Managing Heart Failure in Home Care

1
Managing Heart Failure in Home Care

• Transitioning Patients
• From
• Acute Care to Self Care

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

3
Where Are the Home Care Dollars Spent?
4
Goal of Care

• Independence
• Transition from role of patient to self-care
• No ER visits
• No hospitalizations
• No unscheduled home care visits

5
Objectives

• 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

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

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
8
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

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

10
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

11
Medication Regimen

• Systolic Failure
• Diuretic
• Spironolactone
• Hydralazine
• Furosemide
• Bumetanide
• ACEi
• Beta Adrenergic blocker
• carvedilol

• Diastolic Failure
• Isordil/hydralizine
• ACEi
• Diuretic

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

13
ACEi must reach target
14
Beta Blockade used in Heart Failure Treatment
 
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, doesnt mean
  that patient is homebound

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

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

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

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

20
Heart Failure Exacerbation
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 specificity is imperative for
successful outcomes! Use Zo.
Nurses must help patient identify somatic
sensations associated with exacerbation.
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.

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.
• Dont forget to address weight reduction

24
Breathlessness Scale
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.
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