Francis R.: Older Woman With a Chronic Cardiac Condition

Maxanna Lucas, RN, MS, MBA
Assistant Professor of Clinical Nursing, College of Nursing and Health
University of Cincinnati
Cincinnati, Ohio

Information Obtained during the First Visit/Encounter:

Francis R., a 79-year-old woman, was admitted to a home care agency because of congestive heart failure. She was hospitalized twice in the last six months for a toxic level of Lanoxin (digitalis) and an acute cardiac exacerbation; she is no longer on Lanoxin. Francis lived in her small two-story home for many years. She received social security payments and some retirement income. Her daughters lived far away, but called regularly. They arranged for someone to clean her home monthly. Although her former neighbors moved away, she talked to them often and they visited occasionally. She had a friend who drove her to appointments, purchased her medications, and took her to church. Francis told the nurse that while she misses her husband, she has adjusted since he died ten years ago and is content with her independence and lifestyle.

During the visit, Francis complained of significant fatigue. She said that because she tired so easily, she could not walk out on her patio. She had edema in her lower extremities, decreased appetite, and dyspnea when lying down and with exertion. Her heart rate was 92 and irregular at rest and her blood pressure was 104/74. She weighed 130 pounds and was 5’4”. Francis said she lost ten pounds in the last four to five years. Laboratory data indicated mild anemia; her hemoglobin was 12.0 g/dL. Her last potassium level was 3.4 mEq/L.

The home care nurse and Francis discussed heart failure and how she could manage the symptoms more effectively. Francis was very receptive to weighing herself daily, keeping a symptom diary and calling her providers when appropriate, using energy conservation techniques, elevating her legs regularly, using an extra pillow for sleep, and scheduling her fluid intake. She was pleased that the nurse arranged for the delivery of mobile meals that were high in iron, and would receive those meals beginning the next day.

Francis and the nurse discussed her medications: metoprolol (Toprol XL) 50 mg twice a day, lisinopril (Zestril) 40 mg daily, furosemide (Lasix) 40 mg every other day, potassium 20 mg every other day, and ferrous sulfate 325 mg daily. Francis knew the names and schedule, but not the purpose or side effects. She said that she had no reminder system and occasionally forgot whether she had taken them. The home care nurse described the benefits of using a medication reminder/organizer system and was to bring a system that week.

Francis said that since she now understood how important it was to take her medications regularly and manage her symptoms, she would try harder. Francis and the nurse decided to discuss additional options such as a friendly caller if she still had trouble. She said her daughters would be pleased that she would receive mobile meals since they already told her to do so. Francis said that the nurse could call her daughters after the next visit if the nurse chose to do so.

Application of the Omaha System:

Domain: Psychosocial

Problem: Social contact (low priority: provide interventions and rate if unable to take medications regularly and needs more assistance)

Problem Classification Scheme

Modifiers: Individual and Potential
Risk Factors:

• Francis lived alone and was elderly but indicated that her support system was adequate

Domain: Physiological

Problem: Cognition (low priority: provide interventions and rate if memory problems are significant during future visits)

Problem Classification Scheme

Modifiers: Individual and Potential
Risk Factors:

• Francis’ judgment and memory seemed adequate except for some problems taking medications as scheduled
• Will follow up by contacting daughters if needed

Problem: Circulation (high priority)

Problem Classification Scheme

Modifiers: Individual and Actual
Signs and Symptoms of Actual:

• edema
• abnormal blood pressure reading
• irregular heart rate
• excessively rapid heart rate
• abnormal cardiac laboratory results
   

Intervention Scheme

Category: Teaching, Guidance, and Counseling
Targets and Client-specific Information:

• cardiac care (relief of edema, elevate legs, energy conservation, improving sleep, schedule fluid intake)
• dietary management (eat some iron rich foods)
• signs/symptoms-physical (daily weight, symptom log, when to notify providers)

Category: Case Management
Targets and Client-specific Information:

• dietary management (arranged mobile meals)

Category: Surveillance
Targets and Client-specific Information:

• signs/symptoms-physical (vital signs, changes in severity/status)
   

Problem Rating Scale for Outcomes

Knowledge: 3-basic knowledge (did not recognize worsening condition)
Behavior: 3-inconsistently appropriate behavior (not taking daily weights, elevating legs, or reporting signs/symptoms)
Status: 2-severe signs/symptoms (significant fatigue, edema in lower extremities, increased heart rate, dyspnea)

Domain: Health-related Behaviors

Problem: Medication regimen (high priority)

Problem Classification Scheme

Modifiers: Individual and Actual
Signs/Symptoms of Actual:

• does not follow recommended dosage/schedule
• inadequate system for taking medication
   

Intervention Scheme

Category: Teaching, Guidance, and Counseling
Targets and Client-specific Information

• medication action/side effects (purpose, what to expect/report)
• medication set-up (use/benefit/options for pill organizer)
   

Problem Rating Scale for Outcomes

Knowledge: 2-minimal knowledge (did not know purpose or side effects of medications)
Behavior: 3-inconsistently appropriate (agreed that she needed reminder system)
Status: 2-severe signs/symptoms (two recent hospitalizations)