Managing Heart Failure in Home Care

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

2. Goal of Presentation • Provide overview of heart failure management in home care • 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. McCaughan BSN RN PhD(c)

3. Where Are the Home Care Dollars Spent? Ann K. McCaughan 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 Ann K. McCaughan 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 Ann K. McCaughan 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 Ann K. McCaughan BSN RN PhD(c)

7. 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. McCaughan 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 Ann K. McCaughan 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 Ann K. McCaughan BSN RN PhD(c)

10. 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 Physical Assessment Ann K. McCaughan BSN RN PhD(c)

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

13. 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 ACEi – must reach target Ann K. McCaughan BSN RN PhD(c)

14. DRUG Starting Dosage Target Dosage Carvedilol 3.125mg bid 6.25-25 mg bid Bisoprolol 1.25 mg qd 10 mg qd Metoprolol 12.5 mg qd 200 mg qd Beta Blockade used in Heart Failure Treatment Ann K. McCaughan 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 Ann K. McCaughan 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 Ann K. McCaughan 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 Ann K. McCaughan 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 Ann K. McCaughan 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 repetitively in order to attain regimen integration. Ann K. McCaughan BSN RN PhD(c)

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

21. 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 specificityis imperative for successful outcomes! Use Zo. Nurses must help patient identify somatic sensations associated with exacerbation. Ann K. McCaughan 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. Ann K. McCaughan 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 Ann K. McCaughan BSN RN PhD(c)

24. Grade Degree Description 0 None Not troubled with breathlessness except with strenuous exercise 1 Slight Troubled by shortness of breath when hurrying on level ground or walking up a slight hill 2 Moderate 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 3 Severe Stops for breath after walking approximately 100 yards or after a few minutes on level ground 4 Very Severe Too breathless to leave the house or breathless when dressing and undressing Breathlessness Scale Ann K. McCaughan BSN RN PhD(c)

25. 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. McCaughan 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 Ann K. McCaughan BSN RN PhD(c)