Adhere to documentationrequirements for withdrawing or withholding a CIED. Emphasize the importance of reporting a change in symptom status to the healthcare provider to avert hospitalization for symptom management (Class I; Level of Evidence C). A literature search was performed using the key words skilled nursing facility, long-term care facility, nursing home, palliative medicine, rehabilitation, exercise, discharge, post-hospital, and post-acute meshed with the key word heart failure in PubMed and Ovid. Efficacy, safety and tolerability of beta-adrenergic blockade with metoprolol CR/XL in elderly patients with heart failure [published correction appears in, Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction [published correction appears in. It is reasonable to prescribe both aerobic and resistance training program for all HF patients who are clinically stable, willing, and capable (Class IIb; Level of Evidence A). This communication can be facilitated by both verbal and written methods. Fang J, Luncheon C, Ayala C, Odom E, Loustalot F. Awareness of heart … * What to do if heart failure symptoms worsen. A director of nursing, who must be an RN, oversees the comprehensive assessment of the residents’ needs, including medically defined conditions; functional, nutritional, and psychosocial status; discharge and rehabilitation potential; and drug therapy. The heart failure and sodium restriction controversy: challenging conventional practice. Exercise training meta-analysis of trials in patients with chronic heart failure (ExTraMATCH). Hallway ambulation or lower extremity cycle ergometry are both low-cost training options that can be easily implemented in this setting. The sear-ch on the CINAHL database had the following controlled descriptors: heart failure, congestive heart failure, nursing … Teach your patient how to realize her symptoms are worsening and when to call for help. At the end of life, continuation of HFrEF medications for HFrEF patients and volume management for all HF patients is recommended until medications are limited by decreased oral intake, inability to swallow medication, or hypotension (Class I; Level of Evidence C). Reviewing and ordering a mealReading labels. The transition of care principles listed above apply to the transition from SNF to home. End-of-life care plan quality measures may be very important considerations for HF patients and potentially of value for improving patterns of care.237 Quality measures that address the provision of palliative care and end-of-life care are applicable to eligible patients with end-stage HF. If she has high BP or diabetes, she should work with her healthcare provider to keep these under control. This scientific statement includes a review of the evidence and recommendations for HF SNF care that address pharmacology, ancillary services, nursing management, diet, exercise, education, care transitions, management of implantable devices, palliative care, and measurement of quality outcomes. The cornerstones of quality end-of-life care are communication and shared decision making with the patient and family to facilitate recognition of and planning for death. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. Wasting as independent risk factor for mortality in chronic heart failure. Evidence suggests that preparing low-sodium meals and allowing patients to add salt to taste at the table will result in lower total sodium intake while maintaining flavor. Studies of heart failure disease management reported a reduction in the risk of hospital readmission … Because regulations in SNFs are dictated by the Centers for Medicare and Medicaid Services, many ancillary interventions for older adults with multiple comorbidities are mandated for SNF residents. When will you see your healthcare provider? It may be especially important to have a member of the clergy present for patients with a well-defined faith tradition. High-intensity strength training in nonagenarians: effects on skeletal muscle. In a long-term facility where electrophysiological expertise is not immediately available, the attending physician should contact the physician responsible for following the patient’s CIED for consultation as to which therapies should be deactivated. Performance Measurement Initiatives. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. This may be particularly appropriate when there is any uncertainty about symptom management before and after device deactivation. Advance health planning and treatment preferences among recipients of implantable cardioverter defibrillators: an exploratory study. Identification of the presence of a CIED is the first step in management. This reinforces the importance of the follow-up visit. According to the AHA, she can "start slowly and gradually build up to at least 150 minutes of moderately vigorous physical activity per week" such as "30 minutes of activity, five or more times a week." Twenty percent of patients may receive shocks from their ICDs at the end of life, to the distress of both the patients and their families.169 Shocks have been described as “blow to the chest, being kicked by a mule,”185 and thus, it is not surprising that the pain, anxiety, and fear that occur with or in anticipation of shocks can decrease the quality of life.186,187 All ICDs can be deactivated by placing a doughnut magnet directly over the device. Nutritional recommendations for patients with heart failure. These efforts require organized SNF staff education and may include collaboration with community- or hospital-based HF experts. Predictors of in-hospital mortality among hospitalized nursing home residents: an analysis of the National Hospital Discharge Surveys 2005–2006. Congestive heart failure is the most common indication for admission to the hospital among older adults. September 2009, Volume :40 Number 9 - Supplement: Med/Surg Insider , page 5 - 7 [Free], Join NursingCenter to get uninterrupted access to this Article. Postdischarge appointment for HF patients, University of Colorado School of Medicine, National Heart, Lung, and Blood Institute†; NIH†, Amgen*; Eli Lilly†; Esai*; Purdue Pharma†, Amgen*; Bayer*; Gambro*; Janssen*; Medtronic*; Novartis†, AARP*; Lexi-Comp, Inc. †; Omnicare, Inc.