A systematic review of Randomised controlled trials (RCTs) summarised the effective interventions to enhance regular uptake of medications in patients with heart failure. Most of the included studies were done in the USA. Few studies from UK were also included. The abstracts and papers in English were searched through Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, CINAHL, PsycINFO and EMBASE. There were no date restrictions with search up to December 2010.Findings showed that regular uptake of medications in patients with a history of heart failure could be improved by using range of interventions including telemonitoring programmes, behavioural interventions, simplification of drug regime and other multidisciplinary interventions. Although some of the included trials contravened these results also. Six studies used ‘direct patient contact’ intervention and all of them showed significant effect on adherence. The author was unable to conclude any effective intervention to enhance adherence to medications in patients with heart failure; which is also a limitation of the study. Another limitation is the inability to pool results of studies as they all used different interventions. Also the long-term effect of these interventions could not be assessed. Thus the study provides limited evidence regarding effective interventions to enhance regular uptake of medications in heart-failure patients.
A systematic review of Randomised controlled trials (RCTs) evaluated the effects of giving dietary advice to reduce cardiovascular risk. Fourty four trials were included in the study, out of which 29 were based on US populations. The search databases included Cochrane Central Register of Controlled Trials, HTA database on the Cochrane Library, Database of Abstracts of Reviews of Effects (DARE), EMBASE (Ovid) (1980 to October 2010), MEDLINE (Ovid) (1950 to October 2010), CAB Health (1972 to December 1999), CVRCT registry (2000), CCT (2000), and SIGLE (1980 to 2000). The results indicated that dietary advice lowered total serum cholesterol by nearly 0.15 mmol/L, and LDL cholesterol by almost 0.16 mmol/L, after 3 to 24 months of follow-up. The author concluded that dietary advice could be effective in bringing positive changes in the diet and thus decreasing cardiovascular risk over a period of one year. The limitation of the study was that long-term effects of dietary advice i.e. after one year, could not be known.
A systematic review and meta-analysis was done to assess the effects of exercise interventions on cardiac rehabilitation for heart failure. The following mentioned databases were used for search from January 2008 to January 2013: MEDLINE, MEDLINE In-Process, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, PsycINFO and CINAHL. The study included 33 trials with a study population of 4740 and most of them were based in USA. Results showed improvements in health, and declines in the risk of hospitalisation, in the exercise interventions groups as related with controls regardless of the type of exercise. But there was no noteworthy difference in the combined all-cause mortality between the two groups. Thus author established that exercise-based interpolations increase the health-related quality of life of heart patients. The constraint of the review was that in most of the trials patients were on medications and it was difficult to look for stand-alone effect of exercise-based interventions on heart-patients.
The nursing-care is a holistic concept that goes beyond medical care. Thus here it becomes important to understand that, there are age- associated alterations in the body organizations; which have repercussions on quality of life and welfare (Hanson et al., 2016). The age-related deviations are unavoidable but the accompanying risk factors may have undesirable functional consequences and thus need intercessions (Hunter 2012). In the given case-study, Charlie is an elderly overweight man diagnosed with chronic heart failure. Thus along with adherence to medication; there is a need for right diet and exercise-based rehabilitation.
The evidence has shown that after a heart failure, ability of patients to care themselves decline and also higher levels of depression sets-in which further affects their quality of life (Lee et. al., 2015). Thus intervention by a nurse or nursing care becomes critically important in such patients (Urden, Stacy, & Lough, 2017). It becomes imperative to search the available evidence to priorities the nursing interventions.
I chose the above mentioned three studies because the interventions studied in these three studies are most important to provide nursing care in the given case. The evidence has also shown that maintenance of appropriate diet and physical activity helps maintain good health in elderly and these healthy behaviours could be enhanced by telephone-delivered interventions along with frequent direct contact to patient (John, Hartmann-Boyce, Jebb, & Aveyard, 2014). There was a need to look for interventions that can be included in the nursing care to help patient with his diet, exercise and medications.
