Hypertension and Chronic Heart Failure Case Scenario Discussion

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Use the following Case Scenario, Subjective Data, and Objective Data to answer the Critical Thinking Questions.

Case Scenario

Mrs. J. is a 63-year-old woman who has a history of hypertension, chronic heart failure, and sleep apnea. She has been smoking two packs of cigarettes a day for 40 years and has refused to quit. Three days ago, she had an onset of flu with fever, pharyngitis, and malaise. She has not taken her antihypertensive medications or her medications to control her heart failure for 4 days. Today, she has been admitted to the hospital ICU with acute decompensated heart failure.

Subjective Data

  1. Is very anxious and asks whether she is going to die.
  2. Denies pain but says she feels like she cannot get enough air.
  3. Says her heart feels like it is "running away."
  4. Reports that she is so exhausted she cannot eat or drink by herself.

Objective Data

  1. Height 175 cm; Weight 95.5 kg
  2. Vital signs: T 37.6 C, HR 118 and irregular, RR 34, BP 90/58
  3. Cardiovascular: Distant S1, S2, S3 present; PMI at sixth ICS and faint; all peripheral pulses are 1+; bilateral jugular vein distention; initial cardiac monitoring indicates a ventricular rate of 132 and atrial fibrillation
  4. Respiratory: Pulmonary crackles; decreased breath sounds right lower lobe; coughing frothy blood-tinged sputum; SpO2 82%
  5. Gastrointestinal: BS present: hepatomegaly 4 cm below costal margin

Critical Thinking Questions

What nursing interventions are appropriate for Mrs. J. at the time of her admission? Drug therapy is started for Mrs. J. to control her symptoms. What is the rationale for the administration of each of the following medications?

  1. IV furosemide (Lasix)
  2. Enalapril (Vasotec)
  3. Metoprolol (Lopressor)
  4. IV morphine sulphate (Morphine)

Describe four cardiovascular conditions that may lead to heart failure and what can be done in the form of medical/nursing interventions to prevent the development of heart failure in each condition.

Taking into consideration the fact that most mature adults take at least six prescription medications, discuss four nursing interventions that can help prevent problems caused by multiple drug interactions in older patients. Provide rationale for each of the interventions you recommend.

-A minimum of three academic references from credible sources are required for this assignment.

- Prepare this assignment according to the APA guidelines.

-An abstract is not required.

-You are required to submit this assignment for plagiarism.

Supporting Material:

