Heart Failure in Heart Failure in the Frail Elderly the Frail Elderly

in LTCin LTC Part 2Part 2Deborah Lekan, MSN, RNCDeborah Lekan, MSN, RNCClinical Nurse Specialist, Clinical Nurse Specialist, Gerontological NursingGerontological Nursing

Clinical Leadership through Clinical Leadership through Bedside Clinical TeachingBedside Clinical Teaching

Putting your Putting your clinical clinical knowledge and knowledge and leadership skills leadership skills into practiceinto practice

Gerontogical Nursing HF Gerontogical Nursing HF AssignmentAssignment

Designed as a simulation to help Designed as a simulation to help prepare you for clinical practice as prepare you for clinical practice as an RN, by:an RN, by:

addressing both clinical competence & addressing both clinical competence & leadership skills needed for working leadership skills needed for working w/paraprofessional staff w/paraprofessional staff

focusing on RN delegation & supervisionfocusing on RN delegation & supervision

Uses Uses Bedside Clinical TeachingBedside Clinical Teaching as a as a strategy to involve CNAs & LPNs in strategy to involve CNAs & LPNs in detection/recognition of acute HF detection/recognition of acute HF S&S.S&S.

Part I: Before ClinicalPart I: Before Clinical

Go to the HF Module on BlackboardGo to the HF Module on Blackboard Do the short Pre-testDo the short Pre-test Review the University of Iowa Evidence-Review the University of Iowa Evidence-

based protocol on HF and AMDA HF based protocol on HF and AMDA HF clinical practice guidelineclinical practice guideline

Review HF Powerpoint module –about Review HF Powerpoint module –about an houran hour

Do the Post-testDo the Post-test

Part II. In the Nursing Part II. In the Nursing HomeHome

Clinical Conference: Clinical Conference: Obtain patient assignment and discuss plan for Bedside Obtain patient assignment and discuss plan for Bedside

Clinical TeachingClinical Teaching Complete short Leadership surveyComplete short Leadership survey

Prepare for the HF Assessment and Bedside Clinical Prepare for the HF Assessment and Bedside Clinical TeachingTeaching Review the patient recordReview the patient record Talk with the LPN and CNA about your assignment. Ask about Talk with the LPN and CNA about your assignment. Ask about

their usual assessment approach to the patient with HFtheir usual assessment approach to the patient with HF Ask about the patient’s presentation of S&S of acute HFAsk about the patient’s presentation of S&S of acute HF

Bedside Clinical Teaching Bedside Clinical Teaching Explain to patient and CNA the goal of assessmentExplain to patient and CNA the goal of assessment Conduct the HF assessment with input from CNAConduct the HF assessment with input from CNA Teach CNA how to use the FACES pocket cardTeach CNA how to use the FACES pocket card

Recording and Reporting Recording and Reporting Do Nurses Note and record in chartDo Nurses Note and record in chart Report findings to Charge Nurse and RNReport findings to Charge Nurse and RN

Bedside Clinical Teaching-Bedside Clinical Teaching-A Method to:A Method to:

Bring evidence-based & patient-focused Bring evidence-based & patient-focused information to the bedside to increase information to the bedside to increase information exchange between direct information exchange between direct caregivers (CNAs, LPNs, Charge Nurses) caregivers (CNAs, LPNs, Charge Nurses) & RNs& RNs

Coach paraprofessional and LPN staff inCoach paraprofessional and LPN staff in skill-building in assessment & care skill-building in assessment & care

techniquestechniques demonstration/return demonstrationdemonstration/return demonstration review and targeting of care plan goals review and targeting of care plan goals

Part III. After ClinicalPart III. After Clinical

Submit a Reflection Journal entry-1 Submit a Reflection Journal entry-1 pagepage

Due Date: Friday September 28, Due Date: Friday September 28, 20072007

Assessment ToolsAssessment Tools

HF Nursing Assessment FormHF Nursing Assessment Form HF CNA Warning WorksheetHF CNA Warning Worksheet HF pocket cardHF pocket card

The HF Resident The HF Resident Assessment FormAssessment Form

Designed for the LPN/RN in long term careDesigned for the LPN/RN in long term care Intended as a way to organize assessment Intended as a way to organize assessment

information to facilitate clinical decision-information to facilitate clinical decision-making and communication with the making and communication with the MD/NPMD/NP

Assumes nurse has Assumes nurse has basicbasic assessment skills. assessment skills. Form is simple and easy to use by RN/LPNForm is simple and easy to use by RN/LPN

The ABSN student can apply more The ABSN student can apply more advanced skills in physical assessment to advanced skills in physical assessment to look for indicators of acute HFlook for indicators of acute HF

The HF CNA Warning The HF CNA Warning WorksheetWorksheet

Designed as a short, easy to use Designed as a short, easy to use form to help the CNA observe for form to help the CNA observe for changes in the patient’s functional changes in the patient’s functional status, comfortstatus, comfort

Early indicators of acute HF can be Early indicators of acute HF can be detected and reported to the RN detected and reported to the RN

Timely treatment in the nursing Timely treatment in the nursing home can prevent ER transfers and home can prevent ER transfers and hospitalizationshospitalizations

HF HF Pocket Pocket CardCard

Heart Failure Signs and SymptomsWhat to look for: What to do:

F Fatigue Fast pulse

Assist with care as needed. Pace activity with rest periods.Monitor vital signs, note if pulse is irregular or >100 beats per minute.

