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Heart Failure Clinical Process Guideline
Deborah Ayers, RN, MSNDeborah Ayers, RN, MSN
Quality Improvement Nurse Quality Improvement Nurse ConsultantConsultant
General Information
““Optional” Best Practice ToolOptional” Best Practice Tool Effective date for usage Effective date for usage
Electronic copies of the tool are Electronic copies of the tool are
available on the websiteavailable on the website http://michigan.gov/bhshttp://michigan.gov/bhs; click “Best ; click “Best
Practice Information & GuidelinesPractice Information & Guidelines””
Clinical Advisory Panel
Deborah Ayers RN, MSN - State Deborah Ayers RN, MSN - State QI NurseQI Nurse
Chris Glue- Restorative CNA - Chris Glue- Restorative CNA - Dimondale, LansingDimondale, Lansing
Teresa Gurny, RN/DON - Teresa Gurny, RN/DON - Medilodge of HowellMedilodge of Howell
Dr. Steve Levenson- Geriatrician Dr. Steve Levenson- Geriatrician - Baltimore, Maryland- Baltimore, Maryland
Clinical Advisory Panel (cont.)
Sue Mangan - Pharmacist/Surveyor Sue Mangan - Pharmacist/Surveyor -Metro West Team-Metro West Team
Julie Savage, RN, MSN – Eden CMCFJulie Savage, RN, MSN – Eden CMCF Nancy Wong, RN, BSN - ADON/In-Nancy Wong, RN, BSN - ADON/In-
service Director/Woodward Hills NCservice Director/Woodward Hills NC Barbara Zabitz RD/Surveyor - Metro Barbara Zabitz RD/Surveyor - Metro
West TeamWest Team
Guideline Format
Basic Care Process Basic Care Process StepsSteps
Expectations of Expectations of facilities related to facilities related to stepssteps
Rationale for Rationale for expectationsexpectations
Documentation Documentation Check listCheck list
Relevant TablesRelevant Tables
Heart Failure
A constellation A constellation of of signs/symptoms signs/symptoms that result from that result from the inability of the inability of the heart to the heart to pump blood to pump blood to the body at a the body at a rate the body rate the body needs.needs.
Assessment
Residents with Residents with history/or risk history/or risk factors for factors for heart failureheart failure
Transfer dataTransfer data Labs, EKG, echo, Labs, EKG, echo,
chest filmchest film Anemia, COPD, Anemia, COPD,
other lung other lung diseasesdiseases
Previous Previous treatmenttreatment
Hospitalization Hospitalization for heart failurefor heart failure..
Assess Risk Factors
Coronary artery Coronary artery diseasedisease
Angina/infarctionAngina/infarction Chronic Chronic
hypertensionhypertension Idiopathic Idiopathic
dilated dilated cardiomyopathycardiomyopathy
Valvular heart Valvular heart diseasedisease
ArrhythmiaArrhythmia AnemiaAnemia Fluid volume Fluid volume
overload with overload with noncardiac noncardiac causescauses
Thyroid diseaseThyroid disease
New admissions with CHF
Look for signs and symptomsLook for signs and symptoms
Diagnostic test resultsDiagnostic test results
Document the findingsDocument the findings
Staff and practitioner . . . identify
The severity The severity and and consequences consequences of heart failureof heart failure
Myocardial Dysfunction
Systolic DysfunctionSystolic Dysfunction
Left ventricle has Left ventricle has reduced muscle reduced muscle contractilitycontractility
DiastolicDiastolic
Decreased left Decreased left ventricular fillingventricular filling
Caused by Caused by ventricular ventricular stiffness, stiffness, decreased rate of decreased rate of relaxation, or relaxation, or rapid heart raterapid heart rate
Functional Assessment Class IClass I
No limitations of No limitations of physical activity. No physical activity. No shortness of breath, shortness of breath, fatigue, or heart fatigue, or heart palpitations with palpitations with ordinary physical ordinary physical activity.activity.
Class IIClass II Slight limitation of Slight limitation of
physical activity. SOB, physical activity. SOB, fatigue, heart fatigue, heart palpitations. Patient palpitations. Patient comfortable at rest.comfortable at rest.
Class IIIClass III Symptoms with Symptoms with
minimal exertion. minimal exertion. SOB, fatigue, heart SOB, fatigue, heart palpitations. Patients palpitations. Patients comfortable at rest.comfortable at rest.
Class IVClass IV Severe to complete Severe to complete
limitation of activity. limitation of activity. SOB, fatigue, heart SOB, fatigue, heart palpitations, even at palpitations, even at rest.rest.
