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Heart Failure Nurse Led Management. Suzy Hughes Heart Failure Specialist Nurse Gloucestershire Heart Failure Service. What is Heart Failure?. The heart is incapable of maintaining a cardiac output adequate to meet metabolic requirements and venous return.

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heart failure nurse led management

Heart Failure Nurse Led Management

Suzy Hughes

Heart Failure Specialist Nurse

Gloucestershire Heart Failure Service

what is heart failure
What is Heart Failure?
  • The heart is incapable of maintaining a cardiac output adequate to meet metabolic requirements and venous return.
  • A syndrome, characterised by breathlessness, fatigue and fluid retention, resulting from cardiac dysfunction
  • Most common cause is left ventricular muscle damage.
the patient with heart failure
The patient with heart failure
  • Often severe limitations on daily activities
  • Suffer breathlessness, pain, nausea, fatigue, depression
  • Burden on carer
  • Little understanding of condition or how to manage it
aims of specialist nurse intervention
Aims of specialist nurse intervention
  • Improve quality of life
  • Reduce hospital admissions
  • Ensure evidence based treatments are used
case management
Case management
  • Average caseloads of 40-50 patients
  • Aim to treat and ‘hand back’ to primary care teams where possible
  • Identify high risk patients, manage the risk and instigate self management plans where possible
  • See patients at home / clinic according to need. Telephone contact
  • Promote joint working, creating integrated pathways between home and hospital tailored to individual patient need
heart function clinic
Heart Function clinic
  • Patients with confirmed LVSD
  • GPwSI and specialist nurse
  • History, examination, symptom assessment
  • Establish aetiology – refer cardiologist?
  • Management plan
  • Initiate treatment
  • Appointment for follow up by nurse
  • Secondary care referrals from cardiologist
key symptoms nursing assessment
Key symptoms/Nursing Assessment
  • Breathlessness-walking distances, stairs, washing/dressing
  • Orthopnoea/PND
  • Oedema-ankles, legs, sacrum, abdomen, face
  • Fatigue
  • Chest pains, palpitations
nursing assessment
Nursing Assessment
  • Appetite
  • Fluid intake/alcohol
  • BP, pulse/ECG, chest auscultation
  • Psychological status
  • Social support, carer assessment
nyha classification
NYHA Classification

Class I No limitations. Ordinary activity does not cause undue fatigue, dyspnoea or palpitations

Class II Slight limitation of physical activity Comfortable at rest.

Class III Marked limitation of physical activity. Breathlessness on washing and dressing.

Class IV Symptoms present at rest. Breathless on minimal exertion

patient education
Patient Education
  • Explanation of Heart Failure
  • Explanation of medicines and importance
  • Back up with literature
  • Patient booklet
  • Signs of deterioration and when to seek help. Service helpline number given
non pharmacological management
Non Pharmacological Management
  • Reduce salt intake
  • Appropriate fluid intake
  • Alcohol
  • Smoking cessation
  • Importance of vaccinations
  • Explain avoidance of NSAIDS’s
  • Explain benefit of exercise
pharmacological intervention
Pharmacological Intervention