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Cardiac Rehab By Karen Collins, MS, RDN, CDN, FAND C ardiac rehabilitation programs provide a unique setting in which dietitians can help people adopt heart-healthy eating habits. The inherent structure of multiple weekly sessions offers the chance for frequent patient follow-up that usually doesn’t occur. Yet programs even within the same community can vary widely in how dietitians address patients’ nutrition needs. Most programs employ just one dietitian. Thus, cardiac rehabilitation calls for RDs who can collaborate and provide trusted nutrition expertise as part of a multidisciplinary health care team and find creative ways to meet participants’ needs. What’s Happening Today As evidence has grown demonstrating that cardiac rehab reduces mortality rates and risk of myocardial infarction (MI), so has the number of diagnoses for which it is recommended.1,2 Today’s cardiac rehab includes patients who have had an MI, coronary angioplasty, coronary bypass or valve surgery, or heart transplantation, and those who have stable angina or heart failure. Cardiac rehab provides medically supervised physical activity and individualized treatment plans that may 18 today’s dietitian february 2016 address nutrition, stress management, and tobacco cessation. Participants typically attend three days per week for 12 weeks, with third-party payment covering a total of 36 sessions. These may all be exercise sessions, or some may address nutrition and lifestyle. “I see every patient in the program,” says Judy Hinderliter, MPH, RDN, LDN, CPT, a cardiac rehab dietitian/nutritionist at University of North Carolina Hospital’s Cardiac Rehabilitation Program in Chapel Hill. “First, they get a 60- to 90-minute group class that covers general heart-healthy eating. I think it’s good for patients to hear others’ questions and suggestions about how to eat out, include more vegetables, or prepare fish, for example. Then each is scheduled for an individual session, giving me opportunity to deal with other medical issues, as well as sleep and activity patterns. I go out on the exercise floor, too, where I can address questions and talk with people about changes they’re making.” Not all programs use this combination of group and individual care. Sharon Smalling, MPH, RD, LD, is a dietitian specialist in the Memorial Hermann Cardiac Rehabilitation Program at Memorial Hermann Hospital—Texas Medical Center. Other than dialysis patients, “I see all patients individually for 11⁄2 to two hours. I see people for follow-up if needed for further weight-related help or to address blood sugars Dietitians have the unique opportunity to combine the art and science of nutrition to reduce patient morbidity and mortality. that are out of range when they come to exercise. In addition, since my office is adjacent to the program’s exercise area, I often talk with people while they’re on the treadmill. Everyone knows that if my door is open, they’re welcome to come in and ask questions.” Still, another approach to nutrition in cardiac rehab comes from Karen Ross, MA, RD. “I am the registered dietitian in the Cardiac Therapy Foundation of the Midpeninsula in Palo Alto, California, a 501(c)3 nonprofit. Everyone here is medically referred because of heart disease or related issues. However, unlike traditional programs with a defined number of sessions covered by thirdparty payers, people in this program pay for monthly membership, and some continue for years. I provide nutrition education exclusively through group classes, and focus on a different topic each month. I also provide nutrition information through articles in our monthly newsletter, a presentation at the center’s quarterly luncheon for new members, and through conversations as I walk through [the gym] once every two months while people exercise.” Changing Face of Cardiovascular Nutrition Recommendations for primary and secondary prevention of cardiovascular disease (CVD) have evolved from a primary focus on limiting dietary fat and cholesterol to a broader vision of heart-healthy eating.3,4 These recommendations endorse eating patterns based on the Dietary Approaches to Stop Hypertension (DASH) diet and the USDA Food Pattern (the basis for MyPlate). The Mediterranean diet also has been shown to decrease CVD risk,5,6 so limiting total fat intake to less than 30% of calories no 20 today’s dietitian february 2016 longer is supported as vital to cardiovascular health.7,8 Heart-healthy eating patterns decrease intake of saturated fat, trans fat, and sodium while emphasizing consumption of vegetables, fruits, whole grains, lowfat dairy products, poultry, fish, legumes, nontropical vegetable oils, and nuts, and limiting intake of sweets, sugar-sweetened beverages, and red meats.4 Cardioprotective benefits of a plant-focused eating pattern likely involve dietary fiber, vitamins, minerals, and phytochemicals these foods provide.9 Research supports a shift in cardiac rehab nutrition education, increasing emphasis on heart-healthy food choices. Randomized controlled trials show that dietary patterns high in fruits and vegetables improve blood pressure, lipid levels, insulin resistance, and inflammatory biomarkers.10,11 Observational studies following people post-MI link healthier eating patterns with decreased mortality rates.12-14 In one of these studies, better outcomes were specifically related to greater intake of healthful foods rather than decreased intake of unhealthful foods.12 Most cardiac rehab patients also need help reducing