2. Goal and Objectives
Goal: Students will be competent in the
assessment, management and maintenance of
the LVAD patient in the home.
Objectives: By the end of this course:
Students will be able to describe basic components
of LVAD technology.
Students will be able to identify and implement the
various stages of the Roper-Logan-Tierney Model of
Living.
Students will demonstrate application of the Roper-
Logan-Tierney Model when caring for the LVAD
patient.
Students will express various complication
prevention techniques with LVAD technology.
4. Course Outline
The Roper-Logan-Tierney Model of Living
The 12 components:
Maintaining a Safe Environment
Communication
Breathing
Eating and Drinking
Elimination
Washing and Dressing
Controlling Temperature
Mobilization
Working and Playing
Expressing Sexuality
Sleeping
Death and Dying: Ethical Considerations
5. Course Outline
Think-Pair-Share
Find a partner
Discuss two scenarios
Discussion
Sharing of thoughts from Think-Pair-Share
Question and Answer Session
Write down any questions you may have
during the presentation and save for the end
of the class.
7. What is an LVAD? A
Refresher
Available for patients with severe myocardial
infarct by which the heart cannot sustain itself
Available for chronic CHF patients for which
treatments are no longer an option
Implantable device
Portable
Prolongs life by up to 3-5 years
8. LVAD Uses
Bridge to recovery
Bridge to transplantation
Destination therapy
Photo Credit: www.beliefnet.com
13. Maintaining a Safe
Environment
Use caution with environments that could
cause infection
Emergency planning in case of a power outage
General home safety such as safe walkways,
removing throw rugs, and handrails in the
shower and doorways
Photo credit: www.health-first.org
14. Communication
Family is the most important part of the
interdisciplinary team and must be kept
informed and included!
Keep it simple! Instruction should be at the
level of the patient; do not use large medical
terms!
Facilitate open discussion and therapeutic
communication among family members, and to
the nursing staff.
“Communication works for those
who work at it.” –John Powell
15. Breathing
Provide oxygen as needed
Assess lung sounds for fluid retention
Monitor pulse oximetry, if able
Assess for shortness of breath secondary to
complications
Photo Credit: rr.proquest.com
16. Eating and Drinking
Nausea
Cachexia, malnutrition and hypoalbuminemia
Refer to nutritionist if necessary or requested
Maintain a healthy diet and weight
Photo Credit:
www.nutritionyoudesign.com
17. Elimination
Gastrointestinal problems are common
Assess bowel sounds and output
Reduced gastrointestinal motility
Constipation is common
Request stool stofteners
GI bleeding is a common complication which
may be seen in stool
Renal function is impaired in 10% of the LVAD
population
18. Washing and Dressing
Showering only after surgical site has healed
Instruct family on sponge bathing until surgical
site healed
Stabalization devices must be worn under
clothing
Holsters for batteries are worn outside the
clothing
Effect of LVAD on sense of self secondary to
clothing restrictions
19. Controlling Temperature
Avoid extremes in temperature
Instruct proper monitoring of temperature daily
Photo Credit: www.telegraph.co.uk
20. Mobilization
Patient may not go out alone
Patient may not drive
Carry extra batteries when leaving home!
Photo Credit: www.lifession.com
21. Working and Playing
Cardiac rehab to strengthen patient after
implantation
Encourage patient to improve physical
performance
No strenuous activities or sports
May return to work
No heavy lifting or machinery
Minimize stress
Clip Art
22. Expressing Sexuality
May resume sexual activity
Patients report that resuming sexual activity is
important to quality of life Photo Credit: icoachingzone.com
23. Sleeping
Sleep disruption due to noise from pump is common
Assess sleep each visit
Request sleep aid from doctor if needed
Photo Credit: www.matrac.hu
24. Death and Dying: Ethical
considerations
Patient’s desire to deactivate device may cause
ethical dilemma in family or medical staff
Decreased self esteem, depression, anxiety or
other complications may lead to desire to
deactivate the device
Palliative care team initiated immediately after
surgery to implant device for support and
guidance
26. Scenario One:
Mrs. Mendez is a 56 year old patient with chemotherapy
induced cardiomyopathy with underlying CHF. She has
been given the option to receive an LVAD device as she is
not a candidate for transplant. She arrives home after two
weeks in the hospital and is admitted by your CHHA. She
believes that she can resume her “normal life” of eating
foods from her culture, and she continues to smoke. Mrs.
