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#Post#: 256--------------------------------------------------
The Role of the Heart Failure Specialist Nurse(NMP)
By: Annabeli5 Date: May 14, 2015, 4:36 am
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INTRODUCTION
Congestive Heart Failure accounts for approximately 5% of all
medical admissions to hospital (National Service Framework,
Department of Health 2000). Its prevalence is expected to
continue to rise over the next several decades due to decreased
mortality from cardiovascular disease and the growth of the
elderly population. The National Service Framework for Coronary
Heart Disease (CHD) in Wales (The National Assembly for Wales
2001) sets aims to health authorities, local health groups and
the Specialist Health Services Commission for Wales in tackling
CHD within Wales. The key actions for heart failure patient care
is to provide a comprehensive and cost effective heart failure
service for all, and to implement an agreed pathway for the care
of those with chronic heart failure. An agreement reached with
1-2 tertiary centres to assess resistant/end stage heart failure
patients within an agreed protocol and the development of a
strategy for the palliative management of symptomatic endstage
heart failure.
During the era of uncertainty in health care, cost-conscious
tactics are being implemented widely among primary and secondary
health care sectors. Congestive Heart Failure (CHF) has been the
focus of numerous recommendations, 78% of patients with CHF have
at least two admissions per year for CHF exacerbation and 16%
have had three admissions per year (McMurray et al 1993). It has
been speculated that many of the 1 million CHF hospitalisations
that occur each year could be prevented by improved evaluation
and care.
BACKGROUND
Heart Failure constitutes a major public health problem and it
is the leading cause of morbidity and mortality in most
developed countries (Paul 1997). The Framingham Heart Study
showed that once patients were diagnosed the 6-year mortality
rate was 85% for men and 67% for women, this corresponds to a
death rate four times greater than in the general population of
the same age (Moser & Worster 2000). Hobbs (1999) states that 5
years after diagnosis less than 50% of these patients are still
alive.
Heart Failure can result from coronary heart disease, a
culmination of long-standing hypertension, from advanced
cardiomyopathy or valvular dysfunction (Connolly 2000). Due to
functional abnormalities the heart remodels itself by changing
shape. In left ventricular systolic dysfunction, the myocardium
of the left ventricle becomes thin and enlarged, whereas in left
ventricular diastolic dysfunction the myocardium of the left
ventricle becomes thick and noncompliant. Both types of left
sided heart failure lead to symptoms of dyspnoea and fatigue.
Other signs and symptoms include peripheral swelling, difficulty
sleeping in a supine position, coughing, and the inability to
perform normal activities of daily living and a sudden weight
gain due to fluid retention. Light-headedness, dizziness and
palpitations are also common and can indicate cardiac cachexia
(Connolly 2000).
During a study that examined data from general practices and 2.1
million patients, the age related prevalence of heart failure in
1996 was 9.7 per 1,000 males and 8.2 per 1,000 females (Majeed &
Moser 1999). Paul (1997) suggests that 78% of patients with CHF
have at least 2 admissions per year for CHF exacerbation and 16%
have had 3 admissions. Stewart & Blue (2001) reported that
hospital admissions for patients with heart failure is
increasing rapidly and re-admissions occur within 3 months in at
least 8% of all patients discharged with a diagnosis of heart
failure.
QUALITY OF LIFE
As the grim prognosis of heart failure grows, health care
providers are constantly looking for factors that may predict
patient outcomes, specifically rehospitalisation and death as a
focus for new interventions. Physiological factors such as left
ventricular ejection fraction and exercise tolerance have
traditionally been measured as predictors of heart failure
decompensation and mortality, psychosocial factors such as
quality of life, social support, depression and anxiety are now
also being recognised as important and relevant predicting
factors (Moser & Worster 2000). Approximately 50% of people with
heart failure are symptomatic and as a result have a reduced
quality of life (Dahl & Penque 2000). Heart Failure is graded on
the extent of their fatigue and dyspnoea; a tool often used to
assess their condition is the New York Heart Association
Classification.
New York Association Heart Failure Classification
Class 1 No Limitation. Ordinary activity does not cause undue
fatigue, dyspnoea, or palpitations
Class 2 Slight limitation of physical activity. Comfortable at
rest, but ordinary physical activity results in heart symptoms.
Class 3 Marked limitation of physical activities. Comfortable at
rest, but less than ordinary activity causes heart failure
symptoms.
Class 4 Symptoms of heart failure are present at rest. If any
physical activity is undertaken, discomfort is increased.
