Appendices: Case Study for Heart Failure
Place: Medical Ward
“Good morning, Mrs. Smith. Do you remember me from yesterday. I’m Simone?”
“Yes, Simone, I remember you from yesterday. I see you’re back. This your second day shift?”
“Yes, this is my second. I am doing three days and a night shift this week so we will probably have one more day together. I have your meds here: a beta blocker, ace-inhibitor, and diuretic. But before you take these, I need to check your morning weight and your blood pressure. This is something you’re going to have to do each day on your own.”
“Ok, do you need me to do anything?”
“Nope, just lie back and relax while I take your BP and weight.”
Simone then presses a button on the bed to get Meryl’s weight and then presses the NIBP button on the monitor.
|95% 3 LPM
“Your blood pressure is down to 90/55, which is what we expect. Your heart rate is around 65, which is also what we expected. You have lost 1 kg of fluid since we started the diuretic, which is a bit less than we expected. How are you feeling when you stand at the bedside or use the commode?”
“I feel a bit lightheaded but nothing really serious, I don’t think.”
“Your oxygen has been dialed back to 3 LPM, but is not really changed. I would like to listen to your chest, then I will give you your meds and morning tray.”
Meryl adjusts her gown so that Simone can listen to her heart and lungs. Simone methodically moves through a head to toe assessment and records her findings.
“All done, Mrs. Smith. Here are your pills as we discussed and your breakfast.”
“This is it for breakfast? Some cereal, skim milk, and a couple pieces of fruit?”
“Yes, Addy the dietician you met yesterday has ordered for you the cardiac diet low in sugar and salt. She will be coming by later this AM to discuss diet with you and hopefully Dorothy. Diet is very important in heart failure and knowing more about how food affects your condition will help keep you out of the hospital.”
“Ok, this will take some getting use to. I really like my sausage and eggs for breakfast.”
“I can honestly say me too, but for you the rare sausage or eggs will be ok, just not every day. But Addy would be best to ask.”
Simone heads out of the room to check on her other patients. Meanwhile, Meryl picks up her spoon and moves the cereal around but really does not eat anything other than the half apple and tea on her tray.
“Hello, Mrs. Smith. My name is Addy and I am the dietician for Cardiology. We met yesterday with the rest of the team. You are Dorothy right? Mrs. Smith’s wife?”
Dorothy smiles. “Good memory, yes I am.”
Meryl looks up, “You’re probably here to discuss what I can or cannot eat?”
“That is correct. For you, diet and activity are going to be very important to maintaining good health and keeping you out of the hospital.”
Dorothy looking unhappy and says: “I suppose I’m here to learn as well so that I keep her on the straight and narrow path.”
“Yes, in my experience and in the research: when families are closely involved in the care of a loved one, the care is much more effective. The diet is not all bad, and you and Mrs. Smith will learn how to adapt it to your likes, but there are some things to consider.”
“It is really important that you consider low sodium foods and not adding any additional salt when cooking. Adding salt can lead to further water retention, which can stress your heart and make it not pump as well as it should.”
“Look, Meryl, many of the menu items we already eat. I just need to not add salt.”
“That is correct, Dorothy. Many patients find they are already cooking similar diets. I recommend that you not have a salt shaker on the counter or on the table. That way you’re not tempted to add salt. Look for fresh herbs and spices to add that kick of flavor we all desire. Things like garlic, cilantro, or sage can add some additional flavor to something like a broiled chicken breast.”
“Oh Meryl, we have always said we wanted a herb garden. I guess this will be the encouragement we need to start.” Dorothy’s eyes light up a bit more. “I can go shopping for the stuff we need and when you come home we can start planting.”
“Dorothy, this is not an excuse to go shopping. You always get so excited about things. We need to take this slowly. A garden is a good idea, but let’s start buying and cooking first.”
Dorothy’s eyes shine a bit less brightly, but she nods.
“Ok, you both look like you understand what I am asking you to do,” says Addy. “I would like you to look through the information I have given you. If you have any questions, write them on the sheets and I will come back tomorrow to see how you’re doing. The meal trays you get will be example meals that you should consider making at home. Dorothy, I need you not to bring anything extra in from home until Mrs. Smith is stabilized. Do you think you can do that?”
“I was just thinking of picking her up a milkshake, but I guess that’s out of the question?”
“Yes, until we have things more stabilized and the medications working well, that is for the best.”