A Activities of Daily Living Appetite poor

Decline in ADLs-Assist with care to ↓ effort & shortness of breath.Offer small amounts of food more often.

C CoughCongestionConfusionChest pain

Watch for mucous, especially frothy or bloody sputum. Provide emotional support-stay w/patient. Falls prevention.

E Edema- swelling, weight gain Elimination

Check weights. Protect legs & feet from injury. Watch out for ↓ urine output and nocturia

S Shortness of Breath

Elevate head of bed, use extra pillows. Sit up patient on edge of bed. Offer mouth care, ice chips, lip balm.

Long Term Care Nursing Long Term Care Nursing Staff Staff

-Training in Action….-Training in Action….

Teaching Staff in the Teaching Staff in the WorkplaceWorkplace

Make information practical and relevant.Make information practical and relevant. Focus on essential, need-to-know Focus on essential, need-to-know

information.information. Involve staff in their learning by asking them Involve staff in their learning by asking them

to explain why information is important.to explain why information is important. Build on relevant experiences and previous Build on relevant experiences and previous

knowledge.knowledge. Encourage learner-directed problem solving Encourage learner-directed problem solving

(i.e. After you teach them, ask them to tell (i.e. After you teach them, ask them to tell you what they could do with this you what they could do with this information).information).

Why Teach about HF?Why Teach about HF?

Course of disease is marked by Course of disease is marked by decompensation.decompensation.

Disease progression difficult to predict.Disease progression difficult to predict. Patient may be anxious or panicked-staff may Patient may be anxious or panicked-staff may

misinterpret or dismiss.misinterpret or dismiss. Medical intervention can improve quality of Medical intervention can improve quality of

life, extend life, and prevent acute life, extend life, and prevent acute exacerbations.exacerbations.

Stable Heart Function & VS

Functional status stable

Acute HF:

Severe SOB

Severe edema

VS changes

Confusion

Life threatening

Irreversible, Fast Onset

Consequences

ER

Hospital

Disability

Death

Dominant Mental Model—HF has an

Irreversible Course

Stable Heart Function & VS

Acute HF

Life-threatening

ER, Hospital-ization, Disability, Death

DOE, cough

Mild edema

Fatigue

Agitation, lethargy or confusion

VS change

Dyspnea at rest

PND

Productive cough

Severe edema

Profound fatigue

Angina

VS change

Alternative Mental Model—Progressive & Reversible

Early S&S

Late S&S

Progressive Course

Stable Heart Function & VS

Acute HF

Life-threatening event

ER, Hospital-ization, Disability, Death

Early S&S:

DOE, cough

Mild edema

Fatigue

Agitation, lethargy or confusion

VS change

Later S&S:

Dyspnea at rest

PND

Productive cough

Severe edema

Profound fatigue

Angina

VS change

Alternative Mental Model—Assess & Treat

Early Treatment

Early Detection

Prevent

Developing a Plan for Developing a Plan for Teaching LPNs and CNAs Teaching LPNs and CNAs

about HFabout HF

Know the Know the NursesNurses

Educational preparation (formal and CE)Educational preparation (formal and CE) Licensure and scope of practiceLicensure and scope of practice

Licensure rules Licensure rules http://www.ncbon.com/prac-http://www.ncbon.com/prac-lpnrules.asplpnrules.asp

Decision tree for RN & LPN Decision tree for RN & LPN http://www.ncbon.com/forms/decisiontree.pdfhttp://www.ncbon.com/forms/decisiontree.pdf

Issues of limited literacy, ESLIssues of limited literacy, ESL Local culture: family, staff health Local culture: family, staff health

issues, population risk factors, resident issues, population risk factors, resident risk factorsrisk factors

Deciding What to TeachDeciding What to Teach

Identify content for RN, LPN, CNAIdentify content for RN, LPN, CNA Identify how new info will apply to their roleIdentify how new info will apply to their role

Recognize—Assess/Observe—Report—RecordRecognize—Assess/Observe—Report—Record Develop job aids & checklists to make Develop job aids & checklists to make

learning easylearning easy Use multiple methods/modalities for Use multiple methods/modalities for

teachingteaching Incorporate adult learning principles Incorporate adult learning principles Use Use Bedside Clinical TeachingBedside Clinical Teaching

Bedside Clinical Bedside Clinical Teaching ModelTeaching Model

WhatWhat: : To teach at a teachable moment, to put To teach at a teachable moment, to put new information into practicenew information into practice

Why:Why: To improve patient care by To improve patient care by communicating accurate, new information communicating accurate, new information among staff.among staff.

