Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay

Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay

Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay

Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay

Heart Disease

Heart disease affects the lives of millions of people every year so it is important to understand the characteristics and risk factors associated with this condition.  Risk factors for heart disease fall under two categories: modifiable risks and nonmodifiable risks.  Modifiable risks include things that we can control such as obesity, smoking and high fat intake whereas nonmodifiable risks include things that we cannot control such as gender, heredity and age.  But first, we must understand what heart disease is and how it affects our bodies.  Research suggests that heart disease is a result of damage to the lining and inner layers of the heart arteries.  Plaque begins to build up where there are damaged arteries (What Causes Heart Disease, 2014).  Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay. Factors that can contribute to this damage include smoking, blood vessel inflammation, elevated amounts of sugar in the blood due to insulin resistance or diabetes, high blood pressure and high amounts of fats and cholesterol in the blood.


A1. Pathophysiology

Heart disease is a clinical manifestation when the heart can not provide a sufficient amount of blood flow to maintain the metabolic requirements for systemic venous return.  Heart failure is the result of several mechanisms such as pump function disorder, neurohormonal activation disorder and salt-water retention disorder (Palazzuoli, 2010).  It develops when there is an abnormality in cardiac function causing blood to not pump at a healthy rate.  Several factors can contribute to the damage including smoking, high blood pressure, inflammation of the blood vessels, and increased amounts of cholesterol in the blood. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay.

The average human heart beats almost four million times per year, pumping enough blood to fill an oil tanker during a lifetime.  Composed of striated cardiac muscles, the heart is supplied oxygen and nutrients from the coronary arteries.  Over time, some people experience damage to the cardiac muscles which can lead to a weakening of the heart’s ability to pump blood.  If blood is inadequately being pumped, fluid can build up in the lungs, liver and other vital organs.

There are several conditions that can lead to heart disease including anemia, diabetes, obesity, cardiomyopathy, obstructive sleep apnea and cardiac muscle disease.  Diseases related to the heart valves can also cause heart failure.  Damaged or leaking valves cause the heart to pump harder pump back-flowing blood. Some of the main pathologies of heart disease include over loading of the ventricle with blood during diastole, lowered cardiac output causing an increase in the heart rate, stroke volume decreasing as the ventricle rises at the end of systole, reduced cardiac reserve and hypertrophy (Mandal, 2009) Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay.

A2. Standard of Practice for Heart Disease

The national standard of practice is driven by the Clinical Practice Guidelines published by the National Guideline Clearinghouse (NGC).  The NGC provides a guideline of recommendations on current evidence based practice to help healthcare workers provide safe and efficient care to patients with heart disease.  These evidence based guidelines have the potential to maximize the outcome of a patient (Petruccelli, n.d.).  In 1933 Sir Thomas Lewis wrote in his textbook on heart disease that “The very essence of cardiovascular medicine is the recognition of early heart failure” (Lewis, 1937).

According to the American College of Cardiology a thorough history and physical should be performed in patients that present with heart disease to identify any cardiac or non-cardiac disorders and/or behaviors that may cause the acceleration of the disease.  Volume status and vital signs as well as patient weight, jugular venous pressure and the presence of orthopnea or peripheral edema should be assessed as they may be signs/symptoms of fluid retention.  Risk scores are obtained upon assessment to estimate the risk of mortality in patients with heart disease Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay.

For patients presenting with signs/symptoms of heart failure, initial laboratory evaluations include complete blood count, troponin, serum creatinine, urinalysis, serum electrolytes, bun, glucose, fasting lipid profile, liver function tests and thyroid-stimulating hormone.

Because heart disease has a high mortality rate, results in decreased quality of life, increased hospitalizations and an extensive therapeutic routine, new research and evidence based data is constantly being done to improve outcomes of the proposed therapies.  Because this is a chronic condition, the effect of therapies may not be noticeable right away.  The prognosis varies from patient to patient when taking into account co-morbidities, life style and genetic factors.  As a result, not all treatments will work for all patients, making it difficult to generalize one specific treatment regimen as the “go-to” for heart disease. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay.  The assessment of specific outcomes of therapy are complicated by the potential differential impact of the many co-therapies (Albert, Boehmer, Ezekowitz, Givertz, Klapholz, Linderfeld,…Walsh, 2010).

The complexity and high prevalence of heart disease in today’s society, has resulted in numerous treatment options and practice guidelines.  Different practice guidelines have been created by various organizations.  The American Heart Association [AHA] along with The American College of Cardiology Foundation [ACCF] have developed one set of practice guidelines and have been producing practice guidelines jointly in the area of cardiovascular disease since 1980.  These guidelines are not only comprehensive but they also address all aspects of prevention, evaluation, therapy (both pharmacological and device) as well as disease management for patient’s diagnosed with heart disease.  These guidelines play a major role in clinical management of the disease process. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay.

