The grades of evidence (A1, A2, B1, B2, C1, C2, D) are defined at the end of the "Major Recommendations" field.
Assessment
Admission assessment by a registered nurse using the Long Term Care (LTC) Heart Failure Assessment tool (Appendix A.1 in the original guideline document) is recommended for baseline documentation for patients with:
- Documented diagnosis of heart failure, any cardiac diagnosis, hypertension, or diabetes on admission history and physical
- An ejection fraction of < 40% measured by two dimensional echocardiogram, post hospitalization discharge summary, or
- Any Minimum Data Set that triggers a need for assessment by documentation of a new diagnosis of heart failure (HF) for cardiomyopathy or presence of respiratory, cardiac, or functional decline
- If the facility utilizes Minimum Data Sets for Nursing Homes (MDS) 3.0, assessment using the tool should follow if positive responses are indicated in Sections E1A, G1 and G2; Section I g and I h; and Section J1 and J5 (Centers for Medicare and Medicaid, 2005).
The admission nurse would obtain an order to initiate the HF guideline for the long term care resident who meets any of the above criteria and add the resident to the scheduled interdisciplinary team meetings for care plan update.
Use of the LTC Heart Failure Assessment Tool
The LTC Heart Failure Assessment tool is composed of two profiles that address three components of activities of daily living and eleven components of dyspnea. The assessing nurse is observing for decline in the resident's functional status and positive responses to questions in the dyspnea profile (Creason, 2001).
- The registered nurse documents the patient's status for the components in activities of daily living (ADL) Profile on admission and at four week intervals.
- The higher the score in the ADL profile, the lower the level of function. This score is compared with previous section totals at each assessment interval monitoring for longitudinal deterioration in functional status.
- The nurse then assesses the Dyspnea Profile. Any positive response in this section should trigger an immediate referral to the primary care provider for evaluation (Henkel, 2004; Martinen & Fruendl, 2004).
- If the responses in the dyspnea section are negative, the nurse should refer to the interdisciplinary team to assess for other causes in resident decline and schedule a visit with the primary care provider (Henkel, 2004; Lewis, 2002. Evidence Grade = D).
Each direct caregiver (certified nursing assistant) will:
- Be given "A NEW LEAF" card (Appendix A.3 in the original guideline document).
- Screen residents during the provision of care on a daily basis (Hutt et al, 2003. Evidence Grade = C1).
- Notify the primary nurse if any signs or symptoms are present and provide current vital signs and the weight graphic (Martinen & Fruendl, 2004. Evidence Grade = C1).
The assessment nurse will then:
- Perform an assessment utilizing the LTC Heart Failure Assessment tool and contact the primary care provider for evaluation of positive findings of possible heart failure exacerbation after he or she completes a cardiovascular assessment. This includes observation of
- Respiratory effort
- Bulging neck veins
- Extremity edema
- Auscultation of anterior and posterior breath sounds
- Heart sounds listening for extra sounds and irregularity of rhythm (Dains & Scheibel, 2003)
- Vital signs (blood pressure, pulse, respiration, and pulse oximetry) and weight graphic should be available for the provider (Creason, 2001; Dains & Scheibel, 2003).
- Vital signs will continue to be monitored according to the primary provider's discretion or the long term care facility's procedure and policy.
Interventions
Weight Monitoring
- Residents are placed on a weight regimen by the nursing staff. Weights are obtained three times a week until the resident's weight has been evaluated as stable as defined by a weight gain of less than two pounds for three measurements. (Martinen & Freundl, 2004. Evidence Grade = C1).
- Weight is graphed on a weight graphic (Appendix A Example 2 in the original guideline document).
- Any weight gain of more than 2 pounds triggers:
- An assessment using the LTC Heart Failure Assessment tool
- Vital signs with oxygen saturation (Martinen & Freundl, 2004. Evidence Grade = C1).
- Notification of the resident's primary care provider (Martinen & Freundl, 2004. Evidence Grade = C1).
- After the weight is stable, the resident is then weighed every week at the same time of day, with the same scale, and similar clothing (Martinen & Freundl, 2004. Evidence Grade = C1).
- If the resident's weight registers outside the shaded area in the four week period on the weight flow sheet, heart failure assessment is triggered and the primary care provider should be notified.
Dietary Management
Dietary measures to control the exacerbation of symptoms should be employed to include:
- Reduction in fluid intake in patients with advanced heart failure (Grade III, IV) regardless of the presence of hyponatremia or hypernatremia.
- Fluid restriction of 1.5 to two liters is advised (Remme & Swedberg, 2001. Evidence Grade = B1).
- Use of herbal seasonings in lieu of salt to season foods should be encouraged (Lewis, 2002. Evidence Grade = D).
- Sodium restricted diet to two grams of sodium per day with abstinence from salt substitutes which may contain potassium (Lewis, 2002. Evidence Grade = D).
Immunizations
- Influenza vaccines given every fall and pneumococcal vaccines given every five years are recommended to prevent respiratory infections which may be detrimental to heart failure patients (Remme & Swedberg, 2001. Evidence Grade = B1).
Exercise
- Weight reduction should be included in the treatment of obese chronic heart failure patients (Institute for Clinical Systems Improvement (ICSI), 2004. Evidence Grade = D).
- Exercise should be encouraged in the stable heart failure patient within the limits of the severity of disease.
- The resident should be encouraged to carry out activities of daily living and leisure activities that do not induce symptoms (Institute for Clinical Systems Improvement, 2004. Evidence Grade = D).
Education
- Patient and family education should be provided on topics related to heart failure (Martinen & Freundl, 2004. Evidence Grade = C1).
- Smoking should always be discouraged. The use of smoking cessation aids including nicotine replacement therapies should be actively encouraged (Remme & Swedberg, 2001. Evidence Grade B1).
- Patients and families should be taught the rationale for prescriber avoidance of nonsteroidal anti-inflammatory drugs and nursing staff should be alert to avoid administering them to residents with cardiovascular disease (Bleumink et al, 2003. Evidence Grade C1; Remme & Swedberg, 2001. Evidence Grade B1).
- Alcohol intake should be discouraged in patients with severe heart failure (Institute for Clinical Systems Improvement, 2004. Evidence Grade = D).
Definitions:
Grades of Evidence
A1 = Evidence from well-designed meta-analysis or well-done systematic review with results that consistently support a specific action (e.g. assessment), intervention, or treatment
A2 = Evidence from one or more randomized controlled trials with consistent results
B1 = Evidence from high quality evidence-based practice guideline
B2 = Evidence from quasi experimental trials with consistent results
C1 = Evidence from observational studies with consistent results (e.g. correlational, descriptive studies)
C2 = Evidence observational studies or controlled trials with inconsistent results
D = Evidence from expert opinion, multiple case reports, or national consensus reports