sodium consumption. Intake should be limited to no more than 2,400 mg daily to reduce blood pressure, according to the American Heart Association/American College of Cardiology (AHA/ACC) 2013 guideline, and many in cardiac rehab are among those for whom reduction to 1,500 mg is identified as desirable.4,15 Still, for people unable to reach these levels, even reducing sodium intake by 1,000 mg significantly reduces blood pressure and cardiovascular events.4 Regardless of target, since by far the majority of most Americans’ sodium intake comes from various types of processed food, messages about simply putting away the salt shaker don’t address the problem.16 Optimal nutrition care in cardiac rehab seems to require a three-pronged approach of assessment, counseling, and follow-up. First Stop: Dietary Assessment Since cardiac rehab patient care is based on an individualized treatment plan, some form of dietary assessment is an important starting point. In some programs, nurses conduct this assessment as part of baseline evaluations; in others, dietitians either provide the assessment or evaluate results. Previously, dietary assessment tools focused on intake of dietary cholesterol, total or saturated fat, and some estimate of sodium intake. Choice of assessment tools today ideally reflects the emphasis on broader dietary patterns, takes into account patient literacy level and comfort with technology, and considers staff time to administer the dietary assessment and record results. “I perform a dietary assessment for every patient in the program using the New Leaf tool [see Resources sidebar] and either a three-day food record or 24-hour recall. I also check waist and BMI, and make note of labs and medications,” Hinderliter says. Smalling says, “In our program, patients’ height, weight, and anthropometric measurements are taken by exercise physiologists. Nurses administer the dietary survey on a patient’s first day, along with other baseline assessments. Currently, we use a dietary survey that provides a score based on saturated fat intake, though I plan to switch to another option. Then I see patients individually and do an in-depth diet recall to assess food and beverage intake before their event or hospitalization. Some patients also get an advanced lipid profile, and I discuss results with them.” RESOURCES Cardiac rehab dietitians interviewed for this article suggest the following resources for educational materials, though they develop many of their own handouts to meet the needs of their patient populations. • The American Heart Association (AHA) created Salty Six, an infographic highlighting top sources of sodium and lower-sodium alternatives. It can be downloaded as a printable PDF for patient handouts. The AHA also offers a variety of educational materials in Spanish, Vietnamese, or Chinese, found by selecting from the “languages” option on the website. • New Leaf Dietary Risk Assessment is a comprehensive tool that assesses saturated fat intake and overall diet quality in a low-literacy format. This assessment tool and coordinating teaching materials are available at no cost. To learn more, visit www.centertrt.org/ ?p=intervention&id=1005§ion=12. • The Nutrition Care Manual by the Academy of Nutrition and Dietetics provides a variety of handouts. For more information, visit www.nutritioncaremanual.org. • SCAN Fact Sheets, developed by the Sports, Cardiovascular, and Wellness Nutrition Dietetic Practice Group, can be downloaded free by members and at minimal cost by nonmembers. Topics especially useful in cardiac rehab include sodium, using spices and herbs, quick stop lunches, and heart health for women. For information, visit www.scandpg.org/ cardiovascular/cardiovascular-health-fact-sheets. Obesity Conundrum Obesity among patients in cardiac rehab remains a common, complex problem. Current cardiac rehab care models often aren’t set up to address it. More than 40% of participants in one cardiac rehab program were identified as obese,17 and other research identified 80% of participants as overweight or obese.18 Because of potential for clinically meaningful improvement in several cardiovascular risk factors, a 5% to 10% weight loss is a recommended target for both primary and secondary prevention of cardiovascular events in those with excess body fat.19 However, some controversy involves an “obesity paradox,” in which observational studies show that weight loss by overweight people with heart disease isn’t necessarily associated with better outcomes. Further analysis, however, highlights the importance of distinguishing between unintentional weight loss, which is associated with adverse cardiovascular events, vs weight loss achieved through intentional changes in diet and exercise, which is associated with improvement in cardiovascular risk factors and outcomes.20,21 Despite participation in supervised exercise, average weight loss during cardiac rehab is only 3% to 4%.20,22 Intervention trials demonstrate that clinically significant weight loss can be achieved with exercise plans designed to increase weekly caloric expenditure and behavioral modification of eating habits.22-24 “I am the one who sets weight goals with the patient,” Smalling says. “Patients sometimes set lofty goals, but I generally recommend a 10% weight loss if obese. I talk about ‘reasonable goals,’ including consideration of their weight history.” In fact, Smalling says she often doesn’t address BMI at all, focusing instead on the body fat and waist circumference measures taken as part of baseline