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Duke University School of Nursing, 2007 Heart Failure in the Frail Elderly in LTC: Nursing Assessment Part 1 Deborah Lekan, MSN, RNC Clinical Nurse Specialist,

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Presentation on theme: "Duke University School of Nursing, 2007 Heart Failure in the Frail Elderly in LTC: Nursing Assessment Part 1 Deborah Lekan, MSN, RNC Clinical Nurse Specialist,"— Presentation transcript:

1 Duke University School of Nursing, 2007 Heart Failure in the Frail Elderly in LTC: Nursing Assessment Part 1 Deborah Lekan, MSN, RNC Clinical Nurse Specialist, Gerontological Nursing

2 Duke University School of Nursing, 2007 Heart Failure: Overview A chronic illness or syndrome with impairment in quality of life from severe symptoms and limited survival. A chronic illness or syndrome with impairment in quality of life from severe symptoms and limited survival. QOL influenced by need for frequent medical attention to control symptoms and increased hospitalizations. QOL influenced by need for frequent medical attention to control symptoms and increased hospitalizations.

3 Duke University School of Nursing, 2007 Epidemiology Over 5 million people diagnosed, 550,000 new diagnoses each year Over 5 million people diagnosed, 550,000 new diagnoses each year Most common diagnosis associated with hospitalization in aged 65 years and over Most common diagnosis associated with hospitalization in aged 65 years and over Most common Medicare DRG. Most common Medicare DRG. High rate of hospital readmission- High rate of hospital readmission- About 20% at one month About 20% at one month About 47% at 3-6 months About 47% at 3-6 months Hospital readmissions ↑ in the 6 months prior to death Hospital readmissions ↑ in the 6 months prior to death

4 Duke University School of Nursing, 2007 Prognosis 250,000 deaths per year in US. 250,000 deaths per year in US. 5 year mortality (NHLBI data) 5 year mortality (NHLBI data) Men: 50% Men: 50% Women: 34% Women: 34% In Class IV (NYHA) patients: In Class IV (NYHA) patients: 60% first year mortality (CONSENSUS study) 60% first year mortality (CONSENSUS study) 38% first year mortality (SUPPORT study) 38% first year mortality (SUPPORT study) Class II-III patients: 38% 42 month mortality Class II-III patients: 38% 42 month mortality

5 Duke University School of Nursing, 2007 Natural History Course of HF is marked by de-compensation Course of HF is marked by de-compensation Disease progression difficult to predict Disease progression difficult to predict Precipitating factors for hospitalization: Precipitating factors for hospitalization: Non-adherence to treatment regimen Non-adherence to treatment regimen Uncontrolled hypertension Uncontrolled hypertension Cardiac arrhythmias Cardiac arrhythmias Iatrogenic Iatrogenic Terminal course of disease distinguished by increasing frequent episodes of acute HF exacerbations Terminal course of disease distinguished by increasing frequent episodes of acute HF exacerbations

6 Duke University School of Nursing, 2007 End-of-Life Phase Terminal patients report symptoms of nausea, pain, dyspnea, confusion, fatigue, & depression Terminal patients report symptoms of nausea, pain, dyspnea, confusion, fatigue, & depression Most elderly live at home but experience death in institutions Most elderly live at home but experience death in institutions Hospital deaths for HF: 56% Hospital deaths for HF: 56% Nursing home deaths for HF: 19% Nursing home deaths for HF: 19% The older the patient, the more likely they will die in a hospital or nursing home The older the patient, the more likely they will die in a hospital or nursing home

7 Duke University School of Nursing, 2007 Clinical Practice Guideline on HF Heart Failure Society of America Heart Failure Society of America “The current comprehensive guideline addresses the full range of evaluation, care, and management of patients with HF.” “The current comprehensive guideline addresses the full range of evaluation, care, and management of patients with HF.”