A2a. Pharmacological Treatments
Cardiac Glycosides Can be used for any severity of heart disease

Slows the ventricular rate

Aldosterone receptor antagonists Recommended for advanced heart disease

Improves survival and morbidity

Recommended in addition to Ace-inhibitors and beta-blockers

Diuretics (loop diuretics, thiazides and metolazone)


Decreases fluid overload

Results in rapid improvement of dyspnea and increased exercise tolerance

Should be taken with ACE-inhibitors and beta-blockers

Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay

Beta-adrenoceptor antagonists (Beta-blockers) Used as treatment for a severities of heart disease

Reduces hospitalizations, improves function and can slow down progression of the disease

Slow the heart rate, allowing the left ventricle to fill more completely

Angiotensin-converting enzyme inhibitors (ACE-inhibitors)

Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay

1st Line of defense

Helps improve control of heart disease

Reduces need for hospitalization, improving patient quality of life

Assists with electrolyte and water balance by increasing the release of water and salt to urine, lowering blood pressure

Vasodilation improves hemodynamics in heart disease and reduces blood pressure

Angiotensin II receptor blockers Assists blood vessels to relax and dilate

Helps release water and salt to the urine, lowering blood pressure

Decreases pressure on the left ventricle of the hear must pump against

Anti-thrombotic agents


Heart disease is often accompanied by a hypercoagulable state

Reduces the incidence of coronary ischemic events

Inhibits vasodilation

**Drugs to use with caution for patients with heart failure:  lithium, tricyclic anti-depressants, corticosteroids, calcium antagonists, NSAIDs and Class I anti-arrhythmic agents
(Cleland, 2005)


The pharmacological treatment for heart disease will vary based on the severity of the disease, the patient’s co-morbidities and the patient’s classification.  The AHA and ACCF classify patients into four classes ranging from A to D, with the stages of heart disease distinguishing risk factors and abnormalities of the cardiac structure as being associated with heart disease.  The pharmacological interventions take into account both. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay.

As mentioned previously, the practice guidelines for heart disease as set forth by the AHA and ACCF work hand in hand with the standardized pharmacological treatment throughout the United States.  Virginia, and more specifically my community, utilize these practice guidelines in the treatment of heart disease.  Angiotensin-converting enzyme (ACE) inhibitors should be used in the treatment of heart failure related to systolic dysfunction.  ACE inhibitors cause relaxation of the blood vessels and decrease blood volume.  This leads to lower blood pressure and decreased oxygen demand on the heart.  Some examples of ACE inhibitors include Lisinopril, Captopril, Trandolapril and Enalapril which have all been proven in clinical trials to be effective in reducing morbidity and overall mortality rates in patient with heart disease (Flather & Kober, 2000).  Unless otherwise contraindicated, ACE inhibitors should be considered a priority intervention.

Also for patients with heart disease related to systolic dysfunction, beta blockers are recommended, unless a patient is dyspneic at rest with hemodynamic instability, signs or symptoms of congestion or those with a previous intolerance to beta blockers (Bleske, Chavey,…Van Harrison, 2008).  Beta blockers block the action of adrenaline and noradrenaline.  Coreg, Metoprolol, Propranolol and Atenolol have been proven in clinical trials to decrease overall mortality.  When a patient takes beta blockers, the heart beats more slowly and with less force.  This reduces blood pressure and helps blood vessels to expand, improving blood flow. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay

Aldosterone antagonists are receptor antagonists located at the mineralocorticoid receptor.  They are recommended for patients with heart disease.  Aldosterone receptor antagonists block the effects of hormones produced naturally in the adrenal glands that can cause heart disease to worsen.  They affect the balance of water and salts going into the urine.  They also help lower blood pressure and protect the heart by reducing congestion.  Spironolactone is a nonselective aldosterone antagonist and eplerenone is selective to the aldosterone receptor.  These are the only two aldosterone antagonists commercially available in the United States.  Aldosterone antagonism is recommended for patients with heart disease who also have dyspnea rest as well as for patients post myocardial infarction who have developed systolic dysfunction.

Angiotensin II receptor blockers (ARBs) block the actions of angiotensin II, which is produced in the kidneys.  It prevents angiotensin II from binding with angiotensin II receptors in the blood vessels, causing them to dilate and reduce blood pressure.  ARBs are often used to treat patients with heart disease that cannot tolerate ACE inhibitors, but they can also be added in addition to ACE inhibitors.  Losartan and Valsartan are commonly used ARBs, typically found in the hospital setting.