There is a relationship between adherence to medication in cardiac patients; and their long-term morbidity and mortality (Lambert-Kerzner, Del-Giacco, & Fahdi, 2012). Thus I chose study by Molloy et al to look for interventions that could increase the adherence to medications in case of Charlie. Further the strength of the selected study was to summarise the results in an unbiased manner. I could infer from the study that, although there are many interventions suggested in literature to help patient adhere to medications; the best intervention could be direct contact with patient.
Inability to maintain proper diet is a risk factor in old age; which may lead to metabolic abnormalities and lowered immunity and could further complicate the present conditions of Charlie (Jankovic, 2014; Clegg, Young, Iliffe, Rikkert, & Rockwood, 2013). Thus I chose the study by Rees et. al. to know whether dietary advice could have a beneficial effect in this case. Further the strength of the systematic review was that the study results were pooled and statistically analysed which increased the validity of the review. I learned from the study that dietary advice help patient adhere to an appropriate diet and thus reduce cardiovascular risks.
The studies have shown benefits of exercise in frail elderly, which improve their cognition and quality of life (Francis, et. al. 2013). Thus I selected study by Sagar et. al. to look for the effects of exercise on heart-failure patients. The strength of the systematic review was, that a meta-analysis of all selected studies was done, and that limitations of the study were also clearly stated. I learned from the study that exercise-based interventions reduce the risk of hospitalisation in a cardiac patient.
Further I selected these three studies, as all of them are systematic reviews which have a special place in medical sciences for evidence generation (Gough, Oliver, & Thomas, 2012). Systematic reviews help researchers maintain a high rigour in research (ibid).
The references seleted in annotated bibliography add a lot to clinical practice to manage the condition presented in the case study. Charlie feels breathless, has visible peripheral oedema, tachycardia and a history of chronic heart failure as a result of ischaemic cardiomyopathy and hypertension. He must be on medications as suggested by Cardiologist and a General Physician. As a nurse it becomes important to go beyond clinical judgement, towards promoting overall health and well-being of Charlie. First of all, it is important that patient adhere to pharmacotherapy. As suggested in first annotation, direct contact with patient is important to remind him about his medication.
As Charlie is also overweight, it becomes imperative to manage his weight and diet. There is a need to consult dietician for an effective dietary advice and as a nurse, the care also include management of dietary intake of Charlie. There is also a need that Charlie do a little physical exercise, after consulting his physiotherapist as well as cardiologist, and as a nurse the care should ensure exercise-based rehabilitation of Charlie.
Nurse has an opportunity to be with patients and keep a constant vigilance. Nurse develops a therapeutic relationship with the patients over a period of time. Thus a nurse must have the talent of clinical reasoning which is much more than plain clinical judgement (Levett- Jones et al, 2010). It is vital to add life to the ages of patients rather than only adding ages to their lifespan. The nursing plays a very important part in supporting wellness in patients. The healthcare provided by a nurse goes further than mere normalising physiological parameters. It extends to the surrounding atmosphere of the patients and how it touches the life of a person as a whole i.e. his physiological form, cognizance and inner-self (Hunter, 2012). Nursing interventions should result in wellness outcomes that help patients’ live functional lives. For example, in this particular case, whole medical team is there to regulate physiological parameters such as blood cholesterol and prevent an episode of heart attack; but role of a nurse is a step ahead i.e. to control obesity in patient, to help him adhere to medications, to help him eat an appropriate diet, and help him do a little exercise, to lead a functional life. If a nurse is unable to ponder on these aspects of patient, it may result in cognitive failure on her part and thus worse clinical outcomes. Thus it is very important for a nurse to consider the patient as a whole including his physical, social and cultural environment; and everything that affects his day to day life. To conclude, nursing care should be a comprehensive care.
Clegg, A., Young, J., Iliffe S., Rikkert, M. O., & Rockwood, K. (2013). Frailty in elderly people. The Lancet, 381(9868), 752-762.