Mendez has concerns about her self image, and how
people are going to see her when she is in public.
Additionally, she is fearsome that her husband will not find
her attractive anymore. What education would you
provide to this patient?
27. Scenario Two:
Billy is a 12 year old newly implanted LVAD patient. He
suffers from a congenital heart disease that has required
many surgeries in the past. The doctors have given Billy a
grim prognosis if he does not receive a donor heart soon.
Billy’s family opts for an LVAD device as a bridge to
transplantation. He is sent home three weeks post
implantation and, being a typical 12 year old boy, wants to
play with his friends, go to school, and resume his activity
with the swim team. Billy’s mother has expressed fear
over the sterile dressing change, even though she says
they “taught her in the hospital.” How would you best care
for this family?
29. Conclusion
Feel free to contact me with further questions or
to discuss a patient:
Victoria C. E. Crawley, RN
Oswego County Health Department
70 Bunner Street, Oswego NY
315-349-3414
30. References
Andrus, S., Dubois, J., Jansen, C., & Kuttner, V. (2003). Teaching documentation tool:
Building a successful discharge. Critical Care Nurse, 23(2), 39-48.
Retrieved from http:// search.proquest.com.contentproxy.phoenix.edu/
docview/228205461/accountid=458
Baker, K., Flattery, M., Salyer, J., Haugh, K. H., & Maltby, M. (2010). Caregiving for
patients requiring left ventricular assistance device support. Heart and Lung,
39(3), 196-200.
Bartell, L. A. (2005). Ventricular assist devices: Preparing for catastrophic
environmental events. Progress in Transplantation, 15(3), 264-270.
Casida, J. M., Peters, R. M., & Magnan, M. A. (2009). Self-care demands of
persons Living with an Implantable left-ventricular assist device. Research and
Theory for Nursing Practice, 23(4), 279-93.
Hasin, T., Topilsky, Y., Schirger, J. A., Li, Z., Zhao, Y., Boilson, B. A., . . . Kushwaha, S. S.
(2012). Changes in renal function after implantation of continuous-flow left
ventricular assist devices. Journal of the American College of Cardiology,
59(1), 26-36. doi:http://dx.doi.org/10.1016/j.jacc. 2011.09.038
King, M.L., Thomas, R., & Pina, I. (2010). Cardiac rehabilitation for patients with
ventricular assist devices: An offer to improve strong collaborative
relationships. Journal of the American College of Cardiology 55(10), 1053- 1054.
doi:doi:10.1016/j.jacc.2009.11.044
31. References
Lachman, V. D. (2011). Left ventricular assist device deactivation:
Ethical issues. Medsurg Nursing, 20(2), 98-100.
Marcuccilli, L., & Casida, J. (2012). Overcoming alterations in body image
imposed by the left ventricular assist device: A case report. Progress in
Transplantation, 22(2), 212-6. Retrieved from http://
search.proquest.com/docview/1022994016?accountid=458
McCrae, N. (2012). Whither nursing models? The value of nursing theory in the
context of evidence-based practice and multidisciplinary health care. Journal of
Advanced Nursing , 68(1), 222-229. doi:http://
dx.doi.org.contentproxy.phoenix.edu/10.1111/j.1365.
2648.2011.05821.x
Newsom, L.C., & Paciullo, C.A. (2013). Coagulation and complications of
left ventricular assist device therapy: A primer for emergency
nurses. Advanced Emergency Nursing Journal, 35(4), 293-300. doi:
10.1097/TME.0b013e3182a8ab61
Nursing Theory . (2013). Retrieved from http://www.nursing-theory.org/
theories-and-models/roper-model-for-nursing-based-on-a-model-of-
living.php
32. References
O'shea, G., Teuteberg, J. J., & Severyn, D. A. (2013). Monitoring patients
with continuous-flow ventricular assist devices outside of the
intensive care unit: Novel challenges to bedside nursing. Progress in
Transplantation, 23(1) 39-46.
