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Diabetes and Heart Failure: A Comprehensive Collaboration. Grace Zite RN, MSN, CCRN, CCNS-Cincinnati Sarah Andrews RN, BSN-Lexington Keith Edinger RN, BSN-Pennsylvania Ashley Hancock RN , BSN-Houston Ed Park RN,CCRN, BSN-New Jersey Traceee Rose RN, BSN-San A ntonio.

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Diabetes and heart failure a comprehensive collaboration

Diabetes and Heart Failure: A Comprehensive Collaboration

Grace Zite RN, MSN, CCRN, CCNS-Cincinnati

Sarah Andrews RN, BSN-Lexington

Keith Edinger RN, BSN-Pennsylvania

Ashley Hancock RN, BSN-Houston

Ed Park RN,CCRN, BSN-New Jersey

Traceee Rose RN, BSN-San Antonio


Objectives

  • Describe the disease process of Heart Failure (HF), and understand treatment regimens.

  • Describe the disease process of Diabetes Mellitus (DM), and understand treatment regimens.

  • Discuss the importance of educating pt.'s with HF and DM and provide tools to help with instructions to prevent negative outcomes.

  • Relate the impact of both disease processes on the quality of life and incorporate the synergy model to guide treatment.

Objectives


Heart failure

Heart Failure


Aha nyha
AHA & NYHA producing inadequate cardiac output to meet the needs of tissues, and characterized by volume retention, congestion, and poor perfusion.


Hf causes

  • Coronary heart disease (CAD) and myocardial damage ( Acute myocardial infarction (AMI) is the cause in 75% of cases)

  • Chronic hypertension (HTN) ( 2nd most frequent cause).

  • Cardiomyopathy ( restrictive, dilated, or hypertrophic).

  • Mitral or aortic valve disease, septal defect, endocarditis.

HF causes


Precipitating factors

  • Myocardial ischemia myocardial infarction (AMI) is the cause in 75% of cases)

  • Severe HTN

  • Dysrrthymias

  • Negative inotropic medications

  • Infection

  • Pulmonary embolism (PE)

  • Hyper/hypothyroidism

  • Diabetes

Precipitating factors:


Hf pathophysiology
HF Pathophysiology myocardial infarction (AMI) is the cause in 75% of cases)


Symptoms hf

-Audible congestion - Ascites/ edema

- Rales/ S.O.B. - Obtunation

- JVD - Hepatic tenderness

- Hypotension

- Cool extremities - Narrow pulse pressure

- Fatigue - Elevated BUN/ Creatinine

Symptoms- HF


Treatments hf

  • Pharmacological- Ascites/ edema *Diuretics * ACE inhibitors *Beta blockers * ASA * Statins * Vasodilators * Neurohormonal antagonists * Anticoagulants* *Antidysrrhtymics * Inotropes. Compliance with medication regimen per MD./ARNP.

  • Weight Control { includes daily weights to monitor fluid retention}.

  • Diet Modification- Cardiac diet {Low salt, low fat, fluid restriction} limit ETOH, Fresh foods- fruits & vegetables.

  • Exercise

  • Life-style modification

Treatments- HF


Diabetes

  • DM is a disease where the body fails to properly produce or use insulin. Insulin is a hormone that turns sugar and other foods into another form or energy that can be used by the cells that make up the entire body. Other forms of DM exist ( gestational, medication induced, pre-diabetes), but, two major types are discussed clinically when the term “Diabetes” is mentioned:

    Type I DM – When the body can not produce insulin, which is a hormone that causes the cells to absorb glucose for fuel. About 5-10% of people have type I DM.

    Type II DM- When the body manages to produce insulin but fails to use it properly.

Diabetes


  • Causes: use insulin. Insulin is a hormone that turns sugar and other foods into another form or energy that can be used by the cells that make up the entire body. Other forms of DM exist ( gestational, medication induced, pre-diabetes), but, two major types are discussed clinically when the term “Diabetes” is mentioned:Type I - 1.Family Hx. 2. Viral infections ( rubella, mumps). Usually Diagnosed in children and young adults. Type II- 1. Sedentary life-style. 2. Excess body weight. 3. HTN. 4. High cholesterol. 5. Family Hx .

  • Dx. : 1. Fasting blood sugar (BS). + if BS is >110 & < 126 mg/dL. 2. Oral glucose tolerance test (OTT). Pt. drinks glucola ( 75g of glucose or 100 g for pregnant pt.'s.) BS is checked at 30 min, 1 hr., 2hrs. & 3hrs post glucola ingestion. + if BS is > 140 or < 200mg/dL.

