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- 1. Tertiary Care PROFESSOR CALDWELL NURSING 220 FALL 2022
- 2. HEALTH AND WELLNESS Health defined by World Health Organization as “a state of complete physical, mental, and social well being, and not merely the absence of disease or infirmity.” Wellness is a state of well being. Focuses on the whole being on the individual
- 3. ILLNESS AND DISEASE Illness: highly personal state in which the individuals physical, emotional, intellectual, social, developmental or spiritual functioning in diminished Disease: an alteration in body functions that reduces the capacities or shortens the normal lifespan
- 4. ACUTE AND CHRONIC Acute Illness: typically characterized by severe symptoms of relatively short duration Chronic Illness: one that lasts for extended period, usually 6 months or longer and often for the duration of the individual’s life
- 5. HEALTHY PEOPLE 2030 • Individual health is closely linked to community health • Community health is affected by beliefs and attitudes of those who live there • Partnership are important to improve health of communities
- 6. SELF CONCEPT • How an individual feels about their self (self esteem) and perceives the physical self (body image) and his/her roles, needs and abilities • Affects how individuals view and handle situations
- 7. HEALTH BELIEFS • What an individual believes to be true regarding their health • Effect whether or not a patient will engage in health promotions or follow treatment plans
- 8. LIFESTYLE CHOICES • An individual’s general way of life, living conditions, behaviors, which are influenced by sociocultural factors and personal characteristics. • Behaviors and activities individuals have control over • Assessment includes personal lifestyle and habits as they affect the patient’s health.
- 9. TYPES OF PREVENTIVE SERVICES • Primary prevention: Health promotion and illness prevention. Activity to block disease or injury before it occurs
- 10. TYPES OF PREVENTIVE SERVICES • Primary prevention: Health promotion and illness prevention. Activity to block disease or injury before it occurs • Secondary prevention: Diagnosis and treatment of disease. Activity to reduce the impact of existing disease or injury
- 11. TYPES OF PREVENTIVE SERVICES • Primary prevention: Health promotion and illness prevention. Activity to block disease or injury before it occurs • Secondary prevention: Diagnosis and treatment of disease. Activity to reduce the impact of existing disease or injury • Tertiary prevention: Seek to restore health following an illness or injury that includes rehabilitation or palliative care. Activity to lessen the impact of ongoing illness or injury
- 12. TERTIARY PREVENTION Restoring function and decreasing disease- related complications of an already established disease. When restoration to the previous level of functioning is not possible, care is focused on controlling symptoms and promoting the highest quality of life. Example: Heart Failure Patients: chronic and progressive disease that require care from a heart failure clinic.
- 14. TREATMENT …….BEGINS WITH PREVENTION Sleep apnea
- 15. HEART FAILURE • Main goals: • Slow progression • Reduce cardiac workload • Improve cardiac function (if possible) • Control fluid retention • Treatment strategies are based on progression of disease
- 16. NEW YORK HEART ASSOCIATION (NYHA)FUNCTIONAL CLASSIFICATION OF HEART FAILURE • I (mild): No limitation of physical activity. No SOB with normal physical activity • II (mild): Some limitations due to fatigue and SOB. Comfortable at rest • III (moderate): Increased physical limitations. Less than normal physical activity results in fatigue and SOB. Comfortable at rest • IV (severe): Any degree of physical activity results in increased discomfort. Symptoms while at rest
- 19. TRANSITIONS OF CARE Discharge Readiness: •Near optimal volume status achieved •Near optimal pharmacologic therapy achieved •Exacerbating factors addressed •Transitioned from IV to oral diuretic successfully •LVEF documented •Smoking cessation counseling initiated •Patient and family education •Discharge Documentation •Follow up visit scheduled with Cardiologist or Disease Management Center within 7 days
