Heart Failure Education and Discharge Program - PowerPoint PPT Presentation

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Heart Failure Education and Discharge Program. Program Contents ____________________________________________________________________. Program Goals Prevalence of HF Definition of HF Etiology / Types of HF HF Classification Systems Physiological Response to HF

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Heart Failure Education and Discharge Program

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Heart Failure Education and Discharge Program

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Program Contents


  • Program Goals

  • Prevalence of HF

  • Definition of HF

  • Etiology / Types of HF

  • HF Classification Systems

  • Physiological Response to HF

  • Diagnostic Findings

  • Treatment: Medications

  • Core Measures

  • Teaching Process

  • Review

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Program Goals_______________________________________________________________________

  • For Patients

    • An organized and informed inpatient education process

    • An increased knowledge of the diagnosis and treatment pathway for heart failure

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Program Goals_______________________________________________________________________

  • For Nurses

    • Increased understanding of heart failure

    • Familiarity with HF therapies

    • Recognition of patients needing HF teaching

    • Ability to provide Heart Failure Education as

      part of the hospital’s Core Measure

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Program Goals_______________________________________________________________________

  • For the Hospital

    • Meeting and exceeding national standards of HF care

    • Compliance with TJC core measures

    • Reduce re-admission rates for HF patients

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The Size of the Problem_______________________________________________________________________

  • Approximately 5 million patients in this country have HF

  • Over 550,000 patients are diagnosed with HF for the first time each year

  • In 2001, nearly 53,000 patients died of HF as a primary cause

  • Accounts for 12 to 15 million office visits and 6.5 million hospital days each year

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The Size of the Problem_______________________________________________________________________

  • The incidence of HF approaches 10 per 1000 population after age 65

  • HF is the most common Medicare diagnosis-related group

  • More Medicare dollars are spent on the diagnosis and treatment of HF than on any other diagnosis

ACC,AHA 2009

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Definition of Heart Failure_______________________________________________________________________

  • HF is complex and difficult to define.

  • It can result from any of several structural orfunctional cardiac disorders that impair ventricular filling or ejection.

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Definition of Heart Failure _______________________________________________________________________

  • Some or all of these structural or functional changes may be present in varying degrees, without a precise correspondence to HF.

  • The heart may be damaged, but not failing.

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Definition of Heart Failure _____________________________________________________________________

  • There is no single diagnostic test for HF; rather

  • HF is diagnosed by history and clinical findings:

    • dyspnea and fatigue, which may limit exercise tolerance, and

    • fluid retention, which may lead to pulmonary congestion and peripheral edema.

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Definition of Heart Failure _______________________________________________________________________

Because not all patients have volume overload at the time of initial or subsequent evaluation, the term “heart failure” is preferred over the older term “congestive heart failure.”

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Etiology of Heart Failure_______________________________________________________________________

  • The primary causes of heart failure are:

    • Coronary artery disease

    • Hypertension

    • Dilated cardiomyopathy

  • Risk Factors include:

    Hypertension, smoking, obesity, diabetes, metabolic syndrome, alcohol abuse, COPD, increasing age

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Types of Structural/Functional changes that lead to Heart Failure_______________________________________________________________________

  • Left ventricular systolic dysfunction (LVSD)

  • Diastolic dysfunction

  • Right sided failure

  • Cor Pulmonale

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Types of Heart FailureLeft ventricular systolic dysfunction (LVSD)_______________________________________________________________________

  • Impairment of the ventricle’s ability to contract forcefully and fully enough to provide adequate cardiac output.

  • Usually with diminished Ejection Fraction (EF).

  • This is “classic” heart failure, and the more familiar definition.

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Types of Heart FailureDiastolic dysfunction_______________________________________________________________________

  • Inability of the ventricle to fill adequately related to a “stiff” or non-compliant ventricular wall. The EF may be near normal in this type of failure

  • Although many of the signs and symptoms may be the same, this type of failure is treated somewhat differently

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Types of Heart FailureRight Sided Failure_______________________________________________________________________

  • May occur as a result of left-sided failure.