*DM*


Dm pathophysiology
DM-Pathophysiology use insulin. Insulin is a hormone that turns sugar and other foods into another form or energy that can be used by the cells that make up the entire body. Other forms of DM exist ( gestational, medication induced, pre-diabetes), but, two major types are discussed clinically when the term “Diabetes” is mentioned:


Symptoms dm

  • Type I use insulin. Insulin is a hormone that turns sugar and other foods into another form or energy that can be used by the cells that make up the entire body. Other forms of DM exist ( gestational, medication induced, pre-diabetes), but, two major types are discussed clinically when the term “Diabetes” is mentioned:: Type II:

    -Increased thirst & urination - Dry skin

    -Increased appetite - Skin Ulcers

    -Fatigue - Numbness of hands & feet

    -Blurred vision - Blurred vision

    -Frequent/slow healing infections - Dehydration

    - Wgt. Loss/gain

Symptoms- DM


Treatment of diabetes

  • Pharmacological- *INSULIN- (fast, intermediate, basal insulin's) *Oral hypoglycemics ( metformin, actos, glyburide) *Blood pressure & *cholesterol lowering medications.

  • Dietary modification { high fiber, low saturated fats, carbohydrate modification.

  • Exercise

  • Weight control

  • Monitoring BS ( finger sticks, A1c monitoring).

Treatment of Diabetes


Pharmacology

  • Oral medication should be initiated when lifestyle changes do not control blood glucose levels (Pinhas-Hamiel & Zeitler, 2007)

  • Oral medications include: Biguanides, Thiazolidinediones, Sulfonylureas, Meglitinide analogs, and Glucosidase inhibitors (Pinhas-Hamiel & Zeitler, 2007)

  • Insulin therapy may be necessary for patients with uncontrolled blood glucose levels (Cirone, 1996)

Pharmacology


Pharmacology cont

  • Sulfonylurease do not control blood glucose levels (Pinhas-Hamiel & Zeitler, 2007) are the most commonly prescribed hypoglycemic drugs in patients with heart failure

  • Retrospective cohort studies in the US involving more than 16,000 patients with DM and HF did not show link between sulfonylurea use and mortality

  • A Canadian retrospective cohort study compared Metformin to sulfonylurea use – one year mortality in patients treated with Metformin was lower than in patients treated with sulfolylureas

  • Consider use of a sulfonylurea if Metformin is contraindicated or when given in combination with metformin

  • (MacDonald, 2009)

Pharmacology cont.


Evaluating glycemic control

2 out of 3 fail to meet the goal of do not control blood glucose levels (Pinhas-Hamiel & Zeitler, 2007)

6.5 % HG A1c set by:

  • American Diabetic Association

  • American Association of Clinical Endocrinologist

  • European Association of the Study of Clinical Diabetes

Evaluating Glycemic Control

Levich, B. R. ( 2011). Diabetes Management Optimizing Roles for Nurses in Insulin Initiation. Journal of Multidisciplinary Healthcare


The dawn study

  • Psychosocial barriers to glycemic control do not control blood glucose levels (Pinhas-Hamiel & Zeitler, 2007)

    • Negative attitude toward insulin therapy initiation

      • Guilt by the HCP: failed medical management

      • Feeling like a failure with self management

      • Belief in restricted life style

      • Belief that insulin is the “last resort”

      • Fear of hypoglycemia ( Benroubi, 2011)

The DAWN study

Benroubi, M. (2011). “Fear, guilt feelings and misconceptions: Barriers to effective insulin treatment in type 2 diabetes” Diabetes Research and Clinical Practices. 97-99.


Just the facts ma am
“Just the facts ma’am” do not control blood glucose levels (Pinhas-Hamiel & Zeitler, 2007)


Statistics heart failure

  • In the United States, 5 million individuals live with heart failure.

  • Two thirds of HF pt.'s. die within 5 years of being diagnosed.

  • The estimated annual cost in the United States is 56 billion annually.

  • Medicare spends more on HF than all forms of cancer.

  • HF hospitalizations have tripled over the last 25 years.

  • Most common reason for hospital admissions for pt.'s. > 65 yrs.

  • Greatest contributor to the cost of HF treatment is hospitalizations.

  • Affects Men > Women, but more women than men are admitted for HF.

Statistics- Heart Failure


Statistics diabetes

  • About 20.8 million children and adults in the United States or 7% of the population have DM.

  • 30% of adults in the United States have pre- diabetes….men > women.

  • 14.6 million have been Dx. with DM, but 6.2 million people are unaware they have DM.

  • Affects 10.6 % of all Hispanics & 10.8 % of all African Americans in the United States.

  • DM was the 7th leading cause of death in 2006 .

