Following up on patient assessment
Following up on patient assessment
Nurse practitioner Ellen Daroszewski, RN, PhD, ACNP, at Cedars-Sinai Medical Center in Los Angeles, says initial patient assessment often indicates what is needed beside medical care. Here is where the nurse connects the patient to other caregivers and services, while continuing to collect important personal information. Here are some details to consider:
Special programs.If the patient is obese, weight loss plans could be provided. Smoking cessation programs may be needed — whatever may be indicated to help keep the patient as healthy as possible.
Perhaps the family members would like to learn CPR or how to check blood pressure. Besides the patient, nurses look for who else needs to be educated about what the medication does and how it is to be taken.
Other issues are discussed such as sex counseling, since beta-blockers could cause erectile dysfunction.
Patients may need additional social interaction such as a support group. A social worker can be called in to help patients connect with the local resources available or perhaps talk about advance directives. Patients and their families may need to learn more coping strategies. "Sometimes, just talking to someone is needed," she says.
Daroszewski says here is where nurses and other caregivers excel. Doctors don’t have time to sit down and explain how to read a food label, but there are nurses and other educators available to help. Patients bond with team members this way, she says. The doctors build rapport with their patients as well, but usually over a longer period of time.
Cardiorehab.Cedars is developing its own program specifically for CHF patients. "Medicare and Medical doesn’t pay for it," she notes, adding "Private insurance is getting much better at it.
"If patients can find $500, they can get an extensive heart failure cardiorehab course," she says, noting it is 12 weeks long and has trained staff to monitor participants (but not with telemetry). If patients cannot afford the course, the staff give instructions on how to exercise at home.
The exercise goals are different for CHF patients. "These patients just aren’t as active," she notes. The objective is to maintain muscle tone and endurance to be able to function in everyday life activities. Doing leg extensions while wearing shoes for added weight may be sufficient. If muscles like the thighs atrophy, it makes it difficult for patients to do every day activities like getting out of a chair or on and off a toilet. (For more on exercise routines, see CHF Disease Management, March 1999, pp. 32-36.)
Determine cultural differences
Daroszewski says there are many cultural issues to consider when treating CHF patients, according to differences in the customs a patient may have. Cultural backgrounds tell the nurse a lot about how the patient was raised and the environment where he or she grew up. It’s an important consideration.
"The medication these patients will go on to use will be about the same," Daroszewski says. "But the attitudes for taking them and the motivation to keep going may need a different emphasis."
Here are some of her general guidelines she uses to help advise patients:
1. Hispanics, she says, seem to live life in the present and may not make the future a big priority. Explaining CHF treatment may often show them why what happens here and now affects their health.
2. To Native Americans, diabetes is an especially prevalent comorbidity. Obesity may be an issue as well.
3. Weight control is often important when assessing African-Americans, too, as well as watching out for high-salt diets.
There are plenty of socioeconomic issues associated with exercise. There are also are cultural influences as well. "The concept of going out to the gym to exercise is a pretty white, middle-class phenomenon," she notes, so special emphasis on exercise may be needed for some minority groups.
4. The term "Asians" represents an enormous number of different cultures, such as Koreans, Japanese, Chinese, Vietnamese, Laotians, and many others. They all have different traditions. But as a general rule, compared to people from other parts of the world, they basically are future-oriented.
For these cultures, the nurse often can emphasize the benefits of controlling the disease in order to be around to see grandchildren grow up, for example. Their diets also have high-salt considerations, as soups and soy sauce can cause problems with hypertension.
It may also be important to determine a bit about the patient’s American heritage — as well as how the person was raised. First-generation Americans being raised by their immigrant parents will have different diets and customs from third-generation Asian-Americans who have lived on their own since their early adulthood.
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