Jeannette Wick

The words “heart failure” (HF) are generally modified by a list of depressing adjectives: chronic, progressive, and debilitating. In the United States, more than 5.8 million people have active HF diagnoses.

published a case study in its August 2017 issue that covers the nurse practitioner’s (NP) role in helping patients who have this life-changing disease. Its focus is 3-fold. First, it describes NPs’ interventions with regard to HF patients. Second, it delineates challenges related to identifying secondary HF in patients with complex comorbidities. Finally, it presents concrete suggestions about improving health-related outcomes and prevent hospital readmission.

HF is the leading cause of hospital admissions and readmissions in patients ages 65 years or older. It is also a leading cause of death in the United States among patients who have been previously hospitalized. This makes HF a target for readmission reduction programs.

Most NPs know the basic signs and symptoms of HF, which are related to impaired myocardial ventricular function. Symptoms are generally classified as vascular congestion-related or target organ hypoperfusion. Advance practice nurses should know HF’s signs and symptoms (shortness of breath, lethargy, fluid retention and associated rapid weight gain, hypertension, adventitious breath sounds) because these symptoms can progress very quickly to acute decompensated HF. These symptoms often occur in a constellation as opposed to individually.

The authors emphasize that nurses and NPs should consider HF in their differential diagnosis process in any acutely ill patient who has multiple cardiac risk factors and comorbidities. These patients need a thorough workup and, potentially, referral for hospitalization. Many go directly to the cardiac intensive care unit.

Numerous risk factors predispose patients to HF and include advancing age, left ventricular hypertrophy, cardiomegaly, slow heart rate, elevated blood pressure, reduced vital capacity, and the presence of hypertension, diabetes, valvular disease, or previous myocardial infarction.

It’s important to note that patients often have little insight into the early signs and symptoms that they’re decompensating. They need extensive education, and clinicians must be vigilant. Once home, patients may or may not follow the advice of their clinicians. They also may have complicating issues, such as poor nutrition. Medication adherence is frequently low, having been complicated by a general trend toward multiple medications that have noteworthy adverse effects.

Patients need to be reminded that symptoms like bilateral lower extremity pruritus, swelling, and itching are red flags for decompensation and are often signals of lower extremity cellulitis.

Retail health care practitioners need to have heightened awareness of the implications of systemic infection, elevated blood pressure, and new arrhythmia in patients at risk for HF. Any of these conditions can galvanize progression to acute decompensated HF. When these happen, it’s important to ask patients very directly how they manage their condition at home and to describe their self-care behaviors.

In HF patients, goal-directed interventions are critical. Patients need to be reminded to monitor their symptoms, and control fluid overload appropriately with fluid restriction, reduced sodium intake, and diuretics. Research is underway to determine how each of these contributes to HF control, but for the time being these are the recommended interventions.

Much of this case study covers nursing considerations for hospitalized patients, but a good portion of it emphasizes the need for solid, aggressive care in community settings that are assessable to the patient. This case study covers patient history, physical assessments, imaging, and laboratory studies and can remind retail health care providers of HF treatment’s nuances.

Here, as with other cardiac diseases, following guidelines is essential. The American College of Cardiology and American Heart Association guideline for the management of HF was last updated in 2013; it’s the go-to guideline for this condition and is available free of charge on the Internet.

Gheorghiu V, Barkley TW Jr. Identification and prevention of secondary heart failure: a case study.

Articles

The words â€œheart failureâ€ (HF) are generally modified by a list of depressing adjectives: chronic, progressive, and debilitating. In the United States, more than 5.8 million people have active HF diagnoses. 

The Nurse's Role in Heart Failure: Early Intervention

Employers have countless reasons for encouraging employees to be immunized against influenza. With the annual economic burden in the United States estimated at $30.4 billion, money is one motivator. But other reasons abound to ensure that employees are immunized also. Retail employees are at increased risk of contracting

because they interact with many people every day, and the virus can be transmitted when money is exchanged. Influenza is associated with health risks in people with chronic illnesses, and decreasing spread of influenza among retail employees could also decrease spread among customers.

indicate that nurse practitioners can be part of a multicomponent approach that increases influenza immunization rates among employees. This study describes a nurse practitioner-lead, evidence-based intervention to do just that.

Participating immunizers hope to achieve an influenza immunization rate of at least 50% among employees, and determine if nurse practitioners could positively influence the immunization rate. The researchers compared immunization rates at retail locations that had a nurse practitioner-staffed clinic, and were open weekdays from 9:00 am to 8:00 pm with shortened hours on the weekend.

The site that employed the intervention had an average of 260 employees. The comparison site had an average of 305 employees. Both stores hired additional employees from October through December to accommodate increased traffic during the holidays.

The intervention offered free immunization (and the employee could choose the form of delivery) and a gift card and gift bag after immunization. Participating immunizers also distributed flyers and posted posters on-site.

At the intervention site, the immunization rate reached 45%; this was below the goal but significant regardless. This site’s immunization rate was only 35% the previous year. At the comparison site, the immunization rate languished at 32%.

This study demonstrates a principal that’s growing in popularity. After years of talking about “outreach,” some researchers are beginning to talk about “inreach.” Programs that use outreach seek populations who might not otherwise have access to services. Programs that use inreach look at their own populations and try to find people who have access to the service but simply don’t use it.

This study has implications for retail health practitioners. Mounting a campaign to immunize employees who are co-located with retail health clinics should be easier than trying to find new patients. Retail healthcare practitioners can also influence employees and encourage them to establish mandatory immunization programs.

Montejo L, Richesson R, Padilla BI, Zychowicz ME, Hambley C.

Increasing influenza immunization rates among retail employees: an evidence-based approach.

Employers have countless reasons for encouraging employees to be immunized against influenza. 

Making a Dent in the Flu: Try In-Reach!

Hepatitis A is a viral infection that’s transmitted via the fecal-oral route and causes an acute hepatitis. It is highly infectious and most likely to occur in injection drug abusers or men who have sex with men. However, it can also be transmitted through contaminated water and food, under conditions of poor sanitation, and in crowded living conditions. In the United States, public health officials see community outbreaks from time time—usually associated with childcare centers. Conversely, hepatitis A infection is endemic in Africa, Asia, Central and South America, and Eastern Europe.

Many health care providers do not understand fecal-oral contamination. They think, “This doesn't happen here. We wash our hands and practice good hygiene.”

While fecal-oral contamination often occurs in places where sanitation is poor, it can occur in less likely locations if:

gardeners work in contaminated soil or compost

microscopic quantities of fecal matter transfer from a person who has just changed a baby’s diaper or petted an animal

flies visit a toilet or laundry basket and then land on food

Hepatitis A is generally mild and self-limiting, but it has the potential to cause morbidity and mortality, especially when it occurs among susceptible older adults. Children—among whom approximately 90% have been infected by age 10 years if they live in areas with poor sanitation and living conditions&mdash;usually don’t develop symptoms, while adults who contract hepatitis A later in life usually do. Simply put, increasing age is associated with a greater likelihood of symptomatic hepatitis.

Patients who contract symptomatic hepatitis A often lose their appetite and energy and may experience vomiting, fever, abdominal pain, and, in some cases, jaundice. Patients may report a dark, amber-colored urine or light-colored feces. Many people confuse hepatitis A’s symptoms with those of influenza and do not seek care. Should this disease appear in its fulminant form, it is considered life-threatening.

American public health officials see temporary increases in hepatitis A infections and outbreaks approximately every 10 to 15 years. Between those times, they estimate that approximately 21,000 Americans contract hepatitis A annually. Hepatitis A is vaccine-preventable, and the CDC first recommended routine vaccination for children in the mid-1990s. Since then, the CDC’s recommendations have grown to include additional groups of Americans. Baseline rates of hepatitis A have decreased significantly.

Increases in cases of hepatitis A in 2012 and 2013 indicate that this virus may be mutating. Most cases of hepatitis A have been traced to travel outside the United States. However, a significant number of cases seem to be related to contaminated food. Clinician should note that imports of fresh and frozen fruits, vegetables, and shellfish from countries that have endemic hepatitis A have increased the risk of hepatitis A transmission. A 2016 outbreak in the United States was traced back to frozen strawberries imported from Egypt. Similarly, the state of Hawaii experienced an outbreak that was eventually traced to raw scallops originating in the Philippines.

Patients who develop hepatitis A pursuant to a restaurant visit generally develop symptoms between 2 and 6 weeks after exposure. This makes it particularly difficult to identify others who may have dined at the same establishment or purchased food at the same vendor. Should patients present with hepatitis A symptoms, retail health clinicians should confirm the diagnosis with serologic (serum) testing unless the patient is a household contact of a confirmed case. Blood work will reveal an elevated ALT/AST in many cases. They must also be prepared to treat symptoms.

Supportive care is appropriate. Most patients present with an acute syndrome and may need antiemetics for nausea and vomiting. They should force fluids or be hospitalized if the dehydration is severe. During the acute stage of this illness, patients should rest and engage in activity only as they feel well enough to do so. They should stay home from work, especially if they work in the food or hospitality industries. Clinicians should advise patients to rest their livers by avoiding alcoholic beverages and taking acetaminophen only when absolutely necessary and never exceeding recommended doses. Clinicians should consider hospitalizing the rare patient with fulminant hepatitis. Most cases will resolve on their own over a period of weeks to 6 months.

Having hepatitis A as a child confers lifelong immunity. Patients who develop hepatitis A later in life also develop immunity to future infection. However, they may be at risk for hepatitis B, and retail health care clinicians should recommend patients be vaccinated for hepatitis B. The patients’ contacts can receive post-exposure prophylaxis consisting of the first dose of the hepatitis A vaccine or immune globulin. Patients and their contacts should also be reminded of good hygiene, particularly handwashing and food preparation.

Hepatitis A is a reportable disease in the United States so that public health officials can attempt to find the source of exposure.

Public health officials hope to eradicate hepatitis A in the United States. The best way to do this is to promote vaccination, especially among adults who aged out of pediatric vaccinations before 1996.

Viral hepatitis; Hepatitis A. CDC website. cdc.gov/hepatitis/HAV/index.htm. Accessed April 30, 2017.

Murphy TV, Denniston MM, Hill HA, et al. Progress toward eliminating hepatitis a disease in the United States. MMWR Suppl. 2016;65(1):29-41.

Hepatitis A is a viral infection thatâ€™s transmitted via the fecal-oral route and causes an acute hepatitis. It is highly infectious and most likely to occur in injection drug abusers or men who have sex with men. 

Hepatitis A: Increasingly Rare but Entirely Possible

Herpes zoster, or shingles, is unfortunately quite common in community settings, despite the availability of a preventive vaccine. Patients—usually in their senescence or immunocompromised&mdash;generally seek treatment because they experience excruciating pain. The pain creates sleep disturbances, saps energy, and causes worry and anxiety. Left untreated, the pain may continue and become postherpetic neuralgia (PHN).

Although most cases of herpes zoster will resolve without intervention, patients who develop shingles will need and want medication. Retail health care providers need to be aware of the parameters within which they can prescribe antivirals and pain medications. The likelihood is that when faced with these patients, clinicians will need to consider the potential for medication interactions and possible organ impairment.

Patients may find that applying dressings saturated with 5% aluminum acetate (Burow’s solution) for 30 to 60 minutes up to 6 times daily will soothe some of the lesions. Patients can purchase Domeboro

astringent solution powder packets OTC, but they will need some guidance about how to reconstitute the powder. Calamine lotion may reduce itching.

Antiviral prescriptions, all of which are nucleoside analogues, are most effective if initiated within 72 hours of the appearance of lesions. Some studies indicate that they may be useful even after 72 hours, but the research is not definitive. Antivirals are clearly indicated if the patient has lesions along 2 or more dermatomes, in or near the eyes, or over a large area of the body. They can expedite lesion healing, decrease viral shedding, and decrease pain. Retail healthcare providers should advise patients that antivirals will not prevent PHN.

Oral famciclovir and valacyclovir are now preferred over acyclovir. Both of these antivirals are given 3 times daily for a week, which is an improvement over acyclovir’s 5-times daily dosing schedule. Immunocompromised patients may need longer durations of therapy. Retail health care providers should note that some acyclovir-resistant viral strains have been identified.

Patients who take these drugs may develop nausea, vomiting, headache, central nervous system disturbances, or dizziness. Therefore, those antivirals may be contraindicated in patients who have depression are cognitive impairment. All of these antivirals are excreted through the kidneys. Dose reductions will be needed in patients who have renal impairment, and retail health care providers should encourage patients to hydrate adequately. Patients who run renal dialysis should be advised by retail health care providers to take their dose after treatment.

Some prescribers use corticosteroids in short doses to reduce inflammation and pain.

Patients often need analgesics to deal with herpes zoster pain. In our elderly population, the “start low, go slow” approach is usually best. Increasing analgesic doses slowly often leads to an optimal dose with which pain is controlled and adverse effects are minimized.

·      Patients may find nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen helpful for mild pain. Prescribers must exercise care in patients who have cardiovascular disease or impaired renal function when they prescribe NSAIDs. And, of course, NSAIDs are associated with gastrointestinal upset and ulceration. A history of GI bleed or ulceration is not an absolute contraindication, but providers should prescribe these drugs with caution.

·      Opioids may be warranted in this case although retail health care providers should prescribe them care and provide quantities only sufficient to cover short periods. Constipation is a critical concern, especially in elderly patients, and retail health care providers should prescribe a concurrent high-fiber diet, stool softeners, and laxatives.

·      Antiepileptic drugs and tricyclic antidepressants can be used as adjunct analgesics. Many of these also cause drowsiness, so patients will need to be warned. Gabapentin and pregabalin are used often and, likewise, will need adjustment in renal impairment.

It’s critical to tell patients that if they develop lesions near or on their eyes, then they must return for referral to an ophthalmologist immediately. It’s also important to stress that they need to take the entire course of antiviral medication—even after they begin feeling better. It’s critical to manage patients’ expectations. That means explaining possible adverse effects and describing the usual course of the condition. It’s critical to manage patients’ expectations. The following is a guide to explaining possible adverse effects and describing the usual course of the condition.

·      Blistering, painful lesions will develop over a period of 1 to 2 weeks along at least one dermatome.

·      Over the course of 2 to 4 weeks, the lesions will develop, and as they heal, they’ll crust over.

·      Pain may present as pins-and-needles, itching, burning or as deep as possible.

·      Some patients develop fever or muscle weakness:

o   Until the lesions crossed over, this condition is contagious

o   Patients should avoid contact with others who have not had chickenpox, and with especially pregnant women.

o   Patients should keep skin clean, discard bandages carefully, and discard or wash clothing in hot water if it has come in contact with lesions.

Before ending a visit for shingles, retail health providers who review the patient’s entire medication regimen including their OTC medications and complementary and alternative medications do patients a great service. Often, patients are confused about what they are or should be taking, and spending a few minutes reviewing the regimen can prevent medication misadventure. A brief call to the patient’s pharmacist can also shed light on any vagaries.

Sleep disturbances can be one of the most troubling sequelae associated with shingles. Retail health care providers may prescribe opioids at bedtime, but patients will need counseling so that they don’t experience orthostatic hypotension or falls if they get up during the night.

Experiencing an episode of shingles boosts immunity to the virus and may be protective against future bouts of shingles, but some people develop shingles more than once. The CDC recommends the shingles vaccine for all adults ages 60 and older. Giving the vaccine at the same time as patients are receiving antiviral agents is unwise. Clinicians should wait at least 14 days after the patient has discontinued his or her antiviral regimen to administer the zoster vaccine.

Our elders should receive the vaccine whether or not they have had shingles. It’s important to counsel patients that the shingles vaccine is not 100% effective; some people who receive it will still develop shingles. If they do, the severity and duration of the condition is usually shorter than in unvaccinated individuals. The shingles vaccine is contraindicated in HIV-infected individuals, patients who are on immune system suppressing drugs or treatments, and patients who are pregnant.

Beuscher L, Reeves G, Harrell D. Managing herpes zoster in older adults: prescribing considerations.

April 24, 2017. doi:10.1097/01.NPR.0000516122.15244.0e. [Epub ahead of print]

Giovanni G, Nicoletta V, Parvanè K, Silvia L, Armando S. Prevention of herpes zoster and its complications: from the clinic to the real-life experience with the vaccine.

Herpes zoster, or shingles, is unfortunately quite common in community settings, despite the availability of a preventive vaccine. 

Jeannette Wick

Articles

The Nurse's Role in Heart Failure: Early Intervention

Making a Dent in the Flu: Try In-Reach!

Hepatitis A: Increasingly Rare but Entirely Possible

Acute Management of Herpes Zoster: Prescribing Considerations