Congestive Heart Failure

Ma. Concepcion Copon, Luiza Dumitrascu, Nicisha Fromm, Jessica Kolacinski, Patrick Mayorga, Chun Ngai,

Alysia Williams, & Kelley Young

NURS 480

Spring II 2016

Meet Mr. Carter

Older man. [Photograph].Retrieved from:

https://www.acgov.org/board/district5/caring/images/olderman.jpg

The term congestive heart failure (CHF) makes it sound like the heart is no longer working at all and there's nothing that can be done. Actually, heart failure means that the heart isn't pumping as well as it should be. Your body depends on the heart's pumping action to deliver oxygen- and nutrient-rich blood to the body's cells. When the cells are nourished properly, the body can function normally. With heart failure, the weakened heart can't supply the cells with enough blood. This results in fatigue and shortness of breath and some people have coughing. Everyday activities such as walking, climbing stairs or carrying groceries can become very difficult.

Congestive heart failure diagram. [Photograph]. Retrieved from http://www.at-

homequalitycare.com/wp-content/uploads/Services/congestive_heart_failure_diagram.png

Congestive Heart Failure

Family Introduction

Mr. Carter is a 78 year old retired

lawyer. He is of African American

descent. He is widowed and lives

alone at home. He was admitted to

the hospital for an acute

exacerbation of his CHF with a right-

sided pleural effusion due to

uncontrolled hypertension and diet.

Mr. Carter is noncompliant with his

medication regimen.

Medical History: hypertension,

hypercholesterolemia, coronary

artery disease, BPH, and diabetes.

Socioeconomic status: Mr. Carter is

retired and is able to live comfortably

on his savings and benefits. He lives

by himself in a single story home. He

has Medicare insurance.

Family: Mr. Carter has 2 adult

children. Lisa, who lives two towns

over, is 50-year-old high school

graduate currently working as a

cashier in a grocery store near her

home.

Lisa’s husband is a car mechanic

working in a garage. They have 4

children: Diego, age 24, is a high

school graduate and a car mechanic

in the same garage as his father;

Brenda, age 20, is a full time college

student; Lucia and Mia are twin

sisters, age 15, both are high school

students.

Another daughter, Amanda, lives

within 10 miles of the patient. She is

a 45-year-old college graduate

currently working as an RN in a local

hospital. She has a long-term

boyfriend and no children. Amanda is

the primary caretakers for M.C.

Because Amanda has medical

knowledge as a nurse and has

relatively more free time, she

became the main organizer for her

father’s care between the healthcare

team and her relatives. Amanda

brings Mr. Carter to a community

Baptist church when his health

allows.

Meet the Family

Mr. Carter

78

Lisa

50Amanda

45

Mrs. Carter

1940-2013

Bill

51

Diego Brenda Lucia Mia

24 20 15 15

Carter Family Genogram

Jimmy

45

Male

Female

Deceased

Married

Cohabitating

Developmental Stages

Meet Mr. Carter, he is a 78 year old retired attorney who practiced law for 50 years.

His work as an attorney was very satisfying. Although now he has some regret not

spending more time at home because his plan to enjoy his retirement years was cut

short by the death of his wife three years ago. He has not successfully resolved this

crisis. Leading to what Erickson referred to as lack of ego integrity (Davis & Clifton,

1995). He had played the provider role for the last 50 years. Although now in retirement

he has transitioned into the sick role. His wife took primary care of the home, himself,

and the children. He now lives at home alone. He has 2 adult children Lisa and Amanda

with whom he has good relations with. He stays in close contact, especially with

Amanda who is a nurse and frequently cares for and assists him. He has multiple

preexisting conditions including hypertension, hypercholesteremia, coronary artery

disease, benign prostatic hyperplasia, and type 2 diabetes. His Congestive Heart Failure

(CHF) is poorly managed and he is noncompliant with medications and diet. He has

frequent symptoms which interfere with his daily life. The symptoms leave him unable

to attend church or meet with his friends to watch ball games. He has frequent

admissions to the acute care setting and is currently admitted with acute exacerbation

of CHF with right-sided plural effusion. Resolving his grief, in not spending more time

with his wife, is of key importance in removing the barrier to feeling proud of his

accomplishments. Allow him to feel a sense of integrity, looking back with few regrets,

and have a general feeling of satisfaction (Davis & Clifton, 1995).