Diuretics assist the body to get rid of excess fluid by encouraging the kidneys to make more urine.  They are commonly used for patients with heart disease to manage fluid volume overload, which can be acute or chronic.  Diuretics cause the kidneys to put more sodium in the urine.  As the sodium is excreted from the blood, it takes water with it to the kidneys.  They cause wasting of potassium and magnesium.  Getting rid of the excess fluid lessens the load on the heart because there is less fluid to pump around the body, easing congestion on the lungs.

In my community, use of these drugs are standard practice.  There are best practice guidelines which outline the use of each drug, potential side effects and things that patients should look out for to tell their physician.  A nationally tracked indicator of heart disease management includes asking relevant questions to patients upon discharge related to their heart disease medications, specifically about the use of a beta blocker, ACE inhibitor or ARBs.  Pharmacists within the hospital setting are trained to reconcile medication upon admission and discharge to ensure patients are prescribed the correct medication to optimize their treatment regimen.  Patients are given access to My Chart, which allows them to access their medications post hospitalization at any time in case their community pharmacist has any questions.

Providers within the community have access to electronic health records which allow them to see previously prescribed medications, discontinued medications and the physicians reasoning for adding/deleting a particular medication as well as any adverse reactions noted.

Within the hospital, case managers work directly with patients to provide community resources so they are able to get their medications more easily and affordably once discharged.  Physicians will typically write a 30-day prescription for most medications to give a patient ample time to see their primary care physician or community resource. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay

Extensive efforts to ensure patients have the education and resources needed to remain compliant once discharged to the community, have decreased overall re-hospitalization rates.  It is also important to focus on prevention and education.  My hospital hosts health fairs, blood pressure screenings and community education classes to make people aware of the modifiable risk factors associated with heart disease to try to decrease the risk of heart disease before it gets to the point of having someone hospitalized for heart disease.

A2b. Clinical Guidelines

Quality measures include:

Patients must be given ACE inhibitor angiotensin II receptor blocker. If not, there must be clear documentation of intolerance to both.
Patients must be given adult smoking cessation advice or counseling
Patients given discharge instructions must include:
Weight Monitoring
List of discharge medications and dosages
Follow up care
What to do if symptoms worsen



A diagnosis of heart disease takes into account the whole picture of physical findings, symptoms and tests.  Based on these results, the physician will order a chest x-ray, echocardiogram and electrocardiography to analyze heart shape/size and function as well as evaluating the lungs for fluid build-up.  Certain specifics a physician will test for: Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay

