Download Heart Failure Clinical Process Guideline Deborah Ayers, RN, MSN Quality Improvement Nurse

Heart Failure Clinical Process
Guideline
Deborah Ayers, RN, MSN
Quality Improvement Nurse
Consultant
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”

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

Clinical Advisory Panel (cont.)




Sue Mangan - Pharmacist/Surveyor Metro West Team
Julie Savage, RN, MSN – Eden CMCF
Nancy Wong, RN, BSN - ADON/Inservice Director/Woodward Hills NC
Barbara Zabitz RD/Surveyor - Metro
West Team
Guideline Format





Basic Care Process
Steps
Expectations of
facilities related to
steps
Rationale for
expectations
Documentation Check
list
Relevant Tables
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.
Care Process Steps
It always begins with an
“Assessment”
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.
Assess Risk Factors





Coronary artery
disease
Angina/infarction
Chronic
hypertension
Idiopathic dilated
cardiomyopathy
Valvular heart
disease




Arrhythmia
Anemia
Fluid volume
overload with
noncardiac causes
Thyroid disease
New admissions with CHF

Look for signs and symptoms

Diagnostic test results

Document the findings
Staff and practitioner . . .
identify
The severity and
consequences of
heart failure
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
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.



American College of Cardiology
American Heart Association

Stage A

Stage B

Stage C

Stage D
High risk of HF, no structural
heart abnormality
Structural heart disorder, no
symptoms
Structural disorder, past or
current HF symptoms
End-stage disease, requiring
specialized treatment
Diagnosis/Cause Identification

Practitioner and
staff clarify
known causes of a
resident’s heart
failure, or seek
causes if not
identified.
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
What’s in a work-up?





History/exam
Lab tests
Chest x-ray
EKG
All look for
reversible causes
of CHF
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.
Establish goals

Prolong life

Prevent worsening


Improve quality of
life
Provide comfort
care
Treatment/Problem
Management
Did the staff and practitioner
treat contributing factors and
underlying causes of heart failure?
Like what??





Arrhythmia
Pulmonary embolism
Accelerated/maligna
nt hypertension
Thyroid disease
Valvular heart
disease






Unstable angina
Fluid volume status
Renal failure
Medication-induced
High salt-intake
Severe anemia
Treatment
Base therapy on the
presence/absence of fluid volume
overload, nature of dysfunction
 Include annual flu and pneumococcal
vaccination
 Resident’s goals, choices, values,
are always considered

Consider other relevant
interventions





Dietary counseling
Diet modification
Exercise
Smoking cessation
Address end-stage
HF
Monitoring
Implement approaches to
manage the individual with
heart failure
Monitoring

Collaboration
between the
facility, medical
director, and
practitioner
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

Monitoring

Complications in an
effort to “treat”
heart failure can
occur.
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
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.