duke university school of nursing, 2007 heart failure in the frail elderly in ltc: nursing...

Duke University School of Nursing, 2007

Heart Failure in Heart Failure in the Frail Elderly in the Frail Elderly in

LTC:LTC:Nursing Nursing

AssessmentAssessmentPart 1Part 1

Deborah Lekan, MSN, RNCDeborah Lekan, MSN, RNCClinical Nurse Specialist, Gerontological Clinical Nurse Specialist, Gerontological

NursingNursing


Heart Failure: OverviewHeart Failure: Overview

A chronic illness or syndrome with A chronic illness or syndrome with impairment in quality of life from impairment in quality of life from severe symptoms and limited severe symptoms and limited survival.survival.

QOL influenced by need for frequent QOL influenced by need for frequent medical attention to control medical attention to control symptoms and increased symptoms and increased hospitalizations.hospitalizations.


EpidemiologyEpidemiology Over 5 million people diagnosed, 550,000 Over 5 million people diagnosed, 550,000

new diagnoses each yearnew diagnoses each year Most common diagnosis associated with Most common diagnosis associated with

hospitalization in aged 65 years and overhospitalization in aged 65 years and over Most common Medicare DRG.Most common Medicare DRG. High rate of hospital readmission-High rate of hospital readmission-

About 20% at one monthAbout 20% at one month About 47% at 3-6 monthsAbout 47% at 3-6 months Hospital readmissions ↑ in the 6 months prior Hospital readmissions ↑ in the 6 months prior

to deathto death


PrognosisPrognosis

250,000 deaths per year in US.250,000 deaths per year in US. 5 year mortality (NHLBI data)5 year mortality (NHLBI data)

Men: 50%Men: 50% Women: 34%Women: 34%

In Class IV (NYHA) patients: In Class IV (NYHA) patients: 60% first year mortality (CONSENSUS 60% first year mortality (CONSENSUS

study)study) 38% first year mortality (SUPPORT study)38% first year mortality (SUPPORT study)

Class II-III patients: Class II-III patients: 38% 42 month 38% 42 month mortalitymortality


Natural HistoryNatural History

Course of HF is marked by de-compensationCourse of HF is marked by de-compensation Disease progression difficult to predictDisease progression difficult to predict Precipitating factors for hospitalization:Precipitating factors for hospitalization:

Non-adherence to treatment regimenNon-adherence to treatment regimen Uncontrolled hypertensionUncontrolled hypertension Cardiac arrhythmiasCardiac arrhythmias IatrogenicIatrogenic

Terminal course of disease distinguished by Terminal course of disease distinguished by increasing frequent episodes of acute HF increasing frequent episodes of acute HF exacerbationsexacerbations


End-of-Life PhaseEnd-of-Life Phase

Terminal patients report symptoms of Terminal patients report symptoms of nausea, pain, dyspnea, confusion, nausea, pain, dyspnea, confusion, fatigue, & depressionfatigue, & depression

Most elderly live at home but experience Most elderly live at home but experience death in institutionsdeath in institutions Hospital deaths for HF: 56%Hospital deaths for HF: 56% Nursing home deaths for HF: 19%Nursing home deaths for HF: 19%

The older the patient, the more likely The older the patient, the more likely they will die in a hospital or nursing they will die in a hospital or nursing homehome


Clinical Practice Clinical Practice Guideline on HFGuideline on HF

Heart Failure Society of AmericaHeart Failure Society of America ““The current comprehensive The current comprehensive

guideline addresses the full range of guideline addresses the full range of evaluation, care, and management of evaluation, care, and management of patients with HF.”patients with HF.”

http://www.heartfailureguideline.comhttp://www.heartfailureguideline.com


Here are 2 guidelines that Here are 2 guidelines that apply to HF in Frail Elders apply to HF in Frail Elders

in LTC in LTC American Medical Directors American Medical Directors

Association (AMDA)Association (AMDA) University of Iowa Evidence-based University of Iowa Evidence-based

