1. Heart Failure in the Frail Elderly in LTC Part 2 Deborah Lekan, MSN, RNC Clinical Nurse Specialist, Gerontological Nursing

2. Clinical Leadership through Bedside Clinical Teaching Putting your clinical knowledge and leadership skills into practice Putting your clinical knowledge and leadership skills into practice

3. Gerontogical Nursing HF Assignment Designed as a simulation to help prepare you for clinical practice as an RN, by: Designed as a simulation to help prepare you for clinical practice as an RN, by: addressing both clinical competence & leadership skills needed for working w/paraprofessional staff addressing both clinical competence & leadership skills needed for working w/paraprofessional staff focusing on RN delegation & supervision focusing on RN delegation & supervision Uses Bedside Clinical Teaching as a strategy to involve CNAs & LPNs in detection/recognition of acute HF S&S. Uses Bedside Clinical Teaching as a strategy to involve CNAs & LPNs in detection/recognition of acute HF S&S.

4. Part I: Before Clinical Go to the HF Module on Blackboard Go to the HF Module on Blackboard Do the short Pre-test Do the short Pre-test Review the University of Iowa Evidence-based protocol on HF and AMDA HF clinical practice guideline Review the University of Iowa Evidence-based protocol on HF and AMDA HF clinical practice guideline Review HF Powerpoint module –about an hour Review HF Powerpoint module –about an hour Do the Post-test Do the Post-test

5. Part II. In the Nursing Home Clinical Conference: Clinical Conference: Obtain patient assignment and discuss plan for Bedside Clinical Teaching Obtain patient assignment and discuss plan for Bedside Clinical Teaching Complete short Leadership survey Complete short Leadership survey Prepare for the HF Assessment and Bedside Clinical Teaching Prepare for the HF Assessment and Bedside Clinical Teaching Review the patient record Review the patient record Talk with the LPN and CNA about your assignment. Ask about their usual assessment approach to the patient with HF Talk with the LPN and CNA about your assignment. Ask about their usual assessment approach to the patient with HF Ask about the patient’s presentation of S&S of acute HF Ask about the patient’s presentation of S&S of acute HF Bedside Clinical Teaching Bedside Clinical Teaching Explain to patient and CNA the goal of assessment Explain to patient and CNA the goal of assessment Conduct the HF assessment with input from CNA Conduct the HF assessment with input from CNA Teach CNA how to use the FACES pocket card Teach CNA how to use the FACES pocket card Recording and Reporting Recording and Reporting Do Nurses Note and record in chart Do Nurses Note and record in chart Report findings to Charge Nurse and RN Report findings to Charge Nurse and RN

6. Bedside Clinical Teaching- A Method to: Bring evidence-based & patient-focused information to the bedside to increase information exchange between direct caregivers (CNAs, LPNs, Charge Nurses) & RNs Bring evidence-based & patient-focused information to the bedside to increase information exchange between direct caregivers (CNAs, LPNs, Charge Nurses) & RNs Coach paraprofessional and LPN staff in Coach paraprofessional and LPN staff in skill-building in assessment & care techniques skill-building in assessment & care techniques demonstration/return demonstration demonstration/return demonstration review and targeting of care plan goals review and targeting of care plan goals

7. Part III. After Clinical Submit a Reflection Journal entry-1 page Submit a Reflection Journal entry-1 page Due Date: Friday September 28, 2007 Due Date: Friday September 28, 2007

8. Assessment Tools HF Nursing Assessment Form HF Nursing Assessment Form HF CNA Warning Worksheet HF CNA Warning Worksheet HF pocket card HF pocket card

9. The HF Resident Assessment Form Designed for the LPN/RN in long term care Designed for the LPN/RN in long term care Intended as a way to organize assessment information to facilitate clinical decision-making and communication with the MD/NP Intended as a way to organize assessment information to facilitate clinical decision-making and communication with the MD/NP Assumes nurse has basic assessment skills. Form is simple and easy to use by RN/LPN Assumes nurse has basic assessment skills. Form is simple and easy to use by RN/LPN The ABSN student can apply more advanced skills in physical assessment to look for indicators of acute HF The ABSN student can apply more advanced skills in physical assessment to look for indicators of acute HF

10. The HF CNA Warning Worksheet Designed as a short, easy to use form to help the CNA observe for changes in the patient’s functional status, comfort Designed as a short, easy to use form to help the CNA observe for changes in the patient’s functional status, comfort Early indicators of acute HF can be detected and reported to the RN Early indicators of acute HF can be detected and reported to the RN Timely treatment in the nursing home can prevent ER transfers and hospitalizations Timely treatment in the nursing home can prevent ER transfers and hospitalizations

