Michelle Heim



Evaluation of Evidence-based Practice for CHFMichelle HeimFerris State UniversityAbstractThis paper is an examination of the article “Evaluation of treatment for congestive heart failure in patients aged 60 years and older using generic measures of health status (SF-36 and COOP charts)” (1997) by Jenkinson, K., Jenkinson, D., Shepperd, S., Layte, R., and Petersen, S. The health care problem congestive heart failure (CHF) and its treatments impact on quality of life is the main focus. Firstly, there is a description of the study, which is followed by a discussion of differing treatments among other age groups, a plan of care, and the relevance of the article to nursing care.Evaluation of Evidence-based Practice for CHFCongestive heart failure has been shown in research to have significant improvements in terms of mortality for patients who take the angiotensin converting enzyme inhibitor enalapril. Whether or not improvements in those patients’ quality of life significantly increased as well was never researched, however. The following study was conducted in 1997 in order to identify if an increase in life expectancy also leads to an increase in quality of life.MethodPopulationThe participants within the prospective case-study were all at least 60 years of age with a clinical diagnosis of symptomatic congestive heart failure (CHF), and who presented with no other chronic co-morbidities. All participants were referred to the Department of Clinical Geratology by their general practitioner for involvement in the study. The sample included 61 individuals (18 males, 43 females) with the mean age of participants being 81 years of age.MaterialsMaterials utilized in the study include three questionnaires (the short form 36 health survey, the Dartmouth COOP charts, and the oxygen cost diagram) as well as the angiotensin converting enzyme (ACE) inhibitor enalapril. The short form 36 health survey (SF-36) is an instrument used among individuals with life-altering medical conditions in order to assess their quality of life and the effectiveness of therapeutic interventions. The survey is composed of 36 questions which focus on eight key dimensions: physical functioning, social functioning, role limitations due to physical problems, role limitations due to emotional problems, mental health, energy/vitality, pain, and general health perception (Jenkinson, Jenkinson, Shepperd, Layte, &Peterson, 1997).The Dartmouth COOP charts is also used to assess functional status and quality of life, but is thought to be especially valuable in assessing the elderly population. It is composed of eight questions, each which is supplemented by an illustration, asking patients to assess their well-being in regard to physical fitness, feelings, daily activities, social activities, pain, overall health, social support, and quality of life (Jenkinson, Jenkinson, Shepperd, Layte, & Petersen, 1997). The oxygen cost diagram (OCD) is a tool utilized in order to assess the level of breathlessness in individuals. It is a survey with a 10 cm line in which patients mark on the line anywhere between one end, which represents breathlessness at rest, to the other end, which represents breathlessness upon briskly walking up a hill.Lastly, the ACE inhibitor enalapril was prescribed to participants to take as the only form of medical therapy for their condition being required based on previous research findings which indicated that enalapril significantly improves life-expectancy for CHF patients. However, participants could take additional medications to treat their CHF at the discretion of their doctor.ProcedureParticipants were asked to fill out the SF-36 survey, the Dartmouth COOP charts, and the OCD before starting their treatment on the ACE inhibitor enalapril. The results from these three surveys served as a statistical baseline for quality of life before treatment for the participants. Four weeks into the participant’s treatment for CHF with enalapril the participants were asked to fill the same three surveys out in order to discern if the medical treatment the subjects were receiving was improving not only their medical condition, but their quality of life as well.ResultsThe comparison of the baseline statistics from the three surveys to the treatment statistics over the four week period showed a small effect size, indicating that there was an insignificant improvement in quality of life in the CHF patients after receiving treatment from when they were not receiving any medical treatment at all.LimitationsThe greatest foreseen limitation to the study relies on the thought that elderly patient’s expectations of health improvement are very low and their expectations of improvement in physical ability are very limited. Therefore, any small change that occurs which improves their life quality may appear insignificant in a statistical sense, but may be monumental to the client. As such, evaluation of assessing change to increased or decreased quality of life using standard statistical measures may be inappropriate and underscore the value of change the client truly experienced.DiscussionNursing Care for Differing PopulationsEvery population is unique, and the age spectrum is no exception. The older adult and elderly populations were the main focus in this study that was published in 1997; although these populations slightly differ, they are closer on the spectrum and have more similar characteristics than newborns, toddlers, children, or any of the other populations on the other side of the age spectrum. As such, nursing care will differ slightly. The younger population may have a harder time with activity limitations since they are more inclined to play, so activities which are not physically strenuous should be provided for them. The parents of young children should be assessed for role strain. Children are also thought to be healthy and resilient because they are youthful. Expected outcomes from treatments and limitations should be fully discussed in order to inform parents on what to expect. For the older population, many of them have been taking care of themselves and have been fairly independent for a while, so their feelings about losing some of their independence should be considered. The elderly population may no longer be able to stay at home alone and may need to live with one of their children or at an assisted living facility. A plan will need to be determined before discharge, and the family and patient will need to be assessed for any concerns.Plan of CarePriority nursing diagnosis for CHF include: 1) activity intolerance r/t weakness, fatigue; 2) decreased cardiac output r/t impaired cardiac function; 3) powerlessness r/t illness-related regimen. Important interventions for activity intolerance are allow for periods of rest before and after planned exertion periods such as meals, baths, treatments, and physical activity and assess the client daily for appropriateness of activity and bed rest orders. A desired outcome is for the patient to participate in prescribed physical activity with appropriate changes in heart rate, blood pressure, and breathing rate. Important interventions for decreased cardiac output are monitoring for symptoms of heart failure (HF) and decreased cardiac output by listening to heart sounds, lung sounds, and symptoms such as dyspnea, orthopnea, paroxysmal nocturnal dyspnea, fatigue, and weakness, and place the patient in a semi-fowlers or high fowlers position with legs down and oxygen on if indicated. A desired outcome for the patient is to demonstrate adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm within normal parameters for the client. Important interventions for powerlessness are encouraging the client to share his or her beliefs, thoughts, and expectations about his or her illness and helping the client specify the health goals he or she would like to achieve, prioritize those goals with regard to immediate concerns and identifying actions the goals.Relevance to Nursing PracticeMedical improvement is often thought of as being synonymous with increased quality of life; although it is not a completely erroneous, it is not always true either. This study was a good example of when medical improvement did not lead to significantly increased quality of life. Even though enalapril was found in another study to significantly improve patient outcomes in terms of mortality, this study showed that it did not significantly improve patient outcomes in terms of quality of life. It is relevant in nursing to know the difference between healing physically and healing mentally, emotionally, and spiritually. The most important aspect of nursing that sets nurses apart from doctors, or any other health care provider, is that nursing is holistic in practice. Nurses are responsible for taking care of the entire individual, not just the visible, physical ailments. This article is an exemplary reminder of how holistic nursing is key to best nursing practice.ReferencesJenkinson, C., Jenkinson, D., Shepperd, S., Layte, R., & Petersen, S. (1997). Evaluation of treatment for congestive heart failure in patients aged 60 years and older using generic measures of health status (SF-36 and COOP charts). Age and Aging, 26: 7-13. ................
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