    When the left ventricle fails, increased fluid pressure is transferred back through the lungs, causing congestion, and ultimately damaging the heart's right side. When the right side loses pumping power, blood backs up in the venous system, seen as swelling in the legs and ankles.

  • Can also occur through direct damage (AMI) to the right ventricle

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Types of Heart FailureCor Pulmonale_______________________________________________________________________

Any condition that leads to prolonged high blood pressure in the arteries or veins of the lungs (pulmonary hypertension) strains the right side of the heart. When the right ventricle fails or is unable to properly pump against these abnormally high pressures, cor pulmonale is the result.

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Cor Pulmonale is dilation and hypertrophy of the right ventricle due to pulmonary hypertension, typically caused by chronic lung disease or sleep apnea.



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HF Classification Systems_______________________________________________________________________

The New York Heart Association (NYHA) established a classification system for HF, based upon the caregiver’s observations and assessments of the patient’s functional capacity. These Stages I-IV (“mild”, “mild”, “moderate”, “severe”) have been used for many years to describe the degree of failure.

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New York Heart AssociationClasses of HF_______________________________________________________________________

Class I

No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation or dyspnea.

Class II

Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation or dyspnea.

Class III

Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation and dyspnea.

Class IV

Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased

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HF Classification Systems_______________________________________________________________________

It has been recognized for many years that the NYHA functional classification reflects a subjective assessment by a healthcare provider and can change frequently over short periods of time. It has also been recognized that the treatments used may not differ significantly across the NYHA classes.

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HF Classification Systems_______________________________________________________________________

In 2009, the ACC/AHA Joint Committee on HF Guidelines believed that a staging system was needed that would reliably and objectively identify patients during the course of their developing disease. This would be linked to treatments uniquely appropriate at each stage of illness, and would recognize:

  • Ventricular dysfunction is progressive

  • Progress is in one direction due to the permanence of cardiac remodeling

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Stages of Heart Failure


ACC/AHA 2009 Guidelines for the Diagnosis and Management of Heart Failure in Adults

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HF Classification Systems_______________________________________________________________________

In this classification, movement through the prodromal structural changes of the early disease process and into the functional changes of frank HF is signaled by objective changes. Each Stage is associated with increased therapeutic interventions.

The 2009 Staging System is intended to complement rather than replace the NYHA Classes.

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Heart Failure is Progressive_______________________________________________________________________

  • Control of this disease is a long term project. It cannot be cured, but signs and symptoms can be controlled, and disease progression slowed.

  • Treatment will vary related to the severity, “stage”, or “class” of failure

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HF and Homeostasis_______________________________________________________________________

Perhaps the most difficult thing about this disease is that the body’s homeostatic response to early cardiac dysfunction actually aggravates the pathologic process.

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Physiologic Response to Low Cardiac Output_______________________________________________________________________

  • Increase in circulating catacholamines

    increased heart rate and afterload

  • Increase in angiotensin II and aldosterone

    increase in sodium and water retention

  • Later, an increase in B-type Natriuretic peptide

    • this is the body’s attempt to control salt and fluid retention, and afterload, once it recognizes fluid overload in the atria and ventricles

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Ineffective Compensation_______________________________________________________________________

  • The normal physiologic response to low cardiac output OVER TIME, aggravates the problem and worsens the injury!

