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Diabetes and Heart Failure: A Comprehensive Collaboration Grace Zite RN, MSN, CCRN, CCNS-Cincinnati Sarah Andrews RN, BSN-Lexington Keith Edinger RN, BSN-Pennsylvania

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Text of Diabetes and Heart Failure: A Comprehensive Collaboration Grace Zite RN, MSN, CCRN, CCNS-Cincinnati...

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  • Diabetes and Heart Failure: A Comprehensive Collaboration Grace Zite RN, MSN, CCRN, CCNS-Cincinnati Sarah Andrews RN, BSN-Lexington Keith Edinger RN, BSN-Pennsylvania Ashley Hancock RN, BSN-Houston Ed Park RN,CCRN, BSN-New Jersey Traceee Rose RN, BSN-San Antonio
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  • Objectives Describe the disease process of Heart Failure (HF), and understand treatment regimens. Describe the disease process of Diabetes Mellitus (DM), and understand treatment regimens. Discuss the importance of educating pt.'s with HF and DM and provide tools to help with instructions to prevent negative outcomes. Relate the impact of both disease processes on the quality of life and incorporate the synergy model to guide treatment.
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  • Heart Failure Impaired function/structure of one or both ventricles, producing inadequate cardiac output to meet the needs of tissues, and characterized by volume retention, congestion, and poor perfusion.
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  • AHA & NYHA
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  • HF causes Coronary heart disease (CAD) and myocardial damage ( Acute myocardial infarction (AMI) is the cause in 75% of cases) Chronic hypertension (HTN) ( 2 nd most frequent cause). Cardiomyopathy ( restrictive, dilated, or hypertrophic). Mitral or aortic valve disease, septal defect, endocarditis.
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  • Precipitating factors : Myocardial ischemia Severe HTN Dysrrthymias Negative inotropic medications Infection Pulmonary embolism (PE) Hyper/hypothyroidism Diabetes
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  • HF Pathophysiology
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  • Symptoms- HF -Audible congestion - Ascites/ edema - Rales/ S.O.B. - Obtunation - JVD - Hepatic tenderness - Hypotension - Cool extremities - Narrow pulse pressure - Fatigue - Elevated BUN/ Creatinine
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  • Treatments- HF Pharmacological- *Diuretics * ACE inhibitors *Beta blockers * ASA * Statins * Vasodilators * Neurohormonal antagonists * Anticoagulants* *Antidysrrhtymics * Inotropes. Compliance with medication regimen per MD./ARNP. Weight Control { includes daily weights to monitor fluid retention}. Diet Modification- Cardiac diet {Low salt, low fat, fluid restriction} limit ETOH, Fresh foods- fruits & vegetables. Exercise Life-style modification
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  • Diabetes DM is a disease where the body fails to properly produce or use insulin. Insulin is a hormone that turns sugar and other foods into another form or energy that can be used by the cells that make up the entire body. Other forms of DM exist ( gestational, medication induced, pre-diabetes), but, two major types are discussed clinically when the term Diabetes is mentioned: Type I DM When the body can not produce insulin, which is a hormone that causes the cells to absorb glucose for fuel. About 5-10% of people have type I DM. Type II DM- When the body manages to produce insulin but fails to use it properly.
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  • *DM* Causes: Type I - 1.Family Hx. 2. Viral infections ( rubella, mumps). Usually Diagnosed in children and young adults. Type II- 1. Sedentary life-style. 2. Excess body weight. 3. HTN. 4. High cholesterol. 5. Family Hx. Dx. : 1. Fasting blood sugar (BS). + if BS is >110 & 140 or < 200mg/dL.
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  • DM-Pathophysiology
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  • Symptoms- DM Type I: Type II: -Increased thirst & urination - Dry skin -Increased appetite - Skin Ulcers -Fatigue - Numbness of hands & feet -Blurred vision - Blurred vision -Frequent/slow healing infections - Dehydration - Wgt. Loss/gain
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  • Treatment of Diabetes Pharmacological- *INSULIN- (fast, intermediate, basal insulin's) *Oral hypoglycemics ( metformin, actos, glyburide) *Blood pressure & *cholesterol lowering medications. Dietary modification { high fiber, low saturated fats, carbohydrate modification. Exercise Weight control Monitoring BS ( finger sticks, A1c monitoring).
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  • Pharmacology Oral medication should be initiated when lifestyle changes do not control blood glucose levels (Pinhas- Hamiel & Zeitler, 2007) Oral medications include: Biguanides, Thiazolidinediones, Sulfonylureas, Meglitinide analogs, and Glucosidase inhibitors (Pinhas-Hamiel & Zeitler, 2007) Insulin therapy may be necessary for patients with uncontrolled blood glucose levels (Cirone, 1996)