assessments. Hinderliter emphasizes achievable goals with patients as well, saying she often recommends a 5% to 10% weight loss. In fact, “I really try first to get patients to choose a healthier diet; if weight loss doesn’t occur, then I encourage smaller portions.” She finds that simple changes like drinking more water, especially at the start of meals, or switching use of sweets to a few bites of dessert to top off a meal instead of as snacks, often make a difference. “With some patients, I encourage having no more than one ‘luxury food’ a day (or seven per week). A luxury food is an item with 150 to 200 calories.” She says this is essentially teaching people to choose between options. Education and Engagement It’s important to recognize that patients aren’t coming in to cardiac rehab as “blank slates.” Part of helping them adopt heart-healthy eating habits often involves addressing myths and incorrect advice from well-meaning friends and family. Participants often have questions about various dietary fats from peanut butter to coconut oil, and ask if “butter is back.” While the newly released 2015–2020 Dietary Guidelines for Americans no longer limit daily intake of dietary cholesterol, questions about whether — KC february 2016 www.todaysdietitian.com 21 dietary cholesterol should be limited by all cardiac patients or only those whose LDL levels remain high is controversial, since major organizations have differed on this point.4,25,26 Some cardiac rehab participants are eager to know everything they can do to reduce health risks, while others are reluctant to change eating habits. Smalling created a form to show people their lipid lab results, normal values, and what foods and macronutrients affect them. “I explain to people that I want to review how they were eating before their event or hospitalization to make sure they aren’t unnecessarily giving up favorite foods,” Smalling says. “I suggest we look at what might need to be ‘tweaked’ a bit, which seems to help people open up. Often, I can help them determine another way to prepare a food so it tastes just as good, or close to it, yet is healthier.” Hinderliter says, “I start individual sessions by asking people what they want to accomplish. We come up with nutrition goals together, and I ask what they’re willing to change and how I can support them.” She says one of her most popular tools is a handout she developed based on a review article about cardioprotective diets.9 “I made it colorful and to the point, encouraging people to fill up on healthful foods, as in the Mediterranean and DASH diets.” Ross is an avid reader of nutrition newsletters, and keeps a file to provide background information as she develops classes and articles on topics that pique participants’ interests. “Past classes have covered situational challenges (eating alone, mindless eating, eating in restaurants), preparing and using particular foods (whole grains, seasonal vegetables), and nutritional issues making headlines (sugar and heart disease, sodium issues, meeting calcium needs). It’s especially fun when I can involve members in presenting classes, such as one we did on Indian cuisine.” For classes and individual appointments, visual aids enhance learning and engagement. Food models and measuring cups and spoons are traditional elements in a dietitian’s toolbox. Food labels and empty food containers can help when teaching label reading or discussing choices like flaxseed or phytosterolenriched foods. Where southern “sweet tea” is popular, a bottle filled with an equivalent number of sugar cubes can be powerful. Smalling has samples of unsalted seasonings and calorie-free flavor enhancers for water that patients can try. She also keeps an Internet-connected tablet handy to check nutrition information on products patients want to discuss. Both Hinderliter and Ross say that grocery store tours are popular with patients. “I think it’s really helpful for patients to look at specific products and talk about why something is a good choice,” Hinderliter says. In addition to grocery store tours, Ross has led field trips to a local fish market and to a specialty spice store. She also enjoyed her role in a weekend women’s retreat that was well received by participants. PROFESSIONAL EDUCATION AND NETWORKING Since most cardiac rehab programs employ only one dietitian, it’s helpful to connect with others in the field to share ideas and stay in touch with what’s new. The Sports, Cardiovascular, and Wellness Nutrition (SCAN) Dietetic Practice Group offers relevant webinars and newsletter articles, and the chance for discussions with cardiac rehab RDs nationwide through the Wellness and CV electronic mailing list, available free as part of SCAN membership. To connect with health professionals involved in cardiac rehabilitation across professional disciplines, the American Association of Cardiovascular and Pulmonary Rehabilitation can be a valuable resource. It offers professional education live at its annual meeting and through virtual webcasts throughout the year. — KC Nutrition care in cardiac rehab involves combining that science with the skill of facilitating patients’ behavior change. For example, Smalling says, “Very few of my patients would be able to eat enough food if limiting sodium to 1,500 mg a day. I usually target 2,000 mg of sodium, or aim to decrease intake by 1,000 mg, since the AHA/ACC guideline identifies this as a riskreducing step.4 The goals I set with people may differ depending on barriers they face due to educational level or financial ability