1. Congestive Heart Failure Caroline L. Guglielmetti RN, BSN

2. Patient Profile I.R. is an 85 year-old female Born in Hungary Formerly from assisted living, has lived at the nursing care center for 2 years. Has a daughter who is a teacher and a son who is a pharmacist. Her son is DPOA of medical and finances.

3. Past Medical History Vitamin B12 deficiency Hypothyroidism Severe Depression Dementia Parkinson’s Disease Osteoarthritis- bil. Hips Constipation Osteoporosis with kyphosis DJD bil. Hips & lumbar spine Dependent edema CHF Anemia

4. Medications Synthroid 0.05mg PO QD Vitamin B12 100mcg PO QD Aldactone 25mg PO QD Senokot 2 tabs PO QD Colace 100mg PO QHS Remeron 30 mg PO QD Os-Cal 500mg PO tid Tylenol ES 1-2 PO TID

5. CHF and Anemia Anemia affects 10% to 20% of patients with chronic congestive heart failure (CHF) In most patients, no specific underlying cause is identified, and more than 50% of cases are considered to represent anemia of chronic disease. Low hemoglobin (Hgb) values in CHF patients directly correlate with poor peak oxygen consumption, disabling symptoms, and reduced survival. Pilot studies suggest that correction of Hgb values with recombinant human erythropoietin and iron improves symptoms and exercise capacity, but larger studies are needed before anemia treatment can be routinely recommended for CHF patients. (Crosato M, et al. Heart Fail Monit 2003;4(1):2-6.)

6. CHF and Hypothyroidism Two Common types of CHF 1. Systolic Dysfunction-inability of the heart to contract due to weakness 2. Diastolic Dysfunction-inability of the heart to relax after it pumps out blood Systolic Dysfunction may be due to multiple factors, one being Hypothyroidism

7. CHF and Dementia Requires FREQUENT reminders to… – Keep feet elevated (Dependent Edema) – Wear Ted Hose – Alert family and or nursing staff if you begin to notice symptoms of CHF (exacerbation of CHF) – The importance of daily weights

8. Family Involvement/Education Due to her dementia and severe depression, the family must play an active role in disease management. Nursing must educate family on CHF – Pathphysiology – Etiology – Management- meds, lifestyle modification – Medication regimen – Outside resources – Goals for the patient and the family

9. Outside Resources The CALL Care project is designed to improve quality of life for individuals with a life- threatening illness, bridging gaps between services prior to entering a hospice: COMPREHENSIVE: Focus of services includes strategies to meet physical, emotional, spiritual, and relationship needs. Services are designed for both the ill person and family caregiver, as defined by the ill person. ADAPTABLE: Care and services are flexible over time for the person and caregiver. The approach focuses on linking appropriate existing services, developing new services only when gaps in continuity of services between the community and health care organizations are evident. Services are accessible within the context of a variety of funding or reimbursement strategies. LONGITUDINAL: Program plans are designed to identify persons for whom the illness is progressive and will potentially lead to the person’s death. The inclusion criteria focuses from the time the illness appears to be life-threatening, even if prognosis or life expectancy is unknown. This strategy addresses problems associated with timely referrals to end-of-life services and programs. LIFE-AFFIRMING: Although persons identified for the CALL Care program are likely to be facing the last phase of their lives, the services will focus on assisting them and family caregivers to live fully and meaningfully within the limits of the illness and each person’s goals. Providence Hospital and Medical Centers, Southfield, MI (Coalition member: Ascension Health)

10. Resources (continued) American Heart Association www.americanheart.orgwww.americanheart.org Area Agency on Aging: Oakland County 248.357.2255 Cardiac Rehabilitation for Heart Failure Providence Medical Center (Southfield) 248.849.5855 MEPPS (assistance for obtaining medications) 313.866.5333 Second Chance Heartline, Education & Support Group St. John Hospital and Medical Center 313.343.3157 Cardiac Support Group, St. John Hospital and Medical Center 313.343.3157

11. Nursing Staff Education Since the patient is a resident of a nursing home, it is vital to educate the nursing and support staff. Provide FREQUENT reminders - Elevate lower extremities - I & O (as accurate as possible) - Wear support stockings - OBTAIN A DAILY WEIGHT EVERY MORNING!!! - Enforce fluid restriction Ensure that the dietician is aware of the patients CHF and Dementia and prepares a diet that it LOW SODIUM, NAS,MECHANICAL SOFT Contact in house rehab- have them assess the patient for appropriateness of a mild exercise program 3 times per week or as tolerated. Encourage the nursing and support staff to COMMUNICATE with the family as well as the physician/NP, ask questions, update each other on patient status

12. Rolland’s Family Systems Illness Model Different types and stages of chronic illnesses place similar and different demands on the family 3 Dimensions - “ Psychosocial types” of illness and disability and the demands of a chronic disorder in respect to the diseases different phases - Developmental phases of the illness - Family system Variables Looks at the psychosocial demands of the disease in regards to the family system and strengths/weaknesses

13. Rollands Psychosocial Typology of Illness (CHF) with respect to I.R. and family 1. Onset: Gradual: slower rate of family change required, may generate anxiety before diagnosis is made. 2. Course: Relapsing/Episodic:exacerbations/remissions; may be the most psychosocially challenging for the family, requires flexibility 3. Outcome: Shortened lifespan or sudden death: uncertain outcome, issues of mortality surface

14. Rolland’s Typology (continued) 4. Incapacitation: Moderate/Severe: Impairments evident in:cognition, movement, decreased energy production. 5. Degree of Uncertainty: based on predictability of onset and rate at which disease progresses. Families need to develop perspective, plans, avoid burnout. 6. A. Symptom Visibility: present. DIB with exertion, 3+ pitting edema, abdominal distension B. Liklihood/Severity of crisis: exacerbations becoming more frequent C. Genetic Contribution: unknown D. Treatment regimens: see meds. Family very cautious, in control of med management E.Age at onset: Questionable, exacerbations have become worse over the last 2 years (starting at age 83).

15. Rolland’s Typology (continued) 7. Time Phases of Illness: B. Chronic “Long haul” Key Family Task: maintain a normal life under abnormal conditions, transition, integration of the chronic disease into other aspects of life,maintenance of autonomy for all family members. Avoid mutual dependency. Family Issues Avoid burnout, maintain relationships,maintain autonomy, redefine individual and family goals,intimacy in the face of loss Transition between acute, chronic and terminal phases is critical for all family members.

16. Evaluation/Outcomes The family will -contact and utilize outside resources as needed -communicate regularly with the nursing and support staff as well as medical staff and each other -Recognize the chronic disorder and understand that it can be controlled, but not cured -work to preserve individual family member autonomy -work to maintain a normal life -redefine individual and family goals in regards to illness -recognize uncertainty of loss -provide support with the medical and/or lifestyle modifications necessary to control CHF

17. Evaluation/Goals The Nursing/Medical and support staff will: -Maintain communication with each other and the family -Provide support and education to the family -Remind patient FREQUENTLY to comply with CHF guidelines -Thoroughly assess the patient for changes in status

18. Evaluation/Outcomes By complying with family and Medical/nursing interventions, the client will… – Remember to elevate lower extremities when sitting – Wear support stockings – Comply with daily weight – Comply with diet/fluid restriction – Maintain weight – Work with rehab if appropriate

19. References Anemia.org(2004). Anemia contributes to morbidity and mortality in CHF. Clinical Briefs. Retrieved from www.anemia.org/about_anemia/research_briefs/anemia_contributes.jsp www.anemia.org/about_anemia/research_briefs/anemia_contributes.jsp CALL care Project (2004).Providence Hospital and Medical Centers, Southfield, MI Carpenito, L. Nursing care Plans & Documentation. (1999) Philadelphia: Lippincott Rolland, J.S. Interface of Chronic Illness and the family. Source: Modified from W.Looman