Mr. CarterIntegrity vs Despair

Image source: Untitled. [Online image]. Retrieved from:

http://www.cancer.org/acs/groups/content/@editorial/documents/image/acspc-038661.jpg

Developmental Stages

Meet Lisa, she is a 50 year old cashier in her neighborhood grocery store. She feels like she has not contributed as much as her sister who is a nurse. But she has a husband, Derick, works as an automobile mechanic in a garage. They have four children: Diego, age 24, who works with his father at the garage, Brenda, age 20, a full time college student, Lucia and Mia, age 15, twin sisters and high school students. Lisa plays both the housekeeper and provider role. The family is very close knit and spend a lot of time together. Lisa calls Mr. Carter frequently and although they live 2 towns away they drive the 60 miles to visit Mr. Carter at least once a month. Lisa looks at her life and feels that she could have pursued a career but she did not want to sacrifice being home with her family. She is happy with her life and choices, because they remind her of her mother and their close relationship.

LisaGenerativity vs Stagnation

AmandaGenerativity vs Stagnation

Meet Amanda, she is a 45 year old registered nurse who works in a nearby hospital. She is satisfied with her career but is jealous of her sister’s big family. She has a long-term boyfriend, but no children. She is close with her father. Amanda cares for M.C. as she lives about 10 miles away. Amanda takes M.C. to appointments, does his grocery shopping, and helps him take care of his affairs. Amanda is at her father’s house at least four times a week. M.C. has a housekeeper that comes weekly to clean but more recently Amanda has been helping M.C. to keep up on the house work as well. Amanda plays both the caregiver role and the provider role and has to support herself. Amanda is also grieving the loss of her mother by trying to carry out her role. Amanda goes to church several times a week and takes her father on Sunday when he is well enough. Both Amanda and M.C. enjoy their Baptist church and have deep rooted spiritual beliefs. Amanda may be stagnated in this role until she assists her father to progress past the loss of his wife and take an active role in self care.

Lisa image source: Untitled. [Online image]. Retrieved from http://i.usatoday.net/news/opinion/_photos/2011/02/25/black-

womenx-large.jpg

Amanda image source: Untitled. [Online image]. Retrieved from http://cdn.skim.gs/image/upload/v1456339131/msi/african-

american-woman-hair_wogron.jpg

Religion and CultureLike many families of African American descent, Mr. Carter and his family

are very fond of “soul food” such as rice, seafood, black-eyed peas, deep fried food and carbohydrate-rich food such as bread, yams, potatoes and biscuits (African American Registry, 2013). This diet does not really help Mr. Carter’s diabetes, hypercholesterolemia, coronary artery disease and hypertension.

Music is also deeply ingrained in Mr. Carter as this is one of the things that make the family come together. The whole family loves to sing gospel songs and would sometimes gather around Mr. Carter’s house whenever his daughter, Lisa, is in town with her family. They would also often dine out together when time permits. Their favorite restaurant is Big Jones’ Southern Kitchen close to where Mr. Carter lives.

Prior to Mr. Carter’s most recent hospitalization for acute exacerbation of CHF, he is very active in his church and community. Mr. Carter and his family are deeply spiritual and will always pray for guidance and help whenever Mr. Carter or any member of the family is ill.

He belongs to a Baptist church and would attend services every Sunday with his daughter, Amanda, and her boyfriend. After the service, the community gathers at the church grounds for more fellowship and activities for the families such as games and singing, Bible study for the children or just simply hanging out with each other. Eating together of traditional southern comfort food is also a community event. However, due to Mr. Carter’s increasing fatigue and shortness of breath, he has declined to go to church and would just stay home and read passages from the Bible.

“Spirituality and religious beliefs appear to serve as powerful

protectors embraced by resilient families.”

(Kaakinen, et al., 2015, p. 218)

Strengths• Mr. Carter is well educated, and his

reading abilities will allow him to better educate himself regarding his condition and search out resources to improve his health and prevent acute exacerbations.

• Mr. Carter is financially stable and has reliable medical insurance. He is able to comfortably afford food, medications, and other necessary provisions.