to purchase certain foods.” Ross finds discussions of mindful eating principles helpful to many of those with whom she works. She uses free handouts developed by Michelle May, MD, available at http://amihungry. com/resources/for-health-and-wellness-professionals. Hinderliter, Ross, and Smalling are unanimous in finding value in opportunities while participants are walking on treadmills for brief conversations to answer questions, address media controversies, and provide encouragement for small changes made. Cardiac rehab provides an example of how relationships—with patients and within the health care team—can be an important element in care. — Karen Collins, MS, RDN, CDN, FAND, is chair-elect of the Sports, Cardiovascular, and Wellness Nutrition, or SCAN, Dietetic Practice Group of the Academy of Nutrition and Dietetics. She promotes healthful eating as a speaker, consultant, and syndicated columnist, and through her blog, Smart Bytes, which dietitians can access through her website, www. karencollinsnutrition.com. Follow-Up to Meet Needs Published dietary recommendations summarize evidence of a diet’s effectiveness in shaping health outcomes and provide the science base that can guide priorities for heart-healthy eating. 22 today’s dietitian february 2016 For references, view this article on our website at www.TodaysDietitian.com. Copyright of Today's Dietitian is the property of Great Valley Publishing Company, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. Women and cardiovascular disease Understand women’s unique risks and symptoms to ensure early identification and treatment of CVD. By Melanie Kalman, PhD, RN, CNS, and Margaret Wells, PhD, RN, APN-BC CARDIOVASCULAR DISEASE (CVD), which includes diseases of the heart, brain blood supply, and vascular system, is the number one cause of death in the United States. About 2,200 American adults die of CVD every day—that’s one out of every three deaths. Almost 2 million Americans live with CVD, which can lead to myocardial infarction (MI), strokes, heart failure, renal disease, and peripheral artery disease. Despite improvements in treatment, CVD remains the leading cause of mortality in women. (See By the numbers.) Women—and many healthcare providers—lack knowledge about CVD risk factors and MI symptoms unique to women, which leads to late recognition and inadequate treatment. Risk factors Women’s CVD risk factors are somewhat different from men’s. For example, women with diabetes and those who smoke are at higher risk than men who have diabetes or smoke. Other risk factors for women include age, inflammatory diseases, and pregnancy complications (specifically, pre-eclampsia, pregnancy-induced hypertension, and gestational diabetes). 22 American Nurse Today CNE 1.47 contact hours L EARNING O BJECTIVES 1. State risk factors for cardiovascular disease (CVD) in women. 2. Compare signs and symptoms of myocardial infarction between men and women. 3. Discuss strategies for preventing CVD in women. The authors and planners of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity. See the last page of the article to learn how to earn CNE credit. Expiration: 6/1/21 Volume 13, Number 6 Natural estrogen in premenopausal women is believed to be cardioprotective, but replacement estrogen taken during menopause doesn’t help prevent CVD. Researchers are asking why, if estrogen is cardioprotective, we’re seeing more MIs in younger women. No clear answer exists. However, younger women who have MIs are more likely to be obese or to have hypertension, tachycardia, or type 2 diabetes, but that doesn’t completely answer the question. Women of color are at greater risk for CVD than white women. Black women in the United States are at higher risk for an MI than all other women, and many experience an MI at a younger age. Because they may have no symptoms, they have higher rates of sudden cardiac death. Typically, Hispanic and Black women have more comorbidities (such as diabetes, hypertension, and obesity) than white women. When AmericanNurseToday.com By the numbers Learn about cardiovascular disease (CVD) and women so you can provide the best care. And share this information with your female patients so they understand their risks. • • • More women than men have CVD. • In the United States, over 6.5 million women die annually from CVD and over 53,000 women die from an MI. • • • • • CVD is the leading cause of death for Hispanic and Black women. CVD mortality is greater for women than men. The average age for a woman to have her first myocardial infarction (MI) is 71.8 years old; for men, it’s 65 years old. 26% of women die within 1 year of having an MI, compared to 19% of men. MIs in younger women (45 to 54 years old) are increasing. An estimated 35,000 women younger than 65 years old have an MI each year. Hispanic women are likely to develop heart disease 10 years earlier than white women. Sources: goredforwomen.org/about-heart-disease/facts_about_heart_disease_in_women-sub-category/ statistics-at-a-glance; cdc.gov/dhdsp/data_statistics/fact_sheets/fs_women_heart.htm black women present to the emergency department (ED), they’re less likely than white women to be treated using the American Heart Association (AHA) guidelines. This is particularly true for younger women of color, who are less likely to be prescribed angiotensin-converting enzyme (ACE) inhibitors and beta-blockers after an MI. Furthermore, prevention efforts, such as healthy eating or exercise programs, are less likely to be recommended to women of color. MI symptoms Many women