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/In-
service 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  Transfer data
history/or risk  Labs, EKG, echo,
factors for heart chest film
failure  Anemia, COPD,
other lung
diseases
 Previous treatment
 Hospitalization for
heart failure.
 Assess Risk Factors
 Coronary artery  Arrhythmia
disease  Anemia
 Angina/infarction  Fluid volume
 Chronic overload with
hypertension noncardiac causes
 Idiopathic dilated  Thyroid disease
cardiomyopathy
 Valvular heart
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  Diastolic

 Left ventricle has  Decreased left

reduced muscle ventricular filling
contractility  Caused by ventricular
stiffness, decreased
rate of relaxation, or
rapid heart rate
 Functional Assessment
 Class I  Class III
 No limitations of physical  Symptoms with minimal
activity. No shortness of exertion. SOB, fatigue,
breath, fatigue, or heart heart palpitations.
palpitations with ordinary Patients comfortable at
physical activity. rest.
 Class II  Class IV
 Slight limitation of  Severe to complete
physical activity. SOB, limitation of activity.
fatigue, heart SOB, fatigue, heart
palpitations. Patient palpitations, even at rest.
comfortable at rest.
 American College of Cardiology
American Heart Association
 Stage A High risk of HF, no
structural heart abnormality
 Stage B Structural heart disorder, no
symptoms
 Stage C Structural disorder, past or
current HF symptoms
 Stage D 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  if burden of the
stage conditions work-up is greater
than the benefit
of the treatment
 if it would not
change
management  if causes are
reversible
 in a resident that
refuses treatment
 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  Unstable angina
 Pulmonary embolism  Fluid volume status
 Accelerated/  Renal failure
malignant  Medication-induced
hypertension  High salt-intake
 Thyroid disease  Severe anemia
 Valvular heart
disease
 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.