Heart Failure Amber Achman, Brittani Allen, & Nicholas Gruber Saint Cloud State University Nursing Program

Learning Objectives Staff will recognize the difference between right and left sided heart failure, various treatment methods, and signs/symptoms patients should monitor. Staff will be able, through the information presented, to tailor their patient teaching regarding CHF to the environment the patient will be returning to such as home versus a nursing home. Staff will understand how to perform effective discharge teaching using the Teach-Back method.

What is Heart Failure? It describes the heart’s inability to pump blood throughout the body effectively Decreased perfusion of oxygen and nutrients

Causes of HF HTN Valvular disease MI Pulmonary HTN CAD Heart failure is caused by systemic hypertension in 75% of cases. About one third of clients experiencing myocardial infarction also develop heart failure. Structural heart changes, such as valvular dysfunction, cause pressure or volume overload on the heart.

Left and Right sided HF Possible for one side to fail by itself Most HF begins with left and progresses to failure of both ventricles Left side- decreased EF (<50%) Blood accumulates in pulmonary circulation Right side- R ventricle unable to completely empty Increased volume and pressure in systemic veins -Normal EF=50-70% -Left sided- EF drops d/t decreased contractility (systolic) or EF remains near normal and inadequate filling occurs during diastole so not enough blood being pumped -R side results in venous congestion and peripheral edema

Symptoms of L Ventricular Failure Weakness Fatigue Dizziness Confusion Pulmonary congestion Dyspnea on exertion (DOE) Orthopnea Paroxysmal nocturnal dyspnea (PND) Oliguria Renal Failure Respiratory Signs & Symptoms manifest

Symptoms of R Ventricular Failure Jugular distention Enlarged liver and spleen Anorexia and nausea Dependent edema (legs and sacrum) Distended abdomen Swollen hands and fingers Polyuria at night Weight gain Increased BP

Assessment Findings in HF S₃ Gallop Crackles and Wheezes every breath and remain after cough Weight gain Most accurate monitor of fluid status Labs: BNP increases in response to decreased CO Renal – Cr. And BUN increase due to inadequate perfusion ABG’s out of range Besides the s&sx on the earlier slides may find these w/ HF

Medications General Guidelines NEVER skip a dose NEVER take a medication without the Dr.’s permission NEVER change the dosage of a medication without the Dr.’s permission

ACE Inhibitors What They Do: Vasodilators Cause the blood vessels to expand, lowering blood pressure and reducing the heart's workload RAAS- cascade that occurs in response to low BP. Increases vascular volume by retaining Na+ and therefore fluids. = grreater stress on heart muscle

Diuretics; Thiazide, Loop, K+ Sparing What They Do: Causes the kidneys to remove more Na & H2O from the bloodstream Decreases the heart's workload, due to less fluid needing to be pumped throughout the body Watch labs for lyte changes

Beta Blockers What They Do: Block specific receptors ("beta receptors") on the heart cells This reduces the effects of chemical messengers that increase heart rate Allows the heart to maintain a slower rate and lowers blood pressure Increase contractility and CO

Other Heart Failure Meds Vasodilators Digitalis Preparations Ca+ Channel Blockers Angiotension II Receptor Blockers Blood Thinners Cholesterol Lowering Medications

Diet & Nutrition Why Low Sodium is a Good Thing Sodium makes the body hold on to extra fluid The heart has to work harder to pump the extra fluid Increased weight Increase in symptoms such as swelling and SOB Increased BP

Tips for A Low Sodium Diet Remove salt shaker & use a salt substitute Drain & rinse canned foods before eating them Substitute fresh fruit & veggies instead of canned or frozen Avoid convenience foods Look at labels for “low” or “reduced” sodium…but aware of serving size Know how much sodium is allowed in your diet & what that means 3 grams of salt = 1 teaspoon

Activity & Rest 30 minutes of activity 5 days a week Rest is important Talk to Dr. about how much activity is safe for you Vary activity to keep it interesting Rest is important Allows heart to rest and pump easier Make a time every day to rest such as after lunch

What to Monitor Weight Fluid Intake (if recommended by Dr.) Symptoms Same time every day In the morning Same type of clothes, NO shoes SAME SCALE Fluid Intake (if recommended by Dr.) Symptoms Increased SOB Increased fatigue Persistent cough Shoes fitting tight…increase in edema

Effective Discharge Teaching Use words your patient will understand Caregivers and family members should be present and participate Use different methods to teach (reading material, videos, demonstrations, role play) Use the teach-back method Asking the patient to “teach-back” the material that they were just taught in order to ensure understanding of the material Used by several health care facilities. Teach-back is shown to reduce readmissions

Teach-Back Method Ask what the patient already knows about the illness. This is usually done during the admission process. This will help identify the learning needs of the patient based on their perception of the illness. 2. Clarify the illness and what symptoms brought them in the hospital. This specifies the issues that are clearly not understood by the patient. These are issues that need to be emphasized during the discharge teaching. 3. Teach the learning material in simple the patient can understand. Each patient has different learning needs. Use the video, reading material, and hands-on demonstrations to re-enforce the teachings 4. Ask the patient to “teach-back” the main parts of what they just learned. Example: Ask the patient to show you how many milligrams of Lasix they will need if it is 8am in the morning as compared to 8pm at night based on their prescription.

Teach-Back Method 5. Re-teach the patient any material that seemed misunderstood or unclear. A patient may state that it is ok if they can’t fit in their shoes and are slightly short of breath because they only gained 1.5lbs since yesterday. Re-teach them that it’s not all or nothing. There are several symptoms to be concerned about. 6. Again, ask the patient to teach you the new material. Repeat steps as needed. 7. Document the material taught and the patient response.

Helpful Hints Use the teach-back method during medication administration to help patients learn about new meds. Do not ask the patient “Do you understand?” This puts too much pressure on the patient and they will often say they understand, but they do not. Assume that if the patient does not understand, you were not clear enough. Use another approach. Encourage questions. I know time is an issue, but it is important not to appear rushed, annoyed, or bored during these efforts—your affect must agree with your words.

For Further Information Minnesota Health Literacy Partnership http://healthlit.themlc.org/ Agency for Health Research & Improvement http://www.ahrq.gov/ Mosby’s Nurse Reference on CHI website

References http://www.ahrq.gov/ http://www.americanheart.org/presenter.jhtml?identifier=118#ace_inhibitorsbook=cardio&part=A462 http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi? http://healthlit.themlc.org/ Joanna Briggs Institute Ignatavicius, D., & Worman, L. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). SaintLouis, MO: Elsevier.