*, Columbia University Medical Center, New York, NY, and Yale-New Haven Hospital, New Haven, CT. © 2015 by the American Heart Association, Inc., and the Heart Failure Society of America. ACEI indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; BP, blood pressure; eGFR, estimated glomerular filtration rate; HF, heart failure; HFrEF, HF with reduced ejection fraction; HR, heart rate; IHD, ischemic heart disease; LBBB, left bundle-branch block; LVAD, left ventricular assist device; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association functional class; SBP, systolic blood pressure; SNF, skilled nursing facility; and VAD, ventricular assist device. Initially, all staff need to be educated on the basics of HF management; this could include mandatory face-to-face didactic sessions or World Wide Web–based modules such as the HF physiology and management modules provided by the National Heart Failure Training Program (http://www.nheft.org). Frail elderly patients with HF, multiple comorbidities, and complex care needs require care coordination and disease management.94,233,238 The hospitalization episode before discharge to a SNF provides an opportunity to improve care coordination and determine the therapeutic interventions that patients will need while residing in a SNF.94 Determining the number and types of individualized interventions necessary while a patient resides at a SNF requires a comprehensive assessment of a patient’s physical, cognitive, emotional, and social status before hospital discharge.94,238 Prior studies have suggested that HF patients require a large number of individualized nursing interventions during hospitalization. Patients with rehabilitation or uncertain goals at greater risk for exacerbation should adhere to guidelines applied to community-dwelling patients, including identification of patient’s euvolemic weight and daily weight monitoring.86,90 Long-term lower-risk SNF residents with HF might have weekly weight assessments. In Medicare units, therapy must be developed by a physical therapist and ordered by the physician or nurse practitioner. She'll be more likely to see the importance of an action or a medication if it's started in the hospital. See Teaching about drugs for heart failure. Table 10. A higher resident assignment is common at night. Inspiratory muscle training in a patient with left ventricular assist device. Numerous randomized controlled trials have examined a wide range of pharmacological agents for the treatment of HF with reduced ejection fraction (HFrEF), usually defined as an ejection fraction <45%. use prohibited. Determination of ICD or CRT benefits should include consideration of comorbidities and prognosis, and discussion of ICD or CRT implantation should focus on overall goals of care (Class I; Level of Evidence B). No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. Often, SNF residents tolerate a low to intermediate dose of a β-blocker (eg, 25%–50% of guideline-recommended target dose) without noticeable adverse effects, and this may represent a reasonable compromise in many cases, with the recognition, however, that the benefits of such doses are unsubstantiated.60. 11th ed. Outcome instruments to measure frailty: a systematic review. There is a general lack of knowledge among clinicians regarding care of the patient with HF. Small studies found that opioids are safe and effective for treatment of dyspnea in advanced HF patients224 and reduce dyspnea and fatigue in patients with NYHA functional class II HF.225 Paroxetine is effective for management of depression.226 Thigh muscle strengthening is effective at reducing dyspnea and fatigue.227 Most important to management of symptoms is regular assessment, ideally by patient rating. Rehospitalizations among patients in the Medicare fee-for-service program [published correction appears in. However, many SNFs have developed “palliative” or “hospice” units, often in collaboration with hospice agencies. Inspiratory muscle endurance in patients with chronic heart failure. A caregiver should be identified and taught how to provide or assist with care for a person with HF who has been identified as having either a cognitive or sensory impairment. Alternatively, consultative relationships with HF specialist clinicians for input on the complexities of managing comorbidities and medication interactions can be developed. We use SNFs to include facilities traditionally called nursing homes. Pharmacotherapy for HF in SNF residents should be individualized and should include consideration of prognosis, goals of care, comorbid conditions, potential adverse effects, medication costs, and personal preferences (Class I; Level of Evidence C). Mode of death from congestive heart failure: implications for clinical management. These agents are contraindicated in patients with stage IV or V chronic kidney disease who are not undergoing dialysis. Treatment effect versus selection bias in systolic heart failure patients receiving higher target doses of ACE inhibitors: insights from Studies of Left Ventricular Dysfunction (SOLVD) treatment trial. Compared with patients with HF who return home after hospitalization, patients discharged to SNFs after hospitalization for acute HF are older, have longer lengths of