Salvage, J. (2006). Model thinking. Nursing Standard, 20(17), 24-25.
Retrieved from http://
search.proquest.com.contentproxy.phoenix.edu/docview/21983621
4?accountid=458
Schweiger, M., Vierecke, J., Potapov, E., & Krabatsch, T. (2013).
Management of complications in long-term LVAD support.
International Journal of Artificial Organs, 36(6), 444-446.
Tylus-Earl, N., & Chillcott, S. L. (2009). Mental health and medical
challenges. Journal of Psychological Nursing & Mental Health Services,
47(10), 43-49.
Wilson, S. R., Givertz, M. M., Stewart, G. C., & Mudge, G. H. (2009).
Ventricular assist devices: The challenges of outpatient management.
Journal of the American College of Cardiology, 54(18), 1647-1659.
Editor's Notes
This course is designed to prepare you to effectively and safely care for the LVAD patient in the home. LVAD patients are at risk for a number of complications, and home care after discharge for at least one month is indicated (Lachman, 2011). According to Lachman (2011), “nurses need to know how to manage an LVAD under three conditions: normal operating conditions, pump malfunction, and pump failure” (p. 99). After this presentation, you, as home care nurses will be able to identify and describe how the LVAD works, where it is placed in the body, and the equipment that is necessary for proper use. Additionally, you will be able to identify and implement the different stages of the Roper-Logan-Tierney model, as well as demonstrate proper application of this model during care. Finally, you will be able to express various complications that are often associated with LVAD therapy, and what to do should any of these complications arise.
Our goal is that by the end of the course, you will not only be competent in the assessment, management, and maintenance of the home care patient with an implanted LVAD, but you will also be confident enough to gain the trust of your patient, and assist them to begin their journey through LVAD therapy.
Lets begin.
Here is a quick glance at what you can expect in this class. We begin our course with an introduction and refresher on the LVAD, it’s technology, uses, and potential complications.
Next, we will learn about the Roper-Logan-Tierney Model of Living by which we will base our care plans for our LVAD home care patient. We will break this down into individual parts in just a bit.
Finally, we will split up into pairs, and discuss two potential scenarios with our partner, and then to the class. You have been provided with a paper copy of this presentation, with an area specifically for taking notes. Please write down any questions you may have on your handout for discussion in the question and answer session at the end of this lesson.
Left Ventricular Assist Devices, or LVADs, are becoming more and more common in the treatment of incurable cardiac disease, particularly congestive heart failure (CHF) (Newsom & Paciullo, 2013). CHF is a progressive condition which as of 2013, affected more than five million patients in the United States alone (Newsom & Paciullo, 2013). Previously, heart transplants were the only option for patients who were in end-stage heart failure. However, today, LVADs have become more widely used. Donor hearts are becoming increasingly harder to find, and an LVAD can provide a patient who may be faced with a poor prognosis, a new lease on life, even if only temporarily (Newsom & Paciullo, 2013).
In 1966 the very first version of an LVAD was implanted into a patient. This was a bulky, rudimentary device which did work, however was not very user friendly. Today, the device has advanced rapidly, and is available for use in adult and pediatric patients alike (Newsom & Paciullo, 2013). There are currently three LVADs which have been approved by the Food and Drug Administration for use; however, only two of the devices are currently being used routinely in patients (Newsom & Paciullo, 2013).
LVAD stands for Left Ventricular Assist Device. It is an implanted device which is placed through a median sternotomy, generally during cardiopulmonary bypass surgery (Wilson, Givertz, Stewart, & Mudge, 2009). The main purpose of this implantable device is to replace the heart’s pumping function due to heart failure or severe myocardial infarct (Wilson, Givertz, Stewart, & Mudge, 2009) Heart failure is a progressive disease which is characterized by the inability of the heart to pump blood adequately enough to perfuse the body and keep up with its’ metabolic demands (O’shea, Tutenberg, & Severyn, 2013). While an LVAD’s purpose is not to cure the heart disease, it does restore perfusion to the body, grants the organs recovery from endorgan failure, and can improve activity tolerance (O’shea, Tutenberg, & Severyn, 2013).