Both women nod. Addy gets up and waves good bye to both Dorothy and Meryl, and heads out of the room to see the next patient on her list.
Simone stops Addy a couple of doors down from Meryl’s room. “How did your talk go?”
“Pretty well. They are both intelligent and are ready to learn. They seem less overwhelmed than yesterday. Meryl seems to be feeling better, but is still on oxygen. Dorothy was very excited about making a herb garden. All good signs.”
“Awesome, thanks. If they have any questions are you coming back today?”
“No, I think they will need to digest what I gave them. I said I would be back tomorrow to see how they are doing and to answer any questions.”
“Mrs. Smith, how are you doing? I am back to do another ECG heart tracing on you.”
“Ok, and you are?”
“I’m Denis. I performed the test yesterday. Do you remember?”
“Oh, there was so much happening, I’m so sorry ,I can’t remember everyone’s name that is helping me.”
“That is quite all right. Ok, this test involves me placing some sticky tape on your arms, legs, and chest.”
“That I remember.” Meryl re-adjusts her gown so Denis can place the leads on her chest and arms. Denis pulls the covers up, leaving Meryl’s feet exposed so he can place the leads on each foot. “All done with that. I now need you to stay very still while we do the test.”
Denis pushes the button and the pink coloured paper is slowly pushed out of the machine with the squiggly lines from each of the 10 leads.
“Is there any change?”
“Mrs. Smith, I see lots of patients every day and my apologies. I cannot remember your test from yesterday. All I can say from looking at the ECG is that there is nothing to be done right away and you are not in danger right now.”
“I guess that’s a good thing, thanks.”
Denis prints out a second copy as an interim report for the chart, then removes the leads and stickies from Meryl’s body. “I’ll see you tomorrow.”
Meryl waves him goodbye.
As Denis is exiting the room, Simone pulls him aside. “You have the latest 12 lead?”
“Yes, I was going to place it in the chart.”
“Excellent, let’s do that and compare it to yesterday.”
Both go to the nursing station where Simone pulls up yesterday’s 12 lead and looks back and forth from today’s ECG to yesterdays.
“Do you see any differences Denis?”
“Nope, although it is quite a bit slower than yesterday’s. Did you start her on something?”
“Yes, we started her on a beta blocker to slow her rate down and to prevent any remodeling.”
“Well, it seems to be working. Heart rate is about 65, but other than that everything looks the same as yesterday.”
“Ok. Thanks Denis. See you tomorrow?”
“Yes, I’ll be here about the same time.” Denis then grabs his ECG cart and heads down the hallway to another patient.
“Good afternoon, Mrs. Smith.”
Dorothy looks up to see a slightly stooped women enter the room and pull a chair up to the bedside. “Who are you?” she asks.
“My name is Stella and I am a social worker for the hospital. I come and see all the cardiac patients to make sure things are going well and to see if I can help at all.”
“Oh, not sure what you can offer.”
“Me neither, but lets have a conversation. Then I might have something a bit more definitive.”
Dorothy looks Stella over a bit more. “I guess that’s ok. Meryl has psych coverage as part of the RCMP so not sure what you can help with?”
“That’s good to know. If there’s something that needs to be shared, I can share it with the RCMP. It benefits people to ensure there is good coverage. I have a few set questions to ask, but please feel free to interrupt at any time. I do this to see if there are any gaps and where a social worker can assist you in your new journey to better health.”
Both Meryl and Dorothy nod.
“Ok, how long have you two been together?”
“We have been living together four years, but have dated for about eight years before moving in. I met Dorothy while I was having a coffee break and stretching my legs after being in the patrol car for 10 hours on a stake out. She was sitting in a booth by herself and the restaurant was completely jammed. I asked if she wouldn’t mind sharing her booth and she told me that it was ok and that I looked to be a safe person. We started talking and here we are 10 years later. She was the right person at the right time after my previous relationship dissolved due to him cheating with the teaching assistant.”
“You were previously married?”
“Yes, before Dorothy, I had a traditional family with a male husband. We were together for about six years. I never really felt comfortable in the relationship, but thought that that was what a woman should be when being a wife to a male. Anyway, he started cheating after I had our second child and then I just left.”
“How many kids?”
“Two. A boy, Roger, and a girl Jennie. Very lovely kids, but they’re growing up so quick. Roger is 16 and Jennie is 14. We share custody. Although Matt, my ex-husband, gets weird with me living with Dorothy.”
“Any issues with the coparenting or the kids?”