Protocol on Heart FailureProtocol on Heart Failure

These guidelines are available in full-These guidelines are available in full-text, PDF format in the reference listtext, PDF format in the reference list


Heart Failure Disease Heart Failure Disease PresentationPresentation

Left sided failure S&SLeft sided failure S&S Right sided failure S&SRight sided failure S&S Wide continuum of function & Wide continuum of function &

disability disability Variable progression of the disease Variable progression of the disease

over timeover time Variable impact on quality of lifeVariable impact on quality of life


Risk Factors for HFRisk Factors for HF Coronary Artery Disease-Ischemic Coronary Artery Disease-Ischemic

diseasedisease Heart attack—causes 2/3 of heart failureHeart attack—causes 2/3 of heart failure

Non-ischemic diseaseNon-ischemic disease High blood pressureHigh blood pressure Heart valve diseaseHeart valve disease Cardio-myopathyCardio-myopathy Thyroid hyperactiveThyroid hyperactive AnemiaAnemia Alcohol abuseAlcohol abuse Diabetes mellitusDiabetes mellitus


Risk FactorsRisk Factors

Here is a link to a comprehensive but Here is a link to a comprehensive but brief summary of HF including risk brief summary of HF including risk factorsfactorsReference Article: Shamsham F & Mitchell J. (2000) Essentials of the diagnosis of HF. American Family Physician, 61(5) http://www.aafp.org/afp/20000301/1319.html


What is the Risk of What is the Risk of Developing Heart Failure?Developing Heart Failure?

Risk rises 4-6 timesRisk rises 4-6 times after a heart after a heart attackattack

Risk is doubledRisk is doubled by angina, diabetes, by angina, diabetes, uncontrolled high blood pressureuncontrolled high blood pressure

Other risksOther risks: enlarged heart, family : enlarged heart, family history of heart failure, high history of heart failure, high cholesterol, smoking, chronic or cholesterol, smoking, chronic or excessive alcoholexcessive alcohol


Heart Failure: A Deadly Heart Failure: A Deadly DiseaseDisease

Sudden death: 6 to 9 times > than Sudden death: 6 to 9 times > than general populationgeneral population

Men: 1 year survival rate 57%Men: 1 year survival rate 57%

5 year survival rate of 25%5 year survival rate of 25% Women: 1 year survival rate 64%Women: 1 year survival rate 64%

5 year survival rate of 38%5 year survival rate of 38%


Hallmarks of Heart Hallmarks of Heart FailureFailure

Intravascular volume overloadIntravascular volume overload —extra —extra fluid in the blood vessels, leads to fast fluid in the blood vessels, leads to fast heart rate and decreased cardiac output.heart rate and decreased cardiac output.

Interstitial volume overloadInterstitial volume overload -- extra -- extra fluid in the peripheral tissues and lungs fluid in the peripheral tissues and lungs leads to leg edema, lung congestion, leads to leg edema, lung congestion, cough, and sputum.cough, and sputum.

Inadequate tissue perfusionInadequate tissue perfusion —low —low oxygen in blood leads to fatigue, oxygen in blood leads to fatigue, weakness, confusion.weakness, confusion.


The many The many FACESFACES of Heart of Heart FailureFailure

HF is manifested in many different ways.


Because HF is a syndrome, Because HF is a syndrome, assessment is complex.assessment is complex.

Mrs. V is an 86 year old woman with Mrs. V is an 86 year old woman with HF.HF.

The CNA comes to you and says that The CNA comes to you and says that she “does not look good today.” she “does not look good today.”

You go to see the patient.You go to see the patient. What will you assess?What will you assess?


Here is a simple Here is a simple acronym to help you acronym to help you

organize and organize and remember the S&S of remember the S&S of

HF:HF:

FACES


Remember FACESRemember FACES

• F FF Fatigue, atigue, FFast pulse/respirationsast pulse/respirations

• A AA Activities and ctivities and AAppetite declineppetite decline

• C CC Cough, ough, CCongestion, ongestion, CConfusion, onfusion,

CChest painhest pain

• E EE Edema –weight gain, dema –weight gain, EElimination –limination –nocturia or decreased urine nocturia or decreased urine outputoutput

• S SS Shortness of breathhortness of breathAn easy to remember acronym!