Quality of life is defined by Moser & Worster (2000) as a
"Multidimensional concept referring to a person's total
well-being including his or her functional capacity,
psychological status, social functioning, physical health and
health perceptions."
Quality of life is a relatively recent concept to be addressed
in heart failure research. In studies of quality of life among
patients with heart failure, patients commonly report
psychological distress, including depression, hostility and
anxiety, limitation in their activities of daily living,
disruption of work roles and social interaction with friends and
family, and reduced sexual activity and satisfaction (Grady
1993). Interestingly they state that disease severity as
indicated by left ventricular ejection fraction is unrelated to
measures of emotional distress. This finding highlights the
importance of not assuming that patients with the most severe
disease will automatically have the worst psychological status
or that those with less severe disease will have none. Konstam
(1996) reiterates this and notes that patients describe the
physical limitations, reduced activities of daily living, and
inability to work imposed by their disease. Patients experience
depression, anxiety, and reduced social functioning; they
therefore rate their quality of life as poor.
The economic costs of treating heart failure are considerable.
As resources for providing health care are limited it is
essential to consider both the cost and benefit to the patients
once diagnosis is made. Strategies for improving the cost
effectiveness of care involves identification of the major
factors which produces costs and then target therapy to reduce
this element, while at the same time improving symptoms and
increasing duration and quality of life. When the morbidity rate
is reduced major reductions in cost must result from a reduction
in the cost incurred by repeated hospitalisation (Giles 1996).
Heart failure management should include symptom relief, quality
of life improvement and prevention of further heart failure
progression (Riegel 2000); they also suggest that heart failure
treatment involves pharmacological intervention, risk factor
reduction, dietary adjustment, exercise and education.
SPECIALIST NURSE INTERVENTION
Currently there are several strategies being used to reduce the
total cost of care for CHF patients by lowering acute care use
by principally avoiding inpatient admissions. One such strategy
is the development and implementation of a nurse-directed
multidisciplinary plan of care for patients diagnosed with heart
failure (Rich et al 1995). They suggest that the plan of care
should include intensive education about heart failure, a
detailed drug analysis, early discharge planning and enhanced
follow-up through home health care and telephone contact.
Similar results were found in another study, which utilised a
cardiologist in addition to the heart failure centre for
continued assessment, drug management and education. The results
from this study cited by Dahl & Penque (2000) showed an 85%
reduction in hospital readmission's and improved functional
status.
Patients with heart failure are heavy users of the health care
system and therefore require close clinical management and
encouragement to manage and identify their symptoms. The
specialist nurse (SN) is in an ideal position to do this as she
has the ability to focus on the clinical needs of the patient
and also the educational and supportive needs of the patient and
their family (Dahl & Penque 2000). In order to decrease the
frequency and cost of each patient's hospital admissions it is
essential that inpatient and outpatient care is effectively
co-ordinated.
The aim of the heart failure programme in the community is to
improve patient outcomes and decrease hospital admissions and
therefore cost. Fonarow et al (1997) suggest that patients
derive confidence from regular personal contact with a team
dedicated to their chronic disease. Patients attending the heart
failure clinic are seen by a cardiologist who obtains a full
history and performs a medical evaluation. The SN also sees them
and the basics of heart failure reiterated (Paul 1997). She also
suggests that a pharmacist evaluates the patients' medication
and reviews the purpose, dosage and side effects of each drug.
The patient should be given information about each drug
accompanied by a chart stating the appropriate dosing and
schedule in order to increase and ensure understanding of the
drug regimen, during subsequent clinic appointments the
medication regimen should be reinforced, it is valuable for
patients to hear this information repetitively as their
medications are frequently altered or adjusted. The SN should
spend time with the patient evaluating their dietary and
exercise compliance, reiterating and discussing their daily
weight monitoring and its significance to their treatment
management.
A key role of the SN is to involve the patient and their family
members in their own plan of care therefore empowering the
patient to assess his or her condition. By aiming to ensure that
they can correlate and understand their treatment regimen, can
recognise signs and symptoms and understand their treatment
regimen, and understand the importance and significance of any
changes and the appropriate action to be taken. Deaton (2000)
notes that heart failure nurse support has positive affects on
patient outcomes, for example, the moment patients experience
problems or changes they are able to access a health care
provider and the problem dealt with quickly and therefore in
many cases hospitalisation avoided. Beattie (2000) reinforces
the importance of patient education, stating the importance of
early sign and symptom recognition and knowing when to report
any changes, for example a weight gain of 2-3 pounds overnight
or 5 lbs in a week, changes in activity tolerance, onset of an
acute illness, paroxysmal nocturnal dyspnoea or orthopnoea. She
also notes the importance of patients being able to recognise
and to avoid situations or behaviours that may lead to acute
elevations in blood pressure and ischaemia, which will prevent
unnecessary exacerbations. Education about medication effects
must be repeated and reinforced. Risk factor management must
also be maintained, that is, abstinence from smoking,
maintaining a normal weight, healthy eating and healthy
emotional coping strategies. Weinberger & Kenny (2000) also note
the importance of ensuring that the patient maintains an
appropriate level of daily activity, which will ultimately
decrease oxygen demand and increase exercise tolerance. They
also note that educating, supporting and assisting the patient
and family in understanding and coping with the chronic nature
of CHF as well as providing realistic long-term expectations is
an essential element of the SN's role.
