Congestive Heart Failure

Caroline L.
Guglielmetti RN, BSN
Patient Profile

 I.R. is an 85 year-old female

 Born in Hungary
 Formerly from assisted living, has lived at the
nursing care center for 2 years.
 Has a daughter who is a teacher and a son
who is a pharmacist. Her son is DPOA of
medical and finances.
Past Medical History
 Vitamin B12 deficiency  Osteoporosis with
 Hypothyroidism kyphosis
 Severe Depression  DJD bil. Hips & lumbar
 Dementia spine
 Parkinson’s Disease
 Dependent edema
 Osteoarthritis- bil. Hips
 CHF
 Anemia
 Constipation
 Medications

 Synthroid 0.05mg PO  Remeron 30 mg PO QD

QD  Os-Cal 500mg PO tid
 Vitamin B12 100mcg PO  Tylenol ES 1-2 PO TID
QD
 Aldactone 25mg PO QD
 Senokot 2 tabs PO QD
 Colace 100mg PO QHS
 CHF and Anemia
 Anemia affects 10% to 20% of patients with chronic congestive heart
failure (CHF)
 In most patients, no specific underlying cause is identified, and more
than 50% of cases are considered to represent anemia of chronic
disease.
 Low hemoglobin (Hgb) values in CHF patients directly correlate with
poor peak oxygen consumption, disabling symptoms, and reduced
survival.
 Pilot studies suggest that correction of Hgb values with recombinant
human erythropoietin and iron improves symptoms and exercise
capacity, but larger studies are needed before anemia treatment can be
routinely recommended for CHF patients. (Crosato M, et al. Heart Fail
Monit 2003;4(1):2-6.)
 CHF and Hypothyroidism
 Two Common types of CHF
1. Systolic Dysfunction-inability of the heart to
contract due to weakness
2. Diastolic Dysfunction-inability of the heart to
relax after it pumps out blood
 Systolic Dysfunction may be due to multiple
factors, one being Hypothyroidism
 CHF and Dementia

 Requires FREQUENT reminders to…

– Keep feet elevated (Dependent Edema)
– Wear Ted Hose
– Alert family and or nursing staff if you begin to
notice symptoms of CHF (exacerbation of CHF)
– The importance of daily weights
 Family Involvement/Education
 Due to her dementia and severe depression, the family
must play an active role in disease management.
 Nursing must educate family on CHF
– Pathphysiology
– Etiology
– Management- meds, lifestyle modification
– Medication regimen
– Outside resources
– Goals for the patient and the family
 Outside Resources
 The CALL Care project is designed to improve quality of life for individuals with a life-threatening
illness, bridging gaps between services prior to entering a hospice:
 COMPREHENSIVE: Focus of services includes strategies to meet physical, emotional, spiritual,
and relationship needs. Services are designed for both the ill person and family caregiver, as
defined by the ill person.
 ADAPTABLE: Care and services are flexible over time for the person and caregiver. The approach
focuses on linking appropriate existing services, developing new services only when gaps in
continuity of services between the community and health care organizations are evident. Services
are accessible within the context of a variety of funding or reimbursement strategies.
 LONGITUDINAL: Program plans are designed to identify persons for whom the illness is
progressive and will potentially lead to the person’s death. The inclusion criteria focuses from the
time the illness appears to be life-threatening, even if prognosis or life expectancy is unknown. This
strategy addresses problems associated with timely referrals to end-of-life services and programs.
 LIFE-AFFIRMING: Although persons identified for the CALL Care program are likely to be facing
the last phase of their lives, the services will focus on assisting them and family caregivers to live
fully and meaningfully within the limits of the illness and each person’s goals.
 Providence Hospital and Medical Centers, Southfield, MI
(Coalition member: Ascension Health)
 Resources (continued)
 American Heart Association www.americanheart.org
 Area Agency on Aging: Oakland County 248.357.2255
 Cardiac Rehabilitation for Heart Failure Providence
Medical Center (Southfield) 248.849.5855
 MEPPS (assistance for obtaining medications)
313.866.5333
 Second Chance Heartline, Education & Support Group
St. John Hospital and Medical Center 313.343.3157
 Cardiac Support Group, St. John Hospital and Medical
Center 313.343.3157
 Nursing Staff Education

