pp heart failure

7/30/2019 Pp Heart Failure

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CHRONIC HEART FAILURE

Sandra McCreanor CNS

Darron Webber CNCFiona Love CNS

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BACKGROUND

It is estimated that 300,000 Australians areaffected by heart failure (based on US

data)* In over 50% of new cases IHD is the

underlying cause of heart failure*

* National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand.Guidelines for the prevention, detection and management of chronic heart failure in Australia.

Updated J uly 2011.2


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Five-year survival postFive-year survival post

hospitalisationhospitalisation

WomenWomen MenMen

Stewart et al Eur J Heart Fail

0 12 24 36 48 600.0

0.1

0.2

0.3

0.40.5

0.6

0.7

0.8

0.9

1.0

HeartFailure

MI

Breast

Bowel

Lung

Ovarian

Month of follow-up

(%)S

urvival

0 12 24 36 48 600.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

HeartFailure

MI

Lung

BowelProstate

Bladder

Monthoffollow-up

Surv

ival(%)

Men

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Estimated numbers of people living with chronic heart failure in Australian census collection districts andlocations of CHF management programs

Robyn A Clark, Andrea Driscoll, J ustin Nottage, Skye McLennan, David M Coombe, Errol J Bamford, David Wilkinson andSimon Stewart Med J Aust 2007; 186 (4): 169-173.

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Causes of systolic heart failure

(impaired ventricular contraction)Coronary Artery DiseaseEssential hypertension

Less common causes of heart failureNon ischaemic idiopathic dilated cardiomyopathy

Uncommon causesValve DiseaseNon ischaemic idiopathic dilated cardiomyopathy secondary toalcoholChronic arrhythmia

Thyroid dysfunctionHIV related cardiomyopathyDrug induced cardiomyopathyPeripartum cardiomyopathy

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Causes of heart failure with preserved

systolic function (impaired relaxation)

Coronary Artery DiseaseHypertensionDiabetes

Less common causes of heart failureValve Disease

Uncommon causes

Hypertrophic cardiomyopathyRestrictive cardiomyopathy

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Patient Assessment

Symptoms

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Symptoms physical examination

Raised JVP

Apex beat displaced laterally Third heart sound

Soft fine creps in bases of lungs

Liver enlargement

Oedema

Peripheral and abdominal

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SY

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New York Heart Association Grading (NYHA)

Class I No limitations. Ordinary activity does not cause S&SAsymptomatic LV dysfunction

Class II Slight limitation of physical activity

Mild CHF

Class III Marked limitation of physical activity

Do you get short of breath showering?Moderate CHF

Class IV Unable to carry on any physical activity without

symptomsDo you get short of breath dressing or at rest?Severe CHF

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Pharmacological management ACE Inhibitors or Angiotensin II

receptor blockers Blockers

Diuretics Aldosterone Antagonists

Digoxin

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Drugs to avoid in chronic

heart failure There are many drugs that can impact

on CHF common ones that are importantfrom a nursing perspective include:

Non steroidal anti-inflammatoriesOver the counter medications that

effervesce

Ural, Berroca, soluble Panadol

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Factors that increase the risk of

emergency admission

Hx of non adherence in the past

Poor social support

Increased age

Depression

Hx of failure to seek help early

Co morbidities Poor health literacy

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Most Common Symptoms Before

Hospitalisation Dyspnoea (76%)

Acute dyspnoea (37%) Oedema (35%-66%)

Fatigue (37%) Cough (33%)

Chest pain (25%)

Friedman,1997 Evangelista et al 2001

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THE MAIN FACTORS THAT

CONTRIBUTE TO EMERGENCYRE-ADMISSION

1) Failure to seek medical help (32%)

2) Non adherence to diet (Na+

/ fluid) &medication (40%)

Source: Moser, D 2002

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Home-based Intervention in CHF

Stewart et al, Lancet 199919


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Nurse led heart failure

management

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Non pharmacological management

general dietary recommendations Maintain healthy weight range Saturated fat limit especially in those with CAD

unless end stage CHF Fibre due to fluid accumulation in gut and poor

blood supply & constipation is common Malnutrition (cardiac cachexia) small frequent

meals high in energy with referral to dietitian For alcohol related cardiomyopathy the person

should abstain. For others 10 20 g / daymaximum (min 2 ETOH free days / week)

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specific dietary recommendationsSODIUM is directly related to fluid overload and

impacts quickly on symptoms Assess current diet and assist with low Na

options Pay attention to packaged food: processed meat,

vegemite, crackers & biscuits Low Na product = 120 mg / 100g

- Oats 8mg / 100g vs Cornflakes 720mg / 100g

In winter some elderly people eat packaged soupleading to what heart failure nurses call a Cup ofSoup epidemic

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FLUID MANAGEMENT 1kg = 1 litre

Daily weighing and recording of weight Should be digital scales sensitive to 0.2 kg Fluid intake in general 1.2 1.5 L / day

Considerations need to be made in hot weatherand for those people who are stable or spendingtime outdoors

Dry mouth mouth spray, sips of H20, suckice

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ACTION PLAN

CHECKLIST FOR STAYING WELL

Take your medications

Weigh yourself every dayto watch forfluid build up Limit salt intake

Drink sensible amounts of fluid; around1500mls Report warning signs early

Exercise most days at a comfortable pace Keep your vaccinations up to date

- (Fluvax once a year & Pneumovax

every 5 years) 24


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ACTION PLAN

WARNING SIGNS AND SYMPTOMS THAT FLUID

IS BUILDING UP

A sudden increase in weight (2kgs in 48 hours)Feeling more short of breath than usual

New swelling in feet, legs or abdomenDevelop a cough that does not go awayWaking up at night short of breath

WHAT TO DO

Contact your Heart Failure Nurse and / or take an extrafluid tablet,Frusemide (Lasix, Urex, Uremide,) for one day only or as prescribed.Do not take extra Frusemide unless your doctor has given you permission.