“No, the kids have adjusted nicely to having two moms and have really bonded with Dorothy.”
“How long have you been with the RCMP?”
“Twenty-four years—looking at retirement in about five or six, I think. Got a promotion three years ago that took me out of the patrol car and more desk duty. Been a little less active since that time, riding a desk.”
“Yes, physical activity is important. I think that is Addy’s day two talk after she gives you the news about your diet.”
All three women laugh.
“Oh, I am still active, just not the same level as when I was in a car. I like to walk, run a little, and really enjoy hiking on some of the trails we have around here when the weather is nice.”
“Sounds lovely. Good way to relieve stress in your type of job.”
“Yes, I guess so.”
“Do you smoke?”
Both women shake their heads no. “We both quit years ago. Never felt the need to take it up again.”
“How about alcohol?”
“Dorothy and I enjoy a glass of wine after work and the occasional martini when we go out, but I don’t think it’s excessive. What do you think, Dot?
Dorothy ponders this and a few seconds later answers. “Not sure we do drink every day, but only a glass, so I don’t feel it’s excessive.”
“Sounds quite normal to me. Ok, thank you for answering my questions. You are very normal people and look like you have the coping skills and support needed to make the adjustment that heart failure requires. I don’t think I need to be involved. With your permission, I would like to send a note to your HR benefits person in the RCMP to give them an update, and maybe they can follow up with any necessary assistance. “
“That would be fine.” Meryl then gives Stella her division number and the contact information for benefits in her division.
“Thank you both. Have a great day.”
Stella heads out of the room and to the nursing station to update her notes.
Simone comes by just as Stella is finishing up. “Anything I need to know?”
Stella looks up and smiles. “No, I think she is doing pretty good. I don’t believe the diagnosis has really hit her or her partner yet. Right now they’re still processing. On the plus side, good supportive family, and she has great support from the RCMP so things are setup well for her to be successful in this transition. The real question is: will she be allowed to continue to work or will the RCMP push for retirement? But that’s not my decision and could add quite a bit of stress to Meryl and Dorothy.”
“Thanks Stella. I have a good feeling about them. Will you check in with them again?”
“No. I’ll see them in the healthy heart clinic, but I don’t think I need to follow up beyond that.”
Simone nods and moves over to complete her charting on the other patients she is caring for.
“Hello Mrs. Smith, how are you doing?” Simone asks as she looks over the monitor and does a primary sweep of her patient.
Meryl looks up with reddened eyes, “It’s going ok I guess.”
“Have you been crying, Mrs. Smith?”
“Just a little. I just. Why me?”
“I don’t know why this has happened to you, but I can explain things a bit more to you if you would like?”
“That might help. I think it’s suddenly hitting me that my body is changing and not for the better and I may have to retire and make so many changes. I, oh gawd. I just don’t know what to do.”
“This is perfectly normal. Let me pull up a chair and I can explain what is happening in your heart ,and what the plan is for you. Does that sound ok?”
“Yes, thank you.”
Simone sits down beside Meryl’s bed and explains how heart failure develops when a valve is not working, how valves become diseased, and the various treatments. She also carefully discusses some of the complications that can develop if Meryl does not follow doctor’s orders.
“Oh, thank you. I think I understand a bit better now. It looks like I’m not going to die.”
“Yes, Mrs. Smith, with the correct treatment, and you watching your diet and exercise you can live a very enjoyable life—maybe not the one you envisioned, but still quite enjoyable.”
“Yes, I think it’s all the changes I am facing that is overwhelming me. “
“Could very well be. Often facing one’s mortality can be a bit daunting. You need to give yourself time to grieve and recognize that this has happened to you and that it is not a punishment, but something that you need to deal with. Remember, there are many people here to help you and Dorothy make the best of this situation and diagnosis. You need to allow us to help you.”
“Thank you again. Yes, I will be asking for help now. What is the plan for tomorrow?”
“Much the same as today. You will have another chest X-ray, ECG, and lab work. I hope that I’ll be able to take you off oxygen, and then, if that happens we can introduce you to the heart failure clinic, which will begin an exercise routine with you to help strengthen your heart and your coping skills.”
“It would be nice to begin moving around again.”
“Let’s plan to do that tomorrow, shall we? I can hear the dinner trays being moved about in the hallway, so I’m going to get your meds and check on my other patients.”
Meryl smiles and pats Simone’s hand.
Simone moves the chair back to the corner and heads off to gather meds and check her other patients.