stays, are more likely to be women, and have multiple comorbidities,23 hypotension, higher ejection fraction, and absence of ischemic heart disease.7 Although HF is the leading cause of hospitalization and rehospitalization for Medicare patients,24 clinical outcomes of patients discharged to SNFs after HF hospitalization have not been well studied.7 Data available suggest that HF patients discharged to SNFs are at very high risk for rehospitalization and death. *Based on Riegel et al81 and Centers for Disease Control and Prevention guidelines (http://www.CDC.gov/vaccines). Discharge to a skilled nursing facility and subsequent clinical outcomes among older patients hospitalized for heart failure. ACCF/AHA/AMA-PCPI 2011 Performance Measures for Adults With HF Set: Dimensions of Care Measures Matrix. Effects of digoxin on morbidity and mortality in diastolic heart failure: the ancillary digitalis investigation group trial. These precipitants may be particularly important for patients with HF who are admitted to a SNF for an unrelated problem. However, even at the higher doses used in the DIG trial, digoxin was relatively safe in older adults.73 Digoxin may be used to control heart rate and relieve symptoms among patients with both low blood pressure and uncontrolled atrial fibrillation but who are intolerant of uptitration of β-blockers. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. For SNFs without in-house chest radiograph equipment, radiographs can be obtained by companies that provide portable radiography services, but the majority of these provide only a report versus actual films for review. This level of resistance typically corresponds to the ability to perform 10 to 15 repetitions with good technique. Table 1. The diuretic dose may be further reduced with the addition of a low-salt diet. Hypertension is the most common cause of HF in older women, particularly those with preserved ejection fraction.13 In older men, HF is more often attributable to coronary artery disease. Cognitive functioning and chronic heart failure: a review of the literature (2002-July 2007). Heart failure at the end of life: symptoms, function, and medical care in the Cardiovascular Health Study. Bridging the gap between hospital and home: a new model of care for reducing readmission rates in chronic heart failure. Teach her to read labels so she doesn't eat more than 2 grams of sodium per day. Identify the legal surrogate if the patient lacks capacity. Staff should identify the cardiology team managing the device. High-intensity vs. sham inspiratory muscle training in patients with chronic heart failure: a prospective randomized trial. Another barrier in providing HF management in SNFs is inadequate communication between hospital staff and SNF staff.85 Direct communication from hospital staff to the SNF staff specifically identifying HF management and goals may help to reconcile HF care.92, Recommendations for increasing nursing home staff, improving staff training, and enhancing compensation to improve the quality of care have been well articulated.29,30 The SNF environment is challenged by a high rate of staff turnover93 and low educational levels of staff. The second group, the “uncertain prognosis group” of patients, are often discharged from the hospital with complications, frailty, or multiple comorbidities, with hope of improvement, but recovery is less certain. The Minimum Data Set (MDS) is a general assessment performed on all patients on admission and at key intervals. Managing medication, prescription and nonprescription, Nurse, pharmacist, or occupational therapist. Length of delay in seeking medical care by patients with heart failure symptoms and the role of symptom-related factors: a narrative review. Hypertension and coronary artery disease, both of which are highly prevalent in patients with HFpEF, should be managed in accordance with current practice guidelines. CHF should be considered in the differential diagnosis of any adult patient who presents with dyspnea and/or respiratory failure. This document was approved by the American Heart Association Science Advisory and Coordinating Committee on September 15, 2014, and by the Heart Failure Society of America on August 14, 2014. MERIT-HF Study Group. Assessment by healthcare providers of resident and family capacity to perform HF self-care includes identifying physical and cognitive dysfunction, sensory impairments, health literacy, and psychosocial support. * Discharge medications. Therefore, having all personnel be knowledgeable about the diagnosis of HF is imperative so that weight gain, in conjunction with signs and symptoms of worsening HF, will trigger a warning about the potential for hypervolemia. Health literacy and the patient with heart failure: implications for patient care and research: a consensus statement of the Heart Failure Society of America. Patients’ attitudes toward implanted defibrillator shocks. American Heart Association. The 6-minute walk is associated with frailty and predicts mortality in older adults with heart failure. To reduce rehospitalization, procedures and policies in SNFs are needed for managing patients with HF. Facility must assist resident in obtaining routine and emergent dental care. If a patient is being sent home with death expected in the next several months, hospice care may be appropriate. Update February 2009. http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Hea. In states with physician (or medical) orders for life-sustaining treatment, social work or nursing staff often complete the order form with the patient or family in the SNF and present it to the physician for signature.

congestive heart failure nursing journal articles

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