aren’t aware that their MI symptoms may be different from those of men. For example, women may have prodromal symptoms for up to a year prior to a cardiac event. (See Prodromal symptoms.) Researchers believe that men develop blockages in their main cardiac arteries but that women develop blockages in the main arteries as well as smaller cardiac arteries (coronary microvascular disease), resulting in different MI symptoms. Chest pain is still the number one symptom of MI in women, but it’s not the “elephant sitting on your chest” type of pain frequently experienced AmericanNurseToday.com The gold standard of treatment and risk reduction for all women, regardless of their risk category, is adhering to a healthy lifestyle, including diet, exercise, adequate sleep, stress reduction, and smoking cessation. by men; instead, women feel it as pressure or discomfort. (See MI symptoms.) Women’s symptoms are vague and easy to miss, by both women and healthcare providers. Several factors contribute to women’s higher MI morbidity and mortality rates. Women (and some healthcare providers) may believe that CVD is a “man’s disease,” so they ignore symptoms and delay seeking treatment. In some cases, they delay going to the ED up to 2 hours longer than men; women of color delay going to the hospital longer than white women. Although women’s awareness of CVD risk has improved, a knowledge gap still exists, and it’s even larger for women of color and those who live in rural areas. AHA guidelines The 2011 updated AHA guidelines for the prevention of heart disease in women identify three risk levels: ideal cardiovascular health, at risk, and high risk. (See Know the risk.) Women who have ideal cardiovascular health have no presence of CVD, total cholesterol level < 200 mg/dL, blood pressure ≤ 120/80 mmHg, body mass index < 25 kg/m2, and fasting blood glucose < 100 mg/dL. At-risk women have one or more major risk factor for CVD—cigarette smoking, dyslipidemia, family history of premature CVD, hypertension, obesity, and a sedentary lifestyle. Other women deemed to be at risk are those with a history of preeclampsia, gestational diabetes, pregnancy-induced hypertension, or systemic autoimmune collagen vascular diseases (such as rheumatoid arthritis). Women designated as high risk have known coronary heart disease, cerebral vascular disease, abdominal aortic aneurysm, peripheral vascular disease, end-stage or chronic kidney disease, diabetes, or a 10-year predicted CVD risk ≥ 10%. The gold standard of treatment and risk reduction for all women, regardless of their risk category, is adhering to a healthy lifestyle, including diet, exercise, adequate sleep, stress reduction, and smoking cessation. Diet Let your patients know that the ideal diet consists primarily of whole June 2018 American Nurse Today 23 grains, vegetables, fruits, and protein sources low in saturated fats, such as lean meats and tofu. The AHA recommends no more than 6% of daily calories (about 13 grams) should come from saturated fats found in foods such as red meat, chicken with the skin, cheese, and butter, and that processed breads and baked goods made with refined flour and sugar should be avoided. The AHA supports the Dietary Approaches to Stop Hypertension (DASH) eating plan for weight loss and hypertension control. Reading food labels can help people reduce sodium, sugar, and saturated fat consumption because it might reveal, for example, that something like a “healthy soup” is actually high in all three. The DASH plan recommends eating no more than 2,400 mg of sodium per day. In general, processed foods such as deli meats, canned soups, and frozen meals are very high in sodium and should be avoided. Exercise According to the U.S. Department of Health and Human Services (DHHS) Physical Activity Guidelines for Americans, women should strive for a minimum of 150 minutes per week of moderate-intensity exercise, such as brisk walking. These guidelines are in DHHS’s review process; an update may be available at the end of 2018. The AHA guidelines recommend 150 minutes per week of moderate exercise or 75 minutes per week of vigorous exercise. Examples of vigorous-intensity exercise include running, fast cycling, fast swimming, and heavy shoveling or digging. Two days per week of muscle-strengthening activities that involve all major muscle groups offer additional cardiovascular benefit. For weight loss, women should participate in at least 60 to 90 minutes of moderate-intensity physical activity—such as brisk walking, dancing, house cleaning, and gardening—on most days of the week. 24 American Nurse Today Prodromal symptoms Women may experience any of these symptoms for up to a year before having a myocardial infarction: • • • • • • unusual fatigue difficulty sleeping shortness of breath, especially in black women indigestion anxiety chest pressure. Stress reduction Reducing stress can be challenging for many women. Suggest that patients try meditation, yoga, listening to music, and walking. For success, stress-reduction plans should be individualized; for example, walking a dog might relieve stress in one person but be stress-inducing in another. MI symptoms Women usually don’t experience the same type of pain as men when they have a myocardial infarction (MI). Instead, they’ll present with these symptoms: • • • • chest pain, pressure, or discomfort • nausea or vomiting, sweating, or dizziness (less common symptoms). fatigue shortness of breath pain in the neck, jaw, shoulder, arms, or upper back Adequate sleep The American Academy of