There are two categories for LVADs. They are Pulsatile, and Non-Pulsatile (also known as continuous flow). A pulsatile device has a special blood sac that fills and empties sumilarly to the ventricle (O’shea, Tutenberg, & Severyn, 2013). Blood is redirected from the left ventricle into an inflow cannula which is inserted into the cardiac apex, and then into the pump where it is forced into the aorta, thus pushing blood through the heart as though it were functioning normally. These patients do have a detectable pulse, however, due to the nature of the device, the pulse may not match monitoring devices (O’shea, Tutenberg, & Severyn, 2013).
Non-pulsatile devices, or continuous flow devices do not contain a special blood sac, and instead have a spinning impeller that is continuously moving blood from the left ventricle into the aorta. The actual speed of the impeller is dependent on the device itself, and the patient whom it is implanted in. It is different for everyone (O’shea, Tutenberg, & Severyn, 2013). Because of the way in which this LVAD functions, there will generally be no detectable pulse, and pulse oximetry and automatic blood pressure devices will not work on this patient (O’shea, Tutenberg, & Severyn, 2013). This can make assessing the patient difficult, at best.
There are three distinct types of LVAD uses. The first is called bridge to recovery, and is generally a temporary use of the device while the heart recovers from some sort of insult (Wilson, Givertz, Stewart, & Mudge, 2009). Eventually, the patient is weaned off of the device, and a focused cardiac rehabilitation program takes place (Wilson, Givertz, Stewart, & Mudge, 2009). The next use of the LVAD is called bridge to transplantation. Also a temporary situation, bridge to transplantation affords the patient time while awaiting a heart transplant. In the past, patients have died waiting for an appropriate donor match for a heart. With LVAD bridge to transplantation therapy, patients may actually improve their health through improved perfusion and tolerance of activity while waiting for a donor heart. Increased perfusion, normal organ function, and activity tolerance are all excellent improvements that will assist in a successful transplant and transition to life after transplantation (Wilson, Givertz, Stewart, & Mudge, 2009). Finally, destination therapy allows the patient who is ineligible for a transplant to live up to 5 more years with the device (though the average is around 3) (Wilson, Givertz, Stewart, & Mudge, 2009). With these three types of therapies, patients who would otherwise succumb to their cardiac disease either while waiting for a transplant or where treatment is not an option, are able to live productive lives with their loved ones.
As we have learned, the LVAD is an implantable electronic device which is used for three main reasons: bridge to recovery therapy, bridge to transplantation, and destination therapy (Wilson, Givertz, Stewart, & Mudge, 2009). We have also learned that there are two types of devices, pulsatile and non-pulsatile. The more common of the two, non-pulsatile, or continuous flow, is generally manufactured by HeartMate, the leader in LVAD technology (Bartell, 2005). The LVAD is generally implanted intra-abdominally, or preperitoneally, usually in the left upper quadrant. The inflow cannula of the pump is inserted into the left ventricle’s apex, and the outflow cannula is connected to the ascending aorta, exactly the same as a bipass machine during surgery (Bartell, 2005). Exiting the body roughly four inches to the right and above the umbillicus, is the driveline. This cable controlls the power to the LVAD and is connected to an external system controller, (the white device in the illustration) and to two batteries worn on the body (Tylus-Earl & Chillcott, 2009). The external system of the LVAD consists of a power base unit, a system controller, rechargeable batteries, an the system display unit (Tylus-Earl & Chillcott, 2009). The batteries can be worn holster style under the axilla, or in a “fanny pack” which is a pouch which attaches around the waist. The system controller can often be carried in a pouch and carried across the body or off the shoulder, much like a woman’s purse (Tylus-Earl & Chillcott, 2009).The driveline is protected by a sterile dressing which must be changed daily (Tylus-Earl & Chillcott, 2009).
