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Duke University School of Nursing, 2007

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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 Welcome and thank you for coming (introduce speaker/self and provide brief bio). We’re here to talk about heart failure, a common condition which affects about 5 million Americans. You may be here because you are at risk or think you may have heart failure, or suspect that a close family member or friend may have heart failure. Perhaps you have just been diagnosed and want to learn more about the disease and treatment options. Today I will discuss what heart failure is, its symptoms and risk factors, how it affects your body and the importance of early diagnosis and treatment. We’ll also talk about some of the latest treatment options and how you can work with your doctor to properly manage the condition. Duke University School of Nursing, 2007

2 Heart Failure: Overview
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. Duke University School of Nursing, 2007

3 Duke University School of Nursing, 2007
Epidemiology 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 Medicare DRG. High rate of hospital readmission- About 20% at one month About 47% at 3-6 months Hospital readmissions ↑ in the 6 months prior to death Duke University School of Nursing, 2007

4 Duke University School of Nursing, 2007
Prognosis 250,000 deaths per year in US. 5 year mortality (NHLBI data) Men: 50% Women: 34% In Class IV (NYHA) patients: 60% first year mortality (CONSENSUS study) 38% first year mortality (SUPPORT study) Class II-III patients: 38% 42 month mortality NHLBI: National Heart Lung and Blood Instititute of the NIH and Framingham study. McKee PA, Castelli NP, McNamera PM, et al: The natural history of congestive heart failure: The Framingham study. NEJM, 285:1441, 1971 CONSENSUS Trial Study Group: Effects on enalapril on mortality in severe CHF: Results of the cooperative Scandinavian enalapril survival study. NEJM, 316, 1429, 1987. SOLVD Investigators: Effect of enalapril on mortality and the development of HF in asymptomatic patients with reduced left ventricular ejection fraction. NEJM, 327: , 1992. The SUPPORT Principal Investigators: A controlled trial to improve care for seriously ill hospitalized patients: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT). JAMA, 274, , 1995. Duke University School of Nursing, 2007

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

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

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

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

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

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

11 Duke University School of Nursing, 2007
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) Duke University School of Nursing, 2007

12 What is the Risk of Developing Heart Failure?
Risk rises 4-6 times after a heart attack 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 Duke University School of Nursing, 2007

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

14 Hallmarks of Heart Failure
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. Inadequate tissue perfusion —low oxygen in blood leads to fatigue, weakness, confusion. Duke University School of Nursing, 2007

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

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

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

18 Duke University School of Nursing, 2007
Remember FACES F Fatigue, Fast pulse/respirations A Activities and Appetite decline C Cough, Congestion, Confusion, Chest pain E Edema –weight gain, Elimination –nocturia or decreased urine output S Shortness of breath An easy to remember acronym! Duke University School of Nursing, 2007

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

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

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

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

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

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

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

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

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%. Is this a sign of trouble? Pulse & RR slightly elevated Pulse Ox is WNL Is this clinically significant? Duke University School of Nursing, 2007

28 Duke University School of Nursing, 2007
Yes! 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 PaO2 will drop rapidly & the patient will become much more dyspneic  acute HF Be alert for these early signs! Duke University School of Nursing, 2007

29 Duke University School of Nursing, 2007
Weight 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 AMDA recommends weights 3 times a week in HF patients Duke University School of Nursing, 2007

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

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

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

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

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

35 Duke University School of Nursing, 2007

36 More on Dyspnea Assessment
Dyspnea Flow Sheet Excellent reference article “Dyspnea: Mechanisms, Assessment, Management: A Consensus Statement” Dyspnea Assessment Tools Duke University School of Nursing, 2007

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

38 Duke University School of Nursing, 2007
Heart Assessment Go here for a really great review of heart assessment skills Source: U California San Diego: medicine.ucsd.edu/clinicalmed/extremities.htm Duke University School of Nursing, 2007

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

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. Swelling occurs first in the feet, ankles, and legs, and then throughout the body as the kidneys retain fluid. Duke University School of Nursing, 2007

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

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

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, Duke University School of Nursing, 2007

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

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

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 The edema may be accompanied by stasis dermatitis, a chronic, eczematous condition characterized by edema, hyper-pigmentation, ulceration Duke University School of Nursing, 2007

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

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

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. Duke University School of Nursing, 2007

50 Duke University School of Nursing, 2007
Other Types of 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. Source: U California San Diego: medicine.ucsd.edu/clinicalmed/extremities.htm Duke University School of Nursing, 2007

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

52 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. 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.. Duke University School of Nursing, 2007

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

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

55 Duke University School of Nursing, 2007
Medications for HF Review the medication list for the resident Review drug action and therapeutic goal 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 Is the resident having adverse side effects? Duke University School of Nursing, 2007

56 Diet and Intake Pattern
Low Salt diet recommended 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) A high salt meal MAY provoke HF the next day! Diet may be liberalized if resident is underweight, cachexic, or eating poorly. Nutritional supplements may be needed. Duke University School of Nursing, 2007

57 Duke University School of Nursing, 2007
Fluid Intake Pattern Fluid restriction1,500-2,000 mL/day. No fluid restriction needed for most NH residents, but should avoid excess fluid. Monitor diuretic therapy 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. Duke University School of Nursing, 2007

58 Duke University School of Nursing, 2007
Activity Determine current activity level. 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. Use the NYHA classification to determine your patient’s functional level Duke University School of Nursing, 2007

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 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 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. A functional and therapeutic classification for prescription of physical activity for cardiac patients. Duke University School of Nursing, 2007

60 Duke University School of Nursing, 2007
Lab Tests Chemistry panel 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 Anemia associated with and is trigger of HF Thyroid panel-hyperthyroid a trigger for HF BNP- Brain Natriuretic Peptide Secreted by failing left ventricle, ↑ in HF (>100) Duke University School of Nursing, 2007

61 Duke University School of Nursing, 2007
Diagnostic Tests 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 What is the patient’s EF? If there is systolic dysfunction, >55% is normal If there is diastolic dysfunction, EF may be WNL EKG -looks at rate & rhythm abnormalities, Q wave abnormalities suggestive of MI Duke University School of Nursing, 2007

62 Duke University School of Nursing, 2007
Assessment of Acute HF Obtain a dyspnea progression history 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 Source: Shamsham F & Mitchell J. (2000) Essentials of the diagnosis of HF. American Family Phhysician, 61(5) LINK: Duke University School of Nursing, 2007

63 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 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) Duke University School of Nursing, 2007

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

65 Progression of Acute HF
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) Clinical endpoint is frailty End of life care Source: Shamsham F & Mitchell J. (2000) Essentials of the diagnosis of HF. American Family Phhysician, 61(5) Duke University School of Nursing, 2007

66 Duke University School of Nursing, 2007
Summary Early recognition of HF S&S leads to early treatment & better outcomes 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 Duke University School of Nursing, 2007


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