  • Most common cause of blindness, kidney failure, & amputations in adults & a leading cause of Heart disease & stroke.

  • African Americans are more likely to suffer from higher incidences of DM disabilities & complications.

  • DM is rare in youth ages 12-19 years, but about 16% have pre-diabetes.

  • One of the major risk factors for CAD leading to Heart Failure

  • 20-25% present in HF patients

Statistics- Diabetes


Diabetic cardiomyopathy

  • Diabetic or 7% of the population have DM.cardiomyopathy is defined as significantly impaired cardiac function in diabetic patients in the absence of epicardial vascular disease, left-ventricular hypertrophy, valvular disease, or other causes of cardiomyopathy, making it largely a diagnosis of exclusion.

  • The association between diabetic cardiomyopathy and diabetic retinopathy suggests that microvascular abnormalities may play a role.

  • One of the major risk factors for CAD leading to Heart Failure

  • 20-25% present in HF patients

Diabetic Cardiomyopathy


Diabetic cardiomyopathy1

  • Affects 180 million worldwide or 7% of the population have DM.

  • 2/3 of patients with established CVD have impaired glucose

  • Affects 30% of HF patients

  • Every 1% increase in HgbA1c leads to an 8% increase in HF

Diabetic Cardiomyopathy


Understanding dm effect on hf

High or 7% of the population have DM.proisulin, hyperinsulinemia, hyperglycemia level

Endothelium damage

Accelerated atherosclerosis, cardiovascular remodeling

Increased mortality

Understanding DM Effect on HF


Cascade of events
Cascade of or 7% of the population have DM.Events


Disease progression of diabetes and hf
Disease Progression or 7% of the population have DM.ofDiabetes and HF


Apple a day keeps the doctor away effective self care keeps hospital away
or 7% of the population have DM.apple a day keeps the doctor away”“Effective self care keeps hospital away”

Goal of Self Care


Goal of self care

  • optimize metabolic control or 7% of the population have DM.

    • Hg A1c < 6.5%

  • prevent acute and chronic complications

    • Preventable hospitalization

    • Prevent Multi-organ dysfunction

  • optimize quality of life

Goal of Self Care

Carlson, Karen K. (Ed.) (2009). Advanced critical care nursing. (8th ed.) St. Louis, MO: Saunders


Pearls of patient education

  • Know what you are teaching. or 7% of the population have DM.

    • Medications

    • Keep updated with current guidelines and evidence-based practice

  • Avoid overwhelming the patient

    • Feel like drinking from a fire hose.

    • Is their “life” over?

  • Psychosocial

    • What is all this going to cost?

Pearls of Patient Education


Challenges

  • Pt’s or 7% of the population have DM.. with HF & DM must struggle with necessary treatment regimen’s in order to maintain stability to achieve a sense or normalcy .

  • Increase in survival rates after acute Myocardial infarction (AMI) {due to newer medical advances}, aging population, and increased obesity rates will increase the rates for DM and HF complications.

  • Vulnerable groups ( elderly, & minorities) find themselves predominantly affected by theses diseases due to lack of resources, access to health care, and heredity.

  • Nonadherence to treatment regimens presents another challenge in treating DM/HF, which has many origins.

Challenges


Helping pt s f ace challenges

  • Pt. teaching/education. Not only is it important for the RN to educate the Pt. on DM & HF, but the RN must be confident in knowing the disease process so the right information can be distributed to enhance care.

  • Collaborate with members of the healthcare team to ensure the pt. is ready for discharge from the hospital.

  • Comply with core measures upon hospital discharge to reduce re-admission.

  • Provide resources and literature for DM/HF care upon discharge to help pt’s comply with treatment regimens

Helping Pt.'s Face Challenges


Goals purpose of care

  • Identify & correct precipitating causes of DM/HF. to educate the Pt. on DM & HF, but the RN must be confident in knowing the disease process so the right information can be distributed to enhance care.

  • Relieve symptoms, enhance comfort.

  • Enhance cardiac performance and control BS & decrease the progression of theses diseases.

  • Provide the tools & resources to keep pt.'s. compliant with their treatment regimens.

  • Decrease morbidity

  • Decrease hospitalizations

  • INCREASE THE QUALITY OF LIFE

Goals & Purpose of Care


Patient resources

  • American Heart Association to educate the Pt. on DM & HF, but the RN must be confident in knowing the disease process so the right information can be distributed to enhance care.

