Heart Failure: Nursing Assessment and Care

Transcription

1 Heart Failure: Nursing Assessment and Care

2 Objectives 1. Understand the complexities of CHF and the care needs of a patient with CHF. 2. Employ critical components of diseases management into the care plan for frontline nursing care of the CHF patient

3 Overview of CHF: The Problem One of most common causes of hospitalization, hospital readmission, and death. Nearly 1.4 million hospitalizations (leading cause in > 64 y.o.) 27% readmitted Approximately 5.8 million Americans Outcomes suboptimal 1 in 10 patients die within the first 30 days after hospitalization 1 in 4 patients who survive are readmitted Financial burden $17 billion in total spending

4 Overview of CHF the inability or failure of the heart to provide sufficient forward output to meet the the perfusion and oxygenation requirements of the tissues will maintaining normal filling pressures Mechanisms: Systolic dysfunction: Impaired cardiac contractile function Diastolic dysfunction: Abnormal cardiac relaxation, stiffness or filling

5 Anatomy: two pump system Functions: systole and diastole Cardiac output (CO) and ejection fraction (EF) CO = Stroke Volume X Heart Rate Normal 5.5 l/min (males) 5.0 l/min (females) EF = Stroke Volume / End Diastolic Volume X 100 Normal EF = 55-70%

6 Systolic HF Abnormalities in systolic function Reduced left ventricular ejection fraction (LVEF) Usually with progressive chamber dilation and eccentric remodeling HF with reduced LVEF (HFrEF) EF < 50%

7 Diastolic HF Abnormalities in diastolic function with symptoms Normal LVEF Normal LVEDV Diastolic dysfunction Usually with concentric remodeling or hypertrophy HF with preserved LVEF (HFpEF) EF > 50%

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10 Overview of CHF Simplified Decrease in CO Increase in capillary pressure Symptoms

11 Causes of Heart Failure? Impairment of filling it up or pumping it out Hypertension Cardiomyopathies Coronary artery disease Valvular disorders Dysrhythmias Diabetes Other..

12 Increased workload and end-diastolic volume enlarge the left ventricle. Increased heart rate, pale and cool skin, tingling in the extremities, decreased cardiac output, and arrhythmias.

13 Blood pools in the ventricle and atrium and eventually backs up into the pulmonary veins and capillaries. Dyspnea on exertion, confusion, dizziness, orthostatic hypotension, decreased peripheral pulses and pulse pressure, cyanosis, and an S3 gallop.

14 Rising capillary pressure pushes sodium (Na) and water (H2O) into the interstitial space, causing pulmonary edema. Coughing, subclavian retractions, crackles, tachypnea, elevated pulmonary artery pressure, diminished pulmonary compliance, and increased partial pressure of carbon dioxide.

15 Because the left ventricle can t handle the increased venous return, fluid pools in the pulmonary circulation, worsening pulmonary edema. Decreased breath sounds, dullness on percussion, crackles, and orthopnea.

16 The right ventricle may now become stressed because it s pumping against greater pulmonary vascular resistance and left ventricular pressure. Worsening symptoms.

17 The stressed right ventricle enlarges with the formation of stretched tissue. Increased heart rate, cool skin, cyanosis, decreased cardiac output, dyspnea, and palpitations.

18 Blood pools in the right ventricle and right atrium. The backed up blood causes pressure and congestion in the vena cava and systemic circulation. Increased central venous pressure, jugular vein distention, and hepatojugular reflux.

19 Backed up blood distends the visceral veins, especially the hepatic vein. As the liver and spleen become engorged, their function is impaired. Anorexia, nausea, abdominal pain, palpable liver and spleen, weakness, and dyspnea secondary to abdominal distention.

20 Rising capillary pressure forces excess fluid from the capillaries into the interstitial space. Edema, weight gain, and nocturia.

21 Classification: ACC/AHA High risk of developing heart failure: Hypertension diabetes, CAD, and family history of cardiomyopathy Asymptomatic heart failure: Previous history of MI, left ventricular dysfunction, and valvular heart disease Symptomatic heart failure: Structural heart failure, dyspnea and fatigue, and impaired exercise tolerance Refractory end-stage heart failure: Marked symptoms at rest despite maximal medical therapy

22 Classification: NYHA Class 1 (mild): No limitation of physical activity; physical activity doesn t cause tiredness, heart palpitations, or shortness of breath. Class II (mild): Slight limitation of physical activity; the patient is comfortable at rest, but ordinary activity causes tiredness, heart palpitations, and/or shortness of breath. Class III (moderate): Marked limitations of physical activity; the patient is comfortable at rest, but less than ordinary physical activity causes tiredness, heart palpitations, or shortness of breath. Class IV (severe): Severe limitations of physical activity; the patient is unable to carry out any physical activity without discomfort. Symptoms are present at rest, and any physical activity increases that discomfort.