Heart Failure Heart Failure AssessmentAssessment

Focused HF assessmentFocused HF assessment Look here for tips to help you do a

focused assessment http://www.cuhk.edu.hk/cslc/materials/pclm1011/http://www.cuhk.edu.hk/cslc/materials/pclm1011/pclm1011.htmlpclm1011.html


Assessment of the Resident Assessment of the Resident with HFwith HF

Initial appearanceInitial appearance HistoryHistory Vital signs, pulse oximetry, weightVital signs, pulse oximetry, weight Focused assessment: LOC, dyspnea, Focused assessment: LOC, dyspnea,

edema, heart and lung assessment, edema, heart and lung assessment, fatiguefatigue

Medication reviewMedication review LabsLabs Diagnostic testsDiagnostic tests


Initial AppearanceInitial Appearance

Alertness and level of consciousnessAlertness and level of consciousness Ability to speak in sentencesAbility to speak in sentences Breathing effortBreathing effort Emotional state: AnxietyEmotional state: Anxiety Skin color, diaphoresisSkin color, diaphoresis Body positionBody position Initial impression: Stable or critical?Initial impression: Stable or critical?


Level of ConsciousnessLevel of Consciousness

Observe for fluctuating mental Observe for fluctuating mental status due to delirium/acute status due to delirium/acute confusionconfusion

Administer mental status screening Administer mental status screening test if indicatedtest if indicated Mini-Mental State Exam Mini-Mental State Exam Cognitive Assessment Method (CAM)Cognitive Assessment Method (CAM)


HistoryHistory

Risk FactorsRisk Factors MI, CAD, HTN, DM, thyroid, etc.MI, CAD, HTN, DM, thyroid, etc.

Lifestyle –diet, exercise, alcohol, Lifestyle –diet, exercise, alcohol, tobaccotobacco

Previous treatment & medicationsPrevious treatment & medications Course: frequency of hospital Course: frequency of hospital

admissions or ED transfersadmissions or ED transfers


Vital SignsVital Signs

Quick overview Quick overview http://medicine.ucsd.edu/clinicalmedhttp://medicine.ucsd.edu/clinicalmed/vital.htm/vital.htm

PulsePulse Apical-radial for full minuteApical-radial for full minute

Respirations Respirations


Vital SignsVital Signs Blood pressureBlood pressure Orthostatic Orthostatic

blood pressureblood pressureBe alert to Be alert to falls falls

risk with risk with significant significant orthostatic orthostatic changes!changes!


Pulse OximetryPulse Oximetry

A non-invasive way A non-invasive way to measure oxygen to measure oxygen saturation.saturation.

False readings can False readings can occur so technique occur so technique is important!is important!


Question: Mrs. H.Question: Mrs. H.

This 76 year old This 76 year old patient has a pulse of patient has a pulse of 108, RR of 24, and a 108, RR of 24, and a pulse oximetry of 98%. pulse oximetry of 98%.

Is this a sign of Is this a sign of trouble?trouble? Pulse & RR slightly Pulse & RR slightly

elevatedelevated Pulse Ox is WNLPulse Ox is WNL Is this clinically Is this clinically

significant?significant?


Yes!Yes!

A fast respiratory rate can be an A fast respiratory rate can be an early early signsign of heart failure of heart failure

A normal pulse oximetry is due to the A normal pulse oximetry is due to the rapid respiratory rate. Eventually, the rapid respiratory rate. Eventually, the resident will tire & pulse oximetry/ resident will tire & pulse oximetry/ oxygen saturation will decline & oxygen saturation will decline & respirations will become labored respirations will become labored

PaO2 will drop rapidly & the patient will PaO2 will drop rapidly & the patient will become much more dyspneic become much more dyspneic acute acute HFHF Be alert for these

early signs!