Sleep Medicine and the Sleep Research Society recommend that healthy adults sleep 7 or more hours per night. Recommend that your patients go to bed and get up at the same time every day; remove electronic devices from the bedroom; avoid alcohol, caffeine, and large meals before bedtime; and get regular exercise. Volume 13, Number 6 Smoking cessation Cigarette smoking is contraindicated for a heart-healthy lifestyle. If your patient smokes, help her develop a cessation plan. Start by establishing her readiness to quit. Until she says she’s ready to quit, provide education that outlines the risks associated with smoking. Then, when she’s ready, work with her to develop a plan and direct her to supportive resources, including the “Create my quit plan” tool smokefree.gov/buildyour-quit-plan) and “Smokefree Women” (women.smokefree.gov). The latter site has tools such as text messages (including ones specific for pregnant women), mobile apps, and a craving journal. AHA guidelines and medication The AHA guidelines suggest adding medications when lifestyle interventions alone fail to achieve optimal blood pressure, glycosylated hemoglobin (A1C), and low-density lipoprotein (LDL) cholesterol levels. The patient’s provider should consider prescribing medications when blood pressure is ≥ 140/90 mmHg for most women or ≥ 130/80 mmHg for those with diabetes or chronic kidney disease. The guidelines recomAmericanNurseToday.com Patient story Jan Kent* is a 62-year-old white woman who presents to her family nurse practitioner, Sarah, with flulike symptoms, headache, fatigue, and nausea. Vital signs are pulse 78 beats/minute and blood pressure (BP) 180/110 mmHg. Sarah’s concerned about Ms. Kent’s symptoms and vital signs and sends her via emergency medical services to the emergency department (ED) for evaluation. In the ED, Ms. Kent’s pulse is 80 beats/minute and her BP is 195/116 mmHg. She complains of a “bad” headache and tingling in both arms, and she is diaphoretic, with nausea and vomiting. Her troponin level is 0.918 ng/mL, and the electrocardiogram shows N-STEMI (non-ST-elevation myocardial infarction [MI]). History Ms. Kent has no previous history of cardiovascular disease (CVD) or hypertension. She’s been postmenopausal for 12 years and has sleep apnea, but she doesn’t use a continuous positive pressure airway device. Ms. Kent is overweight; she tries to eat a healthy diet but isn’t always successful. She doesn’t smoke or exercise regularly, and she drinks alcohol occasionally. Ms. Kent says she’s had insomnia and unusual fatigue with no apparent cause for months. She’s not taking any medications. Both of Ms. Kent’s parents had a history of hypertension and CVD. Her mother died of an MI at 74 years. Her father had a quadruple bypass after an MI. Both of Ms. Kent’s siblings have hypertension. Treatment Cardiac catheterization shows that Ms. Kent has a 95% blockage in her left anterior descending artery, so a stent is placed. She’s admitted to the cardiac intensive care unit (ICU), where she recovers and is discharged 2 days later. At discharge, her total cholesterol is 212 mg/dL (high-density lipoprotein [HDL] 39 mg/dL, low-density lipoprotein [LDL] 173 mg/dL), and her BP is stabilized to 120/74 mmHg. Ms. Kent’s discharge medications are carvedilol (a beta-blocker), two 3.125-mg tablets twice a day; losartan potassium (an angiotensin II antagonist), 25 mg every day; aspirin, 81 mg every day; and atorvastatin, 10 mg every day. AHA guidelines According to the American Heart Association (AHA) guidelines, Ms. Kent is at risk for heart disease because of her family history, age, weight, and lifestyle. She needs education about preventive measures—lowering cholesterol, increasing physical activity, and consistently making heart-healthy food choices—to reduce her CVD risk. In addition, she needs education about prodromal and MI symptoms unique to women. If Ms. Kent experiences similar symptoms in the future, she should call 911 to be transported to the ED. She also can share her story with others so more people become aware of MI symptoms in women and what to do if they occur. *Names are fictitious. AmericanNurseToday.com mend including a thiazide diuretic medication unless contraindicated. If women are at high risk, treatment also should include a beta-blocker, an ACE inhibitor, or an angiotensin II receptor blocker. The guidelines also recommend LDL-lowering medications such as statins for women with diabetes whose A1C levels are < 7%, at-risk women whose LDL is < 130 mg/dL, high-risk women whose LDL is < 100 mg/dL, and in some high-risk women whose LDL is < 70 mg/dL. For most women who’ve had a cardiac event, angiotensin II receptor blockers, beta-blockers, and spironolactone should be prescribed. Avoid aspirin therapy in women younger than 65 years old with ideal cardiovascular health because of bleeding risk; however, it should be considered in high-risk women and in those over 65 years old when their blood pressure is controlled and the benefit of stroke and MI prevention outweighs the risk of bleeding. The AHA guidelines also recommend treating women who have atrial fibrillation with aspirin, warfarin, or dabigatran. Postmenopausal hormone therapy and antioxidant and folic acid supplements are class-three interventions that aren’t useful or effective and may even be harmful. Nursing implications Many cardiovascular health disparities exist related to race, ethnicity, and gender, particularly among Black and Hispanic women. Culturally sensitive care and education about CVD risk factors and