American College of Cardiology
American Heart Association Stage AStage A High risk of HF, no High risk of HF, no
structural structural heart abnormalityheart abnormality Stage BStage B Structural heart disorder, no Structural heart disorder, no
symptoms symptoms Stage CStage C Structural disorder, past or Structural disorder, past or
current HF symptomscurrent HF symptoms Stage DStage D End-stage disease, requiring End-stage disease, requiring
specialized treatment specialized treatment
Diagnosis/Cause Identification
Practitioner and Practitioner and staff clarify staff clarify known causes known causes of a resident’s of a resident’s heart failure, or heart failure, or seek causes if seek causes if not identified.not identified.
Is a work-up appropriate?
with terminal/end with terminal/end stage conditionsstage conditions
if it would not if it would not change change managementmanagement
in a resident that in a resident that refuses refuses treatmenttreatment
if burden of the if burden of the work-up is work-up is greater than greater than the benefit of the benefit of the treatmentthe treatment
if causes are if causes are reversiblereversible
What’s in a work-up?
History/examHistory/exam Lab testsLab tests Chest x-rayChest x-ray EKGEKG
All look for All look for reversible reversible causes of CHFcauses of CHF
Treatment/Problem Management
Heart failure treatment:Heart failure treatment:
Based on established Based on established recommendations (i.e. best recommendations (i.e. best practice/http://www.acc.org)practice/http://www.acc.org)
Consistent with resident choices, Consistent with resident choices, values overall condition, and values overall condition, and prognosis.prognosis.
Establish goals Prolong lifeProlong life
Prevent Prevent worseningworsening
Improve quality Improve quality of lifeof life
Provide comfort Provide comfort carecare
Treatment/Problem Management
Did the staff and practitioner Did the staff and practitioner treat contributing factors and treat contributing factors and
underlying causes of heart underlying causes of heart failure?failure?
Like what??
ArrhythmiaArrhythmia Pulmonary embolismPulmonary embolism Accelerated/Accelerated/
malignant malignant hypertensionhypertension
Thyroid diseaseThyroid disease Valvular heart Valvular heart
diseasedisease
Unstable anginaUnstable angina Fluid volume statusFluid volume status Renal failureRenal failure Medication-induced Medication-induced High salt-intakeHigh salt-intake Severe anemiaSevere anemia
Treatment
Base therapy on the Base therapy on the presence/absence of fluid presence/absence of fluid volume overload, nature of volume overload, nature of dysfunctiondysfunction
Include annual flu and Include annual flu and pneumococcal vaccinationpneumococcal vaccination
Resident’s goals, choices, Resident’s goals, choices, values, are always consideredvalues, are always considered
Consider other relevant interventions
Dietary counselingDietary counseling Diet modificationDiet modification Exercise Exercise Smoking cessationSmoking cessation Address end-stage Address end-stage
HFHF
Monitoring
Implement approaches to Implement approaches to managemanage the individual the individual
with heart failurewith heart failure
Monitoring
Collaboration Collaboration between the between the facility, medical facility, medical director, and director, and practitionerpractitioner
Evaluation and Documentation Document assessment of heart Document assessment of heart
function - any complications?function - any complications? Evaluate and document Evaluate and document
reasons why a resident failed reasons why a resident failed to achieve cardiac/functional to achieve cardiac/functional goalsgoals
Review medication regime and Review medication regime and modify as neededmodify as needed
Monitoring
ComplicationsComplications in in an effort to an effort to “treat” heart “treat” heart failure can occur.failure can occur.
Bibliography
AMDA Clinical Practice Guideline – Heart Failure, 2002AMDA Clinical Practice Guideline – Heart Failure, 2002
Aquilani, R, et. al. Is nutritional intake adequate in chronic Aquilani, R, et. al. Is nutritional intake adequate in chronic heart failure patients? Journal of the American College of heart failure patients? Journal of the American College of Cardiology. 2002 (Vol. 2) (7)Cardiology. 2002 (Vol. 2) (7)
Carboral, M.F. Putting the 2005 American College of Carboral, M.F. Putting the 2005 American College of Cardiology/American heart failure association heart failure Cardiology/American heart failure association heart failure guideline into clinical practice: advice for advance practice guideline into clinical practice: advice for advance practice nurses. Retrieved June 30, 2006 from http:// www. nurses. Retrieved June 30, 2006 from http:// www. Medscape .com/view article/533626Medscape .com/view article/533626
Bibliography
Ferris, Mara. Geriatric Emergency Assessment & Ferris, Mara. Geriatric Emergency Assessment & Prevention. 2002; PESI, Eau Clare, WI.Prevention. 2002; PESI, Eau Clare, WI.
Steefel, Lorraine, RN, MSN. New Advances Offer Steefel, Lorraine, RN, MSN. New Advances Offer Hope for Treating Heart Failure. Hope for Treating Heart Failure. Nursing Nursing Spectrum, Spectrum, March 2004; pp12-13.March 2004; pp12-13.