• The patient has familial support available to him, especially in his youngest daughter Amanda who as a nurse, is knowledgeable about the necessary health behaviors the patient should be implementing. This daughter lives close to the patient and with less demands on her time (children, spouse, etc.) she is able to be involved more in M.C.’s health care maintenance at home.

Challenges• Mr. Carter lives at home alone, with no

in-home caregiver or spouse since he is widowed.

• The patient is not adhering to a diet that helps prevent exacerbations of his chronic heart failure. Mr. Carter also has not been following his medication regimen appropriately to control his blood pressure be it from lack of understanding, forgetfulness, or even lack of motivation. These issues of noncompliance puts him at higher risk for more repetitive exacerbations of his condition.

• Mr. Carter may also have some emotional and illness perception barriers to taking care of himself in the way that he really needs because as Larsen & Lubkin (2016) state, “illness perceptions are part of the self-regulation process” and even age, gender, race, marital status, and “one’s education and learning, socialization, and past experience… mediate illness behavior” (pp. 24-26).

VS

The whole family lives relatively local to each other, which allows their communication to happen more easily than families that are more separated from each other. Having a medically knowledgeable daughter like Amanda, able to help support M.C. with his daily needs like grocery shopping and housecleaning, as well as assisting with his medical needs is a benefit to the patient as he and his family are trying to cope with his illness. Lisa, M.C.’s other daughter is clearly very involved with her family, and although she has four children and a job that keep her from being as involved with her father’s care as she would maybe like to be, family is a priority to her. In a family that has a member with a chronic health condition, it can be a challenge “to balance the needs of the ill family member with their own needs and the needs of the family as a whole” (Kaakinen et al., 2015, pp. 237-238). These challenges can be worked out in an ideal way when the family has open, quality communication about their feelings and needs and they work together. This family has those qualities, and M.C. is currently needing to make adjustments in his lifestyle and his daughters can be great resources for him, especially if they can communicate well together and understand the necessary changes that need to be made according to what is medically recommended and even among the family unit.

Communication

Family Systems TheoryIntroduced by Dr. Murray Bowen, the family systems theory is a theory of

human behavior and emotional attachment as a unit. There are eight concepts in the family systems theory that are interlocking. Of these eight concepts, here are a few that apply to the Carter family (genogram, 2016).

Triangles Triangles are the smallest stable relationship system, building the foundation. One side of the triangle represents a conflict, while the other two sides represent harmony. In this triangle we have Mr. Carter. the 78 year old man with CHF and his two daughters Lisa and Amanda being his support and caregivers.

Nuclear family emotional process

Relationship patterns that show where problems may develop in a family. In this case, Mr. Carter has two daughters. His daughter Amanda is his primary caretaker and is a 45 y.o. RN with no children. His daughter Lisa is less active in their her care and has a husband and 4 children. Lisa would be most likely to display emotional distance in her fathers health struggles as she needs to focus on her family at home and knows that her sister Amanda will attend to her fathers needs.

Family projection process

This is transmitting emotional problems from a parent to a child. In this family, M.C. could transmit his emotional problems to his daughter Amanda as his primary caregiver. M.C. is widowed, lives alone, and has several health issues such as CHF, diabetes, and hypertension. He most likely has some depression as evidenced by his noncompliance with proper diet and medications. His daughter Amanda may feel guilt that her father lives alone as his emotions are transmitted to her.

Multigenerational transmission

process

This is the transmission of small differences between parents and their children. In the case of M.C. he has a daughter that is less involved with his care named Lisa. Lisa has four children in which are college and high school age. Although their grandfather is ill, since their mother is not greatly involved with his care, these children will not be greatly impacted by the medical and emotional needs of their grandfather.

Family Systems Theory

Problems Identified

Caregiver role strain: With Amanda being an R.N. and having no children, she has assumed the role as primary caregiver for her father. This leaves the responsibility of his care and well being on her.

Risk for depression: With Mr. Carter living alone and being a widower, he is at risk for depression. He also has several medical issues that could lead him to isolate himself and do not allow for socialization.

Risk to safety : Mr. Carter has not only been diagnosed with CHF but also has diabetes and hypertension that he has been noncompliant with. Living alone is not the safest choice for his safety.

Nursing Process and Interventions

1. Assess for caregiving needs and identify if Lisa is available to assist in some her father’s care to ease the stress that has been placed onto her sister Amanda as the primary caregiver. The sole responsibility should not lie on only one daughter. Mr. Carter’s two daughters could also look into an assistive agency that can come into the home and provide assistance with ADL’s in order to lighten the responsibilities.