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24 Diagnosis History and physical examination Symptoms Tests EKG, Chest X-ray Labs CBC Electrolytes Glucose BUN and Creatinine B-type natriuretic peptide (BNP) Echocardiogram

25 Prognosis If decompensated and hospitalization required: Significant mortality risk of more than 20% at one year NYHA stage IV have mortality rate of up to 50% at one year

26 Treatment Lifestyle modification Smoking cessation Limited alcohol consumption Low sodium diet Fluid restrictions Daily weight / symptom monitoring Medication compliance

27 Treatment Medications Beta-blockers Angiotensin-converting enzyme inhibitors (ACEI) Angiotensin II receptor blocker (ARB) Diuretic (1 liter of urine output = 1 Kg weight lost)

28 Treatment Procedures Cardioversion Ablation Cardiac resynchronization therapy (CRT) Implantable cardioverter defibrillator (ICD) Transplant

29 Caring for the HF Patient Assess Teach/Coach Self Management Advocate

30 Self Management for HF Assess ability to self manage Self Care of Heart Failure Index European Heart Failure Selfcare Behavior Scale

31 Self Management for HF Assess ability to self manage Self Care of Heart Failure Index European Heart Failure Self-care Behavior Scale Medication management Daily monitoring for signs/symptoms Adherence to a low sodium diet Routine exercise

32 Self Management: Meds Obtaining initial and refill prescriptions Incorporating meds into daily routine Adhering to the daily medication schedule Understanding and implementing prescription changes Recognizing common side effects of medications Managing changes of routine (travel, illness)

33 Patient Medication Instruction Take each medication each day at the times indicated by using a system (list, pill box, etc) Do not allow prescriptions to expire of bottels to become empty before refilling Use same pharmacy each time Bring all medications to each doctor s visit Contact their doctor immediately if they feel they are having side effects from medications (rather than stopping them without telling anyone).

34 Medication Management Skills Know which pill is their diuretic Know how to change the dose of the diuretic according to the HF action plan Be able to carry out any additional changes that should accompany diuretic dosage changes i.e. need for earlier refills, addition of potassium supplementation

35 Daily Monitoring of Signs/Symptoms Daily Weights Use scale with large enough print to be readily visible Use a scale that is big enough for the patient to stand on easily Use a scale that is easy to zero, such as a digital scale Weigh themselves at the same time every morning After urinating but before eating or drinking Before getting dressed or in the same amount of clothing each day

36 Heart Failure Signs Edema/swelling Ankle/leg edema Palpitations Abdominal edema Irregular pulse Sudden weight gain Change in urine output compared to normal Weight loss Low blood pressure or orthostatic blood pressure Heart rate <60/min or >120/min Cool, pale or mottled skin

37 Heart Failure Symptoms Shortness of breath Exercise intolerance Orthopnea Profound fatigue with exertion or generalized weakness Dizziness/lightheadedness Nausea/vomiting: diarrhea or loss of appetite Paroxysmal nocturnal dyspnea Restlessness, confusion or fainting Right-sided abdominal fullness, discomfort or tenderness Severe cough Chest pain Wheezing

38 Daily Monitoring of Signs/Symptoms Record the results in a log book or other permanent record (calendar) May be telemonitored Compare results to previous day and to previous week Know their target weight 2 to 5 lb. weight gain in one week, diet/medications changes should be made >5 lb. weight gain in one week requires immediate call to physician/nurse

39 Daily Monitoring of Signs/Symptoms Daily Checks for Edema Examine their legs each day for swelling or an increase in existing swelling Describe how far up the leg the swelling reaches (ankle, shin, knee) or measure ankle circumference Worsening edema requires diet/medication changes

40 Daily Monitoring of Signs/Symptoms Daily Check of Symptom Severity Monitor exercise tolerance Using a scale ranging from no shortness of breath, SOB after moderate exertion, SOB after mild exertion, SOB at rest Monitor their breathing at night Using a scale ranging from no SOB lying flat, needing two or more pillows, sleeping upright or awakening with sudden SOB Watch for dizziness or lightheadedness Using a scale ranging from not dizzy, dizzy, dizzy for a while after standing, near syncope/syncope or fall Less severe needs diet/medication modification Severe symptoms needs immediate call to physician/nurse

