Biomedical subjects
Publications and source records attributed to Nancy M Albert.
Patients with heart failure have special palliative care needs, but palliative measures for treating the symptoms of end-stage heart failure have been largely ignored. A formal disease-management program for heart failure should include palliative care.
OBJECTIVE: The goal of this study was to determine nurses' knowledge of heart failure (HF) self-management education principles. DESIGN: The study was exploratory and descriptive and included a convenience sample. SETTING: Research took place in a large midwestern health care system that included a university-based hospital, community hospitals, and home or palliative care. SUBJECTS: Subjects included 300 nurses who provide care to patients with HF. OUTCOME MEASURE: The outcome measures included overall and topic specific perceptions of basic information important to HF self-management. Topics included diet, fluids or weight, signs or symptoms of worsening condition, medications, and exercise. INTERVENTION: A 20-item, true or false written survey was administered between February 2000 and April 2000. RESULTS: Of the 300 nurses surveyed, 92% were registered nurses and 8% were licensed practical nurses; 38% worked in a large university-based hospital; 44% were employed at 5 community hospitals; and 18% worked in home or hospice-palliative care. Mean HF self-management knowledge score was 15.2 +/- 2.0. Registered nurses scored significantly higher than licensed practical nurses (15.3 vs 14.1; P =.004). Individual questions with overall scores <30% were related to dry or ideal weight in daily weight monitoring (24%), nonsymptomatic, low blood pressure (26%), and short-term dizziness when rising (19%). Individual question scores >30% and < or =75% were related to nonsteroidal anti-inflammatory inhibitor use (49%), potassium-based salt substitute use (52%), rest vs activity (72%), and lean delicatessen meat use in a low sodium diet (75%). In questions with scores <30%, nurses requested more information only 5% to 8% of the time. Overall analysis of variance indicated differences by work experience. HF nurses (primary population) scored higher than critical-care, medical-surgical, or telemetry floor nurses (16.2 +/- 1.7; 15.1 +/- 1.8; and 14.7 +/- 2.0, respectively; P <.001); home care nurses scored higher than hospital or palliative care nurses (15.9 +/- 1.5; 15.1 +/- 2.0; and 14.0 +/- 1.5, respectively; P =.006). CONCLUSION: Nurses may not be properly educated in HF self-management principles and must be provided with the right information so they can improve the quality and amount of information they offer to patients. Nurses who are better prepared to educate patients with HF may be more likely to carry out this nursing function as a part of their daily job role.
Left-ventricular systolic dysfunction, or heart failure (HF), is a chronic, progressive condition with a poor prognosis. Approximately 50% of deaths, especially in mild to moderate cases, are sudden. Most sudden deaths are thought to be due to ventricular tachycardia; however, premature ventricular contractions and couplets parallel severity of HF and have been associated with increased mortality risk as opposed to dysrhythmic death. Ventricular arrhythmogenesis results from many mechanisms (afterdepolarizations, reentry, and enhanced automaticity) and preconditions (electrophysiologic abnormalities, neuroendocrine activation, electrolyte imbalances, scar from an ischemic event in ischemic cardiomyopathy, fibrosis in dilated cardiomyopathy, hemodynamic abnormalities, and HF medical management). Nurses are key caregivers in optimally managing HF, either by direct actions or by using advocacy, communication, and collaboration skills to promote positive outcomes. Ventricular dysrhythmia management consists of facilitating core HF pharmacologic and nonpharmacologic medical therapies, using amiodarone to improve symptoms, as needed, and utilizing implantable cardioverter-defibrillator therapy to reduce the risk of sudden cardiac death.
In women, cardiovascular disease is highly prevalent and is costly in terms of mortality and morbidity. Healthcare providers should educate women about initiating and maintaining a cardiovascular-healthy diet as a cornerstone of primary and secondary prevention. The difficulty comes in determining the correct messaging regarding diet components. Women should routinely consume a diet known to prevent coronary heart disease, stroke, and other cardiovascular risk factors. Essential aspects of good nutrition for women include diets rich in fiber, whole grains, fresh fruits, vegetables, fish, nuts, antioxidants, minerals, vegetable protein, marine and plant omega-3 fatty acids, and vitamins of the B group. Some foods known to provide cardiac protection in women, such as potatoes and citrus fruit juices, may not be cardioprotective in men. Thus, it is important to continue research efforts in women to determine the best diet for cardiovascular health.