8 Duke University School of Nursing, 2007 Here are 2 guidelines that apply to HF in Frail Elders in LTC American Medical Directors Association (AMDA) American Medical Directors Association (AMDA) University of Iowa Evidence-based Protocol on Heart Failure University of Iowa Evidence-based Protocol on Heart Failure These guidelines are available in full-text, PDF format in the reference list

9 Duke University School of Nursing, 2007 Heart Failure Disease Presentation Left sided failure S&S Left sided failure S&S Right sided failure S&S Right sided failure S&S Wide continuum of function & disability Wide continuum of function & disability Variable progression of the disease over time Variable progression of the disease over time Variable impact on quality of life Variable impact on quality of life

10 Duke University School of Nursing, 2007 Risk Factors for HF Coronary Artery Disease-Ischemic disease Coronary Artery Disease-Ischemic disease Heart attack—causes 2/3 of heart failure Heart attack—causes 2/3 of heart failure Non-ischemic disease Non-ischemic disease High blood pressure High blood pressure Heart valve disease Heart valve disease Cardio-myopathy Cardio-myopathy Thyroid hyperactive Thyroid hyperactive Anemia Anemia Alcohol abuse Alcohol abuse Diabetes mellitus Diabetes mellitus

11 Duke University School of Nursing, 2007 Risk Factors Here is a link to a comprehensive but brief summary of HF including risk factors Here is a link to a comprehensive but brief summary of HF including risk factors Reference Article: Shamsham F & Mitchell J. (2000) Essentials of the diagnosis of HF. American Family Physician, 61(5)

12 Duke University School of Nursing, 2007 What is the Risk of Developing Heart Failure? Risk rises 4-6 times after a heart attack Risk rises 4-6 times after a heart attack Risk is doubled by angina, diabetes, uncontrolled high blood pressure Risk is doubled by angina, diabetes, uncontrolled high blood pressure Other risks: enlarged heart, family history of heart failure, high cholesterol, smoking, chronic or excessive alcohol Other risks: enlarged heart, family history of heart failure, high cholesterol, smoking, chronic or excessive alcohol

13 Duke University School of Nursing, 2007 Heart Failure: A Deadly Disease Sudden death: 6 to 9 times > than general population Sudden death: 6 to 9 times > than general population Men: 1 year survival rate 57% Men: 1 year survival rate 57% 5 year survival rate of 25% 5 year survival rate of 25% Women: 1 year survival rate 64% Women: 1 year survival rate 64% 5 year survival rate of 38% 5 year survival rate of 38%

14 Duke University School of Nursing, 2007 Hallmarks of Heart Failure Intravascular volume overload —extra fluid in the blood vessels, leads to fast heart rate and decreased cardiac output. Intravascular volume overload —extra fluid in the blood vessels, leads to fast heart rate and decreased cardiac output. Interstitial volume overload -- extra fluid in the peripheral tissues and lungs leads to leg edema, lung congestion, cough, and sputum. Interstitial volume overload -- extra fluid in the peripheral tissues and lungs leads to leg edema, lung congestion, cough, and sputum. Inadequate tissue perfusion —low oxygen in blood leads to fatigue, weakness, confusion. Inadequate tissue perfusion —low oxygen in blood leads to fatigue, weakness, confusion.

15 Duke University School of Nursing, 2007 The many FACES of Heart Failure HF is manifested in many different ways.

16 Duke University School of Nursing, 2007 Because HF is a syndrome, assessment is complex. Mrs. V is an 86 year old woman with HF. Mrs. V is an 86 year old woman with HF. The CNA comes to you and says that she “does not look good today.” The CNA comes to you and says that she “does not look good today.” You go to see the patient. You go to see the patient. What will you assess? What will you assess?

17 Duke University School of Nursing, 2007 Here is a simple acronym to help you organize and remember the S&S of HF: FACES

18 Duke University School of Nursing, 2007 Remember FACES  F F atigue, F ast pulse/respirations F F atigue, F ast pulse/respirations A A ctivities and A ppetite decline A A ctivities and A ppetite decline C C ough, C ongestion, C onfusion, C hest pain C C ough, C ongestion, C onfusion, C hest pain E E dema –weight gain, E limination –nocturia or decreased urine output E E dema –weight gain, E limination –nocturia or decreased urine output S S hortness of breath S S hortness of breath An easy to remember acronym!

