Part 5 The Rossi Family
5.2 Rossi family case study 1: Maria Rossi – heart failure
Dima Nasrawi and Donna Wilson
Introduction to case study
Learning Objectives
By the end of this case study, you should be able to:
- Identify associated risk factors with the development of chronic cardiac failure.
- Identify the impact of a chronic cardiac failure diagnosis.
- Discuss required lifestyle modifications for patients living with a cardiac failure diagnosis.
- Identify required self-management strategies to manage cardiac failure diagnosis with a specific focus on rural health.
- Discuss the role of the nurse managing a cardiac failure diagnosis.
Scenario: Maria’s diagnosis of chronic cardiac failure
Early last month, Maria began to experience some light-headed episodes, heart palpitations and dizziness at home. She did not report these symptoms to her family or visit a doctor, as she believed it was just ‘a part of ageing’. She believed she could manage with an improvement in her hydration and additional rest. However, last week her husband Maximo finds her after a fall. Maria has collapsed in the dining room and sustains a small bleeding laceration above her left eyebrow. Maximo realises she has likely hit her head on the edge of the chair as she collapsed. As Maria is semi-conscious when Maximo finds her, he calls out to their son John for help. Both John and Elisabeth rush to assist and Elisabeth immediately calls for an ambulance.
When the ambulance arrives, the paramedics explain to Maria’s family that it looks like her heart is not working properly. They say that whilst it does not look like a heart attack, they believe she needs to be urgently transported to the local hospital in Lismore, about 20 minutes away by road. Later that day, Maria’s family are informed that she is in a serious condition, with a new diagnosis of heart block.
Thinking point
The hospital staff start Maria on an isoprenaline infusion, which has a mode of action known as a ‘beta-agonist’, which relaxes the muscles of the airways. This drug increases cardiac output via positive chronotropic and inotropic actions. Cardiac automaticity and atrioventricular nodal conduction are improved under this drug, which can also improve coronary blood flow.
With the isoprenaline infusion underway, Maria is airlifted to a larger hospital just over one hour away from Lismore by road. This tertiary facility specialises in complex cardiac care. On arrival, Maria is transferred urgently to the cardiac catheterisation laboratory (CCL) where she is diagnosed with complete heart block, leading to the need for emergency pacemaker implantation. The cardiac team inform Maximo and John that the infusion has played a big part in saving her as it keeps her heart reasonably stable, long enough for her to be delivered safely to the cardiac facility.
Reflective Questions
- Can you imagine how Maria and her family would have felt during the transport stage of her care?
- As a healthcare professional, how could you offer support to Maria and her family during this stage?
Thinking point
Maria’s pacemaker procedure occurs almost 5 hours after she is found on the floor in the dining room. If Maria lived in a city, she would likely have reached the CCL procedure table within the hour. However, systems in place in her local area enable the swift escalation and retrieval to occur, resulting in Maria accessing the life-saving procedure.
Unfortunately, in the 2 days after the pacemaker implantation, Maria continues to experience palpitations and develops symptoms of shortness of breath, fatigue and swelling in the legs.
Further diagnostic tests reveal Maria is experiencing heart failure with reduced ejection fraction. This results in a new diagnosis of atrial fibrillation with ventricular pacing. Maria’s condition is treated with diuretics, ACE inhibitors and beta-blockers. In addition, she receives some short-term non-invasive ventilation with biphasic positive airway pressure (BiPAP) to assist with her shortness of breath, due to acute pulmonary oedema (APO).
With appropriate treatment and management, Maria’s symptoms improve. She is discharged from the hospital with a referral to the local heart failure community management team, a cardiac rehabilitation program, and a plan for follow-up with her cardiologist. Her condition remains stable; however, she now lives with a new chronic cardiac condition and a reduced overall functionality when it comes to activities of daily living.
Reflective Questions
- Have you considered the impact of living rurally on patients, in terms of accessing life-saving health care services? Maria received this treatment far from home, how would this affect her?
- This situation was a life-threatening situation for Maria. As a healthcare professional, it is always important to consider regular debriefs and self-care strategies, have you considered any of these yet?
Thinking point
Maria travelled just over 100 kms to receive care and treatment in a tertiary hospital facility. The local city of Lismore has a range of healthcare facilities, including a major hospital. She can also access local support via the community health team as well as rural healthcare initiatives and virtual care such as telehealth. Maria and Maximo may benefit from additional in-home support. As an Australian example of additional support in the community for the aged, 2 types of assessments are offered by the Australian government to determine the needs and eligibility for specific types of care.
The first is a home support assessment conducted by a regional assessment service (RAS). This assessment is recommended if only low-level support is required to maintain independence at home and it is part of the Commonwealth home support programme.
The second is a comprehensive assessment conducted by an aged care assessment team (ACAT). This assessment is recommended if the care needs exceed what the Commonwealth home support programme can provide. ACAT assessments cover the following care options: home care packages, short-term care options, and aged care homes.
