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Managing Heart Failure in Home Care


Managing Heart Failure in Home Care Transitioning Patients From Acute Care to Self Care Goal of Presentation Provide overview of heart failure management in home care ... – PowerPoint PPT presentation

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Title: Managing Heart Failure in Home Care

Managing Heart Failure in Home Care
  • Transitioning Patients
  • From
  • Acute Care to Self Care

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

Where Are the Home Care Dollars Spent?
Goal of Care
  • Independence
  • Transition from role of patient to self-care
  • No ER visits
  • No hospitalizations
  • No unscheduled home care visits

  • Adherence to medication regimen
  • Identification of early SS of exacerbation
  • Daily monitoring
  • Zo fluid status
  • Weight
  • Blood pressure
  • Symptoms
  • Breathlessness
  • Verbal understanding and demonstration of
    adherence with a low sodium diet

Disease Etiology
  • Ejection Fraction (EF) less than 40 per
  • 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

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
Taking Heart Failure History
  • SS 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

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

Physical Assessment
  • Auscultation
  • Blood pressure
  • Sitting
  • standing
  • Heart tones
  • S1S2
  • S3
  • Lung sounds
  • crackles
  • Palpation
  • Skin temperature
  • Skin turgor
  • Capillary refill
  • Pulses
  • Radial
  • Dorsalis pedis
  • Edema
  • Ascites
  • Liver border
  • Hepatojugular reflux

Medication Regimen
  • Systolic Failure
  • Diuretic
  • Spironolactone
  • Hydralazine
  • Furosemide
  • Bumetanide
  • ACEi
  • Beta Adrenergic blocker
  • carvedilol
  • Diastolic Failure
  • Isordil/hydralizine
  • ACEi
  • Diuretic

  • Atrial fibrillation common which has high
    recommendation for chronic persistent a-fib and
  • Cardiac Glycoside digoxin
  • Potassium supplementation due to electrolyte
    imbalance resulting from diuresis

ACEi must reach target
Beta Blockade used in Heart Failure Treatment
Inotropic Infusion
  • Intermittant or Continuous
  • Dobutamine (Dobutrex), Milrinone (Primacor),
  • 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, doesnt mean
    that patient is homebound

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

Fluid Restrictions?
  • ACC, Heart Failure Society and American Heart
    Association do not recommend routine fluid
  • More problems arise with electrolyte imbalance
    than with fluid management

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

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 AO x3, nurse
    should give score MO 560, 600, 610 that indicates
    the need to reinstruct repetitively in order to
    attain regimen integration.

Heart Failure Exacerbation
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 specificity is imperative for
successful outcomes! Use Zo.
Nurses must help patient identify somatic
sensations associated with exacerbation.
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.

Monitor Daily Weight
  • Same time
  • Same place
  • Address changes
  • Timeline
  • Causative factors?
  • Report 2 increase in 24 hours or 5 increase in
    one week.
  • Dont forget to address weight reduction

Breathlessness Scale
Monitor Zo Daily Early Indicator of
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
When is the Patient Ready to Transition to
  • 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