Download Supporting Patients with CHF-Maureen Claflin, MSN, RN

Supporting Patients with CHF
Care Transformation Collaborative of R.I.
M AU R E EN C L A F L I N, M S N , R N .
N C M U N I V ERS I TY M E D ICINE
GOV E R NOR STR E E T PR I M A RY C A R E C E N TER
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Heart Failure: Caring for Patients
in the Community
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Stages of Heart Failure
• Acute
Left-sided heart failure:
This is the most common type of heart failure:
◦ systolic heart failure: prevents the left
ventricle from proper pumping
◦ diastolic heart failure: dysfunctional filling of
right ventricle
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Stages of Heart failure
• Acute
Right-sided heart failure:
This usually happens simultaneously with left-sided
heart failure. When the left ventricle fails it results in
increased pressure, and subsequent damage, to the
right side of the heart. The right side of the heart
cannot pump efficiently, causing fluid to accumulate in
the veins, which may cause lower extremity edema.
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Stages of Heart failure
•Chronic
Congestive heart failure:
◦ Left sided CHF indicates damage to left
ventricle causing pulmonary edema.
◦ Right sided CHF indicates damage to right
ventricle and ability to effectively pump
blood to lungs causing fluid accumulation in
lower extremities and abdomen.
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Evidence Based Guidelines for Treatment
• Acute/chronic HF treatment:
 Medication management – diuretics, beta-blockers, ACE inhibitors, ARBs
 O2 therapy
 Surgical repair if indicated
 Cardiac rehabilitation
 Lifestyle changes:
o Weight management
o Smoking cessation
o Exercise as tolerated
o Stress management
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Care Management:
NCM Interventions
• Education
• Teaching patient self-management
• Coaching sessions
• Weekly/monthly check-in/management
• Support
• Community resources
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Patient Self-Management
• Teach patients to know “their problem list”
• Weight monitoring
• Medication management
• Know “red flags” and when to call physician
• Know how to access physicians 24/7
• Exercise
• Stress management
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Your Goal Weight:
Green Zone Means:
Green Zone: All Clear
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No shortness of breath
No swelling
No weight gain
No chest pain
No decrease in your ability to maintain your activity level
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Yellow Zone: Caution
If you have any of the following signs and symptoms:
Weight gain of 3 or more pounds in 2 days
Increased cough
Increased swelling
Increase in shortness of breath with activity
Increase in the number of pillows needed
Anything else unusual that bothers you
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Call your physician if you are going into the YELLOW zone
Your symptoms may indicate that you need an adjustment of
your medications
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Call your physician, nurse coordinator, or home health nurse.
Name:___________________________
Number:__________________________
Instructions: _______________________
__________________________________
Red Zone: Medical Alert
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Yellow Zone Means:
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Your symptoms are under control
Continue taking your medications as ordered
Continue daily weights
Follow low salt diet
Keep all physician appointments
Unrelieved shortness of breath: shortness of breath at rest
Unrelieved chest pain
Wheezing or chest tightness at rest
Need to sit in chair to sleep
Weight gain or loss of more than 5 pounds in 2 days
Confusion
Red Zone Means:
This indicates that you need to be evaluated by a physician right away

Call your physician right away
Physician___________________________
Number____________________________
Call your physician immediately if you are going into the RED zone
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External Care Team/Resources
• Lifespan Transition of Care program
• VNA/home care cardiac care programs
o Infusion resources/supports
o Advanced illness management program
• Tele Health
• Behavioral Health
• Nutrition
• Hospice
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Case Presentation
• Toni 88 yo patient with long-standing right-sided HF with CHF
• Hospitalizations every 3-4 weeks for CHF for IV diuretics
• Managed at home with support of VNA cardiac team and eventually
hospice services.
• Receives IV Bumex 4-5 days/week/support
• Has not been hospitalized in 8 months
•Provider/care team home visits
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Heart Failure: Total Cost of Care
• Complex disease to manage
• Frequent ED encounters/hospitalizations costly
• Moving care/management to the community setting less
costly and can accomplish:
 empowers patient/caregivers to manage disease
 consistent care by primary physician and care team
 early identification of concerns
 support for the stages of care
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