Congestive Heart Failure \"For Every

Congestive Heart Failure

"For every affection of the mind that is attended with either pain or pleasure, hope or fear, is the cause of an agitation whose influence extends to the heart…"

William Harvey (2001, ¶ 4).

"I know I need to make some more changes in my life," Velma Martinez, a 57-year-old Hispanic, African-American, female, recently diagnosed with Congestive Heart Failure (CHF), told Dr. Karen Shoemaker, her cardiologist. Currently, at 5' 3" inches, Velma weighs 236 pounds; approximately 94 pounds overweight (Ideal Weight Calculator, 2010). In addition to being obese, Velma has Type 2 diabetes (Type 2 diabetes, 2010).

Velma quit school when she was 13, right after her mother died. She explains that due to only having a sixth grade education, she has worked as a housekeeper and nanny for a number of different families during the last 43 years. Although Velma quit smoking seven years ago, Joseph, her husband, smokes more than two packs of cigarettes a day; often inside their small modest apartment, above a laundry mat in downtown New Jersey.

Religion/Ethnicity/Beliefs

Velma and Joseph have not been able to conceive children and they do not have any family members living near them as they immigrated to the United States from Mexico 43 years ago; shortly after they married. Velma's mother was African-American; her father, still living in Mexico, is Hispanic. Velma and her three younger siblings grew up eating a high-fat diet, which primarily consisted of fried tortillas and meat. Until she was diagnosed with CHF, Velma continued to eat the way she was raised. Velma reports, however, she recently began cooking more healthy meals.

Joseph, an African-American, also grew up eating a high-fat diet, which also largely consisted of fried foods. He still insists that Velma fry chicken at least once a week for him. Velma and Joseph have basic health insurance through Joseph's employer, a factory that produces and packages bakery items. Velma and Joseph, both Catholics, report they regularly attend Mass on Sunday.

Patients' Habits/Family/Gender Roles

As Joseph strongly believes a woman's primary place in the kitchen; taking care of her husband as well as the home, Velma's life revolves around Joseph and their home. Velma has attended regular health screenings and checkups with Dr. Juan Gomez, her same primary care physician, for more than 20 years. Dr. Gomez prescribes insulin to control Velma's Type 2 diabetes. When he detected symptoms of Velma's CHF, he immediately referred her to Dr. Shoemaker.

Velma reports that Joseph, who has not received a physical examination for more than 15 years, did go to the ER several years ago for stitches after he cut his hand at work. Velma currently works approximately 35 hours a week as a nanny in her employer's home. Health/Illness; Independence/Dependence and Beliefs about Medicine / Nursing

When Dr. Shoemaker elated her concerns to Velma regarding her current and future health, she knew she must encourage Velma to lose weight and also explain implications of Velma's CHF diagnosis to her. Dr. Shoemaker must also ensure that Velma understands which medications she will need to take for the rest of her life.

Joseph seldom accompanies Velma to her medical checkups he reportedly has a strong aversion to hospitals and clinical settings. Because Joe only attended school through the fifth grade, he experiences difficulty understanding what the doctors explain to them. Velma on the other hand, because of ongoing treatment for her Type 2 diabetes, feels comfortable with Dr. Gomez. She especially appreciates the fact that he plainly discusses her health issues with her on a level she can understand. Dr. Gomez consulted with Dr. Shoemaker when he referred Velma and explained that Velma's sixth grade education would require that Dr. Shoemaker explain treatment concerns to Velma on a level a sixth grader could understand.

The Disease Process

"Your heart is weak and unable to pump enough blood to keep your body as stable as it once was," Dr. Shoemaker explained to Velma. "You have Congestive Heart Failure, which could be genetic; something you inherited from your mother or father."

"Am I going to die soon?" Velma asked in a shaky voice.

Dr. Shoemaker smiled and reassured Velma that treatment could help prolong her life. She simplified information relating to CHF, similar to that in the article, "Congestive heart failure" (2008). She also reassured Velma, that even though she had CHF: "In the healthy individual the heart can tolerate large increases of workload for a considerable length of time" (¶ 1). Dr. Shoemaker explained that:

Cardiac failure results from conditions such as coronary artery disease, hypertensive heart disease, valvular insufficiency, and rheumatic heart disease, that interfere with the nutrition and oxygenation of the heart muscle itself. Congestive heart failure develops in 50% to 60% of patients with such disorders, and it can be either acute or chronic. (Congestive heart failure, 2008, ¶ 1).

"You are not alone," Dr. Shoemaker reassured Velma. CHF affects 15 million people all over the world. The risk of CHF goes up the older a person becomes; especially after the age of 65. She warned Velma: "You may sometimes experience being short of breath more quickly than you normally would because your heart has to work much harder to pump the amount of blood out that you body needs," Dr. Shoemaker said. "You heart may also become enlarged because CHR places a strain on your heart and makes it work harder. It is important that you take your medication exactly as prescribed. Not taking your medication could prove fatal. CHF is not usually fatal, however, as many people with mild and moderate CHF can be successfully treated. With proper medical supervision, one can continue a near normal life in many instances" (Congestive heart failure, 2010, ¶ 11).