19 Duke University School of Nursing, 2007 Heart Failure Assessment Focused HF assessment Focused HF assessment ml Look here for tips to help you do a focused assessment ml

20 Duke University School of Nursing, 2007 Assessment of the Resident with HF Initial appearance Initial appearance History History Vital signs, pulse oximetry, weight Vital signs, pulse oximetry, weight Focused assessment: LOC, dyspnea, edema, heart and lung assessment, fatigue Focused assessment: LOC, dyspnea, edema, heart and lung assessment, fatigue Medication review Medication review Labs Labs Diagnostic tests Diagnostic tests

21 Duke University School of Nursing, 2007 Initial Appearance Alertness and level of consciousness Alertness and level of consciousness Ability to speak in sentences Ability to speak in sentences Breathing effort Breathing effort Emotional state: Anxiety Emotional state: Anxiety Skin color, diaphoresis Skin color, diaphoresis Body position Body position Initial impression: Stable or critical? Initial impression: Stable or critical?

22 Duke University School of Nursing, 2007 Level of Consciousness Observe for fluctuating mental status due to delirium/acute confusion Observe for fluctuating mental status due to delirium/acute confusion Administer mental status screening test if indicated Administer mental status screening test if indicated Mini-Mental State Exam Mini-Mental State Exam Cognitive Assessment Method (CAM) Cognitive Assessment Method (CAM)

23 Duke University School of Nursing, 2007 History Risk Factors Risk Factors MI, CAD, HTN, DM, thyroid, etc. MI, CAD, HTN, DM, thyroid, etc. Lifestyle –diet, exercise, alcohol, tobacco Lifestyle –diet, exercise, alcohol, tobacco Previous treatment & medications Previous treatment & medications Course: frequency of hospital admissions or ED transfers Course: frequency of hospital admissions or ED transfers

24 Duke University School of Nursing, 2007 Vital Signs Quick overview Quick overview Pulse Pulse Apical-radial for full minute Apical-radial for full minute Respirations Respirations

25 Duke University School of Nursing, 2007 Vital Signs Blood pressure Blood pressure Orthostatic blood pressure Orthostatic blood pressure Be alert to  falls risk with significant orthostatic changes!

26 Duke University School of Nursing, 2007 Pulse Oximetry A non-invasive way to measure oxygen saturation. A non-invasive way to measure oxygen saturation. False readings can occur so technique is important! False readings can occur so technique is important!

27 Duke University School of Nursing, 2007 Question: Mrs. H. This 76 year old patient has a pulse of 108, RR of 24, and a pulse oximetry of 98%. This 76 year old patient has a pulse of 108, RR of 24, and a pulse oximetry of 98%. Is this a sign of trouble? Is this a sign of trouble? Pulse & RR slightly elevated Pulse & RR slightly elevated Pulse Ox is WNL Pulse Ox is WNL Is this clinically significant? Is this clinically significant?

28 Duke University School of Nursing, 2007 Yes! A fast respiratory rate can be an early sign of heart failure A fast respiratory rate can be an early sign of heart failure A normal pulse oximetry is due to the rapid respiratory rate. Eventually, the resident will tire & pulse oximetry/ oxygen saturation will decline & respirations will become labored A normal pulse oximetry is due to the rapid respiratory rate. Eventually, the resident will tire & pulse oximetry/ oxygen saturation will decline & respirations will become labored PaO2 will drop rapidly & the patient will become much more dyspneic  acute HF PaO2 will drop rapidly & the patient will become much more dyspneic  acute HF Be alert for these early signs!

