Congestive Heart Failure

1
Congestive Heart Failure

• Caroline L. Guglielmetti RN, BSN

2
Patient Profile

• I.R. is an 85 year-old female
• Born in Hungary
• Formerly from assisted living, has lived at the
  nursing care center for 2 years.
• Has a daughter who is a teacher and a son who is
  a pharmacist. Her son is DPOA of medical and
  finances.

3
Past Medical History

• Vitamin B12 deficiency
• Hypothyroidism
• Severe Depression
• Dementia
• Parkinsons Disease
• Osteoarthritis- bil. Hips
• Constipation

• Osteoporosis with kyphosis
• DJD bil. Hips lumbar spine
• Dependent edema
• CHF
• Anemia

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Medications

• Synthroid 0.05mg PO QD
• Vitamin B12 100mcg PO QD
• Aldactone 25mg PO QD
• Senokot 2 tabs PO QD
• Colace 100mg PO QHS

• Remeron 30 mg PO QD
• Os-Cal 500mg PO tid
• Tylenol ES 1-2 PO TID

5
CHF and Anemia

• Anemia affects 10 to 20 of patients with
  chronic congestive heart failure (CHF)
• In most patients, no specific underlying cause is
  identified, and more than 50 of cases are
  considered to represent anemia of chronic
  disease.
• Low hemoglobin (Hgb) values in CHF patients
  directly correlate with poor peak oxygen
  consumption, disabling symptoms, and reduced
  survival.
• Pilot studies suggest that correction of Hgb
  values with recombinant human erythropoietin and
  iron improves symptoms and exercise capacity, but
  larger studies are needed before anemia treatment
  can be routinely recommended for CHF patients.
  (Crosato M, et al. Heart Fail Monit
  20034(1)2-6.)

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CHF and Hypothyroidism

• Two Common types of CHF
• Systolic Dysfunction-inability of the heart to
  contract due to weakness
• Diastolic Dysfunction-inability of the heart to
  relax after it pumps out blood
• Systolic Dysfunction may be due to multiple
  factors, one being Hypothyroidism

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CHF and Dementia

• Requires FREQUENT reminders to
• Keep feet elevated (Dependent Edema)
• Wear Ted Hose
• Alert family and or nursing staff if you begin to
  notice symptoms of CHF (exacerbation of CHF)
• The importance of daily weights

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Family Involvement/Education

• Due to her dementia and severe depression, the
  family must play an active role in disease
  management.
• Nursing must educate family on CHF
• Pathphysiology
• Etiology
• Management- meds, lifestyle modification
• Medication regimen
• Outside resources
• Goals for the patient and the family

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Outside Resources

• The CALL Care project is designed to improve
  quality of life for individuals with a
  life-threatening illness, bridging gaps between
  services prior to entering a hospice
• COMPREHENSIVE Focus of services includes
  strategies to meet physical, emotional,
  spiritual, and relationship needs. Services are
  designed for both the ill person and family
  caregiver, as defined by the ill person.
• ADAPTABLE Care and services are flexible over
  time for the person and caregiver. The approach
  focuses on linking appropriate existing services,
  developing new services only when gaps in
  continuity of services between the community and
  health care organizations are evident. Services
  are accessible within the context of a variety of
  funding or reimbursement strategies.
• LONGITUDINAL Program plans are designed to
  identify persons for whom the illness is
  progressive and will potentially lead to the
  persons death. The inclusion criteria focuses
  from the time the illness appears to be
  life-threatening, even if prognosis or life
  expectancy is unknown. This strategy addresses
  problems associated with timely referrals to
  end-of-life services and programs.
• LIFE-AFFIRMING Although persons identified for
  the CALL Care program are likely to be facing the
  last phase of their lives, the services will
  focus on assisting them and family caregivers to
  live fully and meaningfully within the limits of
  the illness and each persons goals.
• Providence Hospital and Medical Centers,
  Southfield, MI(Coalition member Ascension
  Health)

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Resources (continued)

• American Heart Association www.americanheart.org
• Area Agency on Aging Oakland County 248.357.2255
• Cardiac Rehabilitation for Heart Failure
  Providence Medical Center (Southfield)
  248.849.5855
• MEPPS (assistance for obtaining medications)
  313.866.5333
• Second Chance Heartline, Education Support
  Group St. John Hospital and Medical Center
  313.343.3157
• Cardiac Support Group, St. John Hospital and
  Medical Center 313.343.3157