It is essential that the nurse be well versed in the potential for complications in the LVAD patient, so that he or she can effectively educate the patient on signs and symptoms of a complication. Complications from the device include: pump malfunction, which could require the patient to disconnect the computer drive system controller and utilize a manual hand pump until he or she is able to be transported emergently to the nearest facility (Wilson, Givertz, Stewart, & Mudge, 2009), impaired renal function, which only occurs in 10 percent of the LVAD recipient population but is characterized by lethargy, nausea and vomiting, and dark urine (Hasin, Topilsky, Schirger, Li, Zhao, Boilson . . . Kushwaha, 2012). GI bleed which is evidenced by melena, or dark black stool with a coffee ground like consistency (Wilson, Givertz, Stewart, & Mudge, 2009), driveline infection which can be caused by improper technique when changing the dressing, nausea secondary to the placement of the LVAD device in the abdomen (Wilson, Givertz, Stewart, & Mudge, 2009), clotting disorders from coumadin non-compliance or arrhythmias associated with the LVAD, and stroke. All of these potential complications should be assessed for at each visit, and education be provided initially and reinforced each time the home care nurse is present with the patient for the best possible outcomes (Wilson, Givertz, Stewart, & Mudge, 2009).
McCrae (2012), explains that a Nursing Model is “a systematically constructed, scientifically based and logically related set of concepts, which identify the essential components of nursing practice together with the theoretical basis of these concepts and values required for their use by the practitioner” (p. 224). Nursing theories and models provide “a method by which nursing can be described” (Baker, 2009, p. 410) and provide a foundation by which we can base effective patient care. Nancy Roper, Winifred Logan and Allison Tierney published their model in 1980 and at the time, this was considered groundbreaking work. The theory introduced the concept of treating the individual patient as a unique and individual being, with unique and individual needs (Salvage, 2006). The theory has its’ basis on the patient’s activities of daily living, and attempts to quantify what living truly means (“Nursing Theory,” 2013).
Roper, Logan, and Tierney suggest that 12 essential activities of daily living should be utilized as a guidepost for care planning (“Nursing Theory,” 2013). The 12 components are: Maintaining a safe environment, communication, breathing, eating and drinking, elimination, washing and dressing, controlling temperature, mobilization, working and playing, expressing sexuality, sleeping, and finally, death and dying, and the ethical considerations that go with it (“Nursing Theory,” 2013). This infographic demonstrates the different aspects of the model of living, with “family centered care” in the center. Within the realm of home care nursing, the approach to excellent patient care is an interdisciplinary one. This model allows for our home care concept at the Oswego County Health Department for the patient and their family to be the center of our care, thus making the family the most important part of the interdisciplinary team. Because the family and the patient are always at the center of care in Home Care, this model fits perfectly with not only home care, but our subject of LVAD assessment, management and maintenance in the home, as well.
For the purposes of this class, and in our practice with our LVAD patients after, we will use the 12 aspects of the Roper-Logan-Tierney Model of living to guide our assessment of the patient, and assist us in providing the best care possible.
Home safety is important for all patients, but is an especially unique need for the LVAD patient. The care plan should allow for certain limitations with the LVAD patient, and yet provide the largest amount of autonomy possible as the patient progresses through his or her life with the LVAD. When care planning, the nurse needs to take into consideration these important factors for maintaining a safe environment:
It is extremely important to educate the patient regarding environments that could cause infection. These environments include shopping malls, crowded living conditions, nursing homes, day care facilities, concerts, conferences or festivals, poor hygiene, and contact with ill people. When entering into these areas it is advisable to wear a face mask, or if none is available to practice handwashing precautions and keep hands away from eyes and mouth (Wilson, Givertz, Stewart, & Mudge, 2009).
It is essential that we educate our patients in regards to emergency planning. This includes having a generator present for power outages, what to do in the event of a large storm, equipment failure, and ensuring that the power company and the local ambulance core are aware that there is an LVAD patient in the area. If there is a large storm, we must educate the patient that the local ER or fire station is the best place to seek help and electricity to charge batteries. Additionally, the patient needs to verbalize understanding of individual battery life (this can often be found on discharge instructions) and to keep a second set charged at all times. Finally, following the VAD team’s discharge instructions, reinforce what to do in the case of equipment failure. With many LVAD devices, a hand pump attachment is available to continue the impeller moving blood through the body while the patient is transferred via emergency services to the hospital where the LVAD was implanted (Bartell, 2005)
Finally, general home safety is a must. This includes removing throw rugs and household items that may be blocking a hallway or passageway, instructing to use any assistive devices that the patient may have or need, assessing for handrails in the shower and doorway, and ordering Occupational Therapy for further home safety training if necessary (Wilson, Givertz, Stewart, & Mudge, 2009).