29 Duke University School of Nursing, 2007 Weight Standard care is ‘daily weights’ Standard care is ‘daily weights’ In LTC, weekly weights are standard, with some exceptions when daily weights may be ordered during acute HF with intensive diuretic therapy In LTC, weekly weights are standard, with some exceptions when daily weights may be ordered during acute HF with intensive diuretic therapy AMDA recommends weights 3 times a week in HF patients AMDA recommends weights 3 times a week in HF patients

30 Duke University School of Nursing, 2007 Weight Red flag: Red flag: 2 lb gain overnight, or 5 lb gain in a week 2 lb gain overnight, or 5 lb gain in a week A 2.2 lb of weight gain equals about a liter of fluid! A 2.2 lb of weight gain equals about a liter of fluid! Pulmonary edema is the clinical end point of fluid overload Pulmonary edema is the clinical end point of fluid overload Source: jpg

31 Duke University School of Nursing, 2007 Lung Assessment Here is a fantastic link to brush up on your lung assessment skills Here is a fantastic link to brush up on your lung assessment skills medicine.ucsd.edu/cli nicalmed/extremities. htm medicine.ucsd.edu/cli nicalmed/extremities. htm Source: U California San Diego: medicine.ucsd.edu/clinicalmed/ extremities.htm medicine.ucsd.edu/clinicalmed/ extremities.htm

32 Duke University School of Nursing, 2007 Dyspnea Early sign of cardiac decompensation Early sign of cardiac decompensation It is a complex symptom It is a complex symptom Definitions Definitions Difficult, labored, uncomfortable breathing Difficult, labored, uncomfortable breathing A sensation of breathlessnesss A sensation of breathlessnesss An awareness of respiratory distress An awareness of respiratory distress Influenced by physiologic, psychologic, environmental, social conditions Influenced by physiologic, psychologic, environmental, social conditions

33 Duke University School of Nursing, 2007 Dyspnea Assessment Nursing Best Practice Guideline for Dyspnea Nursing Best Practice Guideline for Dyspnea PD_summary.pdf PD_summary.pdf Animation of normal breathing and dyspnea Animation of normal breathing and dyspnea ma_breat_anim.html ma_breat_anim.html Assessment Assessment Visual analogue scale for dyspnea and HF Visual analogue scale for dyspnea and HF

34 Duke University School of Nursing, 2007 Dyspnea Assessment Continuous vs intermittent Continuous vs intermittent Exertional vs non-exertional Exertional vs non-exertional Severity: orthopnea, paroxysmal nocturnal dyspnea (PND) Severity: orthopnea, paroxysmal nocturnal dyspnea (PND) Accessory muscle use Accessory muscle use Cough Cough Productive vs dry cough Productive vs dry cough Frothy or bloody Frothy or bloody

35 Duke University School of Nursing, 2007

36 More on Dyspnea Assessment Dyspnea Flow Sheet eleconference/Key_for_Dyspnea_Flow_Sheet_ pdf Dyspnea Flow Sheet eleconference/Key_for_Dyspnea_Flow_Sheet_ pdf eleconference/Key_for_Dyspnea_Flow_Sheet_ pdf eleconference/Key_for_Dyspnea_Flow_Sheet_ pdf Excellent reference article “Dyspnea: Mechanisms, Assessment, Management: A Consensus Statement” Excellent reference article “Dyspnea: Mechanisms, Assessment, Management: A Consensus Statement” pages/respiratory-disease-adults/dyspnea1-20.html pages/respiratory-disease-adults/dyspnea1-20.html pages/respiratory-disease-adults/dyspnea1-20.html pages/respiratory-disease-adults/dyspnea1-20.html Dyspnea Assessment Tools html Dyspnea Assessment Tools html html html

37 Duke University School of Nursing, 2007 Dyspnea For Clinical Pearls about How to Assess and Palliate Dyspnea- For Clinical Pearls about How to Assess and Palliate Dyspnea- earls.html