"CHF occurs over a period of time, sometimes it takes a number of years before symptoms appear," Dr. Shoemaker continued. "You did not develop CHF overnight. Having diabetes and being overweight likely increased your chances for developing CHF."

The article, "10 tips for handling heart failure: Take these positive steps to manage a weakened heart muscle if you have one, and to prevent cardiac problems if you don't" (2006), explains that one primary reason for a person to lose excessive weight is that doing so reduces the workload on a person's heart. When a person is extremely overweight, even a 10% weight loss will provide significant relief for the individual's heart.

"I am glad to hear that you have started preparing more healthy meals," Dr. Shoemaker told Velma. "You need to ensure that your diet includes whole grains, chicken, fish, and lean meats, not fried as well as plenty of fresh fruits and vegetables. You also need to be sure you eat foods with potassium, like bananas, because the diuretics you take for your heart deplete the potassium your body needs."

Dr. Shoemaker showed Velma a chart, with the following information to help her better understand what may cause CHF, explaining words that appeared threatening.

Figure 1: Potential Causes of CHF (Congestive heart failure, 2010, ¶ 1).

When a person has congestive heart failure, his "failing" heart continues to work, however it does not work as efficiently as it should. When people with heart failure overexert themselves, they usually become exhausted and short of breath. "As blood flow out of the heart slows, blood returning to the heart through the veins backs up, causing congestion in the tissues. Often swelling (edema) results" Congestive heart failure, 2010, ¶ 3). Usually, the person with CHF experiences swelling in his legs and ankles, however, other parts of his body may also swell. Sometimes, fluid may collect in the person's lungs and interfere his breathing. This causes the shortness of breath, particularly when the individual lies down. CHF also negatively affects the kidneys' capability to get rid of excessive sodium and water in the body; which in turn, makes the body retain water and increases the edema, which is swelling .

Diagnostic Tests

The article, "Tests and diagnosis," by the Mayo Clinic Staff (2009) explains that for a doctor to diagnose heart failure, he takes a thorough medical history and performs a physical examination. The physician specifically checks to see if the individual has risk factors like high blood pressure. Using a stethoscope, the doctor listens to the patient's lungs for any signs of congestion and for any abnormal heart sounds that could indicate heart failure. The doctor may also examine the veins in the patient's neck as well as check for fluid buildup in the person's abdomen and legs. Following the physical exam, the doctor may order some of the following tests:

Blood tests: The sample of blood will reveal the patient's kidney and thyroid functions and may also indicate the presence of any other diseases that may affect the heart. "A blood test to check for a chemical called brain natriuretic peptide (BNP) can help check the pressure in…[the patient's] heart and help in diagnosing heart failure" (Mayo Clinic Staff, 2009, ¶ 2).

Chest X-ray; X-ray images: These images reveal the condition of the patient's lungs and heart. One's heart may appear enlarged in heart failure. The X-ray also may reveal whether ther e is any fluid buildup in the person's lungs. X-rays also sometimes show conditions other than heart failure that possibly cause the patient's signs and symptoms (Mayo Clinic Staff, 2009).

Electrocardiogram (ECG): Through electrodes attached to the patient's skin, an ECG records the electrical activity of person's heart and records the impulses. These impulses, displayed on a monitor, may also be printed on paper. From this test, the doctor can diagnose heart rhythm problems and also ascertain damage the person's heart may have experienced from a heart attack that may underlie heart failure (Mayo Clinic Staff, 2009).

Echocardiogram: From this test, the doctor can diagnose and monitor heart failure. "An echocardiogram also helps distinguish systolic heart failure from diastolic heart failure, in which the heart is stiff and can't fill properly. An echocardiogram uses sound waves to produce a video image of & #8230;[the patient's] heart (Mayo Clinic Staff, 2009, ¶ 5). From the image, by measuring the percentage of blood pumped out of the heart's primary pumping chamber (the left ventricle) with every heartbeat, the doctor can better determine how well the person's heart is pumping. This measurement is known as the ejection fraction. The echocardiogram may also reveal valve problems or show signs of previous heart attacks, as well as other abnormal causes of heart failure (Mayo Clinic Staff, 2009, ¶ 5).

Ejection fraction: An echocardiogram as measures the patient's ejection fraction. This serves as a significant measurement of how well the person's heart is pumping. This test helps the doctor classify heart failure and determine the best treatment. In a person with a healthy heart, the ejection fraction measures approximately 55%. This means that the heart pumps out more than half of the blood that fills the ventricle with each heart beat (Mayo Clinic Staff, 2009).