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  • Pharmacology cont. Sulfonylurease are the most commonly prescribed hypoglycemic drugs in patients with heart failure Retrospective cohort studies in the US involving more than 16,000 patients with DM and HF did not show link between sulfonylurea use and mortality A Canadian retrospective cohort study compared Metformin to sulfonylurea use one year mortality in patients treated with Metformin was lower than in patients treated with sulfolylureas Consider use of a sulfonylurea if Metformin is contraindicated or when given in combination with metformin (MacDonald, 2009)
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  • Evaluating Glycemic Control 2 out of 3 fail to meet the goal of 6.5 % HG A1c set by: American Diabetic Association American Association of Clinical Endocrinologist European Association of the Study of Clinical Diabetes Levich, B. R. ( 2011). Diabetes Management Optimizing Roles for Nurses in Insulin Initiation. Journal of Multidisciplinary Healthcare
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  • The DAWN study Psychosocial barriers to glycemic control Negative attitude toward insulin therapy initiation Guilt by the HCP: failed medical management Feeling like a failure with self management Belief in restricted life style Belief that insulin is the last resort Fear of hypoglycemia ( Benroubi, 2011) Benroubi, M. (2011). Fear, guilt feelings and misconceptions: Barriers to effective insulin treatment in type 2 diabetes Diabetes Research and Clinical Practices. 97-99.
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  • Just the facts maam
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  • Statistics- Heart Failure In the United States, 5 million individuals live with heart failure. Two thirds of HF pt.'s. die within 5 years of being diagnosed. The estimated annual cost in the United States is 56 billion annually. Medicare spends more on HF than all forms of cancer. HF hospitalizations have tripled over the last 25 years. Most common reason for hospital admissions for pt.'s. > 65 yrs. Greatest contributor to the cost of HF treatment is hospitalizations. Affects Men > Women, but more women than men are admitted for HF.
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  • Statistics- Diabetes About 20.8 million children and adults in the United States or 7% of the population have DM. 30% of adults in the United States have pre- > women. 14.6 million have been Dx. with DM, but 6.2 million people are unaware they have DM. Affects 10.6 % of all Hispanics & 10.8 % of all African Americans in the United States. DM was the 7 th leading cause of death in 2006. Most common cause of blindness, kidney failure, & amputations in adults & a leading cause of Heart disease & stroke. African Americans are more likely to suffer from higher incidences of DM disabilities & complications. DM is rare in youth ages 12-19 years, but about 16% have pre-diabetes. One of the major risk factors for CAD leading to Heart Failure 20-25% present in HF patients
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  • Diabetic Cardiomyopathy Diabetic cardiomyopathy is defined as significantly impaired cardiac function in diabetic patients in the absence of epicardial vascular disease, left-ventricular hypertrophy, valvular disease, or other causes of cardiomyopathy, making it largely a diagnosis of exclusion. The association between diabetic cardiomyopathy and diabetic retinopathy suggests that microvascular abnormalities may play a role. One of the major risk factors for CAD leading to Heart Failure 20-25% present in HF patients
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  • Diabetic Cardiomyopathy Affects 180 million worldwide 2/3 of patients with established CVD have impaired glucose Affects 30% of HF patients Every 1% increase in HgbA1c leads to an 8% increase in HF
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  • Understanding DM Effect on HF High proisulin, hyperinsulinemia, hyperglycemia level Endothelium damage Accelerated atherosclerosis, cardiovascular remodeling Increased mortality
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  • Cascade of Events
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  • Disease Progression of Diabetes and HF
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  • apple a day keeps the doctor away Effective self care keeps hospital away 27 Goal of Self Care
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  • optimize metabolic control Hg A1c < 6.5% prevent acute and chronic complications Preventable hospitalization Prevent Multi-organ dysfunction optimize quality of life 28 Carlson, Karen K. (Ed.) (2009). Advanced critical care nursing. (8th ed.) St. Louis, MO: Saunders
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  • Know what you are teaching. Medications Keep updated with current guidelines and evidence-based practice Avoid overwhelming the patient Feel like drinking from a fire hose. Is their life over? Psychosocial What is all this going to cost? Pearls of Patient Education
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  • Challenges Pts. with HF & DM must struggle with necessary treatment regimens in order to maintain stability to achieve a sense or normalcy. Increase in survival rates after acute Myocardial infarction (AMI) {due to newer medical advances}, aging population, and increased obesity rates will incre

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