38 Duke University School of Nursing, 2007 Heart Assessment Go here for a really great review of heart assessment skills Go here for a really great review of heart assessment skills imgurl=http://medicine.ucsd.edu/ clinicalmed/extremities-massive- edema.jpg&imgrefurl=http://medi cine.ucsd.edu/clinicalmed/extremit ies.htm&h=300&w=400&sz=16& hl=en&start=2&tbnid=tfwPhytR2 O1KxM:&tbnh=93&tbnw=124&p rev=/images%3Fq%3Dedema%26 svnum%3D10%26hl%3Den%26lr %3D%26sa%3DN imgurl=http://medicine.ucsd.edu/ clinicalmed/extremities-massive- edema.jpg&imgrefurl=http://medi cine.ucsd.edu/clinicalmed/extremit ies.htm&h=300&w=400&sz=16& hl=en&start=2&tbnid=tfwPhytR2 O1KxM:&tbnh=93&tbnw=124&p rev=/images%3Fq%3Dedema%26 svnum%3D10%26hl%3Den%26lr %3D%26sa%3DN Source: U California San Diego: medicine.ucsd.edu/clinicalmed/ extremities.htm medicine.ucsd.edu/clinicalmed/ extremities.htm

39 Duke University School of Nursing, 2007 Fluid Status Evaluation Fluid overload is manifested by edema, lung congestion & productive cough. Fluid overload is manifested by edema, lung congestion & productive cough. Pulmonary edema is the most serious indicator of fluid overload. Pulmonary edema is the most serious indicator of fluid overload. Source:

40 Duke University School of Nursing, 2007 Pulmonary Edema The heart is unable to pump the necessary amount of blood throughout the body. This causes blood to back up in the veins. Fluid pools in the liver and lungs. The heart is unable to pump the necessary amount of blood throughout the body. This causes blood to back up in the veins. Fluid pools in the liver and lungs. Swelling occurs first in the feet, ankles, and legs, and then throughout the body as the kidneys retain fluid. Swelling occurs first in the feet, ankles, and legs, and then throughout the body as the kidneys retain fluid.

41 Duke University School of Nursing, 2007 Pulmonary Edema Source: Lynne Larson, 1998, Conceptual illustration depicting congestive heart failure.

42 Duke University School of Nursing, 2007 Pulmonary Edema Pulmonary edema begins with an increased filtration through the loose junctions of the pulmonary capillaries. Source: Lynne Larson, 1998,

43 Duke University School of Nursing, 2007 Pulmonary Edema As the intra-capillary pressure increases, normally impermeable (tight) junctions between the alveolar cells open, permitting alveolar flooding to occur. Source: Lynne Larson, 1998,

44 Duke University School of Nursing, 2007 Pulmonary Edema Here is an X-ray showing severe pulmonary edema Here is an X-ray showing severe pulmonary edema Notice the diffuse clouding indicating fluid overload and congestion Notice the diffuse clouding indicating fluid overload and congestion

45 Duke University School of Nursing, 2007 Fluid Status Evaluation Best done by monitoring Best done by monitoring Weight Weight Peripheral edema Peripheral edema Lungs Lungs

46 Duke University School of Nursing, 2007 Peripheral Edema Lower extremity edema, a common sign of heart failure, is usually detected when the extra-cellular volume exceeds 5 L Lower extremity edema, a common sign of heart failure, is usually detected when the extra-cellular volume exceeds 5 L The edema may be accompanied by stasis dermatitis, a chronic, eczematous condition characterized by edema, hyper-pigmentation, ulceration The edema may be accompanied by stasis dermatitis, a chronic, eczematous condition characterized by edema, hyper-pigmentation, ulceration

47 Duke University School of Nursing, 2007 Pedal or LE Edema ASSESS: Size of extremity Size of extremity Color Color Temperature Temperature Sensation Sensation Palpation Palpation Pitting Pitting

48 Duke University School of Nursing, 2007 Edema: Question How would you evaluate and grade this LE Edema? How would you evaluate and grade this LE Edema? Here are some assessment guidelines Here are some assessment guidelines (Link to: Assessment of Peripheral Edema) Link to: Assessment of Peripheral EdemaLink to: Assessment of Peripheral Edema (Link to: Assessment of Peripheral Edema) Assessment of Peripheral EdemaAssessment of Peripheral Edema

49 Duke University School of Nursing, 2007 Answer This presentation is consistent with severe LE edema with pitting. The toes are also pale and ashen with some blue-tinged discoloration. This presentation is consistent with severe LE edema with pitting. The toes are also pale and ashen with some blue-tinged discoloration.

