Category: HEARTe

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Mina feels that all aspects of her life have improved. The carers are helping her with Joe and with meal preparation. A befriender sits with Joe once a week so that Mina can go shopping and buy the food that she likes to cook. On her weekly outing, her friends meet her and take her for coffee. The community physiotherapist has visited and given Mina some exercises to do daily and she feels that her exercise tolerance level is better. Her diuretic therapy has been increased and she is managing her tablets much better now that she and Joe’s medications are delivered in a dosette box. She thoroughly enjoys attending the music therapy sessions with Joe.

Mina appreciates that her conditions will, eventually, be terminal but she is determined to enjoy life at home with Joe for as long as she possibly can.

When the Heart Failure Nurse initially visited Mina to assess her diuretic therapy, Mina indicated that she felt she was losing control of her life and would like to have more say in how her care was organised. When they completed the Distress Thermometer together, it was clear that Mina wanted information and support in a number of areas. The Heart Failure Nurse introduces Mina to the concept of self-management.

Self-management is “a set of approaches with the aim to enable people living with long term conditions to manage their own health and have more control over their health and care”
(Scottish Government, 2008).

The 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure identify key areas where individuals with heart failure, like Mina, might be supported to self manage. PDF link

From their discussion, Mina and the nurse identify specific areas that Mina might be supported to self-manage:

• Pharmacological treatment
• Diet and alcohol
• Exercise
• Sleep and breathlessness
• Psychosocial aspects

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Mina is keen to do what she can independently, in order to manage her conditions.

Mina’s SPARRA score suggested that she might benefit from a medication review. The community pharmacist reviews Mina’s medications using the 7 step approach advocated in NHS Scotland’s Polypharmacy Guidance (see additional information). Rationalisation of medication is an important part of this and includes up-titrating evidence based therapies, whilst stopping or changing those that are of no benefit or contra-indicated in the presence of Mina’s multiple conditions. Mina is prescribed medication based on current clinical guidelines. Following the review, she is prescribed the following:

Heart Failure

Lisonopril 35mgs daily. ACE inhibitors dilate blood vessels and decrease the workload of the heart. They have been shown to improve ventricular function, reduce mortality and hospital admissions. Routine urea & electrolyte checks should be carried out to ensure no worsening of Mina’s renal function.

Furosemide 40mgs x twice daily (morning & lunch). Diuretics are prescribed if there is a diagnosis of fluid overload or congestion. Loop diuretics, such as furosemide, inhibit reabsorption of water and salt from the kidneys and reduce oedema. Mina should weigh herself daily to assess the degree of fluid retention and to ensure that she is receiving the optimal diuretic dose.

Bisoprolol 10mgs daily. Beta-blockers block the beta-adrenoreceptors in the heart, thus slowing the heart rate and reducing blood pressure. Evidence shows that beta-blockers increase ejection fraction and exercise tolerance, and reduce morbidity, mortality and hospital admissions. (N.B. Bisopropol is not licensed for those over 70 years of age.)

Spironolactone 25gs daily. Mineralocorticoid receptor antagonists antagonise the action of aldosterone. Aldosterone is important in maintaining water and electrolyte balance, and is responsible for sodium and water retention and potassium excretion. Although the drug may help reduce Mina’s oedema, she will be carefully monitored for hyperkalaemia and renal dysfunction while she is on the drug.

COPD

Salmeterol inhaler 2 puffs x twice daily. This is a long acting beta2 antagonist which produces bronchodilation. Treatment with beta2 agonists has been claimed to improve survival in COPD patients with heart failure and is recommended (Global Initiative for Chronic Obstructive Lung Disease, 2017. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: 2017 Report, available from GOLD COPD).

Based on their conversation, the Heart Failure Nurse completes an anticipatory care plan for Mina, with a DNACPR form. The format for anticipatory care plans may vary slightly, depending on the health board or clinical area. Useful suggestions on how to develop a plan can be found at:

Good Life, Good Death, Good Grief – Making an Anticipatory Care Plan

NHS Highland Anticipatory Care Patient Alert (ACPA) Form Pack (PDF)

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Mina agrees that she is happy with the plan. She is given a copy and a further copy is given to her GP.