Managing Heart Failure in Home Care

1. 2005 Ann K. Frantz BSN RN PhD(c) 1 Managing Heart Failure in Home Care Transitioning Patients From Acute Care to Self Care

2. 2005 Ann K. Frantz BSN RN PhD(c) 2

3. 2005 Ann K. Frantz BSN RN PhD(c) 3

4. 2005 Ann K. Frantz BSN RN PhD(c) 4 Goal of Care Independence Transition from role of patient to self-care No ER visits No hospitalizations No unscheduled home care visits

5. 2005 Ann K. Frantz BSN RN PhD(c) 5 Objectives Adherence to medication regimen Identification of early S&S of exacerbation Daily monitoring Zo � fluid status Weight Blood pressure Symptoms Breathlessness Verbal understanding and demonstration of adherence with a low sodium diet

6. 2005 Ann K. Frantz BSN RN PhD(c) 6 Disease Etiology Ejection Fraction (EF) less than 40% per echocardiogram Systolic dysfunction Inefficient pumping due to big baggy overstretched heart Diastolic dysfunction Inefficient pumping due to thickened myocardium with not enough space to hold blood

7. 2005 Ann K. Frantz BSN RN PhD(c) 7 Heart Failure Classifications Based on ability to function with symptoms.

8. 2005 Ann K. Frantz BSN RN PhD(c) 8 Taking Heart Failure History S&S exacerbation Activity Breathlessness Number of pillows used at night Sleep patterns Nutrition Urine output and character Last echocardiogram & results Systolic or diastolic failure Medication regimen

9. 2005 Ann K. Frantz BSN RN PhD(c) 9 Physical Assessment Inspection Skin color Nail beds Orientation, concentration, forgetfulness Respirations Presence of cough Level of fatigue Mucous membranes color Jugular venous distention (JVD) Edema measurements ankles/girth/wrists/knee Mood/affect

10. 2005 Ann K. Frantz BSN RN PhD(c) 10 Physical Assessment Auscultation Blood pressure Sitting standing Heart tones S1&S2 S3 Lung sounds crackles Palpation Skin temperature Skin turgor Capillary refill Pulses Radial Dorsalis pedis Edema Ascites Liver border Hepatojugular reflux

11. 2005 Ann K. Frantz BSN RN PhD(c) 11 Medication Regimen Diastolic Failure Isordil/hydralizine ACEi Diuretic Systolic Failure Diuretic Spironolactone Hydralazine Furosemide Bumetanide ACEi Beta Adrenergic blocker carvedilol

12. 2005 Ann K. Frantz BSN RN PhD(c) 12 Medications Atrial fibrillation common which has high recommendation for chronic persistent a-fib and warfarin Cardiac Glycoside � digoxin Potassium supplementation � due to electrolyte imbalance resulting from diuresis

13. 2005 Ann K. Frantz BSN RN PhD(c) 13 ACEi � must reach target

14. 2005 Ann K. Frantz BSN RN PhD(c) 14 Beta Blockade used in Heart Failure Treatment

15. 2005 Ann K. Frantz BSN RN PhD(c) 15 Inotropic Infusion Intermittant or Continuous Dobutamine (Dobutrex), Milrinone (Primacor), Dopamine PICC or Central line Caregiver willing to take responsibility to learn IV hook-up & flushing Refrigerator & telephone required Hemodynamic changes must be well documented Just because inotropic infusion, doesn�t mean that patient is homebound

16. 2005 Ann K. Frantz BSN RN PhD(c) 16 Low Sodium Diet Patient & CG must be taught that diet less than 2500mg sodium. Inventory cupboards Food diary Read labels with patients Instruct etiology behind low sodium

17. 2005 Ann K. Frantz BSN RN PhD(c) 17 Fluid Restrictions? ACC, Heart Failure Society and American Heart Association do not recommend routine fluid restrictions More problems arise with electrolyte imbalance than with fluid management

18. 2005 Ann K. Frantz BSN RN PhD(c) 18 Barriers to Self-Management Despite good information and teaching, patients still did not retain information due to memory loss and poor concentration Rogers, 2000 Symptom burdens and misconceptions or lack of knowledge regarding heart failure self care were the reason for non-adherence Reigal & Carlson, 2001

19. 2005 Ann K. Frantz BSN RN PhD(c) 19 Lack of Concentration Many studies that research heart failure population find that the most common complaints include fatigue, lack of concentration and forgetfulness. (Riegal,2002; Rogers, 2000) Scoring OASIS must reflect this disease trait. Even though on SOC patient is A&O x3, nurse should give score MO 560, 600, 610 that indicates the need to reinstruct repetetively in order to attain regimen integration.

20. 2005 Ann K. Frantz BSN RN PhD(c) 20 Heart Failure Exacerbation

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22. 2005 Ann K. Frantz BSN RN PhD(c) 22 Consistency vs Accuracy In home monitoring, accuracy is not as important as consistency. Always measure physiological parameters consistently at the same time of day and in relation to daily activities; such as before meals, before medication, after morning shower.

23. 2005 Ann K. Frantz BSN RN PhD(c) 23 Monitor Daily Weight Same time Same place Address changes Timeline Causative factors? Report 2# increase in 24 hours or 5# increase in one week. Don�t forget to address weight reduction

24. 2005 Ann K. Frantz BSN RN PhD(c) 24 Breathlessness Scale

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26. 2005 Ann K. Frantz BSN RN PhD(c) 26 When is the Patient Ready to Transition to Self-Care? Within 12-14 visits Stable with goals met Verbalize and demonstrate self-monitoring goals and objectives Verbalizes early exacerbation signs Medication regimen adherence Nurse is no longer needed

27. 2005 Ann K. Frantz BSN RN PhD(c) 27