2. Assess Mr. Carter for signs and symptoms of depression. Assess any outside support such as friends. Mr. Carter could benefit from a widower’s support group.

3. Assess for safety issues in the daily routine of Mr. Carter. Assess if Mr. Carter has a person available at all times in case of emergency. Assess the plans of his daughters if decided that Mr. Carter can no longer live alone.

Source: Kaakinen, et al., 2015

The Evidence

Article 2When a person is diagnosed with a chronic disease like CHF, hypertension, diabetes

mellitus type II, it implies a change for both the individual and the family. In this changed situation, all family members seem to benefit from sharing experiences and receiving support. Current research highlights the individual patient's or family member's perspectives on chronic illness. Årestedt, Persson, & Benzein (2014) family systems nursing (FSN) studies concluded that “living as a family in the midst of chronic illness can be described as an ongoing process where the family members co-create a context for living with illness. They also co-create a context for alternative ways of everyday life” (pp. 31). This is relevant to clinical practice knowledge because it can help nurses adopt a FSN care perspective. This can increase the chances of taking advantage of the ways family members manage situations together, as well as highlight resources within the family.

Article 3Family Systems Nursing intervention research conducted by Östlund and Persson (2014)

found “improved understanding, capability, and enhanced coping evidenced by caring more about each other and the family, improved interactions within and outside family, improved family emotional well-being, and improved individual emotional and behavioral well-being” (pp. 282). These findings might encourage the design of future family nursing intervention research and the selection of family outcome measures to examine the usefulness of Family Systems Nursing interventions and to educate nurses about the advantages of Family Systems Theory in practice.

Article 1Communication within the family is an important part of Family System Theory and

evidence demonstrates that open communication within families living with chronic illness increases the satisfaction of each member by being able to empathize with the sick person, making the situation manageable through support from other family members in order to solve problems, facilitates healing and strengthened family cohesion by bringing family members closer together. Family Health Conversations should be offered as a part of standard care shortly after diagnosis and at various transitions in life (Benzein, Olin & Persson, 2015).

ReferencesAfrican American Registry. (2013). Soul food a brief history. Retrieved from

http://www.aaregistry.org/historic_events/view/soul-food-brief-history

Årestedt, L., Persson, C., & Benzein, E. (2014). Living as a family in the midst of chronic illness. Scandinavian Journal of Caring Sciences, 28(1), 29-37 9p. doi:10.1111/scs.12023

Benzein, E., Olin, C., & Persson, C. (2015). 'You put it all together’-families' evaluation of participating in family health conversations. Scandinavian Journal of Caring Sciences, 29(1), 136-144 9p. doi:10.1111/scs.12141

Congestive heart failure diagram. [Online image]. Retrieved from http://www.at-homequalitycare.com/wp-content/uploads/Services/congestive_heart_failure_diagram.png

Davis, D. & Clifton, A. (1995). Psychosocial theory: Erikson. Retrieved from http://ww3.Haverford.edu/psychology/ddavis/p109g/erikson.stages.html

GenoPro. (2016). Family systems theory. Retrieved from http://www.genopro.com/genogram/family-systems-theory/

Kaakinen, J.R., Coehlo, D.P., Steele, R., Tabacco, A., & Hanson, S.M.H. (2015). Family health care nursing: Theory, practice, and research (5th ed.). Philadelphia, PA: F.A. Davis Company.

Older man. [Online image]. Retrieved from https://www.acgov.org/board/district5/caring/images/olderman.jpg

Östlund, U., & Persson, C. (2014). Examining family responses to family systems nursing Interventions: An integrative review. Journal of Family Nursing, 20(3), 259-286 doi:10.1177/1074840714542962

Untitled. [Online image]. Retrieved from http://www.cancer.org/acs/groups/content/@editorial/documents/image/acspc-038661.jpg

Untitled. [Online image]. Retrieved from http://i.usatoday.net/news/opinion/_photos/2011/02/25/black-womenx-

large.jpg

Untitled. [Online image]. Retrieved from http://cdn.skim.gs/image/upload/v1456339131/msi/african-american-woman-hair_wogron.jpg