WeightWeight

Standard care is ‘daily weights’Standard care is ‘daily weights’ In LTC, weekly weights are In LTC, weekly weights are

standard, with some exceptions standard, with some exceptions when daily weights may be ordered when daily weights may be ordered during acute HF with intensive during acute HF with intensive diuretic therapy diuretic therapy

AMDA recommends weights 3 times AMDA recommends weights 3 times a week in HF patientsa week in HF patients


WeightWeight

Red flag:Red flag: 2 lb gain overnight, 2 lb gain overnight,

or 5 lb gain in a or 5 lb gain in a weekweek

A 2.2 lb of weight A 2.2 lb of weight gain equals about a gain equals about a liter of fluid!liter of fluid!

Pulmonary edema Pulmonary edema is the clinical end is the clinical end point of fluid point of fluid overloadoverload

Source: http://healthgate.partners.org/images/si1619.jpg


Lung AssessmentLung Assessment

Here is a Here is a fantastic link fantastic link to brush up to brush up on your lung on your lung assessment assessment skillsskills

medicine.ucsd.edu/clinicalmed/extremities.htm

Source: U California San Diego: medicine.ucsd.edu/clinicalmed/extremities.htm


DyspneaDyspnea

Early sign of cardiac decompensationEarly sign of cardiac decompensation It is a complex symptomIt is a complex symptom Definitions Definitions

Difficult, labored, uncomfortable breathingDifficult, labored, uncomfortable breathing A sensation of breathlessnesssA sensation of breathlessnesss An awareness of respiratory distressAn awareness of respiratory distress

Influenced by physiologic, psychologic, Influenced by physiologic, psychologic, environmental, social conditionsenvironmental, social conditions


Dyspnea AssessmentDyspnea Assessment Nursing Best Practice Guideline for Nursing Best Practice Guideline for

DyspneaDyspnea http://www.rnao.org/bestpractices/PDF/http://www.rnao.org/bestpractices/PDF/

BPG_COPD_summary.pdfBPG_COPD_summary.pdf Animation of normal breathing and Animation of normal breathing and

dyspneadyspnea http://summit.stanford.edu/pcn/M07_Dysnea/http://summit.stanford.edu/pcn/M07_Dysnea/

norma_breat_anim.htmlnorma_breat_anim.html AssessmentAssessment

Visual analogue scale for dyspnea and HFVisual analogue scale for dyspnea and HF http://www.medscape.com/viewarticle/487962_printhttp://www.medscape.com/viewarticle/487962_print


Dyspnea Assessment Dyspnea Assessment Continuous vs intermittentContinuous vs intermittent Exertional vs non-exertionalExertional vs non-exertional Severity: orthopnea, paroxysmal Severity: orthopnea, paroxysmal

nocturnal dyspnea (PND)nocturnal dyspnea (PND) Accessory muscle useAccessory muscle use CoughCough

Productive vs dry coughProductive vs dry cough Frothy or bloody Frothy or bloody


More on Dyspnea More on Dyspnea AssessmentAssessment

Dyspnea Flow Sheet Dyspnea Flow Sheet http://www.hce.org/medicare/PDF_Documents/http://www.hce.org/medicare/PDF_Documents/dyspnea_teleconference/Key_for_Dyspnea_Flodyspnea_teleconference/Key_for_Dyspnea_Flow_Sheet_157004.pdfw_Sheet_157004.pdf

Excellent reference article “Dyspnea: Excellent reference article “Dyspnea: Mechanisms, Assessment, Management: A Mechanisms, Assessment, Management: A Consensus Statement” Consensus Statement”

http://www.thoracic.org/sections/publications/http://www.thoracic.org/sections/publications/statements/pages/respiratory-disease-adults/dstatements/pages/respiratory-disease-adults/dyspnea1-20.htmlyspnea1-20.html

Dyspnea Assessment Tools Dyspnea Assessment Tools http://summit.stanford.edu/pcn/M07_Dysnea/ahttp://summit.stanford.edu/pcn/M07_Dysnea/assess_tools.htmlssess_tools.html