  • Without intervention, heart failure can become a picture of rapid decompensation

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Common Heart Failure Symptoms and Signs_______________________________________________________________________

  • Symptoms

    Dyspnea, fatigue, edema, orthopnea (dyspnea when head is not elevated), paroxysmal nocturnal dyspnea, cough, anorexia

  • Signs

    Increasing jugular venous distension, S3 gallop, rales, edema

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Common Diagnostic Findings_________________________________________________________________

  • Echocardiogram

    • Evaluation of cardiac structure and


    • Evaluation of left ventricular ejection fraction (EF)

      • The percentage of blood which is ejected from the left ventricle with each contraction

      • (normal ejection fraction is greater than 60%)


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Common Diagnostic Findings_______________________________________________________________________

  • Chest X-Ray

    • May show evidence of fluid overload or pleural effusions

    • This may correlate with the clinical assessment of rales during lung auscultation

    • May show an enlarged cardiac silhouette

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CXR With Fluid Overload and Enlarged Cardiac Silhouette

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Common Diagnostic Findings_______________________________________________________________________

  • Heart Catheterization

    May or may not be done depending on presentation, symptoms, whether new onset of disease or not, and whether there is ischemic heart disease

  • Stress test - as above

    Not recommended as a part of routine evaluation in patients with known heart failure

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Common Diagnostic Findings-Laboratory_______________________________________________________________________

  • B-type Natriuretic Peptide-BNP

    BNP is a substance secreted from the ventricles in response to changes in pressure that occur when heart failure develops and worsens. The level of BNP in the blood increases when heart failure symptoms worsen, and decreases when the heart failure condition is stable. The BNP level in a person with heart failure - even if the HF condition is stable - is higher than in a person with normal heart function.

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Common Diagnostic Findings- Laboratory______________________________________________________________________

  • BNP Levels

    • BNP levels below 100 pg/mL indicate no HF

    • BNP levels above 300 pg/mL indicate mild HF

    • BNP levels above 600 pg/mL indicate moderate HF

    • BNP levels above 900 pg/mL indicate severe HF.

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Common Diagnostic Findings- Laboratory________________________________________________________________________

  • Frequently ordered tests can include: electrolytes, glucose, magnesium, calcium, lipid panels, liver function tests

  • Abnormal findings in these tests are not specificto heart failure, but could be a contributing factor, or a result of heart failure

    • Some abnormal labs could be a result of treatment, for instance low potassium with diuresis

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ECG Findings_______________________________________________________________________

  • May show evidence of myocardial infarction or ischemia

  • May show evidence of left ventricular hypertrophy

  • May have other abnormalities such as arrythmias, bundle branch blocks, pathologic Q waves

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  • Pathologic Q waves in an ECG may indicate a myocardial infarct, either recent or old.

  • They are deep, greater than one “box” on the graph paper

  • Here they are in the anterior leads. They are very conspicuous in V2 and V3 but are also in V4, 5, 6 and AVL

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Common Treatments for HF:Ace Inhibitors (ACEI)_______________________________________________________________________

  • Recommended in asymptomatic and symptomatic patients with an ejection fraction of less than 40%

  • ACE INHIBITORS (angiotensin converting enzyme inhibitors, or ACEI’s):

    enalapril (Vasotec), captopril (Capoten),

    lisinopril (Zestril, Prinivil)


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ACEI-Mechanism of Action_______________________________________________________________________

Angiotensin I is normally converted to angiotensin II by angiotensin converting enzyme (ACE), so an ACE inhibitor blocks formation of Angiotensin II

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Angiotensin II_______________________________________________________________________

  • Many of these effects of angiotensin II are harmful to the HF patient in the long term

    • Sodium and fluid retention

    • Increased catecholamine release resulting in increased heart rate and blood pressure

    • Cardiac “remodeling” resulting in left ventricular wall thickening

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Beneficial Effects of ACEI’s______________________________________________________________________

  • Decrease peripheral vascular resistance and lower blood pressure

  • Decrease the release of aldosterone and catecholamines

    Reduced sodium (and water) retention

    Decreased heart rate and blood pressure

  • Reduce abnormal cardiac “remodeling”

    Reduce cardiac hypertrophy

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Angiotensin II Receptor Blockers(ARB’S)_______________________________________________________________________

  • losartan (Cozaar), valsartan (Diovan)

  • Used in patients who require an ACEI, but cannot take them because of side effects or other problems

  • Especially useful in those patients who develop an ACEI related cough

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Common Treatments for HF:Beta Blockers_______________________________________________________________________

  • Recommended in heart failure with an ejection fraction of less than 40%

  • Used in combination with ACEI/ARB’s

  • Block the effects of sympathetic neurotransmitters (catecholamines) by competing at binding sites

  • Beta blockers are a CORE MEASURE

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Beta Blocker Effects_______________________________________________________________________

  • Anti-anginal agent:

    • decreases myocardial oxygen demand

      decreases both rate and contractility.