Specialist nurse role

  • Optimisation and monitoring of appropriate drug therapy
  • Minimise inappropriate drug therapy
  • Patient support and education
  • Encourage compliance
treatment plan
Treatment Plan
  • Diuretic
  • ACE inhibitor
  • Beta blocker
  • Spironolactone
  • Digoxin
  • Nitrates
  • Warfarin
  • Aspirin / Statins
  • Little published evidence
  • Use for symptom control
  • Start with loop
    • Frusemide 40md od to 80mg bd
    • Bumetinide 1mg to 5mg od
using diuretics
Using Diuretics
  • Monitor U and Es
  • Beware of dehydration - dizziness, falls, thirst, fatigue, gout
  • Compliance issue
  • Flexible dose timing
  • Start with lowest dose possible
  • Monitor weight and symptoms and adjust
ace inhibitors
ACE Inhibitors
  • Indicated for all patients with LVSD unless contra-indicated
  • Improve survival, slow progression,improve symptoms, reduce hospitalisations
  • Start low, increase to maximum tolerated dose
using ace inhibitors
Using ACE Inhibitors
  • BP> 100mmHg, creatinine < 200,
  • Not usually necessary to stop diuretic
  • Start low and increase to maximum tolerated dose over weeks/months
  • Monitor U&E after every dose change
  • Cough
  • Postural hypotension
beta blockers
Beta Blockers
  • Best evidence is for Carvedilol & Bisoprolol.
  • Significantly reduces morbidity and mortality.
  • Effective in all grades of HF.
using betablockers
Using Betablockers
  • Ensure patient stable 4 weeks
  • Monitor BP, pulse, ECG to exclude heart blocks
  • Warn patient and monitor for deterioration
  • Telephone review within 4 days
  • Follow up visit
  • Persistant sodium/water retention
  • NYHA III/IV EF <35%
  • Reduces mortality
using spironolactone
Using Spironolactone
  • Careful monitoring U and Es 10,20,30 days. 4 weekly for 3/12. 3/12 for year. 6/12 thereafter
  • Diarrhoea
  • BP
  • Gynaecomastia
drugs to avoid
Drugs to Avoid
  • Prednisolone
  • CCB (except Amilodipine)
  • Sodium containing medicines.
  • Rosiglitazone
self management plans
Self management plans
  • Many patients with worsening heart failure start to retain fluid 2 weeks prior to admission
  • Monitoring daily weight and giving directions on increases in diuretic based on weight gain does prevent admissions (Blue 2004)
  • Helpline for advice and to inform nurses of treatment changes to arrange repeat blood tests and follow up
preventing admission
Preventing Admission
  • Education – symptoms of deterioration, weight monitoring
  • Encourage self management or seeking help early – telephone advice
  • Close monitoring of effects of medications
  • Support with complicated treatment regimes
  • Hospital inevitable in some cases - patient safety and comfort
  • Specialist nurse liaises with cardiologist and ward staff
Non-compliance with treatment regime
  • Dehydration/Over-hydration
  • Breakdown in social support
  • Poor communication between healthcare providers
palliative care
Palliative Care
  • Difficult to determine ‘end of life’ stage
  • Increasingly frequent deteriorations despite optimal treatments
  • Increasingly difficult management – low BP, low sodium
  • Rule out other cause for deterioration
  • Sudden death
common symptoms in last weeks months
Common symptoms in last weeks/months
  • Pain
  • Breathlessness
  • Low mood
  • Anxiety
  • Constipation
  • Nausea/Vomiting
  • Loss of appetite
preferred place of care
Preferred place of care?
  • Patient and carer fully informed and wishes established
  • GP support
  • District nurses
  • Hospice support/advice
  • Communication - Out of Hours/999
  • 86 year old gentleman
  • Short of breath for 2 years – progressively worse for last 6 months
  • Exercise tolerance 20 metres
  • Stairs = SOB+++
  • Hypertensive
  • Commenced on Frusemide 40mg od
  • Na 142; K 3.9; Urea 4.3; Creatinine 80
referred to hf service
Referred to HF Service
  • ECHO – Mild LVSD confirmed
  • Seen in Heart Function clinic
  • Risk Factors
    • CHD
    • Hypertension
    • Diabetes
    • BMI
    • Smoking history
    • Family history
hf clinic continued
HF Clinic continued:
  • Observations and breathing assessment
    • BP: 180/100 HR: 88bpm
    • Bi-lat crackles to bases
    • Pitting ankle oedema-improved since starting frusemide
    • Weight 87kg
    • Short of breath getting onto examination couch
    • 3 pillow orthopnoea
    • NHYA III
  • Plan: Commence Perindopril 2mg od, increase furosemide to 40mg bd
  • To have U+E’s checked in 7-10 days
nurse clinic @ 2 weeks
Nurse Clinic – @ 2 weeks
  • Less short of breath on stairs
  • Ankle oedema improved
  • BP: 184/75 HR: 78bpm Weight 86kg
  • Na 139; K 3.9; Urea 5.8; Creatinine 84
  • Plan: Increase Perindopril to 4mg od
  • U and E check 7-10 days
nyha classification36
NYHA Classification

Class I No limitations. Ordinary activity does not cause undue fatigue, dyspnoea or palpitations

Class II Slight limitation of physical activity Comfortable at rest.

Class III Marked limitation of physical activity. Breathlessness on washing and dressing.

