These hospitalizations are one of the problems and evidence that Mrs. Fisher’s cardiac condition is worsening. Her CHF and A-fib are causing fluid retention and increased cardiac pre-load, decreased cardiac output, compromised coronary circulation, which is resulting in angina, dyspnea, and weakness (Copstead, 2013; GCU, 2013a). Numerous cardiac medications demonstrate an attempt to treat these signs and symptoms (GCU, 2013b) but Mrs. Fisher may neither truly understand her disease process, nor comprehend the potential side effects of her medications (GCU, 2013a). For these reasons, more nursing care, specifically, increased home health visits will be beneficial. Mrs. Fisher’s poor health and decreased knowledge means that she will need a nurse to visit at least twice weekly, in order to obtain vital signs and provide a physical assessment so there is adequate time to treat any new health problems. During these visits, comprehensive health education may also occur. In review of Mrs. Fisher’s interview, including her health history and discharge instructions, there is concern that further assessment of her medications is needed.
The PCP needs to be contacted and updated on dose increases. Her Digoxin has been increased to 0.25 mg once a day from 0.125 every other day. The patient’s Lasix has been increased to 80 mg twice a day from 40 mg once a day. In addition, she has been prescribed Calan (verapamil) but also has multiple home medications for her heart and BP pressure. She has a nursing diagnosis of knowledge deficit, related to unfamiliarity with her disease process and lifestyle implications of disease process. A nurse should then assess Mrs. Fisher’s learning styles; teach her the pathophysiologic process of her disease, and benefits of taking her medications. Furthermore, a nurse should teach her the importance of assessing a radial pulse before taking Digoxin and following PCP instructions about when not to take it (i.e. HR 60/min or less). Since she is refusing supplemental oxygen, Mrs. Fisher also needs to be educated on the benefit of oxygen and why a physician ordered it for her. Safety, specifically Mrs. Fisher’s risk for injury from falls, is another key issue. She lives by herself and has environmental home issues. Contributing factors include depression, cluttered home environment, dimly lit rooms, throw rugs, medications such as ACE inhibitors, anti-hypertensives, diuretics, antidepressants, showing difficulty with gait, and complaints of fatigue .
Other risk factors include decreased cognitive function, recent depression, and change in elimination pattern. Predictors of fall risks are diagnosis of atrial fibrillation, age greater than 75 years old, living alone, and polypharmacy. Interventions would be for a home-health nurse to educate Mrs. Fisher on how to identify hazards in the home. A physical or occupational therapist may be used to help with this education. Because she lives alone, Mrs. Fisher needs to be taught what to do if she falls and cannot get up and to make sure she has the ability to access an emergency response system. Non-glare lighting or runway-type lighting in the home will help her with balance and fall prevention. Supportive shoes with rubber, non-slip soles will prevent slipping.
Home health nurses can also teach her how to ambulate safely, using handrails installed in her bathroom (Ellenbecker, Samia, Cushman, & Alister, 2008). Beyond these three problems, it is observed that Mrs. Fisher is still grieving for the loss of her husband, as evidenced by the way she speaks of him. This grief may also be leading to depression, which further exacerbates her other problems. If she becomes too depressed, her motivation to improve her physical health will decline. It seemed as though Mrs. Fisher enjoys talking about her husband, this might make it easier to intervene with therapeutic communication.