Blood Tests- kidney and thyroid function, cholesterol levels and the presence of anemia
BNP-level of BNP increases as heart disease worsens
Chest x-ray-shows size of the heart and whether there is fluid build-up
Echocardiogram-provides pictures of the heart’s valves and chambers so the physician can study the action of the heart
Doppler Ultrasound-evaluates blood flow across the heart valves
Ejection Fracture-<55% Stress test- the heart is stressed by walking on a treadmill. This will help identify clogged arteries   Patient Education Understanding Heart Disease Causes of Heart Disease Common Questions Nutritional Planning Adapting Your Lifestyle Plan periods of rest Be sure to get plenty of rest, ensuring that you keep your feet up to minimize swelling in the legs Conserve your energy Cutting down on some of your daily activities or using less energy during tasks will help you have more energy to do more tasks throughout your day Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay Manage a healthy weight Monitor fluctuations in your weight…fast weight gain can mean fluid retention Reading food labels Avoid to much fluid intake Limiting sodium intake Increasing intake of high potassium foods Dried fruits Fresh vegetables Fresh fruits Fish Fresh meat Stop smoking Smoking causes your heart to work harder to supply the body with enough oxygen Be aware of triggers to smoking Being around smokers Alcohol Emotional stress Maintain up-to-date immunizations Respiratory problems can worsen heart disease, vaccinations can provide immunity against flu and pneumonia Monitor your blood pressure and heart rate Gives you confidence in the treatment you are doing Helps give information to the physician about trends Manage your medicines Take your medication as prescribed to get the best possible outcome Take your medications with you when you go to the doctor A2c. Standard Practice of Disease Management Initiatives in Virginia to prevent and combat heart disease include promoting the use of guidelines for primary and secondary prevention as well as increasing quality care in federally funded healthcare centers.  On the national level, in 1999 the National Coalition for Women with Heart Disease, a patient centered organization, was founded creating a wide support network, educational seminars and advocating for legislation.  In 2002, The Heart Truth campaign was created to raise awareness about heart disease, risk factors and preventative action. The standard of practice of care for the management of heart disease is consistent in Virginia as it is across the nation.  Patients with heart disease may experience signs and symptoms of a heart attack such as angina, vomiting, and extreme fatigue, difficulties breathing and swelling in the feet, ankles, legs and abdomen.  Treatment is based on exhibited symptoms and can be pharmacological and nonpharmacological including lifestyle modifications. No single test can diagnose heart disease.  If heart disease is suspected, the national standard is for a physician to order an electrocardiogram to detect and record the hearts electrical activity.  The test will show how fast the heart is beating and if the beat is regular or irregular.  Another standard of care is performing a stress test to make the heart work harder and beat faster through exercise while testing is completed on the heart.  A stress test can show possible signs and symptoms of heart disease such as abnormal changes in the heart rate, blood pressure, shortness of breath and abnormalities in the hearts rhythm. A chest x-ray is typically ordered to give the physician a picture of the organs and structures within the chest and can reveal signs of heart disease.  Blood tests check the levels of cholesterol, sugars, fats and proteins in the blood.  Abnormal levels can indicate heart disease. If other tests suggest heart failure, the physician would order a coronary angiography using a special dye and x-ray to look inside of the arteries (What Causes Heart Disease, 2014). The State of Virginia can help educate the public about the importance of disease prevention through regular check ups.  They can also assist by providing healthcare workers updates on guidelines and best practices for treating patients at risk and affected by heart disease.  Virginia has also established policies for raising awareness for recognizes the signs and symptoms of heart disease and heart attack and helping hospitals implement system changes to adhere to national guidelines and recommendations for victims of heart disease (Moon, 2008). A3. Characteristics of Heart Disease Heart disease affects approximately 5.1 million people (Heart, 2015).   Common symptoms of heart disease include shortness of breath, weight gain, swelling in the feet, ankles, stomach or legs, fatigue and weakness.  Early diagnosis and treatment can greatly increase the quality and length of life for people affected by heart disease.  Treatment typically includes medications, diet modifications, increased physical activity and smoking cessation. There are four stages of heart disease to describe the evolution of the disease. Stage A refers to people who are at high risk for developing heart failure based on one or more risk factors Stage B refers to patients that show no symptoms of heart failure Stage C refers to patients who have in the past, or currently, show symptoms of heart failure with underlying structural heart disease Stage D refers to patients with end-stage heart disease requiring specialized treatments (Diseases, 1964) When thinking about the characteristics of heart disease, genetics should always be a factor.  Individuals that have a parent that suffered a heart attack are at an increased risk for heart disease.  Although we cannot control our gender, heredity or age, there are several risk factors that can be reduced and/or eliminated to lessen the risk of heart disease. Modifiable risk factors include smoking cessation, maintaining a healthy diet and proper weight control.  As little as 20% of a person's body weight increases the cholesterol levels in the body (Mandal, 2009). Access to Care-Approximately 7.3 million Americans with heart disease are currently uninsured (Federal Access to Care Issues, 2013).  This makes them less likely to receive appropriate care which results in worsening medical outcomes, including increased mortality rates.  