50 Duke University School of Nursing, 2007 Other Types of Edema Right sided heart failure may manifest with ascites and not LE edema Right sided heart failure may manifest with ascites and not LE edema Also look for dependent edema in other areas such as the sacrum. Also look for dependent edema in other areas such as the sacrum. Source: U California San Diego: medicine.ucsd.edu/clinicalmed/ extremities.htm medicine.ucsd.edu/clinicalmed/ extremities.htm

51 Duke University School of Nursing, 2007 JVD Here is another view of the jugular vein. Here is another view of the jugular vein. Source: UC San Diego: medicine.ucsd.edu/clinicalm ed/extremities.htm medicine.ucsd.edu/clinicalm ed/extremities.htm

52 Duke University School of Nursing, 2007 Jugular Vein Distention (JVD) Jugular venous distention is assessed while the patient is supine at a 45-degree angle. The top of the waveform of the internal jugular venous pulsation determines the height of the venous distention. An imaginary horizontal line (parallel to the floor) is then drawn from this level to above the sternal angle. Jugular venous distention is assessed while the patient is supine at a 45-degree angle. The top of the waveform of the internal jugular venous pulsation determines the height of the venous distention. An imaginary horizontal line (parallel to the floor) is then drawn from this level to above the sternal angle. A height of more than 4 to 5 cm from the sternal angle to this imaginary line is consistent with elevated venous pressure Elevated jugular venous pressure is a specific (90 percent) but not sensitive (30 percent) sign of elevated left ventricular filling.. A height of more than 4 to 5 cm from the sternal angle to this imaginary line is consistent with elevated venous pressure Elevated jugular venous pressure is a specific (90 percent) but not sensitive (30 percent) sign of elevated left ventricular filling..

53 Duke University School of Nursing, 2007 Fatigue An early sign of evolving acute HF An early sign of evolving acute HF Unremitting and progressive in chronic HF Unremitting and progressive in chronic HF Piper Fatigue Scale, 27 items on a 1-10 scale of severity cale.PDF Piper Fatigue Scale, 27 items on a 1-10 scale of severity cale.PDF cale.PDF cale.PDF Markedly affects QOL & function Markedly affects QOL & function

54 Duke University School of Nursing, 2007 Medication Review: HF drugs ACE Inhibitors Lotensin, Capoten, Vasotec, Altace, Accupril ACE Inhibitors Lotensin, Capoten, Vasotec, Altace, Accupril Beta blockers Carvedilol, Metoprolol Beta blockers Carvedilol, Metoprolol Angiotensin Receptor Blockers Cozaar, Diovan, Teveten, Avapro, Benecar Angiotensin Receptor Blockers Cozaar, Diovan, Teveten, Avapro, Benecar Spironolactone Aldosterone Spironolactone Aldosterone Diuretics Lasix, hydrochlorothiazide Diuretics Lasix, hydrochlorothiazide Digoxin Digoxin

55 Duke University School of Nursing, 2007 Medications for HF Review the medication list for the resident Review the medication list for the resident Review drug action and therapeutic goal Review drug action and therapeutic goal Identify the target heart rate that treatment is hoping to achieve Identify the target heart rate that treatment is hoping to achieve Determine if the BP is too low as an unintentional consequence of drug RX Determine if the BP is too low as an unintentional consequence of drug RX Is the resident having adverse side effects? Is the resident having adverse side effects?

