see Evidence-based guidelines for heart failure discharge teaching). Mrs. L's heart had incurred enough damage that she was experiencing decreased cardiac output and early stage heart failure.
Soon, she was feeling well enough to resume her busy social and family activities. Mrs. L describes herself as a rule-follower: “I changed my diet. I weigh myself and if I gain more than 3 pounds in 2 days, I know I need to go see my doctor. I check my blood sugar. I take my insulin.” She explains that about 2 years ago, she was placed on a long-acting insulin injection and always follows her healthcare provider's recommendations.
Paying attention to context
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Like many patients who require specialist care, Mrs. L sees her cardiologist once a year and otherwise follows up with her general provider for management of her diabetes and other problems as they occur. She lives in a small community just blocks from the hospital, but several hours from her cardiologist in the nearest tertiary hospital. My visit with Mrs. L is preceded by a hospitalization less than 4 weeks earlier.
Mrs. L describes the events leading up to her hospital stay: “I was going along really good—for a long time! Then one day, I noticed...I didn't feel so great. My stomach, oh, it hurt. I wasn't hungry. I would work in the garden and I couldn't finish. I would feel tired and my breathing seemed harder. I just thought maybe I had the flu. But, I also wondered if it was my heart. I weighed myself, but I was not gaining weight and yet, my pants were tight! After a few days of this, I went to the doctor. She listened to me, listened to my heart and lungs, and thought maybe I just had an allergy to whey, you know, dairy.”
Mrs. L left her office visit with instructions to follow a dairy-free diet. She was weighed, but with her reduced appetite and intake, the scale didn't reveal gain. Although she was short of breath, her healthcare provider assured her that her lungs didn't sound congested. Mrs. L continues: “I went home and tried to do my gardening, but I just couldn't. I checked my oxygen and it was 88%. I thought, 'I will just rest.' That night, I lay in bed and I couldn't get my breath. I checked my oxygen and it was 78% or 79%. I called my son. He took me to the ER and they gave me I.V.s and medications to get rid of my water, and also some oxygen and other medications. I stayed in the hospital 3 days getting straightened out.”
The individual with heart failure may maintain—or be in a compensated state—until something in his or her regimen or disease process changes, causing a decompensation. This was the case with Mrs. L. Decompensated heart failure refers to a deterioration, which may present either as an acute or chronic episode.
Acute decompensated heart failure, marked by pulmonary edema, is a medical emergency that requires urgent interventions for overt pulmonary edema and shock. Chronic decompensation is less obvious and often presents as lethargy and malaise, a reduction in exercise tolerance, and increasing breathlessness on exertion. If left untreated, chronic decompensated heart failure will also progress to breathing problems, often but not always due to pulmonary edema, and eventual shock from prolonged low cardiac output.
The cause or causes of decompensation must be identified to guide treatment. Causes may include recurrent ischemia, arrhythmias (such atrial fibrillation), infections, electrolyte disturbances, nonadherence to medications, and changes in diet.
Mrs. L's history of atypical presentation of myocardial damage provides the context for how she might present with further damage. More important, she's a patient who has demonstrated a willingness to follow directions for heart failure care: She watches her diet, weighs herself, keeps her blood glucose under control, and checks her oxygen saturation. The context of an older woman with diabetes who follows her healthcare provider's directions, keeps appointments, and has a history of MI with subsequent heart failure, abdominal pain, nausea, and anorexia warrants further diagnostics and assessment to ensure she isn't decompensating.
Although allergies to food can cause nausea and abdominal pain, Mrs. L's context—her past history—points to other, more likely, causes of her symptoms. However, you may be wondering why her weight didn't increase and why her lung congestion wasn't obvious at her clinic visit.
A subtle presentation
Don't be fooled into thinking that all patients with decompensating heart failure will present with the classic signs and symptoms of obvious edema, pulmonary congestion, and low BP (see Decompensation detective). Initially, many patients may be able to compensate and won't always have pulmonary edema. Anorexia from nausea can mask weight that would be gained by edema, pointing to volume excess. In cases where fluid accumulates in the abdomen (“my pants were tight”) in the context of anorexia, there may actually be weight loss.
Patients who have had multiple areas of ischemia may not present with the classic pulmonary congestion of left-sided heart failure or the classic peripheral edema of right-sided heart failure. In Mrs. L's case, she was rather well-controlled on her diuretic and ACE inhibitor and, according to her, “My heart doctor said my heart still pumped pretty good.”
Interstitial pulmonary edema can develop in patients with right- and left-sided heart failure. The symptoms of dyspnea are present, but congestion may not readily be auscultated. Interstitial edema must be confirmed by X-ray. In Mrs. L's case, an X-ray wasn't obtained.
B-type natriuretic peptide (BNP) analysis is an important lab diagnostic. If you recall, this peptide is naturally produced by our body in response to too much fluid as sensed by the cells in the ventricles. When elevated, BNP indicates the body is attempting to gain or maintain balance in the face of decompensating heart failure. Other diagnostics that may have revealed Mrs. L's decompensation include cardiac enzymes, a 12-lead ECG, liver function tests, a complete blood cell count, and serum chemistries (see Initial diagnostic tests for suspected decompensation). According to Mrs. L, no blood work was drawn at her visit.
Patients who show signs and symptoms of decompensation (acute or chronic) should receive interventions to support their oxygenation, perfusion, and comfort (see Immediate interventions for decompensated heart failure). In some cases of severe acute decompensation, the patient may require an intra-aortic balloon pump or surgery to insert a biventricular device. The intra-aortic balloon pump facilitates better perfusion by decreasing afterload (the pressure against which the left ventricle must pump) and increasing cardiac vessel perfusion. The biventricular device acts to synchronize the beating of the left and right ventricles, which improves cardiac output.
The most important part of the nursing process we can implement on behalf of our patients is to first and foremost listen in context while performing an appropriate focused assessment. A patient with a history of diabetes, previous heart damage from an MI, and subsequent heart failure is at risk for decompensation. This may occur acutely or gradually in the patient with chronic heart failure.
To be effective as an advocate for a patient like Mrs. L, you must first understand how heart failure develops, learn how to recognize signs and symptoms of decompensation, and be knowledgeable about treatment options. Speaking up to offer suggestions for diagnostic tests, or to remind the healthcare provider of the patient's history, might just make a difference in the outcome. Her most recent hospitalization was preceded by Mrs. L herself attempting to relate what she knew deep down to be true—her heart was the problem. Patient care is a function of collaboration among the healthcare team, as well as collaboration with the captain of the team: the patient.
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