Case study questions
- What were Maria’s risk factors for developing chronic cardiac failure?
- Now that Maria has a chronic cardiac failure diagnosis, what do you think could be the impact that this diagnosis has on Maria, Maximo, John and Elisabeth?
- Now that Maria is going to be living with the diagnosis of chronic cardiac failure, what are some of the lifestyle modifications she and the family will need to be aware of?
- Maria and her family live about one hour from the cardiac hospital and specialist care providers, and 20 minutes away from the community healthcare providers in Lismore. Given that she lives rurally, out of town on a farm, what sort of self-management strategies could she and her family put in place?
- How can nurses make a difference to Maria’s experience of managing her cardiac failure condition? Consider the role of the nurse in Maria’s journey.
Key information and links to other resources
- Heart Foundation (Australia)
- Australian Commission on Safety and Quality in Healthcare: Fourth Australian atlas of healthcare variation – Section 2.2 heart failure
- Australian Institute of Health and Welfare: Heart, stroke and vascular disease: Australian facts
- Australian Government My Aged Care: Prepare for your assessment
- NSW Health virtual care
How to assess the cardiac system
Subjective Data:
- Ask the patient about their level of comfort, whether they have any pain and what is normal for them.
- Discuss with the patient about their medical and surgical history.
- Discuss with the patient their nutrition and diet: ask them about their appetite, their diet and whether they are experiencing any nausea.
Objective Data:
- Observe
- Listen: use a stethoscope
- Palpate
- Weigh the patient and record the body mass index (BMI)
- Diet: review the food intake of the patient, and if there is none, commence a food chart
- Observe bowel patterns
- Review the patient’s medication history to see if any bowel medications have been commenced.
Now, before we pick up a stethoscope to perform a cardiac assessment, let’s review how and where to auscultate, and consider what the sounds we hear will be telling us. Watch the video below which demonstrates how to conduct a physical cardiac assessment:
What is heart failure?
Activity: Watch this video for a great visual explanation for ‘What is heart failure?’
Heart failure often arises from heart attack and coronary heart disease, although there are various other factors contributing to its occurrence. People living with heart failure are often also dealing with chronic ailments and comorbidities like lung disease or diabetes. Your heart can become weakened, damaged or stiffened due to underlying conditions that can lead to the development of heart failure, such as:
- Old age
- Chronic conditions: for example, diabetes, HIV and thyroid conditions
- Coronary heart disease and myocardial infarction
- Damaged heart tissues and muscle: cardiomyopathy, causes can include infection, alcohol abuse and certain medications; myocarditis caused by inflammation of the heart muscle
- Heart valve disease
- Cardiac arrhythmias
- Congenital heart disease
- High blood pressure
- Pregnancy: extra strain may cause damage to the heart (Heart Foundation, n.d.)
Symptoms of heart failure can be different for each person which range from serious to mild. The most common symptoms include:
- Chest pain
- Coughing, difficulty with breathing or shortness of breath, especially when doing physical activity, possible overnight waking due to difficulty with breathing
- Dizziness and/or heart pounding or racing (i.e. palpitations)
- Loss of appetite or nausea
- Swollen ankles or legs (i.e. oedema)
- Tiredness and/or weakness (Heart Foundation, n.d.)
Psychological health for patients with heart failure / cardiac disease
When considering ways to promote coping, resilience and improve quality of life, whilst reducing mortality and hospital readmission rates, it is crucial to consider the role of self-care. Many patients struggle to adhere to self-care advice, which may be due to a lack of motivation, knowledge, ability or support. Healthcare professionals play such an important role in supporting these patients with chronic cardiac conditions. This may be via education, assisting with making lifestyle changes, adhering to treatments, monitoring symptoms, responding appropriately to deteriorations, and linking patients to further resources and support agencies (Jaarsma, et al. 2021).
Case study 1 summary
Maria’s case highlights the importance of monitoring patients who undergo cardiac interventions such as pacemaker implantation and for potential complications such as heart failure. Educating patients about their condition can ensure the best possible patient outcomes are achieved. Timely diagnosis, appropriate treatment, and lifestyle modifications can significantly improve outcomes for patients with heart failure.
References
Heart Foundation. (n.d.). What is heart failure? https://www.heartfoundation.org.au/bundles/your-heart/heart-failure
Jaarsma, T., Hill, L., Bayes-Genis, A., Brunner-La Rocca, H.-P., Castiello, T., Celutkiene, J., Marques-Sule, E., Plymen, C. M., Piper, S. E., Riegel, B., Rutten, F. H., Ben Gal, T., Bauersachs, J., Coats, A. J. S., Chioncel, O., Lopatin, Y., Lund, L. H., Lainscak, M., Moura, B., … Stromberg, A. (2021). Self-care of heart failure patients: Practical management recommendations from the Heart Failure Association of the European Society of Cardiology. European Journal of Heart Failure, 23(1), 157–174. https://doi.org/10.1002/ejhf.2008