DyspneaDyspnea

For Clinical PearlsFor Clinical Pearls about H about How to ow to Assess and Palliate Dyspnea- Assess and Palliate Dyspnea-

http://summit.stanford.edu/pcn/http://summit.stanford.edu/pcn/M07_Dysnea/pearls.htmlM07_Dysnea/pearls.html


Heart Assessment Heart Assessment Go here for a really Go here for a really

great review of heart great review of heart assessment skillsassessment skills

http://images.google.com/http://images.google.com/imgres?imgurl=http://imgres?imgurl=http://medicine.ucsd.edu/clinicalmed/medicine.ucsd.edu/clinicalmed/extremities-massive-extremities-massive-edema.jpg&imgrefurl=http://edema.jpg&imgrefurl=http://medicine.ucsd.edu/clinicalmed/medicine.ucsd.edu/clinicalmed/extremities.htm&h=300&w=400extremities.htm&h=300&w=400&sz=16&hl=en&start=2&tbnid=&sz=16&hl=en&start=2&tbnid=tfwPhytR2O1KxM:&tbnh=93&tbtfwPhytR2O1KxM:&tbnh=93&tbnw=124&prev=/images%3Fqnw=124&prev=/images%3Fq%3Dedema%26svnum%3Dedema%26svnum%3D10%26hl%3Den%26lr%3D%3D10%26hl%3Den%26lr%3D%26sa%3DN%26sa%3DN Source: U California San

Diego: medicine.ucsd.edu/clinicalmed/extremities.htm


Fluid Status EvaluationFluid Status Evaluation Fluid overload is Fluid overload is

manifested by manifested by edema, lung edema, lung congestion & congestion & productive cough. productive cough.

Pulmonary Pulmonary edemaedema is the most is the most serious indicator serious indicator of fluid overload.of fluid overload. Source:

http://healthgate.partners.org/images/si1619.jpg


Pulmonary EdemaPulmonary Edema

The heart is unable to pump the The heart is unable to pump the necessary amount of blood necessary amount of blood throughout the body. This causes throughout the body. This causes blood to back up in the veins. Fluid blood to back up in the veins. Fluid pools in the liver and lungs. pools in the liver and lungs.

Swelling occurs first in the feet, Swelling occurs first in the feet, ankles, and legs, and then ankles, and legs, and then throughout the body as the kidneys throughout the body as the kidneys retain fluid. retain fluid.



Source: Lynne Larson, 1998, www.biovisuals.com/alveolus.html

Conceptual illustration depicting congestive heart failure.



Pulmonary edema begins with an increased filtration through the loose junctions of the pulmonary capillaries. Source: Lynne Larson,

1998, www.biovisuals.com/alveolus.html



As the intra-capillary pressure increases, normally impermeable (tight) junctions between the alveolar cells open, permitting alveolar flooding to occur.

Source: Lynne Larson, 1998, www.biovisuals.com/alveolus.html



Here is an X-ray Here is an X-ray showing severe showing severe pulmonary edemapulmonary edema

Notice the diffuse Notice the diffuse clouding indicating clouding indicating fluid overload and fluid overload and congestioncongestion


Fluid Status EvaluationFluid Status Evaluation

Best done by monitoringBest done by monitoring WeightWeight Peripheral edemaPeripheral edema LungsLungs


Peripheral EdemaPeripheral Edema

Lower extremity edema, a common Lower extremity edema, a common sign of heart failure, is usually sign of heart failure, is usually detected when the extra-cellular detected when the extra-cellular volume exceeds volume exceeds 5 L5 L

The edema may be accompanied by The edema may be accompanied by stasis dermatitis, a chronic, stasis dermatitis, a chronic, eczematous condition characterized eczematous condition characterized by edema, hyper-pigmentation, by edema, hyper-pigmentation, ulcerationulceration


Pedal or LE EdemaPedal or LE Edema

ASSESS:ASSESS: Size of Size of

extremityextremity Color Color TemperatureTemperature SensationSensation PalpationPalpation PittingPitting


Edema: QuestionEdema: Question How would How would

you evaluate you evaluate and grade this and grade this LE Edema?LE Edema?