Current advocacy priorities initiated federally include implementing health reform, opposing policies that cut benefits or increase costs under Medicare and Medicaid, supporting funding for community access, expanding access to AEDs and CPR training for high school students, lay rescuers and professional responders, increased public knowledge of lifesaving approaches and increased funding for the National Emergency Medical Services Information System and other EMS programs (Ayanian, 2001). Treatment Options- The goal of treatment is typically the same for men and women with a goal of relieving symptoms, reducing risk factors to slow or stop the buildup of plaque, lowering the potential for blood clot formation, widening plaque clogged arteries and preventing complications related to heart disease.  Treatments include: Lifestyle Changes such as smoking cessation, diet modification, increased physical activity, maintaining a healthy weight, reducing stress and depression.  Medications can help reduce the hearts workload and relieve symptoms, lower cholesterol levels, blood pressure and prevent blood clots and prevent the possibility of a heart or sudden death.  A patient may need surgery to treat heart disease such as angioplasty, CABG, percutaneous coronary intervention and coronary artery bypass grafting.  Cardiac rehab is also part of the national standard of care.  It includes exercise training to teach safe exercising, muscle strengthening and improve stamina as well as education, counseling and training to help the patient understand their condition and identify ways to lower risk for future medical issues related to the heart. Life Expectancy and Outcomes-Since 2004, the death rate related to heart disease has fallen.  In 2013 there were 211 deaths per 100,000 people in Virginia and 223 in the nation.  This gave Virginia the 25th lowest rate in the country (Measuring Cardiovascular Disease, 2015).  Across the state (Virginia) deaths related to heart disease have continued to fall.  According to US government statistics, there are almost 300,000 deaths each year (Moon, 2008).  Of the total heart disease related deaths each year, 8.6 million are women and is the largest single cause of deaths in women worldwide (Fact Sheets, n.d.).  Heart disease is listed as the underlying cause of death for 31% of all deaths in the United States-that's almost 2200 deaths per day. A3a. Disparities Health disparities continue to exist for low income populations and minorities.  There is evidence that these groups have earlier onset of heart disease and earlier death associated with the advanced disease related to biological, psychosocial, environmental and behavioral issues.  Programs have been implemented by public health groups nationwide to modify known risk factors, focusing on tobacco cessation, increased physical activity, healthier diets and preventative screening.  There has been minimal progress noted in the heart disease health disparities among low income and minority populations.  People living in low income communities have less access to affordable and nutritious food, parks for physical activity and limited access to health screenings.  Fresh and organic produce tend to more expensive than canned or frozen food.  Disparities are seen with patients that carry Medicare as well as non-Medicare patients. Disparities are also noted on an international level based on a patients' insurance or noninsured status.  Patients that do not carry insurance and are unable to pay privately, are typically discharged home with minimal prescriptions and no access to home health leaving family members to take care of them. According to the World Health Organization, about 16 million people across the world die of heart disease each year (The World Health Report, 2003).  Due to a lack of resources and education, developing countries are twice as likely to see patient deaths related to heart disease.  Heart disease has no socioeconomic, gender or geographic boundaries. According to The World Health Report, heart disease is the leading cause of death in the European Union, accounts for over 245, 000 deaths in the UK and an estimated 8 million people in Canada have some form of heart disease.  In these countries, the prevalence of hypertension is very high with citizens not being treated.  In low-income countries, there is usually one person that is the primary money maker for the family.  Due to limited financial resources, many are not able to seek the treatment that they need or take the time away from work to seek treatment.  Low-income communities have unequal distribution of goods and little to no access to healthcare services, healthy foods or safe, green outdoor areas for activity.  There is easy access to alcohol, tobacco and unhealthy foods such as fast food. Among African Americans 10.3% suffer from heart disease, 4.9% of Hispanics suffer from heart disease, 3.3% of Asians suffer from heart disease and 5.6% of Caucasians suffer from heart disease (Thom, 2006).  It is estimated that by 2030, over 44% of the United States population will have some form of heart disease.  The American Heart Association's 2020 Impact Goals include improving the cardiovascular health of Americans by as much as 20% while reducing the mortality rate related to heart disease by 20%. Analysis of data sets reported by the Center for Disease Control showed that adults older than 18 years old, disparities were noted for all risk factors examined.  Mexican American men had the highest prevalence of obesity while African American women without a high school education had a high prevalence of obesity.  Regardless of age or sex, African Americans had the highest prevalence of hypertension while Caucasian and Mexican American men had the highest prevalence of hypercholesterolemia along with Caucasian women (Thom, 2006).  Smokers with family incomes lower than the poverty level is twice as likely than adults in the highest family income group. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay A4a. Factors Contributing to Managing Heart Disease Medication compliance is a huge factor in management of heart disease.  Cost is one of the most common reasons people have for not taking their medications.  For patients having financial issues, the physician may be able to prescribe another medication that is more cost effective.  