11. HF Pocket Card Heart Failure Signs and Symptoms What to look for:What to do: F Fatigue Fast pulse Assist with care as needed. Pace activity with rest periods. Monitor vital signs, note if pulse is irregular or >100 beats per minute. A Activities of Daily Living Appetite poor Decline in ADLs-Assist with care to ↓ effort & shortness of breath. Offer small amounts of food more often. C Cough Congestion Confusion Chest pain Watch for mucous, especially frothy or bloody sputum. Provide emotional support-stay w/patient. Falls prevention. E Edema- swelling, weight gain Elimination Check weights. Protect legs & feet from injury. Watch out for ↓ urine output and nocturia S Shortness of Breath Elevate head of bed, use extra pillows. Sit up patient on edge of bed. Offer mouth care, ice chips, lip balm.

12. Long Term Care Nursing Staff -Training in Action….

13. Teaching Staff in the Workplace Make information practical and relevant. Make information practical and relevant. Focus on essential, need-to-know information. Focus on essential, need-to-know information. Involve staff in their learning by asking them to explain why information is important. Involve staff in their learning by asking them to explain why information is important. Build on relevant experiences and previous knowledge. Build on relevant experiences and previous knowledge. Encourage learner-directed problem solving (i.e. After you teach them, ask them to tell you what they could do with this information). Encourage learner-directed problem solving (i.e. After you teach them, ask them to tell you what they could do with this information).

14. Why Teach about HF? Course of disease is marked by decompensation. Course of disease is marked by decompensation. Disease progression difficult to predict. Disease progression difficult to predict. Patient may be anxious or panicked-staff may misinterpret or dismiss. Patient may be anxious or panicked-staff may misinterpret or dismiss. Medical intervention can improve quality of life, extend life, and prevent acute exacerbations. Medical intervention can improve quality of life, extend life, and prevent acute exacerbations.

15. Stable Heart Function & VS Functional status stable Acute HF: Severe SOB Severe edema VS changes Confusion Life threatening Irreversible, Fast Onset Consequences ER Hospital Disability Death Dominant Mental Model—HF has an Irreversible Course

16. Stable Heart Function & VS Acute HF Life- threatening ER, Hospital- ization, Disability, Death DOE, cough Mild edema Fatigue Agitation, lethargy or confusion VS change Dyspnea at rest PND Productive cough Severe edema Profound fatigue Angina VS change Alternative Mental Model—Progressive & Reversible Early S&S Late S&S Progressive Course

17. Stable Heart Function & VS Acute HF Life- threatening event ER, Hospital- ization, Disability, Death Early S&S: DOE, cough Mild edema Fatigue Agitation, lethargy or confusion VS change Later S&S: Dyspnea at rest PND Productive cough Severe edema Profound fatigue Angina VS change Alternative Mental Model—Assess & Treat Early Treatment Early Detection Prevent

18. Developing a Plan for Teaching LPNs and CNAs about HF

19. Know the Nurses Know the Nurses Educational preparation (formal and CE) Educational preparation (formal and CE) Licensure and scope of practice Licensure and scope of practice Licensure rules http://www.ncbon.com/prac-lpnrules.asp Licensure rules http://www.ncbon.com/prac-lpnrules.asp Decision tree for RN & LPN http://www.ncbon.com/forms/decisiontree.pdf Decision tree for RN & LPN http://www.ncbon.com/forms/decisiontree.pdf Issues of limited literacy, ESL Issues of limited literacy, ESL Local culture: family, staff health issues, population risk factors, resident risk factors Local culture: family, staff health issues, population risk factors, resident risk factors

20. Deciding What to Teach Identify content for RN, LPN, CNA Identify content for RN, LPN, CNA Identify how new info will apply to their role Identify how new info will apply to their role Recognize—Assess/Observe—Report—Record Recognize—Assess/Observe—Report—Record Develop job aids & checklists to make learning easy Develop job aids & checklists to make learning easy Use multiple methods/modalities for teaching Use multiple methods/modalities for teaching Incorporate adult learning principles Incorporate adult learning principles Use Bedside Clinical Teaching Use Bedside Clinical Teaching

