Managing Heart Failure in Home Care Transitioning Patients

Managing Heart Failure in Home Care Transitioning Patients From Acute Care to Self Care Ann K. Mc. Caughan BSN RN Ph. D(c) 1

Goal of Presentation Ø Provide overview of heart failure management in home care Ø Increase nurses knowledge and understanding of home care goals & objectives for the heart failure patient population Hand-outs • Gorski, L. 2002. Improving the quality of home care for patients with heart failure. CARING Magazine. March 2002, p. 10 -14. • Gorski, L. 2002. Positivie inotropic drug infusions for patients with heart failure. Home Healthcare Nurse. Vol 20(4) p. 244 -253. • Slides 19 & 23 Ann K. Mc. Caughan BSN RN Ph. D(c) 2

Where Are the Home Care Dollars Spent? Ann K. Mc. Caughan BSN RN Ph. D(c) 3

Goal of Care Ø Independence Ø Transition from role of patient to self-care Ø No ER visits Ø No hospitalizations Ø No unscheduled home care visits Ann K. Mc. Caughan BSN RN Ph. D(c) 4

Objectives Adherence to medication regimen Ø Identification of early S&S of exacerbation Ø Daily monitoring Ø l l l Ø Zo – fluid status Weight Blood pressure Symptoms Breathlessness Verbal understanding and demonstration of adherence with a low sodium diet Ann K. Mc. Caughan BSN RN Ph. D(c) 5

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

Heart Failure Classifications Based on ability to function with symptoms. Classifications of Heart Failure Class I - No symptoms (EF less than 40%) Class II - Symptoms with ordinary exertion Class III - Symptoms with less than ordinary exertion Class IV - Symptoms at rest Ann K. Mc. Caughan BSN RN Ph. D(c) 7

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

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

Physical Assessment Auscultation Ø Blood pressure l l Ø Heart tones l l Ø Sitting standing S 1&S 2 S 3 Palpation Ø Skin temperature Ø Skin turgor Ø Capillary refill Ø Pulses l l Lung sounds Ø crackles Ø l Ø Ø Radial Dorsalis pedis Edema Ascites Liver border Hepatojugular reflux Ann K. Mc. Caughan BSN RN Ph. D(c) 10

Medication Regimen Diastolic Failure Ø Isordil/hydralizine Ø ACEi Ø Diuretic Systolic Failure Ø Diuretic l l Spironolactone Hydralazine Furosemide Bumetanide ACEi Ø Beta Adrenergic blocker Ø l carvedilol Ann K. Mc. Caughan BSN RN Ph. D(c) 11

Medications Ø Atrial fibrillation common which has high recommendation for chronic persistent a-fib and warfarin Ø Cardiac Glycoside – digoxin Ø Potassium supplementation – due to electrolyte imbalance resulting from diuresis Ann K. Mc. Caughan BSN RN Ph. D(c) 12

ACEi – must reach target Drug Dose Range (mg) Frequency Target Dosage Captopril 6. 25 -150 TID 50 mg tid Enalapril 2. 5 -20 BID 10 mg bid Lisinopril 2. 5 -40 QD 20 mg qd Ramipril 2. 5 -10 QD-BID 5 mg qd or bid Quinapril 5 -20 BID 10 mg bid Fosinopril 10 -40 BID 20 mg bid Trandolapril 1 -4 QD 4 mg qd Ann K. Mc. Caughan BSN RN Ph. D(c) 13

Beta Blockade used in Heart Failure Treatment DRUG Starting Dosage Target Dosage Carvedilol 3. 125 mg bid 6. 25 -25 mg bid Bisoprolol 1. 25 mg qd 10 mg qd Metoprolol 12. 5 mg qd 200 mg qd Ann K. Mc. Caughan BSN RN Ph. D(c) 14

Inotropic Infusion Intermittant or Continuous Ø Dobutamine (Dobutrex), Milrinone (Primacor), Dopamine Ø PICC or Central line Ø Caregiver willing to take responsibility to learn IV hook-up & flushing Ø Refrigerator & telephone required Ø Hemodynamic changes must be well documented Ø Just because inotropic infusion, doesn’t mean that patient is homebound Ø Ann K. Mc. Caughan BSN RN Ph. D(c) 15

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

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

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

Lack of Concentration Ø Many studies that research heart failure population find that the most common complaints include fatigue, lack of concentration and forgetfulness. (Riegal, 2002; Rogers, 2000) Ø Scoring OASIS must reflect this disease trait. Even though on SOC patient is A&O x 3, nurse should give score MO 560, 600, 610 that indicates the need to reinstruct repetitively in order to attain regimen integration. Ann K. Mc. Caughan BSN RN Ph. D(c) 19

Heart Failure Exacerbation Ann K. Mc. Caughan BSN RN Ph. D(c) 20

Ambiguous Symptom Monitoring Can Delay Action Self-regulation theory research found “When symptoms were ambiguous and unclear as indicators of illness, care seeking was delayed by 60% of the population. ” Leventhal, 1995 Physiological measurement specificity is imperative for successful outcomes! Use Zo. Nurses must help patient identify somatic sensations associated with exacerbation. Ann K. Mc. Caughan BSN RN Ph. D(c) 21

Consistency vs. Accuracy Ø In home monitoring, accuracy is not as important as consistency. Ø 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. Ann K. Mc. Caughan BSN RN Ph. D(c) 22

Monitor Daily Weight Ø Same time Ø Same place Ø Address changes l l Timeline Causative factors? Ø Report 2# increase in 24 hours or 5# increase in one week. Ø Don’t forget to address weight reduction Ann K. Mc. Caughan BSN RN Ph. D(c) 23

Grade 0 Breathlessness Scale Degree None Description Not troubled with breathlessness except with strenuous exercise 1 2 Slight Moderate 3 Severe 4 Very Severe Troubled by shortness of breath when hurrying on level ground or walking up a slight hill Walks slower than people of the same age on level ground because of breathlessness or has to stop for breath when walking at own pace on level ground Stops for breath after walking approximately 100 yards or after a few minutes on level ground Too breathless to leave the house or breathless when dressing and undressing Ann K. Mc. Caughan BSN RN Ph. D(c) 24

Monitor Zo Daily: Early Indicator of Exacerbation Research indicates that Zo changes as early as two weeks prior to exacerbation allowing for proactive response to fluid change. Patient at Cardiology Infusion Clinic. Zo began declining ten days prior to symptom & weight development. Ann K. Mc. Caughan BSN RN Ph. D(c) 25

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