We communicate every day. We talk with our family, our coworkers, the barista at the coffee shop. However, when a large life event, such as the implantation of a portable LVAD device, which needs very specific and special care by all members of the family, communication becomes paramount, no matter how difficult it may seem. The communication is not only limited to the family, either. Your interactions as a nurse with the family is the most important piece of caring for a patient. Therefore, within the confines of the Roper-Logan-Tierney Model of living in relation to LVAD patient care, communication takes on a whole new meaning.
First, it is essential that the family be informed and included in each discussion and education session. The family needs to be allowed to communicate openly and honestly about their feelings and questions. It is the nurse’s job to facilitate open communication amongst family members and with the home care team (Baker, 2009). Next, any education that you provide must be tailored to the education level of the family. If you are not communicating at the patient and family’s level, important information may be lost (Baker, 2009). If communication is encouraged, and at the appropriate level for the patient and family, then there is a greater chance for success when caring for the LVAD patient.
Breathing is an essential function that healthy people often take for granted. However, after implantation surgery, breathing is a basic bodily function that must be monitored closely, as any alteration may be indicative of a complication (O'shea, Teuteberg, & Severyn, 2013). It is important, then, that the nurse assess and evaluate for proper and effective breathing. In the LVAD patient, it is important to assess the SA02 levels of the patient, if applicable (keeping in mind that some LVADs do not allow for the monitoring of pulse oximetry due to the nature of their function) provide oxygen in the home as needed, assess lung sounds for any new crackles or rhonchi, (which may indicate fluid overload) as well as assessing for shortness of breath which could indicate a greater problem, such as a pulmonary emboli, or shifting of the LVAD device (O'shea, Teuteberg, & Severyn, 2013). When in doubt, report to the doctor immediately, or to emergency services if needed.
Healthy nutrition habits post surgical implantation of the LVAD device is important for achieving optimal health. It is also necessary for preventing certain complications, and for effective healing after surgery. Therefore, it is important that the nurse provide education regarding healthy eating habits, and assess diet and appetite at each visit.
Nausea is a common side effect of LVAD therapy. It is important that the nurse report this to the doctor immediately, requesting an antiemetic to help reduce nausea and maintain an appropriate caloric intake (Casida, Peters, & Magnan, 2009).
If nausea or decreased appetite is not addressed, Cachexia, malnutrition or hypoalbuminemia may occur. This is important to avoid as it can impair healing, and thus encourage infection, as well as potentially lead to dysfunction of the immune system, all of which could be fatal to the patient if not addressed immediately (Wilson, Givertz, Stewart, & Mudge, 2009).
It is recommended that each patient be referred for a nutritional consult with admission. This will ensure that the family and patient has received proper education on diet and healthy eating habits. It is very important for the LVAD patient to maintain a healthy diet and weight post implantation. If the patient does not follow a somewhat strict, healthy diet, then weight gain can occur, which may shift the LVAD placement in the upper abdominal area, potentially causing severe complications (Schweiger, Potapov, & Krabatsch, 2013).
Assessing elimination is an important tool when working with the LVAD patient. Many complications with the gastrointestinal tract are possible with LVAD therapy, and many can be caught early with the proper assessment and plan.
Gastrointestinal problems are very common in the LVAD patient. These complications can range from reduced gastrointestinal motility to constipation, to a GI bleed. Therefore assessing the GI system as well as the color, consistancy and size of any bowel movements is very important to detect problems (Wilson, Givertz, Stewart, & Mudge, 2009).
Assess bowel sounds at each visit carefully to determine if the bowels are hypo/hyperactive, or typical. Because of reduced gastrointestinal motility after LVAD placement, constipation may occur. It is important to request an order for a stool softener as this will not only reduce or resolve the constipation, it will also avoid straining which could lead to a vasovagal event (Wilson, Givertz, Stewart, & Mudge, 2009).