MI symptoms enhance patient adherence to prescribed treatment plans. When discussing healthy lifestyle changes, assess patients’ change readiness and what’s important to them by using motivational interviewing techniques. Develop individualized care plans, offering patients options for maintaining their health. For example, logging food intake and daily exercise may work best for some patients, while others may preJune 2018 American Nurse Today 25 Know the risk The American Heart Association Guidelines include three cardiovascular disease (CVD) risk categories for women. Use these guidelines to help you identify at-risk women and provide timely care. Category Criteria Ideal cardiovascular health • • • • • • • No presence of cardiovascular disease Total cholesterol level < 200 mg/dL Blood pressure ≤ 120/80 mmHg Body mass index < 25 kg/m2 Fasting blood glucose < 100 mg/dL Nonsmoker Regular exercise • One or more major risk factors for CVD: • cigarette smoking • dyslipidemia • family history of premature CVD • hypertension • obesity (central) • sedentary lifestyle • poor diet Advanced subclinical atherosclerosis Metabolic syndrome Poor exercise capacity on treadmill test History of pre-eclampsia, gestational diabetes, or pregnancy-induced hypertension History of systemic autoimmune collagen vascular disease, such as rheumatoid arthritis At risk for CVD • • • • • High risk for CVD • • Known coronary heart disease, cerebral vascular disease, abdominal aortic aneurysm, peripheral arterial disease, end-stage or chronic kidney disease, or diabetes 10-year predicted CVD risk > 10% Source: Mosca et al. 2011 fer using smartphone apps to encourage adherence to treatment plans and medication regimens. Research is needed to determine the effectiveness of these apps. For those who are interested in support groups, provide resources and information. Also, direct women to the Go Red for Women website (goredforwomen.org) to learn more about heart disease, discover ways to live healthy, and participate in activities to spread the word about women and heart disease. Despite education, patients don’t always follow treatment plans. When that happens, explore possible reasons, such as lack of access to primary care providers, time constraints, and resistance to lifestyle modifica26 American Nurse Today tions. Be nonjudgmental when exploring these reasons, and collaborate with the patient to revise the treatment plan. Risk reduction begins with education Education is the cornerstone to reducing CVD risk and death among women. Remind your female patients of the MI symptoms unique to women, and explain that they should seek immediate medical care if they experience any of them. To ensure early identification and treatment of women at risk for a cardiovascular event, all healthcare professionals should adhere to the AHA guidelines for all female patients regardless of race or ethnicity Volume 13, Number 6 and provide culturally sensitive care. Empower at-risk women to make wise lifestyle choices, and support and encourage adherence to prescribed treatment plans. Melanie Kalman is a professor in the college of nursing at Upstate Medical University in Syracuse, New York. Margaret Wells is a professor and nursing department chair at Le Moyne College in Syracuse, New York. Selected references American Heart Association. Heart and stroke statistics. 2018. heart.org/HEARTORG/ General/Heart-and-Stroke-AssociationStatistics_UCM_319064_SubHomePage.jsp Barfield WL, Boyce CA. Sex, ethnicity, and CVD among women of African descent: An approach for the new era of genomic research. Glob Heart. 2017;12(2):69-71. Dracup K, Moser DK, Pelter MM, et al. Rural patients’ knowledge about heart failure. J Cardiovasc Nurs. 2014;29(5):423-8. Ladwig KH, Fang X, Wolf K, et al. Comparison of delay times between symptom onset of an acute ST-elevation myocardial infarction and hospital arrival in men and women 8% b. A woman with diabetes whose A1C is < 7% c. A woman at risk whose LDL is < 50 mg/dL d. A woman at risk whose LDL is < 60 mg/dL 14. Appropriate nursing actions to help women prevent CVD include all the following except: a. Use motivational interviewing techniques. b. Stress the importance of seeking treatment promptly. c. Provide resources such as the Go Red for Women website. d. Recommend always using a smartphone app to log calories. June 2018 American Nurse Today 27 Copyright of American Nurse Today is the property of HealthCom Media and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. 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Running head: NURSING

Topic 3 Discussion
Institutional Affiliation

Topic 3 Discussion
Nursing Interventions
The initial step should be caring for Ms. J as it is required in the nursing procedure. In the
event that there is heart failure, the nursing process requires that before thinking about the
intervention, systematic assessment which entail the establishment of the leading reason behind
the heart failure, potential hazard factors, and aggravating aspects that may impact contemporary
clinical status and quality of life. The primary methods that are of great importance while
looking after the patient with heart failure are patients’ education, management strategies, and
patient assessment (Nancy & Michelle, 2004). The other critical examination should be a
physical one, identifying the abnormal cases on the body morphology and important signs
likewise should be checked upon admittance. Management techniques should be enforced to

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