    • www.heart.org

  • American Diabetes Association

    • www.diabetes.org

  • Center for Disease Control

    • www.cdc.gov

  • Heart Failure Society of America

    • www.hfsa.org

  • American Dietetic Association

    • www.eatright.org

  • Patient Resources


    Synergy model

    • The synergy model identifies 8 patient characteristics: resiliency, vulnerability, stability, complexity, resource availability, participation in care, participation in decision making, and predictability (Hardin & Kaplow, 2005)

    • 8 nursing competencies in the synergy model include: clinical judgment, advocacy, caring practices, collaboration, systems thinking, response to diversity, clinical inquiry and facilitation of learning (Hardin & Kaplow, 2005)

    • By using the synergy model, nurses will use their competencies to address the patient need that is presented (Hardin & Kaplow, 2005)

    Synergy Model


    • Stability: Frequency of dyspnea, weight gain and hospitalization

    • Complexity: Stage of HF, and co morbidities like DM, HTN, COPD, etc

    • Predictability: instabilities and other comorbities

    • Resiliency: Willingness to learn and follow self care regimen to regain equilibrium

    • Vulnerability: Consistency of social and financial support

    • Participation of Decision Making and Care: Cognitive capacity? Family member ?

    • Resource Availability: Family, community or governmental support ?

    Synergy Model

    Hardin, S., & Hussey, L. (2003). AACN Synergy Model for Patient Care: Case Study of a CHF

    Patient. Critical Care Nurse, 23,73-76. Retrieved from http://ccn.aacnjournals.org/content/23/1/73.full


    Case study
    Case Study hospitalization

    Hardin, S., & Hussey, L. (2003). AACN Synergy Model for Patient Care: Case Study of a CHF

    Patient. Critical Care Nurse, 23,73-76. Retrieved from http://ccn.aacnjournals.org/content/23/1/73.full


    References

    Benroubi, M. (2011). “Fear, guilt feelings and misconceptions: Barriers to effective insulin treatment in type 2 diabetes” Diabetes

    Research and Clinical Practices. 97-99.

    Carlson, Karen K. (Ed.) (2009). Advanced critical care nursing. (8th ed.) St. Louis, MO: Saunders

    Funnell, M. M. (2006). The Diabetes Attitudes, Wishes, and Needs (DAWN) Study. Clinical Diabetes.(24) 154-155.

    Doi: 10.2337/diaclin.24.4.154

    Hardin, S., & Hussey, L. (2003). AACN Synergy Model for Patient Care: Case Study of a CHF

    Patient. Critical Care Nurse, 23,73-76. Retrieved from http://ccn.aacnjournals.org/content/23/1/73.full

    Hunt, S., Baker, D., Chin, M., Cinquegrani, M., Feldman, A., Francis, G.,...Smith, S. (2001). Circulation. ACC/AHA Guilelines for

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    American College of Cardiology Journal of the American College of Cardiology. 56, (18 ) 1435–46.doi:10.1016/j.jacc.2010.05.046

    Lee, C. S., & Tkacs, N.C. (2008) Current Concepts of Neurohormonal Activation in Heart Failure. Mediators and Mechanisms.

    AACN Advanced Critical Care, 19 (4), 364–385. Retrieved from http://www.aacn.org/WD/CETests/Media/CI1942.pdf

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    Healthcare. (4) 15-24

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    References


    • American misconceptions: Barriers to effective insulin treatment in type 2 diabetes” Heart Association (2011). Understand your risk for heart failure. Retrieved from http://

      www.heart.org/HEARTORG/Conditions/HeartFailure/UnderstandYourRiskforHeartFailure/Understand-Your-

      Risk-for-Heart-Failure_UCM

    • Debono, M., & Cachia, E. (2007). The impact of diabetes on psychological well being and quality of life. The role of patient education. Psychology, Health and Medicine, 12(5) 545-555.

    • Dries, D., Sweitzer, N., Drazner, M., Stevenson, L., & Gersh, B. (2001). Prognostic Impact of Diabetes in Patients With Heart Failure According to the Etiology of Left Ventricular Systolic Dysfunction Journal of the American College of Cardiology, 38(2) 421-8.

    • Eurich, D., Tsuyuki, R., Majumdar, S., McAlister, F., Lewanczuk, R., Shibata, M., & Johnson, J. (2009, February 9). Metformin treatment in diabetes and heart failure: when academic equipoise meets clinical inquiry. BioMed Central, 10(12). doi: 10.1186/1745-6215-10-12

    • Hunt, S., Baker, D., Chin, M., Cinquegrani, M., Feldman, A., Francis, G.,...Smith, S. (2001). Circulation. ACC/AHA Guilelines for Evaluation and Management of Chronic Heart Failure in the Adult: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American Heart Association, 104: 2996-3007. doi: 10.1161/hc4901.102568

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