Finally, it is necessary to assess a patient’s stools; gastrointestinal bleeding is a potential complication during LVAD therapy and may be noted in the patient’s stool. Remember: melena appears black, with coffee ground like consistency. If blood is suspected in the stool, transfer the patient to the Emergency Department immediately (Wilson, Givertz, Stewart, & Mudge, 2009).
Urinary function is often unaltered after LVAD placement, however, in patients with acute renal failure prior to implantation, it was noted that patients had a return to higher functioning renal status. Rarely, in only 10 percent of LVAD patients was acute renal failure noted after implantation surgery. Assess for rapid onset of nausea, vomiting and lethargy, increased BUN and creatinine levels, decreased urinary output or very dark urine, dry mucous membranes and mouth, and neurological behaviors such as twitching, seizures and or headache. If any of the above are noted, transfer the patient to the Emergency Department immediately (Hasin, Topilsky, Schirger, Li, Zhao, Boilson . . . Kushwaha, 2012).
An important activity of daily living to consider is washing and dressing. These two aspects of daily living are changed dramatically after LVAD implantation. For example, showering is only allowed after the surgical incision is healed, and plastic must be taped over driveline exit site to protect dressing. Additionally, education should be provided to the family on proper sponge bathing techniques until showers are once again possible. Swimming, hot tubs and baths are not permitted (Wilson, Givertz, Stewart, & Mudge, 2009). Clothing has also been reported by patients as an issue after implantation. For example, a stabilization device, often in the form of a belt or strap around the abdomen, must be placed in order to avoid pulling on the driveline. Additionally, holsters for the batteries are worn often over shoulders which places the batteries directly under the axilla, over the clothing. This can lead to impaired sense of self, decreased self esteem, depression, and anxiety. Assess for altered emotional state and allow for open communication with therapeutic listening, which may help the patient overcome these new barriers to dressing as he or she used to (Marcuccilli & Casida, 2012).
Temperature is also an important activity of daily living that must be carefully observed in the newly implanted LVAD patient. It is essential that the LVAD patient avoid extremes in temperature due to the sensitivity of the device. Prolonged exposure to extreme temperatures could cause a malfunction or a false alarm (Wilson, Givertz, Stewart, & Mudge, 2009).
Additionally, a patient’s temperature is a good indicator of health. Therefore, the family should be instructed with return demonstration on the proper method for taking the patient’s temperature. An elevated temperature could be indicative of infection or other complications and should not be taken lightly. Assess temperature at each visit, instructing the family to take the temperature daily, and report any temperature that is above 99.9 to the doctor immediately (Wilson, Givertz, Stewart, & Mudge, 2009).
According to Wilson, Givertz, Stewart, & Mudge (2009), the LVAD patient should not leave the home alone, as device malfunction or alarm, battery drainage or loss of power to the device, or any physical complication such as dizziness could occur, leaving the patient vulnerable. Additionally, for many of these same reasons, the LVAD patient may no longer drive under any circumstances (p. 1650). When the patient does leave the home, which is encouraged to enrich sense of well being and quality of life, extra batteries and dressing supplies should always be carried in case of emergency (Tylus-Earl & Chillcott, 2009).
Working and playing is also an important part of our lives. The LVAD patient has to be aware of what his or her limitations are, and it is the home care nurse’s job to provide proper education and reinforcement in order to assist the LVAD patient achieve the highest quality of life as possible after implantation. After discharge, the patient is generally required to partake in cardiac rehabilitation. According to King, Thomas, & Pina (2010), “Cardiac rehabilitation is an excellent environment to reinforce self-management; provide emotional support; and increase exercise tolerance, functional capacity, and quality of life” (p. 1054). Because of the nature of cardiac disease, patients are often deconditioned or have low endurance and tolerance for physical activity. Post implantation, the LVAD patient can participate in cardiac rehabilitation to strengthen and restore physical function. It is the nurse’s job therefore to help the LVAD patient by providing education and support beyond the support received from the cardiac rehabilitation team. This will ensure reinforcement of healthy habits and may encourage the patient to continue with his or her therapy (King, Thomas, & Pina, 2010).
