Heart Failure Clinical Process Guideline

1
Heart Failure Clinical Process Guideline

• Deborah Ayers, RN, MSN
• Quality Improvement Nurse Consultant

2
General Information

• Optional Best Practice Tool
• Effective date for usage
• Electronic copies of the tool are available on
  the website
• http//michigan.gov/bhs click Best Practice
  Information Guidelines

3
Clinical Advisory Panel

• Deborah Ayers RN, MSN - State QI Nurse
• Chris Glue- Restorative CNA - Dimondale, Lansing
• Teresa Gurny, RN/DON - Medilodge of Howell
• Dr. Steve Levenson- Geriatrician - Baltimore,
  Maryland

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Clinical Advisory Panel (cont.)

• Sue Mangan - Pharmacist/Surveyor -Metro West Team
• Julie Savage, RN, MSN Eden CMCF
• Nancy Wong, RN, BSN - ADON/In-service
  Director/Woodward Hills NC
• Barbara Zabitz RD/Surveyor - Metro West Team

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Guideline Format

• Basic Care Process Steps
• Expectations of facilities related to steps
• Rationale for expectations
• Documentation Check list
• Relevant Tables

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Heart Failure

• A constellation of signs/symptoms that result
  from the inability of the heart to pump blood to
  the body at a rate the body needs.

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Care Process Steps

• It always begins with an Assessment

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Assessment

• Residents with history/or risk factors for heart
  failure

• Transfer data
• Labs, EKG, echo, chest film
• Anemia, COPD, other lung diseases
• Previous treatment
• Hospitalization for heart failure.

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Assess Risk Factors

• Arrhythmia
• Anemia
• Fluid volume overload with noncardiac causes
• Thyroid disease

• Coronary artery disease
• Angina/infarction
• Chronic hypertension
• Idiopathic dilated cardiomyopathy
• Valvular heart disease

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New admissions with CHF

• Look for signs and symptoms
• Diagnostic test results
• Document the findings

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Staff and practitioner . . . identify

• The severity and consequences of heart failure

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Myocardial Dysfunction

• Systolic Dysfunction
• Left ventricle has reduced muscle contractility

• Diastolic
• Decreased left ventricular filling
• Caused by ventricular stiffness, decreased rate
  of relaxation, or rapid heart rate

13
Functional Assessment

• Class I
• No limitations of physical activity. No shortness
  of breath, fatigue, or heart palpitations with
  ordinary physical activity.
• Class II
• Slight limitation of physical activity. SOB,
  fatigue, heart palpitations. Patient comfortable
  at rest.

• Class III
• Symptoms with minimal exertion. SOB, fatigue,
  heart palpitations. Patients comfortable at rest.
• Class IV
• Severe to complete limitation of activity. SOB,
  fatigue, heart palpitations, even at rest.

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American College of CardiologyAmerican Heart
Association

• Stage A High risk of HF, no structural heart
  abnormality
• Stage B Structural heart disorder, no
  symptoms
• Stage C Structural disorder, past or current
  HF symptoms
• Stage D End-stage disease, requiring
  specialized treatment

15
Diagnosis/Cause Identification

• Practitioner and staff clarify known causes of a
  residents heart failure, or seek causes if not
  identified.

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Is a work-up appropriate?

• with terminal/end stage conditions
• if it would not change management
• in a resident that refuses treatment

• if burden of the work-up is greater than the
  benefit of the treatment
• if causes are reversible

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Whats in a work-up?

• History/exam
• Lab tests
• Chest x-ray
• EKG
• All look for reversible causes of CHF

18
Treatment/Problem Management

• Heart failure treatment
• Based on established recommendations (i.e. best
  practice/http//www.acc.org)
• Consistent with resident choices, values overall
  condition, and prognosis.

19
Establish goals

• Prolong life
• Prevent worsening
• Improve quality of life
• Provide comfort care

20
Treatment/Problem Management

• Did the staff and practitioner treat contributing
  factors and underlying causes of heart failure?

21
Like what??

• Arrhythmia
• Pulmonary embolism
• Accelerated/malignant hypertension
• Thyroid disease
• Valvular heart disease

• Unstable angina
• Fluid volume status
• Renal failure
• Medication-induced
• High salt-intake
• Severe anemia

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Treatment

• Base therapy on the presence/absence of fluid
  volume overload, nature of dysfunction
• Include annual flu and pneumococcal vaccination
• Residents goals, choices, values, are always
  considered

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Consider other relevant interventions

• Dietary counseling
• Diet modification
• Exercise
• Smoking cessation
• Address end-stage HF

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Monitoring

• Implement approaches to manage the individual
  with heart failure

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Monitoring

• Collaboration between the facility, medical
  director, and practitioner

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Evaluation and Documentation

• Document assessment of heart function - any
  complications?
• Evaluate and document reasons why a resident
  failed to achieve cardiac/functional goals
• Review medication regime and modify as needed

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Monitoring

• Complications in an effort to treat heart
  failure can occur.

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Bibliography

• AMDA Clinical Practice Guideline Heart Failure,
  2002
• Aquilani, R, et. al. Is nutritional intake
  adequate in chronic heart failure patients?
  Journal of the American College of Cardiology.
  2002 (Vol. 2) (7)
• Carboral, M.F. Putting the 2005 American College
  of Cardiology/American heart failure association
  heart failure guideline into clinical practice
  advice for advance practice nurses. Retrieved
  June 30, 2006 from http// www. Medscape
  .com/view article/533626

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Bibliography

• Ferris, Mara. Geriatric Emergency Assessment
  Prevention. 2002 PESI, Eau Clare, WI.
• Steefel, Lorraine, RN, MSN. New Advances Offer
  Hope for Treating Heart Failure. Nursing
  Spectrum, March 2004 pp12-13.