- 20. TRANSITION TO HOME • Must be patient focused • Care focuses on promoting the highest possible level of independence, sense of control, and wellness • Modify activities • Learn to manage with physical limitations and discomfort • Understand medications and treatment plans • Case Management: collaborative process to assess, plan, and provide services to meet the individuals needs. Goal is to reach and maintain the individual’s optimal level of health, quality of life, and (ADLs)
- 21. WHAT TO DISCUSS WITH PATIENT GOING HOME? •Disease process and effects of patient’s daily life •Warning signs of decompensation •Side effects of medications •Importance of adherence with medications and treatment plan •Low sodium diet and fluid restriction •Exercise program •Monitoring daily weights •Importance of follow up appointments •Providing referrals •Give booklets with information – ensure patient can read this and understands it (health literacy)
- 22. ACTIVITIES OF DAILY LIVING • Perform as many ADLs independently as possible • Space out activities to allow for periods of rest • Perform activities at a comfortable pace • Stop anything that causes chest pain, SOB, faintness, dizziness, or sweating • Avoid straining and heavy lifting • Eat a high fiber diet and plenty of fluids to prevent constipation
- 23. TIPS FOR CONSERVING ENERGY • Sit while preparing meals • Keep chairs around the house to take breaks • Minimize trips up and down stairs • Allow plenty of time for dressing and bathing- do not rush • Take a shower or bath when you have the most energy during the day • Shower bench to sit if become tired in shower
- 24. ASSIST THE PATIENT TO UNDERSTAND WHAT SODIUM IS • Sodium is a component of salt • Review nutrition label reading • 1500-2000mg sodium diet is recommended • Sodium attracts fluid which makes the fluid build up in the body • Too much sodium causes your body to hold onto fluid and can cause weight gain, SOB and
- 26. DIET • Give patient options for low sodium foods • Consult dietician • Examples: pasta cooked without salt, quinoa, shredded wheat, unsalted crackers, low fat milk, yogurt, fresh fruits and vegetables, cream cheese, swiss cheese, fresh meat (beef, pork, chicken, lamb, fish, eggs, jello, popsicles,
- 27. TIPS FOR DINING OUT • Plan ahead and review menu • Carry own spices with low sodium • Ask: • Dressing or sauces on the side (to use a small amount) • Oil and vinegar or lemon juice instead of dressings • Fresh fruit or salad instead of soups • Sherbet or ice cream instead of pastries or pies
- 28. WEIGHT MONITORING/FLUID RETENTION • Ensure the scale is on a flat surface • Weigh yourself everyday • Same time • Same scale • Same clothing
- 29. FLUID RESTRICTION • If low serum Na+ the provider may order a fluid restriction • Educate patient on what is considered fluid intake: soups, popsicles, coffee, tea, milk in cereal, etc. • Encourage hard candy, chewing gum or mouth lubricant (Biotene)
- 30. EXERCISE • Prolonged bedrest not recommended • Moderate, progressive activity program to improve myocardial function • Start slowly and gradually progress • Activity level can be different for different patients • Example of exercise plan: Aerobic exercises 3-7 times per week • 10-15 minute warm up • 20-30 minutes exercise at recommended intensity
- 32. MEDICATION TEACHING • Have a pill box • Updated medication list • Do NOT stop taking medications without speaking to physician • Do NOT double dose if you missed a dose • Encourage patients to ask questions • Discuss side effects of the medications and when to report
- 33. GUIDELINE DIRECTED MEDICAL THERAPY(GDMT) • Patients with HFrEF are encouraged to complete 3 months of GDMT • A repeat echocardiogram will be ordered
