What are the primary guidelines for managing Congestive Heart Failure (CHF) in nursing homes?

Primary Guidelines for CHF Management in Nursing Homes

Nursing home management of congestive heart failure should focus on careful monitoring for fluid overload, appropriate medication management, and advance care planning discussions to reduce mortality and hospitalizations while maintaining quality of life. 1

Assessment and Monitoring

Vital Signs and Weight Monitoring

• Daily weight measurements using standardized procedures:
  • Weigh at same time each day
  • Have patient void before weighing
  • Use same clothes and same type of scale (standing vs. wheelchair)
  • If using wheelchair, ensure same chair for each weight 1

Signs and Symptoms to Monitor

• Basic level monitoring (for all staff):

  • Any degree of edema
  • Abnormal lung sounds
  • Cough, especially when lying down
  • Dyspnea, orthopnea, paroxysmal nocturnal dyspnea
  • Jugular vein distension
  • Sleep disturbances
  • Poor appetite
  • Nocturia
  • Fatigue 1

• Advanced level monitoring (for nursing staff):

  • Decreased circulation to extremities, abdomen, kidneys, heart, or brain
  • Complications: peripheral vascular disease, GI symptoms, kidney insufficiency, MI, TIA, stroke 1

Medication Management

Evidence-Based Pharmacotherapy

• ACE inhibitors/ARBs for patients with left ventricular systolic dysfunction
• Beta-blockers for patients with left ventricular systolic dysfunction
• Mineralocorticoid receptor antagonists when appropriate
• Diuretics for volume management
• Digoxin and anticoagulants as indicated 1

Medication Considerations for Elderly

• Continue HF medications for heart failure with reduced ejection fraction until limited by:
  • Decreased oral intake
  • Inability to swallow medication
  • Hypotension 1

Nutrition and Exercise

Dietary Recommendations

• Sodium restriction (2-3g/day) with consideration for patient satisfaction
• Adequate protein intake (minimum 1g/kg) to meet metabolic demands
• Consider multivitamin supplementation for residents taking loop diuretics 1

Exercise Recommendations

• Low-intensity, high-repetition resistance training paradigm
• Aerobic exercise at lower volumes than typically recommended for adults
• Combination of aerobic and resistance training to improve functional capacity 1

Staff Education Requirements

Basic Level (All Staff)

• Understanding of heart as a pump and fluid overload
• Recognition of signs/symptoms of fluid retention
• Proper weighing procedures
• When to notify the nurse in charge 1

Advanced Level (Nursing Staff)

• Understanding of pulmonary, cardiovascular, and renal systems
• Knowledge of common HF medications
• Recognition of signs/symptoms of decreased cardiac output
• Understanding of precipitants of HF (infection, arrhythmias, metabolic disturbances)
• Knowledge of implantable devices
• Laboratory test interpretation 1

End-of-Life Care and Advance Planning

Advance Care Planning

• Discussions about goals of care and end-of-life preferences should occur:
  • At admission to the nursing home
  • Whenever there is a change in health status or level of care 1

Device Management

• For patients with implantable devices (pacemakers, ICDs):
  • Preferences regarding deactivation should be part of advance care planning
  • Patient preferences should be informed by consultation with a cardiologist 1

Quality Measures

Key Quality Indicators

• Assessment of left ventricular ejection fraction
• Symptom and activity assessment
• Patient self-care education
• Beta-blocker therapy for left ventricular systolic dysfunction
• ACE inhibitor or ARB therapy for left ventricular systolic dysfunction
• Post-discharge appointment for heart failure patients 1

Common Pitfalls to Avoid

1. Failure to monitor weight properly - Inconsistent weighing practices lead to inaccurate assessment of fluid status
2. Inadequate staff education - Staff must recognize early signs of decompensation
3. Overlooking advance care planning - Discussions should occur early and be revisited regularly
4. Inappropriate medication discontinuation - HF medications should generally be continued even in palliative care approaches
5. Neglecting surveillance for infections - Common triggers for HF exacerbation in nursing home residents 1

Indications for Hospitalization

• Worsened heart failure unresponsive to nursing home interventions
• Significant electrolyte imbalances
• Respiratory or urinary tract infections with hemodynamic compromise
• Sepsis
• Altered mental status not easily correctable 1

Following these guidelines can help nursing homes provide optimal care for residents with CHF, reducing hospitalizations while maintaining quality of life and respecting patient preferences for end-of-life care.