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Nursing Staff Education

• Since the patient is a resident of a nursing
  home, it is vital to educate the nursing and
  support staff.
• Provide FREQUENT reminders
• - Elevate lower extremities - I O (as
  accurate as possible)
• - Wear support stockings
• - OBTAIN A DAILY WEIGHT EVERY MORNING!!!
• - Enforce fluid restriction
• Ensure that the dietician is aware of the
  patients CHF and Dementia and prepares a diet
  that it LOW SODIUM, NAS,MECHANICAL SOFT
• Contact in house rehab- have them assess the
  patient for appropriateness of a mild exercise
  program 3 times per week or as tolerated.
• Encourage the nursing and support staff to
  COMMUNICATE with the family as well as the
  physician/NP, ask questions, update each other on
  patient status

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Rollands Family Systems Illness Model

• Different types and stages of chronic illnesses
  place similar and different demands on the family
• 3 Dimensions
• - Psychosocial types of illness and disability
  and the
• demands of a chronic disorder in respect
  to the
• diseases different phases
• - Developmental phases of the illness
• - Family system Variables
• Looks at the psychosocial demands of the disease
  in regards to the family system and
  strengths/weaknesses

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Rollands Psychosocial Typology of Illness (CHF)
with respect to I.R. and family

1. Onset Gradual slower rate of family change
   required, may generate anxiety before diagnosis
   is made.
2. Course Relapsing/Episodicexacerbations/remission
   s may be the most psychosocially challenging for
   the family, requires flexibility
3. Outcome Shortened lifespan or sudden death
   uncertain outcome, issues of mortality surface

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Rollands Typology (continued)

• 4. Incapacitation Moderate/Severe Impairments
  evident incognition, movement, decreased energy
  production.
• 5. Degree of Uncertainty based on predictability
  of onset and rate at which disease progresses.
  Families need to develop perspective, plans,
  avoid burnout.
• 6. A. Symptom Visibility present. DIB with
  exertion, 3 pitting edema, abdominal distension
• B. Liklihood/Severity of crisis exacerbations
  becoming more frequent
• C. Genetic Contribution unknown
• D. Treatment regimens see meds. Family very
  cautious, in control of med management
• E.Age at onset Questionable, exacerbations have
  become worse over the last 2 years (starting at
  age 83).

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Rollands Typology (continued)

• 7. Time Phases of Illness
• B. Chronic Long haul
• Key Family Task maintain a normal life under
  abnormal conditions, transition, integration of
  the chronic disease into other aspects of
  life,maintenance of autonomy for all family
  members. Avoid mutual dependency.
• Family Issues
• Avoid burnout, maintain relationships,maintain
  autonomy, redefine individual and family
  goals,intimacy in the face of loss
• Transition between acute, chronic and terminal
  phases is critical for all family members.

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Evaluation/Outcomes

• The family will
• -contact and utilize outside resources as needed
• -communicate regularly with the nursing and
  support staff as well as medical staff and each
  other
• -Recognize the chronic disorder and understand
  that it can be controlled, but not cured
• -work to preserve individual family member
  autonomy
• -work to maintain a normal life
• -redefine individual and family goals in regards
  to illness
• -recognize uncertainty of loss
• -provide support with the medical and/or
  lifestyle modifications necessary to control CHF

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Evaluation/Goals

• The Nursing/Medical and support staff will
• -Maintain communication with each other and the
  family
• -Provide support and education to the family
• -Remind patient FREQUENTLY to comply with CHF
  guidelines
• -Thoroughly assess the patient for changes in
  status

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Evaluation/Outcomes

• By complying with family and Medical/nursing
  interventions, the client will
• Remember to elevate lower extremities when
  sitting
• Wear support stockings
• Comply with daily weight
• Comply with diet/fluid restriction
• Maintain weight
• Work with rehab if appropriate

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References

• Anemia.org(2004). Anemia contributes to morbidity
  and mortality in CHF. Clinical Briefs. Retrieved
  from www.anemia.org/about_anemia/research_briefs/a
  nemia_contributes.jsp
• CALL care Project (2004).Providence Hospital and
  Medical Centers, Southfield, MI
• Carpenito, L. Nursing care Plans Documentation.
  (1999) Philadelphia Lippincott
• Rolland, J.S. Interface of Chronic Illness and
  the family. Source Modified from W.Looman