- 34. LIFEVEST Criteria •Cardiac arrest due to VF or VT •Familial or inherited SCA risk •MI with an EF<35% •Dilated Cardiomyopathy (including NICM) with an EF<35% •ICD Explantation Consideration •Take off LifeVest when a patient is admitted to the hospital •Patient needs to demonstrate ability to use device and follow commands •If English is not the patient’s preferred language, arrange for an in-person interpreter •Not all Skilled Nursing Facilities will accept a patient with a LifeVest 34
- 35. ICD/CRT/BIV Implantable Cardioverter Defibrillator (ICD) • Indicated for primary or secondary prevention of sudden cardiac death in patients with HF or cardiomyopathy who have had syncope and either induced or spontaneous Ventricular Fibrillation (VF) • GDMT should be started first and usually for at least 3 months • Ischemic cardiomyopathy, evaluate 40 days post MI, more than 3 months following revascularization Cardiac Resynchronization Therapy (CRT) • Improves symptoms and survival for patient in reduced EF (<35%) and prolonged QRS • Usually meet criteria for ICD and receive a combo device (CRT- D) • Involves pacing of the left and right ventricles to restore ventricular synchrony and improve LV function
- 36. CARDIOMEMS DEVICE • Implanted Pulmonary Artery (PA) pressure measurement system • Transducer placed in pulmonary artery for implanted sensor • Elevated PA pressures are associated with high risk for hospitalization and mortality • CardioMEMS device allows providers to monitor PA pressures and titrate medical therapy according to response
- 37. STOPLIGHT EDUCATION Heart Failure Zone Sheet Helps track a HF patient’s signs and symptoms • Record the discharge weight on the HF Zone Sheet • Emphasize the importance of daily weights and assessing symptoms according to zone • Confirm patient’s understanding on what to do if symptoms are in the green, yellow or red zone
- 38. USE STOP LIGHT TO DETERMINE WHAT TO DO • GREEN ZONE (All Clear) • No shortness of breath • No weight gain • No swelling • No chest pain What to do? Keep up the good work! Take medications, continue with low sodium diet and weigh yourself daily.
- 39. USE STOP LIGHT TO DETERMINE WHAT TO DO • YELLOW ZONE (Take Action) • Weight gain of 3 lbs in one day or 5 lbs in one week • Difficult to breath while lying down • Increased SOB • Increased swelling • Increased coughing • More fatigued What to do? Call your provider!
- 40. USE STOP LIGHT TO DETERMINE WHAT TO DO • RED ZONE (Emergency) • Chest pain or tightness • Struggling to breath even at rest • Fainting • Confusion What to do? Call 911 or go to hospital
- 41. ADVANCED HEART FAILURE STAGED
- 42. • Circulatory assistance LV A D L E F T- V E N T R I C U L A R A S S I S T D E V I C E ( LV A D )
- 43. CARDIAC TRANSPLANTATION Nursing care • Bleeding precautions • Chest tube care • Assess for cardiac tamponade • Monitor for and treat atrial dysrhythmias • Treat hypothermia • Assess and treat infection or rejection of the heart
- 44. END STAGE HFrEF MEDICATION Central venous access device (PICC, port, etc) • Milrinone-+ Inotrope • Decreases preload/afterload • Palliative treatment- improves quality of life • Side effects: headaches, tachycardia, and arrhythmias • Nursing intervention: monitor HR and BP
- 45. END OF LIFE CARE • Patient and family need to discuss options • Discuss advanced directives (living will and power of attorney) • How to make patient comfortable (position changes, limiting exertion, opioids and ) • Focus on symptom relief in palliative care-improving quality of life for patient and family
- 47. REFERENCES Adams, M. P, Holland, N., & Urban, C. (2017). Pharmacology for Nurses, A Pathophysiologic Approach (5th ed.), Hoboken, New Jersey: Pearson Pearson Education (Ed.) (2019). Nursing A Concept- Based Approach to Learning (Vols. 1-2) (3rd ed.) Hoboken, New Jersey: Pearson https://doi.org/10.1161/CIR.0000000000001063open_in_new https://hfsa.org/ https://professional.heart.org/en/science-news/-/media/832EA0F4E73948848612F228F7FA2D35.ashx https://www.aahfn.org/ https://www.heart.org/en/health-topics/heart-failure https://youtu.be/oAGN7cyizs0