heart failure in the frail elderly in ltc part 2 deborah lekan, msn, rnc clinical nurse specialist,...
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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: [email protected]@mc.duke.edu