Francis R.: Older Woman With a Chronic Cardiac Condition
Maxanna Lucas, RN, MS, MBA
Case Manager
American Mercy Home Care
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 heart failure. She was hospitalized twice in the last six months for a toxic level of Lanoxin (digitalis) and an exacerbation of heart failure; 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 regularly. 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 3+ pitting edema in her lower extremities, decreased appetite, and dyspnea when lying down and with exertion. Her heart rate was 88 and irregular at rest, blood pressure was 104/74, and pulse oximetry was 95%. 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 11.0 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, and using an extra pillow to elevate her head and shoulders to decrease dyspnea while sleeping. She agreed to schedule the amount and time of her fluid intake based on the nurse’s recommendations. 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 daily, 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 of each medication and the 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; Francis was pleased that the nurse planned to bring a system later that week. Francis agreed to record notes about her medications, their actions, and their side effects in her symptom diary.
Francis said that since she now understood how important it was to take her medications regularly and manage her symptoms, she would try harder. She was glad that the nurse planned to call her doctor’s office, and looked forward to the nurse’s regular visits. Francis and the nurse decided to discuss additional options such as a friendly caller if she needed more help with reminders. 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; they would appreciate receiving the phone call.
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: PHSYIOLOGICAL
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 to begin the next day)
Category: Surveillance
TARGETS AND CLIENT-SPECIFIC INFORMATION:
signs/symptoms-physical (vital signs, changes in severity/status)
Problem Rating Scale for Outcomes
Knowledge: 2-minimal knowledge (did not recognize worsening condition)
Behavior: 2-rarely 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 AND 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)
Category: Surveillance
TARGETS AND CLIENT-SPECIFIC INFORMATION:
medication action/side effects (take as prescribed, notes)
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)