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

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.

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.

AHA & NYHA

HF causes

• Coronary heart disease (CAD) and myocardial damage ( Acute myocardial infarction (AMI) is the cause in 75% of cases)

• Chronic hypertension (HTN) ( 2nd most frequent cause).

• Cardiomyopathy ( restrictive, dilated, or hypertrophic).

• Mitral or aortic valve disease, septal defect, endocarditis.

Precipitating factors:

• Myocardial ischemia • Severe HTN • Dysrrthymias • Negative inotropic medications • Infection • Pulmonary embolism (PE)• Hyper/hypothyroidism• Diabetes

HF Pathophysiology

Symptoms- HF

• -Audible congestion - Ascites/ edema

- Rales/ S.O.B. - Obtunation

- JVD - Hepatic tenderness

- Hypotension

- Cool extremities - Narrow pulse pressure

- Fatigue - Elevated BUN/ Creatinine

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

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.

*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 & < 126 mg/dL. 2. Oral

glucose tolerance test (OTT). Pt. drinks glucola ( 75g of glucose or 100 g for pregnant pt.'s.) BS is checked at 30 min, 1 hr., 2hrs. & 3hrs post glucola ingestion. + if BS is > 140 or < 200mg/dL.

DM-Pathophysiology

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

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).

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)

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)

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

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.

“Just the facts ma’am”

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.

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- diabetes….men > 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 7th 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

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

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

Understanding DM Effect on HF

High proisulin, hyperinsulinemia, hyperglycemia level

Endothelium damage

Accelerated atherosclerosis, cardiovascular remodeling

Increased mortality

Cascade of Events

Disease Progression of Diabetes and HF

“apple a day keeps the doctor away”

“Effective self care keeps hospital away”

Goal of Self Care

Goal of Self Care

optimize metabolic control Hg A1c < 6.5%

prevent acute and chronic complications Preventable hospitalization Prevent Multi-organ dysfunction

optimize quality of life

Carlson, Karen K. (Ed.) (2009). Advanced critical care nursing. (8th ed.) St. Louis, MO: Saunders

• 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

Challenges

• Pt’s. with HF & DM must struggle with necessary treatment regimen’s 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 increase the rates for DM and HF complications.

• Vulnerable groups ( elderly, & minorities) find themselves predominantly affected by theses diseases due to lack of resources, access to health care, and heredity.

• Nonadherence to treatment regimens presents another challenge in treating DM/HF, which has many origins.

Helping Pt.'s Face Challenges

• Pt. teaching/education. Not only is it important for the RN to educate the Pt. on DM & HF, but the RN must be confident in knowing the disease process so the right information can be distributed to enhance care.

• Collaborate with members of the healthcare team to ensure the pt. is ready for discharge from the hospital.

• Comply with core measures upon hospital discharge to reduce re-admission.

• Provide resources and literature for DM/HF care upon discharge to help pt’s comply with treatment regimens

Goals & Purpose of Care

• Identify & correct precipitating causes of DM/HF.• Relieve symptoms, enhance comfort.• Enhance cardiac performance and control BS & decrease

the progression of theses diseases.• Provide the tools & resources to keep pt.'s. compliant

with their treatment regimens.• Decrease morbidity• Decrease hospitalizations• INCREASE THE QUALITY OF LIFE

• American Heart Association• www.heart.org

• American Diabetes Association• www.diabetes.org

• Center for Disease Control• www.cdc.gov

• Heart Failure Society of America• www.hfsa.org

• American Dietetic Association• www.eatright.org

Patient Resources

Synergy Model

• The synergy model identifies 8 patient characteristics: resiliency, vulnerability, stability, complexity, resource availability, participation in care, participation in decision making, and predictability (Hardin & Kaplow, 2005)

• 8 nursing competencies in the synergy model include: clinical judgment, advocacy, caring practices, collaboration, systems thinking, response to diversity, clinical inquiry and facilitation of learning (Hardin & Kaplow, 2005)

• By using the synergy model, nurses will use their competencies to address the patient need that is presented (Hardin & Kaplow, 2005)

Stability: Frequency of dyspnea, weight gain and hospitalization Complexity: Stage of HF, and co morbidities like DM, HTN, COPD, etc Predictability: instabilities and other comorbities Resiliency: Willingness to learn and follow self care regimen to regain

equilibrium Vulnerability: Consistency of social and financial support Participation of Decision Making and Care: Cognitive capacity? Family

member ? Resource Availability: Family, community or governmental support ?

Hardin, S., & Hussey, L. (2003). AACN Synergy Model for Patient Care: Case Study of a CHFPatient. Critical Care Nurse, 23,73-76. Retrieved from http://ccn.aacnjournals.org/content/23/1/73.full

Synergy Model

Case Study

Hardin, S., & Hussey, L. (2003). AACN Synergy Model for Patient Care: Case Study of a CHFPatient. Critical Care Nurse, 23,73-76. Retrieved from http://ccn.aacnjournals.org/content/23/1/73.full

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Carlson, Karen K. (Ed.) (2009). Advanced critical care nursing. (8th ed.) St. Louis, MO: Saunders

Funnell, M. M. (2006). The Diabetes Attitudes, Wishes, and Needs (DAWN) Study. Clinical Diabetes.(24) 154-155.Doi: 10.2337/diaclin.24.4.154

Hardin, S., & Hussey, L. (2003). AACN Synergy Model for Patient Care: Case Study of a CHFPatient. Critical Care Nurse, 23,73-76. Retrieved from http://ccn.aacnjournals.org/content/23/1/73.full

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