There are also public and private programs that offer discounted or free medications such as manufacturers' aid or patient assistance programs.  Income and age will often determine eligibility.  It is estimated that three out of four Americans so not take their medications as directed (Medication Adherence, n.d.).  Poor medication adherence takes the lives of 125,000 Americans annually. Some medication assistance programs that can assist a patient better manage heart disease are: RX Outreach- a charitable nonprofit patient assistance program that provides access to affordable generic and brand name medications FamilyWiz Community Service Partnership-distributes free prescription savings cards and a price look up tool NeedyMeds-a national non-profit resource that helps people locate assistance programs to help them afford medications and healthcare costs Due to the high cost of medications, some patients do not purchase them.  A patient with heart disease can experience many complications if they do not follow their medication regimen as prescribed.  Research has proven that a variety of medications are needed for the best outcomes in the treatment of heart disease.  Each medication treats a different symptom or contributing factor to promote the overall treatment.  Each individual medication cannot do their job correctly if not taken correctly.  In a nutshell, proper use of prescribed medications for the treatment of heart disease has been proven to save lives, prolong life and improve overall heart function. Medication noncompliance can lead to an unmanaged disease process as evidence by the mechanism of action of the medications.  For example, diuretics are prescribed to heart disease patients to help the body to rid itself of excess fluids and sodium via urination.  If a patient is not taking their medications as prescribed, there can be an increased workload of the heart as well as increased buildup of fluid in the lungs, ankles and legs making the condition much worse. Lack of insurance coverage can also affect a patient's ability to manage their heart disease.  Plans such as Medicare Part B covers for preventative screening every 5 years.  There are no costs for the tests and everyone who has Medicare Part B is covered.  Medicare also covers one visit per year as a preventative service.  For patients that are experiencing heart failure, Medicare offers comprehensive cardiac rehabilitation that includes exercise, education and counseling (Your Medicare Coverage, n.d.).  This program is provided in a hospital outpatient setting or in a doctor's office. A patient that has private insurance typically will have a rehabilitation plan included as part of their coverage.  For instance, with Anthem, a patient can receive up to sixty visits in a calendar year for rehabilitation services without a prior authorization being needed.  The severity of the illness must meet a predetermined standard for a patient to be approved for inpatient rehab which provides for four to six hours daily of therapy as compared to a skilled facility placement that only would provide one to two hours daily.  The decision of coverage is ultimately determined by the medical director working within the insurance company who receives the case information, reviews it based on the documentation provided and approves coverage limits, amount of days and times based on this information.  Unfortunately, this is not often in line with the physician discharge instructions or the patient/family request.  Often times, these predetermined limits will not provide enough coverage for the patient to get back to a normal state. Some patients do not have traditional insurance or Medicaid.  These patients are also often limited in access to care because they have options in care that are either high in cost or limited.  For example, with hospital based programs, a patient can only see certain physicians and are bundled into managed products.  With managed products, a patient is assigned to a specific physician or medical group and is unable to see an outside physician without a referral.  Appointments are limited and often times done during clinic times so seeing the same physician consistently is rare.  These limited appointments often result in patients having to seek care in the Emergency Room which does not provide ongoing care.  This can result in a breakdown in communication between physicians and a lack of consistency of treatment plans. Without the needed ongoing care, patients can fall between the cracks, with constantly changing treatment and medication regimens and inconsistency of the plan of care.  The frustration of long waits during clinics, different physicians every visit and having to wait get on a waiting list to even get into a clinic can lead to an unmanaged disease process due to a lack of frequent, consistent visits and updated plans of care and treatment regimens based on changes in the disease process. Not having access to proper nutrition can affect a patient's ability to manage heart failure.  One of the standard modifications recommended is diet modification.  The role of a proper diet is key to lowering cardiovascular risk.  Patients that do not have access to healthy foods such as fruits and vegetables, low sodium items, fish, nuts and soy have a higher risk of death related to heart disease.  Food assistance programs such as SNAP (Supplemental Nutritional Assistance Program), Nutritional Programs for Seniors and WIC (Special Supplemental Nutrition Program for Women, Infants and Children) provide assistance for those in need so they can purchase healthier foods. Proper nutrition is very important when trying to manage heart disease.  Continuing to eat an unhealthy diet can lead to co morbidities that can increase that rate of mortality related to an unmanaged disease process.  For example, high blood pressure is a major risk factor with heart disease so a diet high in sodium will increase a patients' risk for hypertension.  A high fat intake will increase the likelihood of becoming obese (which puts addition strain on the heart) and developing high cholesterol.  Sugary foods can increase the chance of a patient becoming a diabetic.  Abnormal blood lipids are related to what we eat and have a strong correlation to heart disease, heart attack and ultimately coronary death. 