56 Duke University School of Nursing, 2007 Diet and Intake Pattern Low Salt diet recommended Low Salt diet recommended No Added Salt, or 2 gram /3 gram NA diet typical No Added Salt, or 2 gram /3 gram NA diet typical Determine if resident is very salt sensitive (prone to rapid onset of HF with salty meal) Determine if resident is very salt sensitive (prone to rapid onset of HF with salty meal) A high salt meal MAY provoke HF the next day! A high salt meal MAY provoke HF the next day! Diet may be liberalized if resident is underweight, cachexic, or eating poorly. Diet may be liberalized if resident is underweight, cachexic, or eating poorly. Nutritional supplements may be needed. Nutritional supplements may be needed.

57 Duke University School of Nursing, 2007 Fluid Intake Pattern Fluid restriction  1,500-2,000 mL/day. Fluid restriction  1,500-2,000 mL/day. No fluid restriction needed for most NH residents, but should avoid excess fluid. No fluid restriction needed for most NH residents, but should avoid excess fluid. Monitor diuretic therapy Monitor diuretic therapy Monitor for poor intake Monitor for poor intake Some older residents who have trouble eating enough may actually need to be encouraged to drink fluids, & may need nutritional supplements. Some older residents who have trouble eating enough may actually need to be encouraged to drink fluids, & may need nutritional supplements.

58 Duke University School of Nursing, 2007 Activity Determine current activity level. Determine current activity level. Important to stay active, to pace activity with rest periods, & allow extra time to complete activities. Important to stay active, to pace activity with rest periods, & allow extra time to complete activities. Some level of fatigue may be present—it is still important to help resident stay as active as possible. Some level of fatigue may be present—it is still important to help resident stay as active as possible. Use the NYHA classification to determine your patient’s functional level Use the NYHA classification to determine your patient’s functional level

59 Duke University School of Nursing, 2007 NY Heart Association Classification of HF: To rate disease severity based on functional status Class I: no limitation of activities; no symptoms (fatigue, palpitation, dyspnea or anginal pain) from ordinary activities. Class I: no limitation of activities; no symptoms (fatigue, palpitation, dyspnea or anginal pain) from ordinary activities. Class II: slight, mild limitation of activity; comfortable at rest or with mild exertion. Class II: slight, mild limitation of activity; comfortable at rest or with mild exertion. Class III: marked limitation of activity; comfortable only at rest. Less than ordinary activity produces symptoms. Class III: marked limitation of activity; comfortable only at rest. Less than ordinary activity produces symptoms. Class IV: Patients w/ cardiac disease resulting in inability to do any physical activity w/o discomfort. Symptoms of HF may be present at rest. If any physical activity is undertaken, discomfort increases. Usually bed or chair bound. Class IV: Patients w/ cardiac disease resulting in inability to do any physical activity w/o discomfort. Symptoms of HF may be present at rest. If any physical activity is undertaken, discomfort increases. Usually bed or chair bound.

60 Duke University School of Nursing, 2007 Lab Tests Chemistry panel Chemistry panel Electrolytes-usually normal but hypo-natremia can occur from potassium-sparing diuretics, & hyper- natremia from ACE Inhibitors Electrolytes-usually normal but hypo-natremia can occur from potassium-sparing diuretics, & hyper- natremia from ACE Inhibitors Liver enzymes can be ↑ secondary to liver congestion Liver enzymes can be ↑ secondary to liver congestion Anemia associated with and is trigger of HF Anemia associated with and is trigger of HF Thyroid panel-hyperthyroid a trigger for HF Thyroid panel-hyperthyroid a trigger for HF BNP- Brain Natriuretic Peptide BNP- Brain Natriuretic Peptide Secreted by failing left ventricle, ↑ in HF (>100) Secreted by failing left ventricle, ↑ in HF (>100)