Here are some Here are some assessment assessment guidelines guidelines

(Link to: Assessment (Link to: Assessment of Peripheral Edema)of Peripheral Edema)(Link to: Assessment (Link to: Assessment of Peripheral Edema)of Peripheral Edema)


AnswerAnswer

This presentation This presentation is consistent with is consistent with severe LE edema severe LE edema with pitting. The with pitting. The toes are also pale toes are also pale and ashen with and ashen with some blue-tinged some blue-tinged discoloration. discoloration.


Other Types of EdemaOther Types of Edema

Right sided heart Right sided heart failure may failure may manifest with manifest with ascitesascites and not LE and not LE edemaedema

Also look for Also look for dependent edema dependent edema in other areas such in other areas such as the as the sacrumsacrum.. Source: U California San

Diego: medicine.ucsd.edu/clinicalmed/extremities.htm


JVDJVD

Here is another Here is another view of the jugular view of the jugular vein.vein.

Source: UC San Diego: medicine.ucsd.edu/clinicalmed/extremities.htm


Jugular Vein Distention Jugular Vein Distention (JVD)(JVD) Jugular venous distention is Jugular venous distention is

assessed while the patient is assessed while the patient is supine at a 45-degree angle. The supine at a 45-degree angle. The top of the waveform of the top of the waveform of the internal jugular venous pulsation internal jugular venous pulsation determines the height of the determines the height of the venous distention. An imaginary venous distention. An imaginary horizontal line (parallel to the horizontal line (parallel to the floor) is then drawn from this floor) is then drawn from this level to above the sternal angle. level to above the sternal angle.

A height of more than 4 to 5 cm A height of more than 4 to 5 cm from the sternal angle to this from the sternal angle to this imaginary line is consistent with imaginary line is consistent with elevated venous pressure elevated venous pressure Elevated jugular venous Elevated jugular venous pressure is a specific (90 pressure is a specific (90 percent) but not sensitive (30 percent) but not sensitive (30 percent) sign of elevated left percent) sign of elevated left ventricular filling.. ventricular filling..


FatigueFatigue

An early sign of evolving acute HFAn early sign of evolving acute HF Unremitting and progressive in Unremitting and progressive in

chronic HFchronic HF Piper Fatigue Scale, 27 items on a 1-Piper Fatigue Scale, 27 items on a 1-

10 scale of severity 10 scale of severity http://www.pdxinternational.com/docs/piper/Pipehttp://www.pdxinternational.com/docs/piper/Piper_Fatigue_Scale.PDFr_Fatigue_Scale.PDF

Markedly affects QOL & functionMarkedly affects QOL & function


Medication Review: HF Medication Review: HF drugsdrugs

ACE Inhibitors ACE Inhibitors Lotensin, Capoten, Lotensin, Capoten, Vasotec, Altace, AccuprilVasotec, Altace, Accupril

Beta blockers Beta blockers Carvedilol, Metoprolol Carvedilol, Metoprolol Angiotensin Receptor Blockers Angiotensin Receptor Blockers

Cozaar, Diovan, Teveten, Avapro, BenecarCozaar, Diovan, Teveten, Avapro, Benecar Spironolactone Spironolactone AldosteroneAldosterone Diuretics Diuretics Lasix, hydrochlorothiazideLasix, hydrochlorothiazide DigoxinDigoxin


Medications for HFMedications for HF

Review the medication list for the Review the medication list for the residentresident

Review drug action and therapeutic goal Review drug action and therapeutic goal Identify the Identify the target heart ratetarget heart rate that that

treatment is hoping to achievetreatment is hoping to achieve Determine if the BP is too low as an Determine if the BP is too low as an

unintentional consequence of drug RXunintentional consequence of drug RX Is the resident having adverse side Is the resident having adverse side

effects?effects?