OTHER IMPORTANT SIGNS

Develop a temperature or infectionPalpitations or racing heart with feeling light headed Contact GP

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Psychosocial assessment & considerations

welcome to my world

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Psychosocial assessment and considerations

Symptoms Co-morbidities

Family, living arrangements, social support

Current or previous work, hobbies

Cognition, coping, hygiene

ADLs, mobility problems

Psychological Hx depression, anxiety, stress

etc Financial and / or social stressors

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Traditionalapproach to

education-> persuasion

AdviseExplain

WarnMake suggestions

Disagree, quote statisticsReassure

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Persuasion encourages the person to re-affirm the reasons why they cannot changeand increases their resistance to change.

Telling the person what to do will lead them to say:

yes but

yes but

yes but

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Approaches that are effective

Utilising good communication skills inparticular active listening

Personalised & realistic goal settingMotivational InterviewingHealth CoachingGroup programs / mentoring

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PROFESSIONAL CONSIDERATIONS


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PROFESSIONAL CONSIDERATIONS

Remember one day you or some one you love willbe faced with a crisis and/or death Treat people how you would like to be treated

Contemplate the issue of power

Remain professional

People in crisis often behave in ways not usualfor them

Try not to be judgmental 31


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CASE STUDY 76yr old male

(Robert)Issues prior to admission to rehabilitation

- MI while overseas- Presented to ED with leg cellulitis / lethargy

- Found to be in AF with Congestive Cardiac

Failure.- Cardiac arrest in ED

- Coronary Angiogram for CABGs- Echo impaired LVEF

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Post op recovery following

CABGs- Intra-aortic balloon pump inserted

- AF, hypotension requiring inotropesupport

- VF arrest day 2

- Extubated day 7- AICD day 13 (Automated Implantable Cardioverter

Defibrillator)

- Oedema legs, PEG bandages- Mild SOB on exertion

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Transfer to Rehabilitation

Hospital Underwent a multi-disciplinary team

assessment involving nursing staff,physiotherapist, occupational therapist andsocial worker

Echo showed LVEF 20-25% with severe globalsystolic dysfunction. Remained in AF

Hypotensive asymptomatic Oedema of legs improved with PEG bandaging Walking with rollator. Falls prevention

program. Denied pain throughout admission

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Discharged home Married. Wife in good health

Function at discharge- Mobility independent with stick- Self care independent- Cognition intact- Continent

- Wounds small areas ooze in both legs- Wears compression stockings

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Medications on discharge Carvedilol 3.125mg Bd

Frusemide 60mg mane Atorvastatin 40mg nocte

Omeprazole 20mg Bd Spironolactone 12.5mg mane

Amiodarone 100mg mane

Warfarin variable dose daily

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Participated in Heart Failure program learning

about heart failure signs and symptoms andself management of heart failure

Completed Heart Failure program but

returned to participate in heart failuremaintenance exercise class

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Completed Cardiac Rehabilitation program(learnt about secondary prevention for hisischaemic heart disease) and also returned to

complete exercise program Admission to hospital 6 months later gained

6kgs! Despite having Flexible Diuretic Regime

approved (? Non compliance of selfmanagement plan)

On discharge lasix increased to 40mg Bd

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ECHO 18 months showed severely dilated leftventricle with severe global systolicdysfunction and EF of 14%

Also diagnosed with sleep apnoea Admission to hospital around this time

required inotropic support for BP

At one time lasix dose was up to 120mg BdAmiodarone was ceased and Digoxin 62.5mcgdaily commenced

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Approximately 18 months later referred to

Palliative care due to deterioration of hiscondition

Arrangements were made to have Roberts

AICD turned off Admitted to Palliative care ward for a short

stay for respite and then returned home

At this time medications were warfarin 3mgdaily, Digoxin 62.5mcg daily, slow K+ 1 Bd,Isosorbide Mononitrate 30mg nocte,

Frusemide 120mg Bd, Caltrate 2 Tds, somac40mg mane, Ostelin 2 Bd and Aranesp weeklyhowever client non compliant

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Over the next 11 months despite continual

review of medications Roberts conditioncontinued to deteriorate and was underpalliative care team at home until he passed

away 4 years after initial MI

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Unpredictable illness trajectory

Time

Functional

Disability

or

Severity of

Illness

Chronic

Heart Failure

LungCancer

Death

Clear Phase of Decline--

Allows PC Referral

Death Unpredictable--No Clear Decline Path

Source: Lynn et al. American Center to Improve Care of the Dying(with permission) in Davidson et al JCVN 2004.

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Thankyou!Illawarra Heart Failure Service &

Cardiac Rehabilitation ServiceLevel 3

Port Kembla HospitalHeart Failure Service 4223 8413

Cardiac Rehabilitation 4223 8149

Fax number 4223 8008

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