Class IV Symptoms present at rest. Breathless on minimal exertion

non pharmacological management37
Non Pharmacological Management
  • Explanation of heart failure
  • Explanation of weighing self
  • Explanation of salt restriction
  • Explanation of fluid intake and diet
  • Importance of vaccinations
  • Explain avoidance of NSAIDS’s
  • Explain benefit of exercise
  • Recognising when to seek help
nurse clinic @ 4 weeks
Nurse Clinic – @ 4 weeks
  • Virtually no ankle oedema, chest clear
  • Can climb the stairs at home in one attempt
  • BP: 150/70 HR: 76bpm Weight 85kg
  • Na 140; K 4.3; Urea 9.4; Creatinine 81
  • Furosemide decreased to 40mg od
plan beta blockade
Plan: Beta blockade
  • 12 lead ECG to check for heart blocks
  • Commence Carvedilol 3.125mg bd
  • Warn patient of side effects
  • Start tablets on Monday; Ring on Thursday, See in 7 days
telephone consultation
Telephone consultation
  • Weight?
  • Breathing assessment
    • Flat ground / slopes?
    • Orthopnoea?
    • PND?
  • Dizzy spells?
  • Oedema?
  • Energy levels?
  • Confirm Mondays appointment!
titrate up as per protocol
Titrate up as per protocol
  • Week 5
    • BP: 136/60 HR: 66bpm Chest clear
    • Weight 84.5kg NHYA II
  • Week 6
    • BP: 134/60 HR: 68bpm Chest clear
    • Weight 84.5kg NHYA II
  • Carvedilol increased to 6.25mg bd
  • Get new script (don’t double up), start Monday, ring Thursday, see in 14 days
continue titration
Continue titration
  • Telephone consultation completed on day 4, feeling lethargic, reassured
  • Week 8
    • BP: 122/70 HR: 54bpm Chest clear
    • Feeling a little tired, but better than last wk
    • Weight 85kg NHYA II
  • Continue at Carvedilol 6.25mg bd
  • Reassure and encourage patient, see in 28 days
titration continued
Titration continued
  • Week 12
    • BP: 118/60 HR: 58bpm Chest clear
    • Weight 85kg NHYA I
  • Carvedilol increased to 12.5mg bd
  • Get new script
  • Start Monday, ring Thursday, see in 14 days
titration continued44
Titration continued
  • Week 13
    • BP: 104/60 HR: 54bpm Chest clear
    • Patient still feeling lethargic since increase
    • Weight 85kg NHYA I
what to do next
What to do next?
  • Reassure patient
  • Arrange to see patient in 1 month
  • Plan: continue current medications
    • Furosemide 40mg od; Perindopril 4mg od; Carvedilol 12.5mg bd
    • Aim to increase Carvedilol to 25mg bd in future if possible, but be prepared to reduce if lethargy continues
case study47
Case Study
  • Joyce, 78 yrs
  • Independent, lives warden controlled
  • PMH: ^BP, ^cholesterol, osteoarthritis, angina, vertigo, anaemia
2004: diagnosed moderate LVSD
  • Seen by heart failure service
  • Medicines titrated, education given
  • Kept under 3 monthly clinic review
clinic review
Clinic review
  • BP 115/70, pulse 58
  • Exercise tolerance ‘few hundred yards’
  • Managing stairs to flat
  • Chest clear
  • Oedema, mild to ankles (persistent)
  • Education re: fluid intake
  • Showing good understanding of medications
  • Bloods: Sodium 136, potassium 4.6, urea 11.0, creatinine 131
  • Appointment for 3 months
  • Lisinopril 20mg nocte Bisoprolol 5mg od
  • Furosemide 40mg od ISMN S/R 60mg od
  • Simvastatin 40mg nocte Aspirin 75mg
  • Co-codamol PRN
  • Ferrous sulphate 200mg od
  • Bezafibrate 200mg tds
  • Spironolactone 25mg od
  • Prochlorperazine 5mg tds
10 weeks later
10 weeks later….
  • Warden calls GP concerned re breathlessness and general deterioration
  • Oedema to upper thigh-severe
  • Chest, crackles to mid zones
  • ET few yards, struggling to care for herself
  • BP 140/85, pulse 95 reg
  • GP increases furosemide to 80mg am 40mg pm and refers to intermediate care
  • GP calls HF nurse to review in 4 days
hf nurse review 4 days later
HF nurse review-4 days later
  • BP 130/75, pulse 92bpm
  • Oedema to upper thigh
  • Breathless on minimal exertion, not getting dressed
  • Chest crackles to mid zones
  • Denies any PND (sleeps upright)
  • No chest pain
  • No palpitations
  • Upset by her condition
  • Discusses fluid intake
  • Asks about tablets……….patient very tearful, 2 carrier bags of tablets in bedroom.
  • Bloods Sodium 131, potassium 4.2, urea 7.1, creatinine 125
  • Discuss with GP
  • Arrange dossett box
  • Medications left unchanged
  • Liaise with warden and intermediate care
  • Review 3 days