Question

Mrs. A. is an 84-year-old woman who was recently discharged from the hospital with a diagnosis that includes an exacerbation of congestive heart failure (CHF). She also has diabetes and hypertension. Mrs. A. was discharged from the hospital on multiple medications and lives alone. Home care services were initiated with skilled nursing care visits, some home health aide support, and orders to include daily telemonitoring of her vital signs. The telehealth device will remotely monitor Mrs. A.’s blood pressure, heart rate, oxygen saturation, and weight. In addition, the patient will answer customized questions about her disease on a daily basis. This information will then be transmitted daily to the home care agency, where the telenurse can determine appropriate clinical actions based on the data trends and preset baseline alerts that indicate when set parameters have been exceeded.

• What assessment information in the patient situation is the most important and of immediate concern for the nurse?
• What patient condition(s) are consistent with the most relevant information?
• Which possibilities or explanations are most likely to be present in the patient situation? Which are the most serious or a priority?
• What actions would most likely achieve the desired outcome for this patient?
• Which actions are the most appropriate and how should they be implemented?
• What patient assessment would indicate your actions were effective

Answer 1

• Diabetes Mellitus has a negative influence on the prevalence, presentation, severity and prognosis of Congestive Heart Failure. In addition,diabetes complicates the management of heart failure as heart failure complicates the management of heart failure.Patient has to monitor and record their weight on a daily basis.
• Hypertension is strongly linked to CHF in patients with diabetes .Indeed, hypertension is widely considered to be the single most important modifiable risk factor for heart failure .
• Elevated blood pressure and diabetes are the equally important incase of CHF.So need immediate concern from the nurse.   
• Blood pressure and sugar level and obesity are consistent with the most relevant information.
• Patients with CHF shows breathing difficulties, Cyanosis, pulmonary edema, etc..Treatment includes, symptomatic treatment and treatment of underlying conditions. Initially, correction of underlying conditions anemia, atrial fibrillation, valvular disease.
• Lowering blood pressure is required to reduce the vascular risk in patient with diabetes.
• High blood sugar can damage blood vessels and nerves that control patient heart.
• High blood pressure increases the force of blood through arteries and can damage artery walls.

So blood pressure and sugar level should be controlled in patient with CHF.

• ACE inhibitors and ARBs are preferred agents in the management of CHF patients with diabetes and hypertension. The patient can not tolerate ACE inhibitors then next choice is ARBs.
• Beta blocker's not used in the treatment of CHF. These have negative inotropic effect.
• Thiazide diuretic is preferred second line therapy for patients with diabetes.
• Drugs like metformin and thiazolidinediones are mainly used to treat diabetes but both are contraindicated in patient with advanced heart failure.
• Obesity is linked to CHF, diabetes and hypertension. The greater the elevation in body mass, the greater the risks and the worse the clinical outcomes. So keep weight in a healthy range.