Francis, L., Thien, T. M. V., Kathleen, C., Gilles, D., Marie-Jeanne, K., Louis, B. (2013). Benefits of Physical Exercise Training on Cognition and Quality of Life in Frail Older Adults. J Gerontol B Psychol Sci Soc Sci, 68 (3), 400-404. doi:10.1093/geronb/gbs069
Gough,D.,Oliver,S.,andThomas,J. (2012). Movingforward.In:D.Gough,S.Oliver,andJ. Thomas, eds. Introduction to systematic reviews. London: Sage.
Hanson, M. A., Cooper, C., Aihie Sayer, A., Eendebak, R. J., Clough, G. F. and Beard, J. R. (2016). Developmental aspects of a life course approach to healthy ageing. J Physiol, 594, 2147–2160. doi:10.1113/JP270579
Hunter, S. (Ed). (2012). Miller’s nursing for wellness in older adults. Sydney: Wolters Kluwer/Lippincott, Williams and Wilkins.
Jankovic, N., Geelen, A., Streppel, M. T., Groot, L. C., Orfanos, P., Van- den- Hooven, E. H., Pikhart, H., Boffetta, P., Trichopoulou, A., Bobak, M., Bueno-de-Mesquita, H. B., Kee, F., Franco, O. H., Park, Y., Hallmans, G., Tjønneland, A., May, A. M., Pajak, A., Malyutina, S., Kubinova, R., Amiano, P., Kampman, E., Feskens, E. J. (2014). Adherence to a Healthy Diet According to the World Health Organization Guidelines and All-Cause Mortality in Elderly Adults From Europe and the United States. Am J Epidemiol, 180 (10), 978-988. doi: 10.1093/aje/kwu229
John, D. J., Hartmann-Boyce, J., Jebb, S. A., Aveyard, P. (2014). Diet or Exercise Interventions vs Combined Behavioral Weight Management Programs: A Systematic Review and Meta-Analysis of Direct Comparisons. Journal of the Academy of Nutrition and Dietics, 114(10), 1557-1568.
Lambert-Kerzner, A., Del Giacco, E. J., Fahdi, I. E. (2012). Multifaceted Intervention to Improve Cardiac Medication Adherence and Secondary Prevention Measures (Medication) Study Investigators. Patient-centered adherence intervention after acute coronary syndrome hospitalization. Circ Cardiovasc Qual Outcomes, 5(4), 571-576.
Lee, C, S., Mudd, J, O., Hiatt, S, O., Gelow, J, M., Chien, C., & Riegel, B. (2015). Trajectories of heart failure self-care management and changes in quality of life. Eur J Cardiovasc Nurs, 14(6), 486-94. doi: 10.1177/1474515114541730.
Levett-Jones, T. (Ed.). (2013). Clinical reasoning: Learning to think like a nurse. Frenchs Forest, NSW: Pearson.
Molloy, G., O'Carroll, R., Witham, M., & McMurdo, M., (2012). Interventions to enhance adherence to medications in patients with heart failure: a systematic review. Circulation Heart Failure, 5(1), 126-133.
Rees, K., Dyakova, M.,Wilson, N., Ward, K., Thorogood, M., & Brunner, E. (2013). Dietary advice for reducing cardiovascular risk. Cochrane Database of Systematic Reviews, Issue 12. Art. No.: CD002128. DOI: 10.1002/14651858.CD002128.pub5.
Sagar, V., Davies, E., Briscoe, S., Coates, A., Dalal, H., Lough, F. … Taylor, R. (2015). Exercise – based rehabilitation for heart failure: Systematic review and meta-analysis. Open Heart, 2 : e000163. doi:10.1136/openhrt-2014- 000163.
Urden, L. D., Stacy, K. M., & Lough, M. E. (2017). Critical care nursing: diagnosis and management. Elsevier Health Sciences.