As previously mentioned one of the primary goals is to decrease
the readmission rates and improve the quality of life for CHF
patients. A key mechanism to achieve this goal is to ensure that
each patient has a contact or resource, especially if CHF is a
new diagnosis. For many independent patients, having a contact
number or address may be an adequate resource; others will need
more long-term support. Patients should receive a follow up call
from the SN approximately one week after discharge and further
input and support implemented according to the patients and the
families needs, to answer questions, evaluate understanding and
adherence to the treatment regimen and to offer support and
reinforcement when necessary. Krumholz et al (1997) discuss the
importance of emotional support as a predictor of cardiovascular
events. They note that patients without emotional support had a
three-fold increase in the risk of cardiovascular events in the
year after admission compared with patients with emotional
support. Lukkarinen & Hentinen (1998) discuss gender differences
and social support; they found that the relationship between
lack of emotional support and greater incidence of events was
strong for women but not as significant in men.
Major symptoms of CHF include dyspnoea and fatigue, which can
often occur at rest, it is therefore often difficult for the
patient to function independently especially outside their
homes, therefore making clinic journeys difficult. For this
reason it is essential that these patients have frequent contact
and support from the SN in the home environment. In a survey of
100 home care cardiac patients, patients following one home
visit were able to answer a cardiac health questionnaire
correctly 58% of the time, following home care intervention they
answered with 90% accuracy (Goodwin 1999). Goodwin also notes
that patients fail to adhere to prescribed treatments for many
reasons, including lack of understanding of the treatment plan,
lack of motivation or belief that the treatment was necessary or
would be effective, the SN is therefore in an ideal position to
provide advice and information in a more familiar and less
restrictive environment for the CHF patient.
Heart failure must be recognised as a terminal disease. Many
patients underestimate the seriousness of their illness with 50%
of patients thought not to have known they were dying (McCarthy
et al 1996). Stewart & Blue (2001) note that many CHF patients
should be informed of their diagnosis but many doctors do not do
this, and avoid referring to heart failure as they believe that
patients find it frightening. They also note that the palliative
nature of the disease process needs to be discussed with the
patient and their families if they are to make informed choices
about their treatment aims and the plan of care for the future.
CONCLUSION
Congestive Heart Failure is a major public health problem.
Hospital admissions are often unplanned readmission's that have
a high mortality rate. A co-ordinated disease management
approach may be implemented that includes early assessment in
the hospital, comprehensive education, and behaviour
modification in order to improve disease management and improve
patients' quality of life. Nurses are the integral providers
involved in educating, coaching, monitoring and supporting
patients and their families during the CHF disease process.
Smith et al (1997) states that to obtain better outcomes for the
patient and to control and reduce costs, the care of CHF
patients must be moved to specialists in heart failure clinics.
Riley & Blue (2001) note that a SN as part of a
multi-disciplinary heart failure team has an important role in
educating patients and their families on the disease process,
management and control of symptoms and also providing support
following diagnosis of CHF.
In conclusion, the SN can assess the signs and symptoms of
cardiac destabilisation, provide education, emotional support,
counsel, develop behaviour modification techniques, monitor
therapy compliance and also act as the healthcare liaison for
the patient and their family. With this in mind, the ultimate
aim is to prevent rehospitalisation, increase functional ability
and improve quality of life.
#Post#: 261--------------------------------------------------
Re: The Role of the Heart Failure Specialist Nurse(NMP)
By: admini5 Date: May 14, 2015, 4:44 am
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Please include reference to the study..... :)
#Post#: 262--------------------------------------------------
Re: The Role of the Heart Failure Specialist Nurse(NMP)
By: Annabeli5 Date: May 14, 2015, 4:46 am
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For more information on the Heart Failure specialist nurse
topic, go to :
HTML http://www.priory.com/cmol/heartfail.htm
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