21. Bedside Clinical Teaching Model What: To teach at a teachable moment, to put new information into practice What: To teach at a teachable moment, to put new information into practice Why: To improve patient care by communicating accurate, new information among staff. Why: To improve patient care by communicating accurate, new information among staff. How: In a short encounter of 10-20 minutes, you will interactively discuss the resident at his/her bedside while teaching & demonstrating care techniques. How: In a short encounter of 10-20 minutes, you will interactively discuss the resident at his/her bedside while teaching & demonstrating care techniques. Assessment: Return demonstration & discussion Assessment: Return demonstration & discussion Feedback: Interactive & ongoing with staff Feedback: Interactive & ongoing with staff Bedside Clinical Teaching Procedure click here

22. Using Bedside Clinical Teaching Preparation- what to know about the resident Preparation- what to know about the resident Chart review Chart review Talk to staff/MD/family Talk to staff/MD/family Talk to resident Talk to resident Teaching goal- target for this session Teaching goal- target for this session Determine target learning goal Determine target learning goal Determine what staff should do differently in the care of the patient Determine what staff should do differently in the care of the patient Structure the teaching encounter Structure the teaching encounter Follow-up, repeat Follow-up, repeat

23. How do you explain HF to staff with different levels of education? With HF, the weakened heart pumps less blood than usual. With HF, the weakened heart pumps less blood than usual. The blood stalls, or congests, in the body's tissues. This makes it harder for the heart to pump blood through the arteries on the next beat. This causes more fluid build-up. The blood stalls, or congests, in the body's tissues. This makes it harder for the heart to pump blood through the arteries on the next beat. This causes more fluid build-up. With fluid build-up, the legs and ankles swell. Fluid may also collect in the lungs and cause breathing problems, especially when lying down. Some patients have fluid build-up in the stomach. With fluid build-up, the legs and ankles swell. Fluid may also collect in the lungs and cause breathing problems, especially when lying down. Some patients have fluid build-up in the stomach. The kidneys have trouble getting rid of sodium and water and this causes more fluid build-up throughout the body. The kidneys have trouble getting rid of sodium and water and this causes more fluid build-up throughout the body. Without treatment, HF worsens and may prevent the heart from pumping enough blood to keep the person alive. Without treatment, HF worsens and may prevent the heart from pumping enough blood to keep the person alive.

24. Where is there expertise among staff? Ms Diamond, LPN, pointed out that one resident, Mrs. Flow, had R sided heart failure and had different symptoms from other patients. She gets abdominal edema-ascites -as the primary sign, not LE edema. Ms Diamond, LPN, pointed out that one resident, Mrs. Flow, had R sided heart failure and had different symptoms from other patients. She gets abdominal edema-ascites -as the primary sign, not LE edema. This is Right-sided Heart Failure. This is Right-sided Heart Failure. “If you were looking for swelling in the legs you wouldn’t find it, you would miss her early signs completely and she would be in full blown failure before you knew it!” “If you were looking for swelling in the legs you wouldn’t find it, you would miss her early signs completely and she would be in full blown failure before you knew it!”

25. Where is there expertise among staff? Ms. Edie, CNA, has been at the NH for 8 years and knows patients well. Ms. Edie, CNA, has been at the NH for 8 years and knows patients well. She knows most of what to look for when HF patients start to decompnesate: “They get real tired and short of breath, a little confused. I know they are getting into trouble, so I get the nurse to assess!” She knows most of what to look for when HF patients start to decompnesate: “They get real tired and short of breath, a little confused. I know they are getting into trouble, so I get the nurse to assess!” She also has family members with HF and has helped them with their hospitalizations & meds. She also has family members with HF and has helped them with their hospitalizations & meds.

26. How to use staff expertise Involve in co-teaching education programs. Involve in co-teaching education programs. Use in Bedside Clinical Teaching. Use in Bedside Clinical Teaching. Mentor to help them grow in their role. Mentor to help them grow in their role. Pair with other staff to teach during care activities. Pair with other staff to teach during care activities.

27. Summary: Bedside Clinical Teaching A technique to build knowledge and skill among staff with diverse education, experience, literacy. A technique to build knowledge and skill among staff with diverse education, experience, literacy. A way to strengthen communication and teamwork. A way to strengthen communication and teamwork. A powerful tool for improving quality of care within existing capacity of the NH. A powerful tool for improving quality of care within existing capacity of the NH. A strategy for RN delegation and supervision. A strategy for RN delegation and supervision.

28. Good Luck! Good Luck! Call or email with questions: Call or email with questions: Deborah Lekan, MSN, RNC Deborah Lekan, MSN, RNC Office: 684-8849 Office: 684-8849 Email: lekan001@mc.duke.edu Email: lekan001@mc.duke.edulekan001@mc.duke.edu