  • Cardioprotective:

    • inhibits circulating catecholamine stimulation

  • Class II antidysrhythmic:

    • useful in the control of tachydysrhythmias

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Beta BlockersDecrease Cardiac Workload

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Other Common HF Medications_______________________________________________________________________

  • Diuretics

    • Loop Diuretics (like furosemide)

    • Thiazide Diuretics (like hydrochlorothiazide)

    • Potassium Sparing Diuretics

      • Amiloride

      • Spiranolactone-an aldosterone antagonist which reduces sodium and fluid retention

  • Nitrates

    • Isosorbide, Nitroglycerin

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Other Common HF Medications_______________________________________________________________________

  • Digoxin

  • Anticoagulants and Antiplatelet Drugs

    • Aspirin

    • Warfarin

    • Clopidogrel (after coronary interventions/stents)

  • Antidysrhythmics

    • Amiodarone (Cordarone), dofetilide (Tikosyn), flecainide (Tambacor), others.

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The “Vicious Cycle”_______________________________________________________________________

The widespread incidence of HF is due to a difficult combination of factors:

  • Risk factors are common and not well controlled.

  • Progression from risk factor to HF is not curable, but it is generally controllable.

  • Numerous therapeutic choices arise within the natural history of the disease.

  • HF will worsen without careful attention to maintenance and therapy by patient and caregivers.

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How We Can Break the“Vicious Cycle”_______________________________________________________________________

  • Provide appropriate treatment and teaching during inpatient admissions

    • Educate the pt to provide appropriate self-care.

    • Educate the pt to seek assistance promptly when indicated

  • Ensure inpt diagnostic and therapeutic work completed in a timely manner

  • Support integrated care management through communication with the physician’s office

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    Core Measures…_______________________________________________________________________

    • Are performance standards agreed upon by TJC (formerly JCAHO) and CMS on best outcomes of important diagnoses.

    • Were chosen to have the greatest impact on quality and outcomes of care.

    • Allow TJC to collect and trend specific data.

      Core Measures will be used to guide “pay for performance” reimbursement in the near future.

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    Core Measures…_______________________________________________________________________

    • Core Measures currently collected:

      • Myocardial Infarction

      • Pneumonia

      • Heart Failure

      • Surgical Care Improvement (SCIP)

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    Heart Failure-Core Measures_______________________________________________________________________

    • For Physicians

      • Document in the hospital record that left ventricular function (EF) was assessed either before arrival, during hospitalization, or as outpatient.

      • For LVEF < 40%, ACEI ordered or contraindications documented

        • ARB’s may be substituted when appropriate

      • Beta blocker ordered or contraindications documented.

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    Heart FailureCore Measures_______________________________________________________________________

    • For Nurses: Patient/Family Education

      • Smoking Cessation (if smoked anytime within the past year!)

      • Activity Level

      • Diet

      • Follow-Up Appointments

      • Weight Monitoring

      • What to do if symptoms worsen

    • HF patients are discharged home with written instructions addressing all of these items.

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    Initiating the HF Teaching Process_______________________________________________________________________

    • Identify those patients with a primary or secondary diagnosis

      of heart failure on admission

  • If HF becomes a diagnosis after admission

    • Process issue: by regulation a patient admission is “coded” on review after discharge. The primary diagnosis is ultimately determined by the “preponderance of care”.