61 Duke University School of Nursing, 2007 Diagnostic Tests Chest X-ray -looks at size and shape of heart, presence of effusion Chest X-ray -looks at size and shape of heart, presence of effusion Echocardiogram -looks for decreased ejection fraction (EF), dilated LV, enlarged heart, LV hypertrophy Echocardiogram -looks for decreased ejection fraction (EF), dilated LV, enlarged heart, LV hypertrophy What is the patient’s EF? If there is systolic dysfunction, >55% is normal If there is systolic dysfunction, >55% is normal If there is diastolic dysfunction, EF may be WNL If there is diastolic dysfunction, EF may be WNL EKG -looks at rate & rhythm abnormalities, Q wave abnormalities suggestive of MI EKG -looks at rate & rhythm abnormalities, Q wave abnormalities suggestive of MI

62 Duke University School of Nursing, 2007 Assessment of Acute HF Obtain a dyspnea progression history Obtain a dyspnea progression history Rest dyspnea  Orthopnea  Paroxysmal nocturnal dyspnea  Dyspnea while walking on level area  Dyspnea while climbing Rest dyspnea  Orthopnea  Paroxysmal nocturnal dyspnea  Dyspnea while walking on level area  Dyspnea while climbing The patient should be questioned about cough, nocturia, fatigue & other signs and symptoms The patient should be questioned about cough, nocturia, fatigue & other signs and symptoms Source: Shamsham F & Mitchell J. (2000) Essentials of the diagnosis of HF. American Family Phhysician, 61(5) LINK:

63 Duke University School of Nursing, 2007 Progression of Acute HF Dyspnea, a cardinal symptom of HF, progresses from dyspnea on exertion to orthopnea (unable to lie flat), paroxysmal nocturnal dyspnea (PND) to dyspnea at rest/during speech Dyspnea, a cardinal symptom of HF, progresses from dyspnea on exertion to orthopnea (unable to lie flat), paroxysmal nocturnal dyspnea (PND) to dyspnea at rest/during speech Cough, usually nocturnal & nonproductive, may accompany dyspnea and often occurs on exertion or when the patient is supine Cough, usually nocturnal & nonproductive, may accompany dyspnea and often occurs on exertion or when the patient is supine Source: Shamsham F & Mitchell J. (2000) Essentials of the diagnosis of HF. American Family Physician, 61(5)

64 Duke University School of Nursing, 2007 Progression of Acute HF Nocturia develops secondary to increased renal perfusion while supine Nocturia develops secondary to increased renal perfusion while supine May be  urine output during the day May be  urine output during the day Generalized fatigue-can be profound & disabling Generalized fatigue-can be profound & disabling Increasing peripheral edema-LE, ascites Increasing peripheral edema-LE, ascites Source: Shamsham F & Mitchell J. (2000) Essentials of the diagnosis of HF. American Family Phhysician, 61(5)

65 Duke University School of Nursing, 2007 Progression of Acute HF GI symptoms may develop (bloating, anorexia, fullness in the RU quadrant) GI symptoms may develop (bloating, anorexia, fullness in the RU quadrant) With severe, longstanding HF, cardiac cachexia (emaciation) may develop secondary to protein- losing enteropathy & increased levels of cytokines (IL-6 & TNF) With severe, longstanding HF, cardiac cachexia (emaciation) may develop secondary to protein- losing enteropathy & increased levels of cytokines (IL-6 & TNF) Clinical endpoint is frailty Clinical endpoint is frailty End of life care End of life care Source: Shamsham F & Mitchell J. (2000) Essentials of the diagnosis of HF. American Family Phhysician, 61(5)

66 Duke University School of Nursing, 2007 Summary Early recognition of HF S&S leads to early treatment & better outcomes Early recognition of HF S&S leads to early treatment & better outcomes Treatment optimization can lead to improvement in morbidity, mortality & QOL Treatment optimization can lead to improvement in morbidity, mortality & QOL RN role is to empower staff to use evidence- based approaches to observe & assess changes in patient status and communicate/report in an effective & timely manner RN role is to empower staff to use evidence- based approaches to observe & assess changes in patient status and communicate/report in an effective & timely manner


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