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Overview

Heart failure (HF) is the most common cause of hospital admission in the older adult.  Hospitalizations for HF account for approximately 50% of all cardiovascular hospital admissions.  The evidenced-based literature demonstrates that as many as half of these admissions are readmissions and are preventable.  Early identification of patients at risk for rehospitalization during hospital stay provides opportunity for interventions to impact the readmission rate.  The epidemic growth in HF prevalence is commensurate with an aging population and has stimulated a focus of research to identify those patients at high risk for hospitalization and readmission.  Symptoms of HF compel patients to seek medical aid; however, evidence to date has shown HF patients postpone seeking medical assistance 12 hours to 14 days before recognition of these changes as harmful to bodily functioning.  The delay causes further deterioration in cardiac status requiring acute  hospitalization. 

Nursing Standard of Practice Protocol: Heart Failure: Early Recognition, and Treatment of the Patient At Risk for Hospital Readmission

Judith E. Schipper, Jessica Coviello, and Deborah A. Chyun

Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. The text is available here.

  1. GOAL: To reduce the incidence of hospital readmission of older adult patients with heart failure (HF).
  2. OVERVIEW

A. HF is the most common cause of hospitalization of adults over the age of 65 (Krumholz et al., 1997; Funk & Krumholz, 1996) and is the cause of functional impairment and ultimate morbidity and mortality as well as significant hospital costs (Lloyd-Jones et al., 2010; Thom et al., 2006).

B. Hospitalization can be prevented by identifying the high-risk HF patients, early recognition of sign and symptoms of decompensation, and timely initiation or regulation of medical therapy (Lloyd-Jones et al., 2004; Rich et al., 1995; Ross et al., 2008).

C. Recognition of risk factors and routine monitoring for potential HF decompensation should be part of comprehensive nursing care of older adults (Lloyd-Jones et al., 2004; Rich et al., 1995; Ross et al., 2008).

III. BACKGROUND AND STATEMENT OF PROBLEM

A. Definition: HF is the inability of the heart to pump blood sufficient to metabolic needs of the body or cannot do so without greatly elevated filling pressures (Miller & Pina, 2009). Acute HF can develop swiftly or over the preceding weeks as the primary initial event. Acute decompensated HF is the result of chronic HF (Brucks et al., 2005).

B. Etiology and Epidemiology

    1. Prevalence and incidence: There are over 5.8 million individuals with HF in the United States and approximately half a million new cases every year (Lloyd-Jones et al., 2010; Thom et al., 2006).
    2. Etiology: Deficiency in myocardial pump function as a result of nonischemic progressive cardiomyopathy or more prevalent ischemic causes such as coronary heart disease and MI with a resulting development of signs and symptoms such as edema, dyspnea, and orthopnea (Bertoni et al., 2004; Chyun et al., 2002; Lewis et al, 2003).
    3. Risk factors: Predisposing age (70 years old and older), severity of illness, comorbidities such as HTN, coronary artery disease, diabetes, valvular heart disease, and obesity. Additionally, cognitive impairment, depression, sensory impairment, fluid and electrolyte disturbances, and polypharmacy also impose an increased risk (Ho et al., 1993; Hypertension in Diabetes Study Group, 1993; Levy et al., 1996; Piccini et al., 2004). Precipitating: High sodium diet, excess fluid intake, sleep disordered breathing, chronic kidney disease, anemia, cardiotoxims such as chemotherapeutic agents, NSAIDS, illicit drugs, or alcohol (Schocken et al., 2008). Environmental factors: low socioeconomic status, sychological stress (Schocken et al., 2008).
    4. Outcomes: HF has a downward trajectory that through preventative measures can be delayed; however, not without considerable impact on quality of life (Grady et al., 2000).

IV. PARAMETERS OF ASSESSMENT

A. Assess at initial encounter and every shift

1.  Baseline: Health history NYHA classification of functional status and stage of HF, cognitive and psychosocial support systems (Brucks et al., 2005)
2.  Symptoms: dyspnea, orthopnea, cough, edema; Vital signs: BP, HR, RR (Pickering et al., 2005; Pickering et al., 2008; Sansevero, 1997). Physical assessment with signs: rales or “crackles”; peripheral edema, ascites, or pulmonary vascular congestion of chest x-ray (Stevenson & Perloff, 1989)
3.  Medications review – Optimal medical regimen according to ACC/AHA/HFSA guideline unless contraindicated (Brenner et al., 2001; Riegel et al., 2009; Wing et al., 2003)
4.  Electrocardiogram/telemetry review: Heart rate, rhythm, QRS duration, QT interval (Bertoni et al., 2004; Chyun et al., 2002; Chyun et al., 2003)
5.  Review echocardiography, cardiac angiogram, muga scan, cardiac CT or MRI for left ventricle and valve function: left ventricular ejection fraction (LVEF; Bertoni et al., 2004; Chyun et al., 2002; Lewis et al., 2003)
6.  Laboratory value review (Cygankiewicz et al., 2009; Huang et al., 2007; Hunt et al., 2005) Metabolic evaluation: Electrolytes (hyponatremia, hypokalemia), thyroid function, liver function, kidney function Hematology: Evaluation for anemia: Hemoglobin, hematocrit, iron, iron-binding capacity, and B12 folic acid Evaluation for infection (fever, WBCs with differential, cultures)
7.  Impaired mobility/deconditioned status: physical therapy or structured cardiac rehabilitation inpatient or outpatient