Diet and Intake PatternDiet and Intake Pattern

Low Salt diet recommendedLow Salt diet recommended No Added Salt , or 2 gram /3 gram NA diet No Added Salt , or 2 gram /3 gram NA diet

typicaltypical Determine if resident is very salt sensitive Determine if resident is very salt sensitive

(prone to rapid onset of HF with salty (prone to rapid onset of HF with salty meal)meal)

A high salt meal MAY provoke HF the next day!A high salt meal MAY provoke HF the next day! Diet may be liberalized if resident is Diet may be liberalized if resident is

underweight, cachexic, or eating poorly. underweight, cachexic, or eating poorly. Nutritional supplements may be needed.Nutritional supplements may be needed.


Fluid Intake PatternFluid Intake Pattern Fluid restrictionFluid restriction1,500-2,000 mL/day.1,500-2,000 mL/day. No fluid restriction needed for most NH No fluid restriction needed for most NH

residents, but should avoid excess fluid.residents, but should avoid excess fluid. Monitor diuretic therapyMonitor diuretic therapy Monitor for poor intakeMonitor for poor intake

Some older residents who have trouble Some older residents who have trouble eating enough may actually need to be eating enough may actually need to be encouragedencouraged to drink fluids, & may need to drink fluids, & may need nutritional supplements.nutritional supplements.


ActivityActivity

Determine current activity level.Determine current activity level. Important to stay active, to pace Important to stay active, to pace

activity with rest periods, & allow extra activity with rest periods, & allow extra time to complete activities.time to complete activities.

Some level of fatigue may be present—Some level of fatigue may be present—it is still important to help resident stay it is still important to help resident stay as active as possible.as active as possible.

Use the NYHA classification to Use the NYHA classification to determine your patient’s functional determine your patient’s functional levellevel


NY Heart Association NY Heart Association Classification of HF: Classification of HF:

To rate disease severity based on To rate disease severity based on functional statusfunctional status

Class IClass I: no limitation of activities; no symptoms : no limitation of activities; no symptoms (fatigue, palpitation, dyspnea or anginal pain) from (fatigue, palpitation, dyspnea or anginal pain) from ordinary activities. ordinary activities.

Class IIClass II: slight, mild limitation of activity; : slight, mild limitation of activity; comfortable at rest or with mild exertion. comfortable at rest or with mild exertion.

Class IIIClass III: marked limitation of activity; comfortable : marked limitation of activity; comfortable only at rest. Less than ordinary activity produces only at rest. Less than ordinary activity produces symptoms.symptoms.

Class IVClass IV: Patients w/ cardiac disease resulting in : Patients w/ cardiac disease resulting in inability to do any physical activity w/o discomfort. inability to do any physical activity w/o discomfort. Symptoms of HF may be present at rest. If any Symptoms of HF may be present at rest. If any physical activity is undertaken, discomfort physical activity is undertaken, discomfort increases. Usually bed or chair bound.increases. Usually bed or chair bound.


Lab TestsLab Tests Chemistry panelChemistry panel

Electrolytes-usually normal but hypo-Electrolytes-usually normal but hypo-natremia can occur from potassium-sparing natremia can occur from potassium-sparing diuretics, & hyper-natremia from ACE diuretics, & hyper-natremia from ACE InhibitorsInhibitors

Liver enzymes can be Liver enzymes can be ↑↑ secondary to liver secondary to liver congestioncongestion

Anemia associated with and is trigger of HFAnemia associated with and is trigger of HF Thyroid panel-hyperthyroid a trigger for HFThyroid panel-hyperthyroid a trigger for HF

BNP- Brain Natriuretic PeptideBNP- Brain Natriuretic Peptide Secreted by failing left ventricle, Secreted by failing left ventricle, ↑↑ in HF in HF

(>100)(>100)