Stress test: A stress tests measures how the person's heart and blood vessels respond to exertion. For this test, while attached to an ECG machine, the person my walk on a treadmill or pedal a stationary bike. The doctor may instead give the person a drug intravenously to stimulate his/her heart similar to exercise. From the stress tests, the doctors can better determine if the person has coronary artery disease as well as how the person's body is responding to his/her heart's diminished pumping effectiveness. A doctor may order a nuclear stress test see images of the person's heart while he/she exercises. This test resembles an exercise stress test, but in addition, the doctor injects dye into the patient that special imaging techniques trace to further reveal the patient's heart condition (Mayo Clinic Staff, 2009).

Cardiac computerized tomography (CT) or magnetic resonance imaging (MRI): The CT and MRI tests also help diagnose heart problems and causes of heart failure. When given a cardiac CT scan, the patient lies on a table inside a doughnut-shaped machine where the machine's internal X-ray tube rotates around the person's body taking images of his/her heart and chest (Mayo Clinic Staff, 2009).

In some instances, CHF may be treated by prescribing medication for the person's high blood pressure. When an abnormal heart valve causes CHR, the valve may be surgically replaced. If the heart is too damaged to be repaired, the physician may consider a more radical approach; sometimes a heart transplant may be an option. " Most people [,however,] with mild and moderate congestive heart failure can be treated" (Congestive heart failure, 2010, ¶ 11). Proper medical supervision and treatment, a person will not likely become an invalid.

Possible Medical or Nursing Therapies

"One option you have for your CHF," Dr. Shoemaker explained to Velma, "is to receive regular treatment at an outpatient CHF clinic. These clinics asses their patients, prescribe medications and educate the patient regarding CHF."

Beth F. Crowder, M.D. (2006), an Advanced Practice Nurse, Little Rock, Arkansas, explains in the study, "Improved symptom management through enrollment in an outpatient congestive heart failure clinic," that those individuals regularly attending an OP CHF clinic typically realize improvements in their lifestyles that include increasing their functional capacity and their quality of life. They also experience a decrease in emergency room visits "hospital re-admissions, length of stay for re-admissions, and total costs" (Ibid., ¶ 2). Dr. Shoemaker explained to Velma that going to a CHF outpatient clinic would be a wise decision. "These clinics typically deal with patients who have one or more chronic illness," she told Velma. "This would prove helpful for you since you have CHF and Type 2 diabetes."

To help decrease Velma's fears, Dr. Shoemaker related what another patient who had participated in CHF outpatient treatment stated: "If I hadn't gone to the heart failure clinic I wouldn't be here. I thought I was gonna die. I'm convinced of that' (Crowder, 2006, Fear section, ¶ 1). It is also important that Joseph accompany you to your treatments," Dr. Shoemaker added, "it will help you by providing moral support and help him to overcome his fear of hospitals and clinics. Tell your husband that patients who have family members supporting them have a much higher rate of staying healthy longer."

"It is also important for you to continue to change you eating habits to healthier ones," Dr. Shoemaker also said. "CHF will cause you to retain more fluids she in addition to eating a low fat diet, you have to monitor your sodium intake and fluids. To maintain a proper fluid level, you will need to also take diuretics. Exercise is also important," Dr. Shoemaker stressed. "Walking several times a week would be a good habit to help maintain a healthier lifestyle."

Commonly Prescribed Medications

When Dr. Shoemaker reviewed Velma's medical records, she noted that Velma took insulin to control her Type 2 diabetes, not TZDs, a factor in Velma's favor. "Diabetes medications known as thiazolidinediones (TZDs) significantly increased the risk of heart attack, congestive failure and death in older patients, a study in an issue of JAMA last month found" (Diabetes medications known…, 2008, ¶ 1).

V-HeFT-I the first Vasodilator-Heart Failure Trial demonstrated that black patients had a decrease in annual mortality while taking a combination of isosorbide dinitrate and hydralazine as compared to similar white patients following the same regimen. This drug combination serves as a NO donor, thereby replenishing an important antioxidant that is diminished in blacks. (Schmitz, 2007, Research finding section, ¶ 2).

In the article, "Nutritional influences on illness: The influence of vitamins on congestive heart failure," Dr. Melvyn R. Werbach (2008) reports that as many as one-third of patients with congestive heart failure (CHF) may be thiamine-deficient. CHF may constitute "part of the presentation of wet beriberi, the classic cardiovascular disease of thiamine deficiency, manifested by peripheral vasodilatation with increased cardiovascular output, myocardial lesions, sodium and water retention, and biventricular myocardial failure" (Werbach, ¶ 1). When thiamine is replenished, however, the patient experiences a rapid improvement.

Another concern for Velma, Dr. Shoemaker noted was that the diuretic furosemide she had to take could cause urinary loss of thiamine, and lead to even more impaired cardiac function. One study, according to Werbach (2008) found that when this occurs, "thiamine supplementation has been shown to be beneficial…. Even refractory heart failure can be quickly reversed when it is secondary to a deficiency of thiamine" (Werbach, 2008, ¶ 2). Dr. Shoemaker explained to Velma that CHF generally requires a patient's treatment program to include: