Nursing Case Study American Heart Association

Question: Describe about the Nursing Case Study for American Heart Association. Answer: Introduction This study aims to present a complex case study and undertake a critical analysis of the chosen case. The medical problem that has been selected for the case study is Chronic Cardiac Failure (CCF) with type 2 diabetes. The study will provide the details of the relevant medical history and present condition of the selected case. It will describe the pathophysiology underlying the main reason for the current hospital admission. A list of medications, rationales and the special considerations associated with the medications of the selected case will be highlighted. A discussion regarding the relevant and current diagnostics/ treatments will be provided in this study. In addition, a log of daily activities in relation to the nursing care implemented for chronic cardiac failure with type 2 diabetes will be provided. Besides all these, the study will reflect on the nursing care provided and the outcomes of care together with the improvements that can be made with respect to chronic cardiac failure with type 2 diabetes. Case study Mrs. Smith is 67-year-old Hispanic female; who is suffering from Chronic Cardiac Failure along with type 2 diabetes has been admitted in the hospital in the morning due to the exacerbation of her symptoms. She is obese and smokes one pack of cigarette a day. The patient states that her readings of home blood sugar have increased. She admits that while going out with her family she consumes dessert and some other stuff, which contains less amount of sugar. For exercises, she walks half an hour every day. She denies polydipsia and polyphagia. She has a family history of diabetes, as her father was diabetic and had died 10 years back. The medical history of the patient is significant for type 2 diabetes that has been diagnosed 3 years back when she had a random glucose level of 278 mg/dL. At that time, her HBA1c level was 8.5%. She was prescribed metformin 50 gm twice every day and within a span of three months, her HbA1c levels had dropped to 7.5%. At that time, metformin was increased to 1000 mg twice every day. Her vital signs are temperature: 98.2 F, blood pressure 124/76 mm Hg, respiratory rate 19, heart rate 80, BMI 33.2, Height 56 and weight 195 pounds. The current medications of the patient include insulin, triarnterene and hydrochlorothiazide and metformin. The patient states that she is not following any specific diet and is worried regarding hypoglycemia as she is in a habit of consuming extra snacks. She has been advised by her family doctor to improve her health conditions. The patient complains that her knee-pain is not allowing her to perform exercise and physical activities on a daily basis. On laboratory examination, her creatinine and liver function tests, urine microalbumin and thyroid function tests are normal. After being explained by the doctor that the increased doses of insulin is contributing in weight gaining process and there is a need reducing her dose of insulin together with intake of high calorie food preventing hypoglycemia, she agreed for following a calorie-restricted diet and top reduce her doses of insulin. The physician reassures her that the further reduction of insulin would help in preventing hypoglycemia. Pathophysiology This section will describe the pathophysiology of chronic cardiac failure with type 2 diabetes. In the diabetic populations, heart failure may occur irrespective of typical factors of risk like high blood pressure and coronary artery disease (Zinman et al., 2015). A number of hypotheses have been proposed for explaining the reduced myocardial contractility in the individuals suffering from type 2 diabetes. These comprise myocardial fibrosis, metabolic disturbances, autonomic neuropathy, accumulation of AGE, impaired calcium homeostasis, insulin resistance and small vessel disease (Gheorghiade et al., 2013). In the patients suffering from type 2 diabetes, the changes in metabolism are elicited by hyperglycemia. Normally, the free fatty acids are use by the myocytes as a key energy source while performing aerobic exercises. In the patients suffering from type 2 diabetes, an altered metabolism is related to increased consumption of myocardial oxygen as well as increased concentrations of free fatty acids in the serum (Zinman et al., 2015). A high consumption of oxygen is required for the metabolism of enormous levels of free fatty acids leading to intracellular accumulation of intermediates that are toxic in nature and may have a negative effect on the myocardial performance. In oxidative stress, high levels of glucose gets oxidized within the cell starts the production of reactive oxygen species and it also boost oxidative stress. The increased levels of reactive oxygen species might result in cardiac dysfunction through the mechanisms except cellular injury (Jaarsma et al., 2013). In diabetic patients, endothelial dysfunction takes place in the coronary vessels and may result in reduced or impaired flow of blood. It has been found by few researchers that the concentration of chronic elevated glucose induces the reduction of plasma nitric oxide. It has been reported that reactive oxygen species are responsible for impairing the endothelium-dependent vascular relaxation by means of nitric oxide inactivation (Montalescot et al., 2013). The accumulation of the end products of advanced glycation takes place in the tissues and can result in the morphological modifications in the heart. This accumulation not only decreases the elasticity of the walls of the vessel but it also lead to myocardial dysfunction. Hyperglycemia in myocardial fibrosis may result in an abnormal expression of gene and transformation of signal transduction that can lead to the activation of pathways, which are responsible for apoptosis. It can stimulate the necrosis of myocytes directly that le ads to an increased collagen deposition (McMurray et al., 2014). In diabetic patients, the modifications in the structure and function of the small vessels can also result in chronic heart failure. Some of the studies have revealed that the pathological modifications in the capillaries are not responsible for developing myocardial dysfunction (Frederich et al., 2015). Cardiac autonomic neuropathy is related to the enhanced cardiovascular risk in the diabetic patients and it can lead to impairment in the diastolic function. Numerous studies have revealed a relationship between the parasympathetic and cardiac dysfunction with reduced variation in the mean heart rate (Look AHEAD Research Group, 2013). Medications A number of studies related to the heart failure have revealed that different classes of medications (drugs) which are best to treat heart failure with type 2 diabetes (Holloway Wheeler, 2013).The patients suffering from this condition may require several medications. Each of these is used for treating a different symptom and comes with specific instructions (Grove, Burns Gray, 2014). If these medications are are not taken in a correct manner, then they will not be able to perform their action appropriately. Some of the most common medications include Ramipril, Fosinopril, Captopril, Trandolapri, and Quinapril. These medications fall in the category of Angiotensin-converting Enzyme (ACE) Inhibitirs. The other category of medications includes Angiotensin II Receptor Inhibitors, which comprise Valsartan, Losartan and Candesartan (Boonman-de Winter et al., 2012). In addition to these, the other category of medications includes Beta-blockers, which include Carvedilol, Metoprolol and Bi soprolol. Besides all these, the other categories of medications include Aldosterone Antagonists, which comprise Eplerenone and Spironolactone. It has been observed that some of the other medications, which can be prescribed to the patients, include Digoxin, cholesterol lowering drugs and Anticoagulants. Digoxin may be prescribed to some of the patients having chronic heart failure as prescribed by the doctor. Anticoagulants are also known as blood thinners and can be prescribed to the patients having heart failure along with atrial fibrillation (Marso et al., 2016). They are not used for the treatment of chronic heart failure patients who do not have atrial fibrillation. The doctor may prescribe cholesterol-lowering drugs to the patients having high cholesterol levels or the patients who suffered from a heart attack previously. These drugs are not used specifically for the treatment of heart failure, except other conditions as indicated (Holloway Wheeler, 2013). The medications of diabetes include pioglitazone and rosiglitazone. Both of these drugs belong to the known as thiazolidinediones. Initially for controlling glycemia, Troglitazone was effective but it has been removed from the market, as it is toxic for the liver. Pioglitazone and Rosiglitazone are indicated either in the form of monotherapy or as a blend with metformin, sulfonylurea, or