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1. 2005 Ann K. Frantz BSN RN PhD(c) 1 Managing Heart Failure in Home Care Transitioning Patients
From
Acute Care to Self Care
2. 2005 Ann K. Frantz BSN RN PhD(c) 2
3. 2005 Ann K. Frantz BSN RN PhD(c) 3
4. 2005 Ann K. Frantz BSN RN PhD(c) 4 Goal of Care Independence
Transition from role of patient to self-care
No ER visits
No hospitalizations
No unscheduled home care visits
5. 2005 Ann K. Frantz BSN RN PhD(c) 5 Objectives Adherence to medication regimen
Identification of early S&S of exacerbation
Daily monitoring
Zo fluid status
Weight
Blood pressure
Symptoms
Breathlessness
Verbal understanding and demonstration of adherence with a low sodium diet
6. 2005 Ann K. Frantz BSN RN PhD(c) 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. 2005 Ann K. Frantz BSN RN PhD(c) 7 Heart Failure Classifications Based on ability to function with symptoms.
8. 2005 Ann K. Frantz BSN RN PhD(c) 8 Taking Heart Failure History S&S 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. 2005 Ann K. Frantz BSN RN PhD(c) 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. 2005 Ann K. Frantz BSN RN PhD(c) 10 Physical Assessment Auscultation
Blood pressure
Sitting
standing
Heart tones
S1&S2
S3
Lung sounds
crackles Palpation
Skin temperature
Skin turgor
Capillary refill
Pulses
Radial
Dorsalis pedis
Edema
Ascites
Liver border
Hepatojugular reflux
11. 2005 Ann K. Frantz BSN RN PhD(c) 11 Medication Regimen Diastolic Failure
Isordil/hydralizine
ACEi
Diuretic Systolic Failure
Diuretic
Spironolactone
Hydralazine
Furosemide
Bumetanide
ACEi
Beta Adrenergic blocker
carvedilol
12. 2005 Ann K. Frantz BSN RN PhD(c) 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. 2005 Ann K. Frantz BSN RN PhD(c) 13 ACEi must reach target
14. 2005 Ann K. Frantz BSN RN PhD(c) 14 Beta Blockade used in Heart Failure Treatment
15. 2005 Ann K. Frantz BSN RN PhD(c) 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. 2005 Ann K. Frantz BSN RN PhD(c) 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. 2005 Ann K. Frantz BSN RN PhD(c) 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. 2005 Ann K. Frantz BSN RN PhD(c) 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. 2005 Ann K. Frantz BSN RN PhD(c) 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 A&O x3, nurse should give score MO 560, 600, 610 that indicates the need to reinstruct repetetively in order to attain regimen integration.
20. 2005 Ann K. Frantz BSN RN PhD(c) 20 Heart Failure Exacerbation
21. 2005 Ann K. Frantz BSN RN PhD(c) 21
22. 2005 Ann K. Frantz BSN RN PhD(c) 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. 2005 Ann K. Frantz BSN RN PhD(c) 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. 2005 Ann K. Frantz BSN RN PhD(c) 24 Breathlessness Scale
25. 2005 Ann K. Frantz BSN RN PhD(c) 25
26. 2005 Ann K. Frantz BSN RN PhD(c) 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
27. 2005 Ann K. Frantz BSN RN PhD(c) 27