B. Sensory impairment—vision, hearing—limitations in ability for self-care (Davos et al., 2003; Faris et al., 2002)

C. Signs and symptoms—assess for changes in mental status every shift (Davos et al., 2003; Faris et al., 2002)

V. NURSING CARE STRATEGIES

A. Obtain HF/cardiology and geriatric consultation (Rich et al., 1995; Naylor, 2006; Naylor & Keating, 2008; Naylor et al., 2004).

B. Eliminate or minimize risk factors

1.  Administer medications according to guidelines and patient assessment (Brenner et al., 2001; Riegel et al., 2009; Wing et al., 2003)
2.  Avoid continuous intravenous infusion especially of saline (Cavallari et al., 2004; Lancaster et al., 2003; Riegel et al., 2009; Taylor et al., 2004)
3.  Maintain euvolemia once fluid overload is treated. Prevent/promptly treat fluid overload, dehydration, and electrolyte disturbances. Maximize oxygen delivery (supplemental oxygen, blood, and BP support as needed (Cavallari, et al., 2004; Lancaster, et al., 2003; Riegel et al., 2009; Taylor, et al., 2004)
of the Patient At Risk for Hospital Readmission
4.  Ensure daily weights accurately charted (Grady et al., 2000; Riegel et al., 2004; Riegel et al., 2009)
5.  Provide adequate nutrition with a 2-g sodium diet (see Chapter 22, Nutrition)
6.  Provide adequate pain control (see Chapter 14, Pain Management)
7.  Use sensory aids as appropriate
8.  Regulate bowel/bladder function

D. Provide self-care education with maintenance and management strategies (Masoudi et al., 2005; Nesto et al., 2004; Pharmacotherapy for Hypertension
in the Elderly, 2006)

1.  Activity recommendation as appropriate to functional status. Assess for safety in ambulation hourly rounds with encouragement to toilet.
2.  Facilitate rest with schedule of diuretic medications for limited nocturia.
3.  Maximize mobility: limit use of urinary catheters.
4.  Communicate clearly; provide explanations.
5.  Emphasize purpose and importance of daily weights.
6.  Dietician referral for educational needs re-sodium.

E. Identify care partners. Reassure and educate

1.  Foster care support of family/friends
2.  Assess willingness and ability of care partner to assist with self-care: dietary needs of sodium restriction, daily weight logging, symptom recognition,
and medical follow-up.

VI. EVALUATION/EXPECTED OUTCOMES

A. Patient

1.  Absence of symptoms of congestion
2.  Hemodynamic status remains stable (prior to acute decompensation)
3.  Functional status returned to baseline (prior to acute decompensation)
4.  Improved adherence to medical and self-care regimen
5.  Discharged to same destination as prehospitalization

B. Health Care Provider

1.  Regular use of self-care heart failure index screening tool
2.  Increased detection of symptoms before acute decompensation
3.  Implementation of appropriate interventions to prevent/treat volume overload
4.  Improved nurse awareness of patient/caregiver self-care confidence and ability
5.  Increased management using guideline-directed therapy

C. Institution

1.  Staff education and interprofessional care planning
2.  Implementation of HF specific treatments
3.  Decreased overall cost
4.  Decreased preventable readmission and length of hospital stay
5.  Decreased morbidity and mortality
6.  Increased referrals and consultation to above-specified specialists
7.  Improved satisfaction of patients, families, and nursing staff of the Patient At Risk for Hospital Readmission

VII. FOLLOW-UP MONITORING OF CONDITION

A. Decreased frequency of readmission as a measure of quality care

B. Incidence of decompensated HF to decrease

C. Patient days with symptoms of congestion to decrease

D. Staff competence in prevention, recognition, and treatment of HF

E. Documentation of a variety of interventions for HF Na1 5 sodium; BUN/Cr 5 blood urea nitrogen/creatinine ratio; BP 5 blood pressure; HR5heart rate; RR respiratory rate; Hgb/Hct 5 hemoglobin and hematocrit; SpO2 5 pulse oxygen saturation; WBCs 5 white blood cells; URI 5 upper respiratory infection; UTI 5 urinary tract infection; ROM 5 range of motion

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