How:How: In a short encounter of 10-20 minutes, In a short encounter of 10-20 minutes, you will interactively discuss the resident at you will interactively discuss the resident at his/her bedside while teaching & his/her bedside while teaching & demonstrating care techniques.demonstrating care techniques.

AssessmentAssessment: : Return demonstration & Return demonstration & discussiondiscussion

FeedbackFeedback: : Interactive & ongoing with staffInteractive & ongoing with staff

Bedside Clinical Teaching Procedure Bedside Clinical Teaching Procedure click hereclick here

Using Bedside Clinical Using Bedside Clinical TeachingTeaching

PreparationPreparation-- what to know about the what to know about the residentresident Chart reviewChart review Talk to staff/MD/familyTalk to staff/MD/family Talk to residentTalk to resident

Teaching goal-Teaching goal- target for this session target for this session Determine target learning goalDetermine target learning goal Determine what staff should do differently Determine what staff should do differently

in the care of the patientin the care of the patient Structure the teaching encounterStructure the teaching encounter Follow-up, repeatFollow-up, repeat

How do you explain HF to How do you explain HF to staff with different levels of staff with different levels of

education?education? With HF, the weakened heart pumps less blood than With HF, the weakened heart pumps less blood than

usual. usual. The blood stalls, or congests, in the body's tissues. This The blood stalls, or congests, in the body's tissues. This

makes it harder for the heart to pump blood through the makes it harder for the heart to pump blood through the arteries on the next beat. This causes more fluid build-up.arteries on the next beat. This causes more fluid build-up.

With fluid build-up, the legs and ankles swell. Fluid may With fluid build-up, the legs and ankles swell. Fluid may also collect in the lungs and cause breathing problems, also collect in the lungs and cause breathing problems, especially when lying down. Some patients have fluid especially when lying down. Some patients have fluid build-up in the stomach. build-up in the stomach.

The kidneys have trouble getting rid of sodium and water The kidneys have trouble getting rid of sodium and water and this causes more fluid build-up throughout the body. and this causes more fluid build-up throughout the body.

Without treatment, HF worsens and may prevent the heart Without treatment, HF worsens and may prevent the heart from pumping enough blood to keep the person alive. from pumping enough blood to keep the person alive.

Where is there Where is there expertiseexpertise among staff?among staff?

Ms Diamond, LPN, pointed out Ms Diamond, LPN, pointed out that one resident, Mrs. Flow, that one resident, Mrs. Flow, had R sided heart failure and had R sided heart failure and had different symptoms from had different symptoms from other patients. She gets other patients. She gets abdominal edema-ascites -as the abdominal edema-ascites -as the primary sign, not LE edema. primary sign, not LE edema.

This is Right-sided Heart Failure This is Right-sided Heart Failure ..

““If you were looking for If you were looking for swelling in the legs you swelling in the legs you wouldn’t find it, you would wouldn’t find it, you would miss her early signs miss her early signs completely and she would be completely and she would be in full blown failure before in full blown failure before you knew it!”you knew it!”

Where is there Where is there expertiseexpertise among staff?among staff?

Ms. Edie, CNA, has been at Ms. Edie, CNA, has been at the NH for 8 years and knows the NH for 8 years and knows patients well. patients well.

She knows most of what to She knows most of what to look for when HF patients look for when HF patients start to decompnesate: start to decompnesate: “They “They get real tired and short of get real tired and short of breath, a little confused. I breath, a little confused. I know they are getting into know they are getting into trouble, so I get the nurse trouble, so I get the nurse to assess!”to assess!”

She also has family members She also has family members with HF and has helped them with HF and has helped them with their hospitalizations & with their hospitalizations & meds.meds.

How to use staff How to use staff expertiseexpertise

Involve in co-teaching education Involve in co-teaching education programs.programs.

Use in Bedside Clinical Teaching.Use in Bedside Clinical Teaching. Mentor to help them grow in their Mentor to help them grow in their

role.role. Pair with other staff to teach during Pair with other staff to teach during

care activities.care activities.

Summary: Bedside Clinical Summary: Bedside Clinical TeachingTeaching

A technique to build knowledge and A technique to build knowledge and skill among staff with diverse skill among staff with diverse education, experience, literacy.education, experience, literacy.

A way to strengthen communication A way to strengthen communication and teamwork.and teamwork.

A powerful tool for improving quality of A powerful tool for improving quality of care within existing capacity of the NH.care within existing capacity of the NH.

A strategy for RN delegation and A strategy for RN delegation and supervision.supervision.

Good Luck!Good Luck!

Call or email with questions:Call or email with questions:

Deborah Lekan, Deborah Lekan, MSN, RNCMSN, RNC

Office: 684-8849Office: 684-8849

Email: Email: lekan001@mc.duke.edulekan001@mc.duke.edu