Chronic heart failure (CHF) is a serious and far-reaching complex condition that affects about five million people in the U.S.1
According to the Centers for Disease Control and Prevention, one in nine deaths included heart failure as a contributing cause and about half of people who develop heart failure die within five years of diagnosis.1
CHF commonly affects older adult patients in whom it has a major impact on longevity and quality of life, but symptoms can be managed by medication and modification of various lifestyle factors.
Through its innovative organizational strategies, learning modules and library of resources, Nurses Improving Care for Healthsystem Elders (NICHE)– a nurse-driven program based at New York University’s College of Nursing– recognizes the importance of cardiac care and emphasizes it in its curriculum.
“We feature a targeted educational module and several webinars that provide nurses with information on managing heart failure in older adult patients,” said Barbara Bricoli, MPA, NICHE managing director.
One helpful resource is NICHE’s Critical Care Nursing of Older Adults curriculum, which provides evidence-based guidelines for the nurse clinician working with older adults in critical care, step-down-units, and trauma and emergency departments.
Following completion of the course, nurses have the knowledge to spot predisposing age-related changes; understand pathophysiology, symptomatology, and assessment; manage care; and provide patients and families with education related to older adults with heart failure, according to Bricoli.
Identifying Symptoms
“Nurses must be able to recognize the signs and symptoms of heart failure exacerbation,” said Rebecca Boxer, MD, MS, associate professor of medicine at the University of Colorado in Denver, and a frequent contributor to NICHE’s educational programming.
Nurses, as the frontline caregivers, are most likely to observe and discuss patients’ symptoms. In this regard, they play a crucial role in diagnosing heart failure and educating patients on follow-up care. Care provided by specialist nurses has been shown to improve outcomes for patients with CHF, significantly reducing the number of hospital readmissions, lengths of stay, costs, and morbidity and mortality rates.
“Heart failure is one of the leading reasons for readmissions,” said Bricoli. “Nurses are best positioned to lead teams that coordinate care and help ensure optimal outcomes, reducing re-admissions.”
People with heart failure can’t get rid of fluid very well because of a poorly functioning heart.
Resulting symptoms can include swelling in legs, feet, or abdomen; shortness of breath due to fluid in lungs, paroxysmal nocturnal dyspnea (PND-attacks of severe shortness of breath and coughing that generally occur at night); and orthopnea-shortness of breath when lying in flat position.
Older adults with heart failure may also feel irritable or agitated, very fatigued, experience loss of appetite, nausea, constipation, diarrhea, and other abdominal symptoms.
“It (heart failure) can be more difficult to identify if patients have cognitive problems like dementia because they can’t really complain of their symptoms, so a lot is discovered through observation,” Dr. Boxer said.
This is where good care is dependent on nurses to be observant and know the heart failure signs.
“Many times, patients get accustomed to the symptoms and think they are a normal part of aging,” she said. “It takes astute observation from nurses to aid in diagnosis of heart failure.”
Nurses must take it even further by asking the right questions. Nurses should look at the patient’s medical history. If the patient has a history of hypertension, arrhythmia, diabetes, or heart attack, and sometimes alcohol use or chemotherapy, they are at risk for CHF.
If they actually have a documented history of heart failure, that’s the biggest indication that the patient needs to be watched very closely, Boxer said. Then again, there’s always the first time a patient is admitted for heart problems, she pointed out.
Heart failure diagnosis is made at the bedside, Boxer said, and nurses are a very important part of this.
During a physical exam, the nurse should look for jugular venous pressure (bulging neck veins). Does the patient have cracking in the chest, or decreased breath sounds at the base of the lung?
Other signs that might present in the physical exam are a very slow or very fast heartbeat, or a heart that feels very enlarged to the touch of the chest. This is known as a dynamic chest because the heart is so large you can feel it, Boxer explained.
“But you can’t hang your hat on any one physical exam sign,” Boxer said. While jugular venous pressure is the best indicator of heart failure, she said, the most unreliable is a lung exam. A patient could be in terrible heart failure and have a normal lung exam.
There are many symptoms that indicate CHF, and a patient may have only one. To facilitate the diagnosis, the care team must put together a lot of information based on the patient’s history, symptoms, and physical exam.
Management & Treatment
Another important part of the nurse’s role is to educate the patient and family on disease management after discharge, said Dawn Hippensteel, MS, BSN, RN, CCRN, GCNS, gerontological clinical nurse specialist and NICHE program coordinator, Pinnacle Health System, Harrisburg, Pa.
Nurses with geriatric training are better equipped to provide patient and caregiver education, conduct post-discharge interviews, and help with medication management, added Bricoli.
There are several key points that nurses must help patients understand when it comes to managing heart failure:
Patient Education
Teach patients how to recognize symptoms of heart failure.Pinnacle Health System uses a stoplight tool to help patients recognize the signs and symptoms that mean they are getting into trouble. For example, if the patient’s abdomen becomes bloated or he/she is out of breath, these are signs of heart failure flare up. Patients need to be taught to call their doctor rather than let symptoms get out of control and end up hospitalized. “Patients don’t often make that connection, and that really has to be taught by nurses so they can catch it early next time,” Boxer said.
Medication Management
“Nurses must help patients understand to take their medications regularly and as prescribed after discharge,” Boxer emphasized. Make sure medications get refilled on time. Don’t let patients wait until they’re out of a prescription to refill, because going a few days without medication can cause their condition to get out of control, she said.
Weight Tracking
Instruct patients to track their weight every day to follow weight gain. “We teach patients to call the heart failure clinic or their cardiologist if they have more than a two- or three-pound weight gain in one day or five pounds in one week,” Hippensteel said.
Low-Salt Diet
Keeping blood pressure in check includes learning how to read packaged food labels for sodium content and cooking fresh food from scratch.
Exercise
Staying physically active has many benefits for older adults, especially for heart failure patients. Exercise can strengthen the heart and cardiovascular system, reduce heart disease risk factors, such as high blood pressure and being overweight, and improve circulation.
Emergency Contact Info
Patients must know whom to call when they get into trouble. Boxer and her team give each patient a form that lists what their symptoms are, what are the signs that symptoms are getting worse, and instructions for what to do if symptoms worsen.
The nurse’s role in heart failure management cannot be taken for granted.
Nurses “actually can perform the lion’s share of care for patients,” said Boxer.
“Nurses are essential to chronic disease management for heart failure,” she added. “Part of my passion about working with NICHE is that I feel like nurses might not realize how important they are in this care. It’s about getting the skill set and then being able to make a real difference in the lives of these older adults.”
For more information, including educational tools and programming, visit www.NICHEprogram.org.
Additionally, NICHE has the following webinars on heart failure available in its archives:
Assessment and Management of Older Adults with Heart Failure (Parts 1 and 2)
A Nurse-Driven Care Coordination Redesign for Patients with Heart Failure
Nursing Practice Implications for Older Adults with Heart Failure Across Healthcare Settings
The Role of the GRN in the Heart Failure Clinic
References for this article can be accessed here.
Elizabeth Rosto Sitko is a freelance writer.