 Since the patient is a resident of a nursing home, it is vital to educate the nursing
and support staff.
 Provide FREQUENT reminders
- Elevate lower extremities - I & O (as accurate as possible)
- Wear support stockings
- OBTAIN A DAILY WEIGHT EVERY MORNING!!!
- Enforce fluid restriction
 Ensure that the dietician is aware of the patients CHF and Dementia and prepares
a diet that it LOW SODIUM, NAS,MECHANICAL SOFT
 Contact in house rehab- have them assess the patient for appropriateness of a
mild exercise program 3 times per week or as tolerated.
 Encourage the nursing and support staff to COMMUNICATE with the family as well
as the physician/NP, ask questions, update each other on patient status
 Rolland’s Family Systems Illness
Model
 Different types and stages of chronic illnesses place
similar and different demands on the family
 3 Dimensions
- “Psychosocial types” of illness and disability and the
demands of a chronic disorder in respect to the
diseases different phases
- Developmental phases of the illness
- Family system Variables
 Looks at the psychosocial demands of the disease in regards to the family
system and strengths/weaknesses
Rollands Psychosocial Typology of
Illness (CHF) with respect to
I.R. and family

1. Onset: Gradual: slower rate of family change

required, may generate anxiety before diagnosis is
made.
2. Course:
Relapsing/Episodic:exacerbations/remissions; may be
the most psychosocially challenging for the family,
requires flexibility
3. Outcome: Shortened lifespan or sudden death:
uncertain outcome, issues of mortality surface
Rolland’s Typology (continued)
 4. Incapacitation: Moderate/Severe: Impairments evident in:cognition,
movement, decreased energy production.
 5. Degree of Uncertainty: based on predictability of onset and rate at
which disease progresses. Families need to develop perspective, plans,
avoid burnout.
 6. A. Symptom Visibility: present. DIB with exertion, 3+ pitting edema,
abdominal distension
B. Liklihood/Severity of crisis: exacerbations becoming more frequent
C. Genetic Contribution: unknown
D. Treatment regimens: see meds. Family very cautious, in control of
med management
E.Age at onset: Questionable, exacerbations have become worse over
the last 2 years (starting at age 83).
 Rolland’s Typology (continued)
 7. Time Phases of Illness:
B. Chronic “Long haul”
 Key Family Task: maintain a normal life under abnormal conditions,
transition, integration of the chronic disease into other aspects of
life,maintenance of autonomy for all family members. Avoid mutual
dependency.
 Family Issues
 Avoid burnout, maintain relationships,maintain autonomy, redefine
individual and family goals,intimacy in the face of loss
 Transition between acute, chronic and terminal phases is critical for all
family members.
 Evaluation/Outcomes
 The family will
-contact and utilize outside resources as needed
-communicate regularly with the nursing and support staff as well as
medical staff and each other
-Recognize the chronic disorder and understand that it can be
controlled, but not cured
-work to preserve individual family member autonomy
-work to maintain a normal life
-redefine individual and family goals in regards to illness
-recognize uncertainty of loss
-provide support with the medical and/or lifestyle modifications
necessary to control CHF
 Evaluation/Goals
 The Nursing/Medical and support staff will:
-Maintain communication with each other and
the family
-Provide support and education to the family
-Remind patient FREQUENTLY to comply with
CHF guidelines
-Thoroughly assess the patient for changes in
status
 Evaluation/Outcomes

 By complying with family and Medical/nursing

interventions, the client will…
– Remember to elevate lower extremities when sitting
– Wear support stockings
– Comply with daily weight
– Comply with diet/fluid restriction
– Maintain weight
– Work with rehab if appropriate
 References
 Anemia.org(2004). Anemia contributes to morbidity and mortality in CHF. Clinical
Briefs. Retrieved from
www.anemia.org/about_anemia/research_briefs/anemia_contributes.jsp

 CALL care Project (2004).Providence Hospital and Medical Centers, Southfield, MI

 Carpenito, L. Nursing care Plans & Documentation. (1999) Philadelphia: Lippincott

 Rolland, J.S. Interface of Chronic Illness and the family. Source: Modified from W.Looman