Page 599 - Cardiac Nursing

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C HAPTER 24 / Heart Failure and Cardiogenic Shock 575
Baseline intelligence and NYHA functional class have been shown why patients over the age of 65 years require hospitalization. 4
to predict the degree of impairment. 136 Increased age, presence of Three-month rehospitalization rates exceed 50%. 141 The primary
comorbidities, and abnormalities of serum sodium, potassium, al- reason for rehospitalization is volume overload followed by angina
bumin, and glucose all increased the relative risk of cognitive im- and arrhythmias. 142 Common precipitants of readmission include
pairment. 137 While the precise mechanisms of impairment re- medication nonadherence, dietary indiscretion, inappropriate
main unclear, included in the list of hypotheses are chronic medications, and delay in seeking care. 143 Identification of the
cerebral hypoperfusion and/or hypoxia, and repeated cerebral mi- early onset of HF symptoms may prompt therapeutic interven-
croembolic events. Small observational studies of patients with tions instituted on an ambulatory basis and prevent rehospitaliza-
HF have shown an association between diminished cerebral blood tion. Coordination of care by a nurse-directed multidisciplinary
flow as measured by single photon emission computed tomogra- team (including nurses, cardiologists, primary care providers, case
phy brain imaging and abnormalities noted on neuropsychologi- managers, dieticians, pharmacists, and cardiac rehabilitation spe-
cal testing. 138 cialists) can provide HF initiatives to guide evidence-based prac-
Cognition changes are often barriers to a patient’s ability to en- tice, enable self-care at home, and coordinate clinical care across
gage in self-care behaviors. A conceptual framework of cognitive de- the continuum. 144 A growing trend has been to have advanced
fects in patients with HF has recently been proposed 139 (Fig. 24-12). practice nurses coordinate these programs. 145
While this model continues to evolve, and perhaps should include The goal of HF disease management programs is to reduce
an expanded list of contributing factors, it forms an initial platform symptom burden, improve functional capacity, reduce hospital vis-
to develop interventions aimed at improving cognition. its, and reduce rehospitalization. Components of disease manage-
ment programs include discharge planning, education and counsel-
Disease Management Programs ing, medication optimization, early attention to deterioration and
Whether in a hospital, clinic, nursing home, or patient’s home, vigilant follow-up. HF disease management programs have been
the nurse cares for patients in all stages and phases of the syn- shown to improve quality of life 141 and patient satisfaction with
drome of HF. The nurse may be the first person to identify the care. 146 Application of these strategies by nurses has been shown to
risk factors for or presence of HF. The best means for reducing reduce the likelihood of 90-day readmission by 56% 141,147 and to
the number of patients with HF is by prevention, early identifi- improve significantly 1-year survival without readmission. 148,149
cation of HF risk, and implementation of targeted interventions. There is mounting evidence to suggest that HF disease manage-
The importance of early diagnosis is highlighted by evidence that ment programs reduce not only readmission but also mortality. 150
treatment of asymptomatic patients can slow progression and im-
prove clinical outcomes. 69,140 Screening for high blood pressure, Patient and Family Education. The health care community
diabetes, dyslipidemia, metabolic syndrome, smoking, athero- is increasingly faced with a growing division between what is
sclerosis, and breathing and valvular disorders may ensure known to improve patient outcome and our ability to encourage,
aggressive treatment and may prevent the subsequent syndrome apply, and teach these behaviors to the patients and populations we
of HF. serve. An early study demonstrated that education successfully
Once a diagnosis of HF has been established, a major goal is alters adherence in patients living with chronic diseases. 151 Educa-
determining the type and severity of the underlying disease and tion and support have been shown to improve self-care behaviors
the extent of the syndrome. HF remains the number one reason in patients with chronic HF. 152,153 Multidisciplinary education
and support interventions have been shown to reduce rehospital-
ization rates in this patient population. 148,154 Comprehensive dis-
charge planning and postdischarge follow-up of elderly patients
g
Contributing factors Covariates
with HF has been shown to not only reduce the need for rehospi-
Age Medications
talization but may even reduce 1-year mortality. 155 However, edu-
Comorbid conditions Sex
Hypertension Education cation alone certainly does not predict patient behavior in the
Depressive symptoms home setting. 156
Several investigators have described a relationship between social
support and health outcomes in this patient population. 148,153
Patient-related decompensation of chronic HF can be attributed to
g
Chronic heart failure Cognitive deficits knowledge deficit of the disease, diet and medications; nonadher-
Circulatory insufficiency Attention ence to medication and diet; inability to recognize signs and symp-
Severity (NYHA, LVEF) Working memory toms of HF; inadequate social support; and inability to access health
Duration Memory care providers. Several clinical studies have demonstrated a decline in
Oxygen saturation Learning
Executive function hospital readmissions by as much as 50% with aggressive telephone
Psychomotor speed follow-up care. Telemanagement of HF undertaken by advanced
practice nurses, 157 has been shown to promote consistency of care
across health care sites. Even short one-on-one teaching sessions can
significantly reduce need for rehospitalization and death. 158
Health-related quality
of life Specialized HF centers are being established to oversee therapeu-
tic options, including complex polypharmacy, device therapy, and
investigational agents. 159 Nursing plays a key role in these centers
■ Figure 24-12 Conceptual model of cognitive deficits in heart
failure. (From Bennett, S. J., Sauve, M. J., & Shaw, R. M. [2005]. A and clinics, coordinating care that impacts the physical, psychologi-
conceptual model of cognitive deficits in chronic heart failure. Jour- cal, and social challenges that these patients face. In addition to mor-
nal of Nursing Scholarship, 37[3], 222–228.) bidity and mortality, quality of life is an equally important outcome