BACKGROUND: Gender differences abound in patients undergoing coronary artery bypass graft (CABG) surgery. Most research was conducted in the early 1 990s. It is unknown if gender differences have diminished over time. RESEARCH OBJECTIVES: To determine whether gender differences exist in the current era of CABG surgery by examining preoperative, intraoperative, and postoperative factors known to affect outcomes. SUBJECTS AND METHODS: In this descriptive, correlational study of all patients undergoing primary, isolated CABG at a large, urban Midwestern healthcare center, data in 1993 and 2003 were analyzed to determine if gender and time differences existed and if there was a time and gender interaction effect. Trained nurses prospectively collected data during the index hospitalization for the institution's Cardiovascular Information Registry. RESULTS: 2,200 patients were studied; women accounted for one-fourth of the sample. Age over 65 years; current smoking; presence of hypertension, cerebrovascular accident; and insulin-dependent diabetes; symptomatic heart failure and chest pain were significantly associated with female gender (all P' s < .001). Intraoperatively, internal mammary arteries were used less as a graft conduit in women (P < .001); gender differences were most pronounced in patients requiring 2 bypass grafts. Postoperatively, cardiac pump failure and median hospital stay were greater in women (both P' s < .001); however, both decreased over time. CONCLUSIONS: Gender differences continue to exist in patients undergoing CABG. Differences do not affect hospital mortality rates but play a role in hospital length of stay and may affect postdischarge recovery. Research targeted at modifiable preoperative factors may improve postoperative recovery.
There is little information on the effectiveness of emergency department (ED) observation unit (OU) heart failure (HF) therapy. The authors' objective was to evaluate outcomes after implementation of an ED-OU treatment protocol for HF exacerbation. Unblinded assessment of the effectiveness of an HF protocol was performed, controlled by outcome for 9 months prior to implementation. This included diagnostic and therapeutic algorithms, cardiology consultation, close monitoring, patient education, and discharge planning. Adverse outcomes were defined as the 90-day rates of ED HF revisits, hospital HF readmissions, or death, as determined by chart review, computer database search, and phone follow-up. One hundred fifty-four patients were enrolled; 50 entered before, and 104 after protocol implementation. Only six (12%) in the preprotocol and one (1%) of the postprotocol group were lost to follow-up. After an OU visit, postprotocol 90-day ED HF revisit rates declined 56% (0.90-0.51; p<0.0000) and the 90-day HF rehospitalization rate decreased 64% (0.77-0.50; p=0.007). The 90-day rates of death and OU HF readmission decreased from 4% to 1% (p=0.096) and 18% to 11% (p=0.099), respectively. An intensive outpatient ED OU HF management protocol safely decreases 90-day rates of emergency department visits and inpatient hospitalizations.
Heart failure is the major cause of morbidity and mortality in the United States. Stage D heart failure has a greater mortality rate than many cancers and has equivalent symptom burden and severity. There has been a paradigm shift in our understanding of the pathophysiology of heart failure. Progressive heart failure is associated with ventricular remodeling and a maladaptive neurohumoral response. Drug classes have evolved that curtail ventricular remodeling, and blunt neurohumoral responses reduce morbidity and mortality. Despite combination drug and device therapies, the management of Stage D heart failure includes palliation. Both cardiology and palliative specialists need to learn from one another in order to palliate these highly symptomatic patients. Such collaboration will enhance care and are the basis for well-conceived research trials.
There is a gap between the evidence that supports treatments used in heart failure and day-to-day patient care. Clinical practice guidelines are evidence-based and suggest best practices; however, healthcare providers, patient and system factors complicate the diagnosis and must be addressed. Performance measures specific to nursing can be derived from the guidelines to guide practice and increase high-quality care. Innovative practice improvement programs, clinical leaders, and system tools are needed to close the gap. Nurses can facilitate processes that advance care planning and promote effective care delivery as part of a multidisciplinary team of healthcare providers.