While the LVAD patient may resume mild to moderate exercise and work, there are limitations to what the LVAD patient can tolerate physically. The patient should avoid strenuous activities or sports (as well as swimming, as we have previously discussed). Additionally, any activity which includes heavy lifting or machinery may put the LVAD at risk for shifting should be avoided (Wilson, Givertz, Stewart, & Mudge, 2009). Finally, minimizing stress is advisable as it can cause anxiety or depression which can lead to further complications and decreased quality of life (Casida, Peters, & Magnan, 2009).
LVAD patients can range in age anywhere from young children all the way to the elderly. Within that spectrum, there is a large population of people who were able to express their sexuality prior to implantation. There was much debate for several years as to whether or not the LVAD patient could resume sexual activity post implantation. However, with recent research, it has been determined that a patient can indeed resume sexual activity, and, if he or she so desires it, should (Andrus, Dubois, Jansen, & Kuttner, 2003). In another study, patients themselves reported that maintaining a healthy sex life was an important factor to quality of life (Wilson, Givertz, Stewart, & Mudge, 2009). Therefore, it is important for the home care nurse to allow for conversation regarding the patient’s need to express his or her sexuality, providing support and education where needed to facilitate the patient being comfortable with the idea of sexual activity post implantation (Wilson, Givertz, Stewart, & Mudge, 2009).
Sleep is vital to our survival. Without it, we can experience hallucinations as well as are at risk for accidents related to inability to focus or remain awake. LVAD patients have reported that sleep is disrupted post implantation; the placement of the LVAD itself can cause sleep disruption, as well as being disturbed by the sound of the blood pump (Casida, Peters, & Magnan, 2009). Anxiety or worry about the patient’s new lifestyle can also affect sleep. Because of this, the nurse needs to assess for sleep disruption at each visit, and request an order for a sleep aid from the doctor if necessary (Casida, Peters, & Magnan, 2009).
Like dialysis, the LVAD patient may choose to stop treatment for his or her own reasons. This topic has been the subject of debate as long as the LVAD has been in use. For many different reasons, nurses may find the act of deactivating the device unethical secondary to religious convictions, or the nurse can refuse to participate due to the section of the Nurses Code of Ethics entitled “conscientious objection” (Lachman, 2011). However, according to Lachman (2011), United States Courts have “upheld the patient’s right to refuse treatment and request a withdrawal of any treatment, even if the treatment prolongs the patient’s life and not using it causes the patient’s death” (p. 99). What would cause the LVAD patient to consider deactivating the device? Often the reasons vary, but are generally related to repeat medical intervention secondary to complications of the device or decreased self esteem and depression secondary to difficulty adjusting to the new lifestyle over his or her old way of living (Casida, Peters, & Magnan, 2009). As such, a palliative care team is initiated immediately after the patient is out of surgery, to provide support, guidance, planning for the future, and education to the patient regarding the potential of complications that could lead to the need for end of life care. Additionally, the LVAD destination therapy patient lives on average 3 years post implantation. While this gives the patient some time to consider end of life, teams have found that honesty and a good grasp on the reality of life with the LVAD can help the patient cope in many ways (Lachman, 2011).
We will now work on a few scenarios together in order to help make sure that you are comfortable with the information you just learned.
Pick a partner. You will work together on the following two scenarios.
Once you have spent a few minutes discussing with your partner, you will share your thoughts with the group.
Once with your partner, consider the following two scenarios, and have your discussion answer ready to share with the class. You will be alerted during the discussion period when you have 2 minutes to allow for time to finish your discussion with your partner.
Discuss this scenario with your partner and prepare an answer to be shared with the class.
LVAD therapy has changed drastically in the last 50 years. It has allowed for countless patients, from pediatric patients to the elderly, to have a new lease on life as they prepare for transplant, recover from a cardiac insult, or live the rest of their lives with an LVAD device. While there can be many potential complications, the home care nurse can be of monumental importance in care plan development, education and support. By using the Roper-Logan-Tierney model of living, we have discovered the many ways in which the home care nurse can assist the patient resume typical activities of daily living.
