Managing Heart Failure
in Home Care
Transitioning Patients
From
Acute Care to Self Care
Ann K. McCaughan BSN RN PhD(c)
1
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
Ann K. McCaughan BSN RN PhD(c)
2
Where Are the Home Care Dollars
Spent?
Percent of Patients per Diagnosis Category Discharged to Home Care
72%
Heart failure
Orthopedic problems
Pneumonia
Ann K. McCaughan BSN RN PhD(c)
CABG
COPD
3
Goal of Care
 Independence
 Transition
from role of patient to self-care
 No ER visits
 No hospitalizations
 No unscheduled home care visits
Ann K. McCaughan BSN RN PhD(c)
4
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
Ann K. McCaughan BSN RN PhD(c)
5
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
Ann K. McCaughan BSN RN PhD(c)
blood
6
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
Ann K. McCaughan BSN RN PhD(c)
7
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
Ann K. McCaughan BSN RN PhD(c)
8
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
Ann K. McCaughan BSN RN PhD(c)
9
Physical Assessment
Auscultation
 Blood pressure



Heart tones



Sitting
standing
Palpation
 Skin temperature
 Skin turgor
 Capillary refill
 Pulses
S1&S2
S3


Lung sounds

crackles




Radial
Dorsalis pedis
Edema
Ascites
Liver border
Hepatojugular reflux
Ann K. McCaughan BSN RN PhD(c)
10
Medication Regimen
Diastolic Failure
 Isordil/hydralizine
 ACEi
 Diuretic
Systolic Failure
 Diuretic




Spironolactone
Hydralazine
Furosemide
Bumetanide

ACEi
 Beta Adrenergic
blocker

carvedilol
Ann K. McCaughan BSN RN PhD(c)
11
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
Ann K. McCaughan BSN RN PhD(c)
12
ACEi – must reach target
Drug
Dose Range (mg)
Frequency
Target Dosage
Captopril
6.25-150
TID
50 mg tid
Enalapril
2.5-20
BID
10 mg bid
Lisinopril
2.5-40
QD
20 mg qd
Ramipril
2.5-10
QD-BID
5 mg qd or bid
Quinapril
5-20
BID
10 mg bid
Fosinopril
10-40
BID
20 mg bid
Trandolapril
1-4
QD
4 mg qd
Ann K. McCaughan BSN RN PhD(c)
13
Beta Blockade used in Heart
Failure Treatment
DRUG
Starting Dosage
Target Dosage
Carvedilol
3.125mg bid
6.25-25 mg bid
Bisoprolol
1.25 mg qd
10 mg qd
Metoprolol
12.5 mg qd
200 mg qd
Ann K. McCaughan BSN RN PhD(c)
14
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, doesn’t mean that
patient is homebound
Ann K. McCaughan BSN RN PhD(c)
15
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
Ann K. McCaughan BSN RN PhD(c)
16
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
Ann K. McCaughan BSN RN PhD(c)
17
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
Ann K. McCaughan BSN RN PhD(c)
18
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
repetitively in order to attain regimen
integration. Ann K. McCaughan BSN RN PhD(c)
19
Heart Failure Exacerbation
Early S&S
Exacerbation
Late S&S
Exacerbation
Acute
Exacerbation
 A ppetite
Fatigue
Bloated feeling
Fullness in ears
 Perip heral edema
 SOB wit h exert io n
Pitting edema
 SOB @ rest
Develops S3
 ZO
 Pillow use
Develop s a co ugh
Weight gain
 Abdominal g irth
Develop s crackles
SaO2 
JVD
Zo less t han 15 ohms
This is when home care nursing intervention must
occur to prevent CHF and hospitalization.
Ann K. McCaughan BSN RN PhD(c)
20
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.
Ann K. McCaughan BSN RN PhD(c)
21
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.
Ann K. McCaughan BSN RN PhD(c)
22
Monitor Daily Weight
 Same
time
 Same place
 Address changes


Timeline
Causative factors?
 Report
2# increase in 24 hours or 5#
increase in one week.
 Don’t forget to address weight reduction
Ann K. McCaughan BSN RN PhD(c)
23
Breathlessness Scale
Grade
Degree
Description
0
None
Not troubled with breathlessness except
with strenuous exercise
1
Slight
Troubled by shortness of breath when
hurrying on level ground or walking up a
slight hill
2
Moderate
Walks slower than people of the same age on
level ground because of breathlessness or has
to stop for breath when walking at own pace on
level ground
3
Severe
Stops for breath after walking
approximately 100 yards or after a few
minutes on level ground
4
Very
Severe
Too breathless to leave the house or
breathless when dressing and undressing
Ann K. McCaughan BSN RN PhD(c)
24
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.
One month Zo data predicting early exacerbation
25
December 23; w eight 186
20
Zo values
15
10
January 12
w eight = 187
January 20
w eight = 187
Patient at Cardiology Infusion Clinic. Zo began
declining ten days prior to symptom & weight
development.
January 22
w eight = 193
crackles 1/3 up
Demedex 80mg
5
Ann K. McCaughan BSN RN PhD(c)
25
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
Ann K. McCaughan BSN RN PhD(c)
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