insulin while performing exercises or having diet (Parahoo, 2014). If any of these drug is prescribes individually then a sufficient glycemic control cannot be resulted. Besides lowering the blood glucose levels, these two drugs may be advantageous for the cardiovascular parameters like endothelial function, inflammatory biomarkers, blood pressure, fibrinolytic status and lipids (Polit Beck, 2013). These advantageous effects of thiazolidinediones on cardiovascular risk factors and glycemia have made them potential agents for the patients suffering from type 2 diabetes and are prone to develop cardio vascular diseases (Grove, Burns Gray, 2014).The risk factors of chronic heart failure such as high blood pressure and coronary artery disease commonly occur in the diabetic patients. These factors of risk perform synchronously in diabetes for increasing the risk of chronic heart failure (Grove, Burns Gray, 2014). These classes of drugs can be prescribed to the patients suffering from type 2 diabetes and having significant asymptomatic cardiac disease (American Diabetes Association, 2013). Diagnosis Chronic heart failure diagnosis is performed through the association of distinctive sign and symptoms with confirmation for instance obtained from an electrocardiogram, chest x-ray and plasma natriuretic peptide testing (Johansson et al., 2016). Imaging studies that documents the diastolic and systolic dysfunction as well as biomarkers are beneficial for diagnosis. In differentiating diastolic and systolic heart failure, systolic heart failure physical examination is not advantageous since the similar findings, together with S3 gallop and cardiomegaly can be observed in both the conditions (Marso et al., 2016). In chronic heart failure, the heart of the patient may is enlarged and the buildup of fluid can be evident in the lungs (Polit Beck, 2013). The doctor can employ an x-ray for diagnosing the conditions except chronic heart failure that can give details regarding the signs and symptoms. Electrocardiogram is test, which is used for recording the electrical activity of the heart by means of electrodes that are attached with the skin of the patient (Fried et al., 2013). The impulses are recorded in the form of waves and are printed on a paper or are displayed on a screen. Electrocardiogram helps the doctor to diagnose the problems associated with the rhythm of the heart and the damage to the heart due to heart attack. For diagnosing chronic heart failure, echocardiogram is an important test (Grove, Burns Gray, 2014). It helps in distinguishing between diastolic heart failure and systolic heart failure in which there is stiffness in the heart and it cannot fill accurately. It uses sound waves for producing a visual image of the heart and the doctors can be benefitted from this method for seeing the shape and size of the heart and to observe the proper functioning of the heart (Polit Beck, 2013). In addition, it can also assist the doctors for checking the problems in valve or confirmation of a previous heart attack and other abnormalities or some uncommon c auses of chronic heart failure (Marso et al., 2016). The measurement of ejection fraction can also be done during an electrocardiogram and it can be measured by cardiac MRI, Cardiac catheterization and nuclear medicine tests (Grove, Burns Gray, 2014). It is a significant measurement regarding whether the heart is pumping properly and it is used to assist in classifying heart failure as well as guide treatment (White et al., 2013). In addition to these, stress tests can evaluate how the the blood vessels and heart act in response towards exertion. Stress tests the doctor in determining whether the patient has coronary artery disease. They also help in determining how well the patients body is acting in response to the reduced pumping effectiveness of the heart and can help as a guide in making long-term decisions associated with the treatment of the patients. In addition, myocardial biopsy can also be helpful, in which a small and flexible biopsy cord is inserted by the doctor into the vein of the neck or groin region and small portions of muscles of the heart is taken. This test can be performed for diagnosing certain types of diseases associated with the heart muscle that cause chronic heart failure (Paneni et al., 2013). Log of daily activities Observations Rationale Evaluation The diet of the patient will be monitored regularly. The patient will be advised to have a diet which is relatively low in cholesterol, saturated fat and sodium (Feltner et al., 2014). To reduce weight as the patient is suffering from this condition will be benefitted effectively. The patient will be instructed to avoid high calorie food together with the foods having a low concentration of salt (Mebazaa et al., 2015). The outcomes will be evaluated based on the improvements in the health of the patient. The fluid retention capacity will be monitored by weighing the patient on a daily basis (Billings Halstead, 2015). To have an adequate balance of fluid in the body (Stamp, Machado Allen, 2014). The evaluation of outcomes will be done with respect to the improvements in the health of the patient. The patient will be monitored daily whether she is performing exercises or not (Taylor et al., 2014). Physical activities and aerobic exercise has an advantageous effect on the health of the patient. The outcomes will be evaluated on the basis of the improvements in the health of the patient Monitoring of patients health and wellbeing will be done For determining, whether the patient is not facing any issues of mental health and wellbeing (Pandey et al., 2015). The evaluation of outcomes will be done with respect to the improvements in the health of the patient. The patient will be allowed for a moderate consumption of caffeine in a day and will be monitored regularly (Butcher et al., 2013). To maintain a proper health of the patient (Stamp, Machado Allen, 2014). The outcomes will be evaluated on the basis of the improvements in the health of the patient Patients blood pressure will be monitored on a regular basis. The monitoring of blood pressure will ensure to provide medications to the patient. The readings of blood pressure will be charted for getting information whether the blood pressure is elevated or reduced To provide information to the patient regarding her blood pressure and assure her that it will be managed as several researches has revealed that regular monitoring of blood pressure is helpful (Mebazaa et al., 2015). The evaluation of outcomes will be done with respect to the improvements in the health of the patient. The nurse will observe that whether the patient is taking adequate rest or not (McMurray et al., 2012). Adequate rest and sleep is essential for the patient for improving her symptoms. The patient will be advised to have sufficient as well as peaceful sleep in the night by pillows for propping up her head and she should avoid big meals and sleep before bedtime, as it is not good for her health. The outcomes will be evaluated on the basis of the improvements in the health of the patient The nurse will monitor that the patient wears appropriate clothing as tight clothing can slow down the flow of blood in body and can develop clots. If in case, there is a need for adding or removing the layers of clothing it can be done by the nurse depending on the condition of the patient (Ekman et al., 2012). For ensuring that the patient feels comfortable and there is no obstruction in the the flow of blood in the body of the patient (Pandey et al., 2015). The evaluation of outcomes will be done with respect to the improvements in the health of the patient. The nurse must ensure that the patient is getting enough support in order to overcome from her condition (restedt et al., 2013). By having support from, the patient will be comfortable and her symptoms of the disease will improve (Stamp, Machado Allen, 2014). The outcomes will be evaluated on the basis of the improvements in the health of the patient Keeping a track of the symptoms on a regular basis and recording the changes (Feltner et al., 2014). This will help to identify the problem areas that are responsible for the exacerbation of the symptoms of the disease (Mebazaa et al., 2015). The evaluation of outcomes will be done with respect to the improvements in the health of the patient Monitoring the health and wellbeing of the patient To determine, whether the patient is not facing any issues related to her mental health and wellbeing (Pandey et al., 2015). The outcomes will be evaluated on the basis of the improvements in the health of the patient In addition to all these, the patient should be provided with education regarding the management of chronic heart failure with type 2 diabetes (Mebazaa et al., 2015). The patient must be instructed for checking their weight after urinating in the morning and before taking breakfast. The patient must also be taught to wear light clothes. The nursing intervention that will be provided to the patient must focus on educating the patient along with her family to avoid the chronic episodes. The most important role of the nurse is to educate the patient for bringing the prescriptions in every appointment in the clinic or at the time of readmission in the hospital, as it is easy for identifying the possible lapses, increase in dose or certain type of confusions (Stamp, Machado Allen, 2014). The patient is also recommended for identifying the absence of presence of weakness together with shortness of breath while carrying out the daily living activities and will be instructed for monitoring the improvement or exacerbation of symptoms (Pandey et al., 2015). The patent will be instructed to avoid high calorie food accompanied by the foods having a high concentration of salt as it is not good for health and might aggravate her health conditions. The patient should be allowed for a moderate consumption of caffeine in a day and will be monitored regularly. The patient will be advised to avoid the drugs such as corticosteroids, tricyclic antidepressants and calcium-channel blockers. The nurse should keep a track of the symptoms on a regular basis and should report the changes in the health condition of the patient to the physician on a daily basis (Shively et al., 2013). The nurse must observe that whether the patient is taking adequate rest or not. The monitoring of the patients health and wellbeing should be carried out regularly to determine, whether the patient is not facing any issues of mental health and wellbeing (Mebazaa et al., 2015). Physical activities and aerobic exercise can have a beneficial effect on the health of the patient. The blood pressure of the patient must be monitored on a regular basis (McHugh Ma, 2013). The monitoring of blood pressure will ensure to provide medications to the patient. The readings of blood pressure must be charted for getting information whether the blood pressure is high or reduced (Feltner et al., 2014). The regime of medication must be evaluated with the patient and presented to her schematically, by highlighting the names of medication, schedules, dosages, indications and potential side effects (Allen et al., 2012). One of the simplest strategies that can be employed involves the making of a table comprising of the names as well as time of taking the drugs or medications and this table can be placed somewhere, which is easily visible to the patient as well as her family members. In addition, the nurse must advise the patient to take her medication even if she feels well as it will be effective for her health conditions (Wakefield et al., 2013). Reflection, nursing outcomes and required improvements In my opinion, the nursing care provided to the patient is appropriate and the outcomes of the nursing care have identified what has been done well and what has not been done well. Since the patient has been suffering from chronic heart failure with type 2 diabetes, she has been provided with the nursing care that is appropriate for improving the outcomes. The patient was instructed to maintain the adequate balance of fluid in the body. After carefully monitoring the fluid retention capacity of her body, it has been found her bodys capability of fluid retention has improved. The patient was instructed to perform exercises on a daily basis. After vigilantly monitoring her, I have analyzed that her symptoms have improved to a certain extent and this nursing care has proved to be beneficial for the patient. In my opinion, exercises are helpful for the patients suffering from chronic heart failure as it improves their health conditions. The patient was instructed to monitor her blood pre ssure regularly and after monitoring her, I have found that sometimes she forget to monitor her blood pressure and due this, I am unable to analyze whether her blood pressure is constant or it fluctuates on a daily basis. The patient has been instructed to have adequate rest and sleep for improving her symptoms. After monitoring her, it has been found that she is taking adequate rest and sleep and her symptoms have improved significantly. In my opinion, this nursing care has proved to be effective in improving the symptoms of the patient. The patient has been instructed to wear loose clothes so that the blood flow in her body remains uniform. After monitoring her on a regular basis, I have found that her symptoms have improved up to a certain extent. In my opinion, this nursing care has a role in main in preventing the formation of clots, therefore wearing of loose clothes is beneficial and there is always a need to ensure that the patient is comfortable there is no obstruction in t he flow of blood in the body of the patient. The nurse kept a track on the symptoms of the patient on a regular basis and has recorded the changes. In my opinion, this step plays a significant role in identifying the problem areas which are responsible for the aggravation of symptoms of the patients disease. I have analyzed that the health outcomes of the patient has improved since the doctor is getting all the information regarding the symptoms of her disease, particularly the improvements in health or exacerbation of health. In addition to all of these, the diet of the patient has been monitored regularly and the patient was advised to consume a cholesterol free diet and she must also avoid sodium and saturated fat. After carefully monitoring her, it has been found that her cholesterol level has reduced and she did not gain enough weight as she had followed a strict diet. In my opinion, this nursing care has been effective in managing her symptoms and helped her to reduce her weig ht. In addition she was also instructed to consume diet which has low salt concentration and it has helped her to maintain her blood pressure levels. It is evident that a majority of the nursing care has been beneficial in improving the outcomes of the patient however; some of them have not been much effective. The care of the patient could be improved by educating the patient regarding modification of lifestyle and benefits of exercise. The nurse should keep a track of the symptoms regularly and should report the changes in the health condition of the patient to the physician on a daily basis. The patent must be instructed to avoid high calorie food and the foods having a high concentration of salt. She should be allowed for a moderate consumption of caffeine in a day and will be monitored regularly. She should be educated regarding weight management and fluid retention. In addition, the nurse should encourage the patient to perform anaerobic exercise in combination with pharmacological therapy in her management plan in an efficient manner. References Allen, L. A., Stevenson, L. W., Grady, K. L., Goldstein, N. E., Matlock, D. D., Arnold, R. M., ... Havranek, E. P. (2012). Decision making in advanced heart failure a scientific statement from the American Heart Association.Circulation,125(15), 1928-1952. American Diabetes Association. (2013). Standards of medical care for patients with diabetes mellitus.Puerto Rico Health Sciences Journal,20(2). restedt, K., Saveman, B. I., Johansson, P., Blomqvist, K. (2013). Social support and its association with health-related quality of life among older patients with chronic heart failure.European Journal of Cardiovascular Nursing,12(1), 69-77. Billings, D. M., Halstead, J. A. (2015).Teaching in nursing: A guide for faculty. Elsevier Health Sciences. Boonman-de Winter, L. J. M., Rutten, F. H., Cramer, M. J. M., Landman, M. J., Liem, A. H., Rutten, G. E. H. M., Hoes, A. W. (2012). High prevalence of previously unknown heart failure and left ventricular dysfunction in patients with type 2 diabetes.Diabetologia,55(8), 2154-2162. Butcher, H. K., Bulechek, G. M., Dochterman, J. M. M., Wagner, C. (2013).Nursing interventions classification (NIC). Elsevier Health Sciences. Ekman, I., Wolf, A., Olsson, L. E., Taft, C., Dudas, K., Schaufelberger, M., Swedberg, K. (2012). Effects of person-centred care in patients with chronic heart failure: the PCC-HF study.European heart journal,33(9), 1112-1119. Feltner, C., Jones, C. D., Cen, C. W., Zheng, Z. J., Sueta, C. A., Coker-Schwimmer, E. J., ... Jonas, D. E. (2014). Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis.Annals of internal medicine,160(11), 774-784. Frederich, R., Alexander, J. H., Fiedorek, F. T., Donovan, M., Berglind, N., Harris, S., ... Mahaffey, K. W. (2015). A systematic assessment of cardiovascular outcomes in the saxagliptin drug development program for type 2 diabetes.Postgraduate medicine. Fried, L. F., Emanuele, N., Zhang, J. H., Brophy, M., Conner, T. A., Duckworth, W., ... Reilly, R. F. (2013). Combined angiotensin inhibition for the treatment of diabetic nephropathy.New England Journal of Medicine,369(20), 1892-1903. Gheorghiade, M., Vaduganathan, M., Fonarow, G. C., Bonow, R. O. (2013). Rehospitalization for heart failure: problems and perspectives.Journal of the American College of Cardiology,61(4), 391-403. Grove, S. K., Burns, N., Gray, J. R. (2014).Understanding nursing research: Building an evidence-based practice. Elsevier Health Sciences. Holloway, I., Wheeler, S. (2013).Qualitative research in nursing and healthcare. John Wiley Sons. Jaarsma, T., Strmberg, A., Gal, T. B., Cameron, J., Driscoll, A., Duengen, H. D., ... Kberich, S. (2013). Comparison of self-care behaviors of heart failure patients in 15 countries worldwide.Patient education and counseling,92(1), 114-120. Johansson, I., Dahlstrm, U., Edner, M., Nsman, P., Rydn, L., Norhammar, A. (2016). Prognostic implications of type 2 diabetes mellitus in ischemic and nonischemic heart failure.Journal of the American College of Cardiology,68(13), 1404-1416. Look AHEAD Research Group. (2013). Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes.N engl J med,2013(369), 145-154. Marso, S. P., Daniels, G. H., Brown-Frandsen, K., Kristensen, P., Mann, J. F., Nauck, M. A., ... Steinberg, W. M. (2016). Liraglutide and cardiovascular outcomes in type 2 diabetes.New England Journal of Medicine,375(4), 311-322. McHugh, M. D., Ma, C. (2013). Hospital nursing and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia.Medical care,51(1), 52. McMurray, J. J., Adamopoulos, S., Anker, S. D., Auricchio, A., Bhm, M., Dickstein, K., ... Jaarsma, T. (2012). ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012.European journal of heart failure,14(8), 803-869. McMurray, J. J., Packer, M., Desai, A. S., Gong, J., Lefkowitz, M. P., Rizkala, A. R., ... Zile, M. R. (2014). Angiotensinneprilysin inhibition versus enalapril in heart failure.New England Journal of Medicine,371(11), 993-1004. Mebazaa, A., Yilmaz, M. B., Levy, P., Ponikowski, P., Peacock, W. F., Laribi, S., ... McDonagh, T. (2015). Recommendations on pre?hospital early hospital management of acute heart failure: a consensus paper from the Heart Failure Association of the European Society of Cardiology, the European Society of Emergency Medicine and the Society of Academic Emergency Medicine.European journal of heart failure,17(6), 544-558. Meta-analysis Global Group in Chronic Heart Failure (MAGGIC. (2012). The survival of patients with heart failure with preserved or reduced left ventricular ejection fraction: an individual patient data meta-analysis.European Heart Journal,33(14), 1750-1757. Montalescot, G., Sechtem, U., Achenbach, S., Andreotti, F., Arden, C., Budaj, A., ... Ferreira, J. R. (2013). 2013 ESC guidelines on the management of stable coronary artery disease.European heart journal,34(38), 2949-3003. Pandey, A., Parashar, A., Kumbhani, D. J., Agarwal, S., Garg, J., Kitzman, D., ... Berry, J. D. (2015). Exercise training in patients with heart failure and preserved ejection fraction meta-analysis of randomized control trials.Circulation: Heart Failure,8(1), 33-40. Paneni, F., Beckman, J. A., Creager, M. A., Cosentino, F. (2013). Diabetes and vascular disease: pathophysiology, clinical consequences, and medical therapy: part I.European heart journal, eht149. Parahoo, K. (2014).Nursing research: principles, process and issues. Palgrave Macmillan. Polit, D. F., Beck, C. T. (2013).Essentials of nursing research: Appraising evidence for nursing practice. Lippincott Williams Wilkins. Shively, M. J., Gardetto, N. J., Kodiath, M. F., Kelly, A., Smith, T. L., Stepnowsky, C., ... Larson, C. B. (2013). Effect of patient activation on self-management in patients with heart failure.Journal of Cardiovascular Nursing,28(1), 20-34. Stamp, K. D., Machado, M. A., Allen, N. A. (2014). Transitional care programs improve outcomes for heart failure patients: an integrative review.Journal of Cardiovascular Nursing,29(2), 140-154. Taylor, R. S., Sagar, V. A., Davies, E. J., Briscoe, S., Coats, A. J., Dalal, H., ... Singh, S. (2014). Exercise?based rehabilitation for heart failure.The Cochrane Library. Wakefield, B. J., Boren, S. A., Groves, P. S., Conn, V. S. (2013). Heart failure care management programs: a review of study interventions and meta-analysis of outcomes.Journal of Cardiovascular Nursing,28(1), 8-19. White, W. B., Cannon, C. P., Heller, S. R., Nissen, S. E., Bergenstal, R. M., Bakris, G. L., ... Wilson, C. (2013). Alogliptin after acute coronary syndrome in patients with type 2 diabetes.New England Journal of Medicine,369(14), 1327-1335. Zinman, B., Wanner, C., Lachin, J. M., Fitchett, D., Bluhmki, E., Hantel, S., ... Broedl, U. C. (2015). Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes.New England Journal of Medicine,373(22), 2117-2128.