4Ai. Characteristics of a Patient with Unmanaged Heart Disease Patients with uncontrolled heart disease may experience several symptoms such as shortness of breath, rapid heart beat, lethargy, light headedness, swelling in the extremities and chest pain.  They may even experience pain in the jaw, neck or back.  Sometimes a patient with uncontrolled heart disease may experience nausea and vomiting as well as unexplained fatigue. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay For patients with unmanaged heart disease the prognosis depends on the cause and severity of the disease. Complications can include: Kidney Failure Heart disease can reduce the blood flow to the kidneys and cause a patient to need dialysis Heart valve Problems Valves may not function correctly if the pressure in the heart is high due to heart disease Heart Rhythm Complications Arrhythmias can be a complication of heart disease Liver Damage Heart disease can lead to fluid buildup that puts excessive pressure on the liver   How Does Heart Disease Affect Patients, Families and Communities? Heart Disease can be a devastating illness that affects not only patients but their families and community as well. For the patient it can affect their ability to live independently and care for themselves. The patient may not be able to continue working as the physical and emotional stress takes its toll.  This can result in a loss of income, further increasing a patient's stress level and depression especially if they are not able to care for themselves or their family.  There is also the added anxiety over familial and caretaking concerns such as, "Who will take care of my house and my spouse" and "How will he/she manage without me?" Family members may have to face the possibility of caring for a sick loved one. This can put an emotional and financial strain on the dynamics of the household.  The family will also have to be prepared to deal with the possibility of the sick family member to experience depression and other changes in their emotional state.  Their tolerance for noise and disturbances may be decreased and this may be hard for young children to understand.  They may feel that they have lost a parent or that their parent is behaving differently around them but not understand why. For the community, a patient who has decreased or lost their income, may rely on community and government assistance for medications and healthcare related costs. These costs may be absorbed by the local hospitals or state funded programs such as Medicare. If a patient is not able to provide for their family, they may need to turn to other government based assistance programs such as food assistance programs and housing assistance programs. B1. Financial Costs Patient – In 2010, the cost of heart disease in the United States alone exceeded $444 billion (Feature, n.d.).  Pulling from this total 64% were direct costs, 45% were hospital costs, drugs were 19.5% and physician visits were 14.8%.  The cost of treating heart disease exceeds diabetes treatment. DIRECT MEDICAL COSTS INDIRECT MEDICAL COSTS LONG TERM MAINTENANCE Ambulance Lost Productivity and Income Drugs Diagnostic Testing Continued Testing Hospital Charges Cardiologist Appointments Surgery (if needed) Appointments for Co-Morbidities or Illnesses as a Result of Heart Disease For the patient, heart disease results in many increased costs outside of medications and hospital visits.  For instance, fresh, healthy or organic foods cost more than fast food, frozen or canned foods.  That is why it is hard for many people to adopt a healthier nutritional lifestyle.  A meta-analysis of pricing of healthy versus unhealthy diet patterns found that the healthiest diet patterns cost, on average, ≈$1.50 more per person per day (Thom, 2006).  As a result of the illness and its effects on the body, a patient may have to miss work or work less frequently causing their income to decrease. A patient can help offset some of the costs by researching cheaper medications or generic substitutions, ensure they have adequate health insurance and consider disability insurance to replace some of the lost income. Family – For families of heart disease patients, the financial toll can also be high.  Family members may have to become the sole person responsible for finances within the household.  Family members may also experience some form of loss in income if they are forced to miss work to take their loved ones to physician appointments, hospital visits and for treatments.  For families with children, there is also the additional expense of childcare while the healthy parent is taking the ill parent to appointments. Populations – In the United States, heart disease more Medicare allocation dollars than any other illness.  In 2009 over seven million Medicare beneficiaries experienced over 12.4 million inpatient hospital visits (Treating Congestive Heart Failure, 2014). Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay Promoting Best Practices & Evaluation Method The first strategy I would implement to promote best practices would be to implement for a nutritionist to meet regularly with all patients admitted with new or current heart disease.  Part of minimizing recurrent visits to the hospital and implementing a healthier lifestyle is education about proper nutrition.  It is important that patients are given the knowledge about implementing heart healthy eating patterns, proper intake of fruits, vegetables, gains, fish, legumes and sources of proteins low in saturated fat.  The nutritionist would also be responsible for educating the patient of weight management and reduction (if needed) through a balance of physical therapy, monitoring caloric intake and programs to maintain/achieve a healthy BMI. Evaluation-The nutritionist would also be responsible for a one month, three months and six months follow up where the patient can have their BMI checked, weight checked, basic labs taken etc. to gauge their progress and give the patient an opportunity to ask questions and get guidance on any concerns they may have regarding their diet and weight management. The second strategy I would implement for best practice would be psychological assessment and support for patients suffering from heart disease and undergoing cardiac treatment.  