    • Hence, an elderly patient admitted and discharged with a Dx of pneumonia, with complications of an old MI and hypertrophy, might easily stay an extra day or so, and the preponderance of care might eventually be deemed to be in support of HF.

    • Thus, the onus falls (retroactively) on the hospital to provide that patient with appropriate HF teaching.

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    Step by Step_______________________________________________________________________

    • Step One: Place the “Mandatory Heart Failure Core Measurement” sheet under the physician’s order tab in the patient chart.

      • This is primarily intended to remind physicians

        of the Core Measure requirements associated

        with this diagnosis.

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    Step by Step______________________________________________________________________

    • Step Two: Start heart failure teaching

      • Hand out the Fight Against Heart Failure Handbook

      • Initiate the “HF Pt/Fam Discharge Information”

        • Initial each topic as you review it with the patient and/or family

        • Patient to agree at discharge

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    Step by Step______________________________________________________________________

    • Step Two:

      Start heart failure teaching

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    Step by Step______________________________________________________________________

    • Step Two:

      Start heart failure teaching

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    Who will do HF Teaching?_______________________________________________________________________

    • All Clinical Caregivers

      • Dieticians, respiratory therapy, nursing staff

      • Responsible for items on patient teaching sheet

      • Each caregiver will initial and date as HF teaching is accomplished

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    How Do We Know What to Teach?_______________________________________________________________________

    • All the pertinent information is in the Heart Failure patient Handbook

      • Please familiarize yourself with the content

    • Caregivers need to review the heart failure teaching points and provide the Handbook to the patient/family

    • Please take the time to review the heart failure video before the patient/family viewing.

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    Step by Step______________________________________________________________________

    • Step Three: Have the patient and/or family watch the heart failure DVD

      • About 15 minutes long

      • Document if your patient refused to watch the


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    Step by Step_______________________________________________________________________

    • Step Four: Review the “Heart Failure Action Plan” with the patient and/or family

      • Make sure they understand the need to seek help promptly for yellow and red conditions!

      • Make sure they take it home!

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    Step by Step______________________________________________________________________

    • Step Five: On discharge, the nurse..

      • Is responsible for the final check to assure completion of the HF teaching plan

      • Completes the HF Discharge Information sheet

        • Make a duplicate if the patient wishes and the original for the chart. The patient acknowledges receiving the indicated instruction

      • Provides other discharge services

        • Carenotes for discharge medication

        • Nursing discharge summary

        • Physician prescriptions and unit specific paperwork

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    • Physician core measures include:

      • documentation of cardiac EF

      • the use of ACEI/ARB’s and beta blockers, if appropriate. If not, reason(s) for not prescribing them must be documented.

    • Nursing core measures include:

      • education on smoking cessation (if smoked anytime in the past year)

      • activity, diet, physician follow up, daily weight, monitoring for worsening symptoms and taking appropriate action

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    Heart failure is a progressive disease which requires ongoing monitoring and interventions to preserve function and to delay clinical progression. It is not curable, but it is generally manageable.

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    • Diagnosis of heart failure is based on:

      • Pertinent history and risk factors

        • Hypertension, myocardial infarction, known coronary artery disease, diabetes, COPD

      • Clinical presentation

        • Fatigue, dyspnea, fluid retention,

      • Clinical confirmation

        • Decreased ejection fraction (core measure), evidence of diastolic dysfunction, structural disease (left ventricular remodeling)

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    • Pharmacological treatment of heart failure can include:

      • ACEI’s/ARB’s (core measure)

      • Beta Blockers(core measure)

      • Diuretics

      • Other drugs

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    • Nursing Core Measures include Education on:

      • Smoking Cessation

        • All patients who have smoked within the last year should receive counseling

      • Activity Level

      • Diet

      • Discharge Medications

      • Follow up appointments

      • Daily weight monitoring

      • How to recognize and what to do for worsening symptoms

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    Thank You for your time and attentionto this very important quality of care issue.Our HF patients and families are thankful for the time and attentionyou give to them!!



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