41 Self Management: Diet Adherence to low sodium (2 gram) diet No clinical trials demonstrating benefit Patients hospitalized with acute exacerbation of HF found that excess dietary sodium to be a precipitating event in 1/5 of patients Sodium restriction can reduce BP and enhance the response to antihypertensive drugs

42 Patient Diet Instruction Understand the relationship between sodium intake and edema Know that salt and sodium are the same Demonstrate ability to read a nutrition label Demonstrate ability to calculate total sodium intake in a day Recognize hidden sources of salt intake

43 Dietary Management Skills Select low-salt foods and avoid high-salt foods, including processed meats, hot cereals, condiments Reduce salt added during home cooking Ask for reduced-salt meals at restaurants and avoid known sources of salt Rinse canned goods before cooking and/or eating Avoid instant foods and salty snacks

44 Self Management: Exercise Screen for absence of significant ischemia or arrhythmias using exercise testing prior to training Generally safe for NYHA class II and Cardiac rehabilitation program

45 Self Management: Smoking Cessation Current smoking independent predictor of mortality in patients with HF Self Management: Limited Alcohol < 2 standard drinks per day or < 1 standard drink per day in women

46 Barriers to Self Care Inability to afford medications Generics Medication Assistance Programs Good Rx Therapy-related factors Common adverse effects / benefits Minimize pill quantity Side effects (impotence, depression, incontinence) Low health literacy Screen patients at risk Document learning preferences Integrate strategies to facility health understanding

47 Barriers to Self Care Multimorbidity Multiple clinicians Confusing or conflicting recommendations Aspiring in patient with CAD, Hx GI bleeding, and HF Depression and anxiety Highly prevalent in HF patients Effects cognition, social support, motivation and engagement Higher rates of medication nonadherence, hospitalization and mortality Healthcare team/system factors Clinicians unable to provide self-care education, monitoring and reinforcement Ancillary resources unavailable Rare reimbursement for counseling, follow-up and monitoring

48 Promoting Effective Self Care Knowledge Skills Behavior change/patient engagement

49 Promoting Knowledge Utilize teach-back techniques to assure patient understands the materials Ask specific questions to ensure the patient understands the materials Limit teaching point to no more than 3 or 4 per session Repeat, reinforce and review teaching points at regular intervals

50 Promoting Skill Development Experimental teaching have pt. read Rx label and take out correct amount of medications, calculate the amount of salt in a food product, etc. Role playing have pt. practice telling provider about worsening symptoms Group sessions allows patients to learn from the experience of other, similarly situated patients

51 Behavior Change/Pt Engagement Use motivational interviewing techniques Question patients explicitly about their beliefs in disease etiology and efficacy of treatment Engage patients in developing a plan, and in filling out a notebook or monitoring materials Use brainstorming with patients to help them incorporate self-management into their lives: build on patient s own experience and routines Help patients identify one or two concrete actions they can do for each self-care Have patients describe their self-management practices and offer feedback to improve them, rather than suggesting or imposing self-management practices

52 Heart Failure Action Plan Developed between patient /family and provider Essential Discussion Completed Early in Course Hope for the best and prepare for the worst

53 Heart Failure Action Plan Identification of an approach to care Hospital vs home care or hospice for example Identification of goals Continued interventions to maximize function or length of life versus simplifying treatment and focusing on managing symptoms A plan to manage current interventions to achieve goals, including each medication and device Assistance for family and care givers in delivering care Resources for spiritual and emotional support for patient and family

54 Heart Failure Action Plan Developed between patient and provider Divided into zones: Green STABLE state Maintain plan as is Yellow WORSENING status Additional diuretic intake Renewed vigilance to diet and medication compliance Orange ACUTE EXACERBATION Immediate call to provider Rapid evaluation Red CARDIAC EMERGENCY Call 911

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57 Heart Failure Disease Management Multidisciplinary disease management Physician Nurse Pharmacist Case Manager Exercise Specialist Dietitian Social Worker Spiritual Care Palliative Care Family

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59 End of Life Considerations Symptom management Treatment of HF Fatigue Dyspnea Pain Anorexia and cachexia Emotional, spiritual, psychological and social support ICD deactivation Hospice care

60 Summary All patients deserve to know it is a terminal disease.