Stress, anxiety and other psychological factors can greatly affect a patients' wellness and cardiac rehabilitation.  I would ensure that a psychologist or psychiatrist met with the patient throughout their hospital stay.  They would not only complete assessments to ensure the patient is psychologically handling their diagnosis but also be available for a patient to discuss any concerns, negative emotions, concerns about post discharge factors such as work and family life as well as discuss any depression they may be experiencing.  The psychologist/psychiatrist would also provide education about stress management, recognizing signs and symptoms of depression as well as helping the patient find mental support resources within the community post discharge. Evaluation-The psychologist/psychiatrist will continue to monitor the patients' mental health throughout their visit, identifying any variances from upon admission.  They will also meet with the patient upon discharge to complete another assessment to ensure the patient is mentally stable to be discharged.  They will also monitor the patient based on their initial baseline for any negative effects related to new or modified medications The third strategy I would implement is a post heart disease diagnosis care team.  Once a patient is discharged from the hospital, they would be seen by the care team the following day.  The care team would include the physician, nutritionist, social worker, physical therapist, psychologist/psychiatrist and cardiac nurse educator.  The team would follow the patient for one-year post admission to provide support for the patient.  Their initial evaluations would be completed while the patient is in-patient.  Upon discharge, the care team would also provide educational opportunities and support groups for patients to participate in.  The team will also assist the patient with smoking cessation programs and medication management.  Following the patient will allow the care team to monitor and changes in condition while helping the patient get oriented to their new diagnosis and symptom management. Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay Evaluation-The care team will review and track their patients for compliance with medications, dietary modifications, smoking cessation and overall quality of life.  As symptoms arise, the team will also help the patient with symptom management and teach them the skills needed to live with heart disease on their own.  Evaluation of outcomes would be analyzed overtime to identify areas of opportunity and the potential for team expansion.   References Albert, N., Boehmer, J., Ezekowitz, J., Givertz, M., Klapholz, M., Lindenfeld, J.,…Walsh, M. (2010). Executive Summary: HFSA 2010 Comprehensive Heart Failure Practice Guideline. Journal of Cardiac Failure (16)475-539. Retrieved from   Ayanian, J. Z., & Qiunn, T. J. (2001, May). Health Affairs. Retrieved April 12, 2016, from   Bleske, B., Chavey, W., Hogikyan, R., Kesteron, S., Nicklas, J., Van Harrison, R. (2008). Pharmacological Management of Heart Failure Caused by Diastolic Dysfunction. American Family Physician. (7)957-964. Retrieved from   Burke, N., Desmeules, M., Georee, R., Lim, M., Luo, W., O'Reilley, D., …Tarride, J. (2009). A review of the cost of cardiovascular disease. Canadian Journal of Cardiology, 25(6). doi:10.1016/s0828-282x(09)70098-4 Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay     Cleland, J., Dargie, H., Drexler, H., Follath, F., Komadja, M., Swedberg, K., (2005, May 18). Guidelines for the diagnosis and treatment of chronic heart failure: Executive summary. Retrieved March 27, 2016, from   Diseases of the heart and blood vessels: Nomenclature and criteria for diagnosis (6th ed.). (1964). Boston: Little, Brown. Retrieved March 25, 2016.   Doering, L. V., McKinley, S., Riegel, B., Moser, D. K., Meischke, H., Pelter, M. M., & Dracup, K. (2011). Gender-Specific Characteristics of Individuals with Depressive Symptoms and Coronary Heart Disease. Heart & Lung: The Journal of Critical Care, 40(3), e4–e14.   Fact Sheets. (n.d.). Retrieved April 12, 2016, from   Feature, R. M. (n.d.). Heart Disease: The Cost of Medical Bills and Disability. Retrieved April 12, 2016, from Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay   Federal Access to Care Issues. (2013, July 8). Retrieved April 12, 2016, from   Heart Failure Fact Sheet. (2015, November 30). Retrieved March 24, 2016, from   Lewis, T. (1937). Diseases of the heart, described for practitioners and students. London: Macmillan and, Limited.   Mandal, MD, A. (2009, April 5). Heart Failure Causes. Retrieved March 24, 2016 from   Measuring Cardiovascular Disease in Virginia – Virginia Performs. (2015, March 16). Retrieved April 12, 2016, from   Medication Adherence – Taking Your Meds as Directed. (n.d.). Retrieved April 07, 2016, from—Taking-Your-Meds-as-Directed_UCM_453329_Article.jsp#.VwYmXP72ZoA   Moon, M.A. (2008). Heart Failure Patients Greatly Overestimate Life Expectancy. Family Practice News, 38(13). Doi:10.1016/s0300-7073(08)70804-1   Palazuoli, A., & Nuti, R. (2010, April 20). Heart Failure: Pathophysiology and clinical picture. Retrieved March 27, 2016, from   Petruccelli, D. F. (n.d.). JCAHO Core Measures. Retrieved April 8, 2016, from   Thom, T. (2006). Heart Disease and Stroke Statistics–2006 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation, 113(6). doi:10.1161/circulationaha.105.171600   Treating Congestive Heart Failure and the Role of Payment Reform. (2014). Retrieved April 13, 2016, from   Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Drazner, M. H., . . . Wilkoff, B. L. (2013). 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. JACC-Journal of the American College of Cardiology, 128(16). doi:10.1161/cir.0b013e31829e8776   Yoon, J., Fonarow, G. C., Groeneveld, P. W., Teerlink, J. R., Whooley, M. A., Sahay, A., & Heidenreich, P. A. (2016). Patient and Facility Variation in Costs of VA Heart Failure Patients. JACC: Heart Failure.   What Causes Heart Disease? (2014, April 21). Retrieved April 11, 2016, from   What Is Being Done at The National Level to Prevent Heart Disease In Women? (n.d.). Retrieved April 03, 2016, from   Your Medicare Coverage. (n.d.). Retrieved April 07, 2016, from Pathopharmacological Foundations for Advanced Nursing Practice: Heart Disease Essay

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