Diagnostic TestsDiagnostic Tests Chest X-rayChest X-ray -looks at size and shape of -looks at size and shape of

heart, presence of effusionheart, presence of effusion EchocardiogramEchocardiogram -looks for decreased -looks for decreased

ejection fraction (EF), dilated LV, enlarged ejection fraction (EF), dilated LV, enlarged heart, LV hypertrophyheart, LV hypertrophyWhat is the patient’s EF?What is the patient’s EF? If there is systolic dysfunction, >55% is normalIf there is systolic dysfunction, >55% is normal If there is diastolic dysfunction, EF may be WNLIf there is diastolic dysfunction, EF may be WNL

EKGEKG -looks at rate & rhythm abnormalities, -looks at rate & rhythm abnormalities, Q wave abnormalities suggestive of MIQ wave abnormalities suggestive of MI


Assessment of Acute HFAssessment of Acute HF

Obtain a dyspnea progression Obtain a dyspnea progression historyhistory Rest dyspneaRest dyspnea

OrthopneaOrthopneaParoxysmal nocturnal Paroxysmal nocturnal dyspneadyspneaDyspnea while walking on Dyspnea while walking on level arealevel areaDyspnea while climbingDyspnea while climbing

The patient should be questioned The patient should be questioned about cough, nocturia, fatigue & about cough, nocturia, fatigue & other signs and symptomsother signs and symptoms

Source: Shamsham F & Mitchell J. (2000) Essentials of the diagnosis of HF. American Family Phhysician, 61(5)

LINK: http://www.aafp.org/afp/20000301/1319.html


Progression of Acute HFProgression of Acute HF Dyspnea, a cardinal symptom of HF, Dyspnea, a cardinal symptom of HF,

progresses from dyspnea on exertion progresses from dyspnea on exertion to orthopnea (unable to lie flat), to orthopnea (unable to lie flat), paroxysmal nocturnal dyspnea (PND) paroxysmal nocturnal dyspnea (PND) to dyspnea at rest/during speechto dyspnea at rest/during speech

Cough, usually nocturnal & Cough, usually nocturnal & nonproductive, may accompany nonproductive, may accompany dyspnea and often occurs on exertion dyspnea and often occurs on exertion or when the patient is supineor when the patient is supineSource: Shamsham F & Mitchell J. (2000) Essentials of the diagnosis of HF. American Family Physician, 61(5) http://www.aafp.org/afp/20000301/1319.html


Progression of Acute HFProgression of Acute HF

Nocturia develops secondary to Nocturia develops secondary to increased renal perfusion while increased renal perfusion while supinesupine

May be May be urine output during the day urine output during the day Generalized fatigue-can be profound Generalized fatigue-can be profound

& disabling& disabling Increasing peripheral edema-LE, Increasing peripheral edema-LE,

ascites ascites Source: Shamsham F & Mitchell J. (2000) Essentials of the diagnosis of HF. American Family Phhysician, 61(5) http://www.aafp.org/afp/20000301/1319.html


Progression of Acute HFProgression of Acute HF GI symptoms may develop (bloating, GI symptoms may develop (bloating,

anorexia, fullness in the RU quadrant)anorexia, fullness in the RU quadrant) With severe, longstanding HF, With severe, longstanding HF,

cardiac cachexia (emaciation) may cardiac cachexia (emaciation) may develop secondary to protein-losing develop secondary to protein-losing enteropathy & increased levels of enteropathy & increased levels of cytokines (IL-6 & TNF)cytokines (IL-6 & TNF)

Clinical endpoint is Clinical endpoint is frailtyfrailty End of life careEnd of life careSource: Shamsham F & Mitchell J. (2000) Essentials of the

diagnosis of HF. American Family Phhysician, 61(5) http://www.aafp.org/afp/20000301/1319.html


SummarySummary

Early recognition of HF S&S leads to Early recognition of HF S&S leads to early treatment & better outcomesearly treatment & better outcomes

Treatment optimization can lead to Treatment optimization can lead to improvement in morbidity, mortality & improvement in morbidity, mortality & QOL QOL

RN role is to empower staff to use RN role is to empower staff to use evidence-based approaches to observe & evidence-based approaches to observe & assess changes in patient status and assess changes in patient status and communicate/report in an effective & communicate/report in an effective & timely mannertimely manner