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Question for RN's reagrding CHF in LTC

Specializes in Critical Care/ICU.

I have a question for RN's in LTC regarding CHF in LTC facilities.

What would you do with this patient:

Female, late 80's, DNR (a very clear advance directive and POAHC follows her everywhere)

Previously independent living alone with daily checks and help from family and friends

Her husband of nearly 70 years just passed away beginning of December

Longstanding hx of afib

Coumadin until recently (see hospitalization below)

ACE inhibitor

Lasix

Inhalers

Vitamins

Synthroid

(I'm sure there are more meds, I just can't think of them right now)

Week long end of December hospitalization for GI bleed (scoped and cauterized gastric bleed) - coumadin d/c'd, UTI developed, altered mental status

Discharged to a "rehab" facility

One month now at LTC rehab facility

Two weeks into stay: dependent edema, requires 02, frequently SOB, very depressed, still somewhat altered mental status with periods of clarity

One month into stay: Severe weeping edema at both lower extremities below the knees; periphery cool to touch; knees mottled, syncope, requires 02 24hrs, SOB, still confused at times, but better, very depressed, no appetite

I'm not completely clear on meds except that lasix was started last week (finally!).

I'm just wondering at what point would a person such as this be sent to the hospital for treatment. Before her hospitalization in December, her CHF was under control with occasional exacerbations that were usually picked-up on and treated right away, succesfully. They did do a ultrasound to check for clots - negative (thank goodness!), but especially with her a-fib, I'm afraid they are letting this go too long. I'm not sure of her renal staus or if she's actually diuresing from anywhere other than her lower legs, and I don't know if they've even checked her blood or have done a chest xray. I'm afraid she'll end up either with pneumonia or pulmonary edema and rotting lower legs and feet.

This is my grandmother. My family, especially my mom, has been through the ringer in the last several months with first my dad dying in October after a year filled with surgeries, illness, and a 4 month hospitalization, then my grandfather (my mom's dad) died in December, and now she's dealing with her mother in this condition. My mom has been the primary family caregiver for both her parents and my dad's mom who's also in LTC.

I'm trying to get information from my mom so I can help her help her mom. Unfortunately, I live 2000 miles away and my mom's burning out BIG TIME. It would be her's and my dad's 49th wedding anniversay on Tuesday. I feel so sad for her, she just really doesn't need anymore stuff like this.

So what do you think? Does this sound like a patient who needs to get more agressive care for the CHF probably in the hospital? My mom told me that when she visited on Sunday, she changed my grandmother's socks 3 times in 3 hours because they were soaked. She ended up taking paper towels from the bathroom and wrapping them around grandma's legs. :stone

She's brought this up with the Nurse more than once, actually each time she visits (3-4x/wk), but doesn't feel she's getting anywhere and fears for her mother's well-being. DNR doesn't mean ignore things that can be treated.

What can/should we do or what are some thoughts? What would you normally see in a case such as this?

I have absolutely NO experience in LTC. I'm an ICU nurse who's very uncomfortable with the way this is being handled.

:confused:

CoffeeRTC, BSN, RN

Has 25 years experience.

First Hugs to you and family.

Why didn't the LTC pick up on this? (I know you prob asked this)

Do they notify POA with any changes in condiiton asap? they should. DNRs are treated and shouldn't be ignored. They missed the ball when the lasix wasn't reordered. I would prob ask doc/ family/ resident if they want hospital treatment if not we would treat at the nursing home. She should definalty be on I/O, does she need a fluid restriction? Chest Xray and diruetics. Good skin care is a must, too. As far as the mood changes/confusion/ or depression. Gosh she's been thru alot. Might be medically related and could take a few months to resolve. Sometimes an antidepressant could help and some docs might order aricept or namenda for memory, but I would be hesitant to add more meds.

I would ask why the nurses aren't being more agressive or at least letting the POA know what is going on. ( this is a regulation) Also...tell POA to call the doc directly.

Hope you get some answers or action!

I would suggest she have a meeting set up with the care plan team and the doctor to discuss the situation. Then you have the whole team there at once to ask questions and get some answers.

Tell her to demand it immediately!

begalli

Specializes in Critical Care/ICU.

Thank you both for your thoughtful replies.

I probably didn't make it clear, but my mom is the POA. I didn't find out until yesterday just how sick my grandmother is when my mom starting talking about grandma "wetting her socks." I wasn't that surprised with grandma's altered mental state given all the changes in environment, the GI bleed, the UTI, and huge emotional blow due to the loss of my grandpa and my dad. This is what has been most bothersome to my mom and what we have been talking about for several weeks. Now that I know more of the story....

I guess I better get on the ball. My poor mom :o . She has reached her limit emotionally, mentally, physically, and humanly. I think she may have overlooked or has been in denial about some of the obvious symptoms grandma has because so much of what is happening to my grandmother now is VERY much the way my dad looked when he died.

I think I just needed some confirmation about the feelings I was having about this. I so wish I could be there. I will have to see how I can help from across the country. This has been a bank-busting, tumultuous year.

The more I think about it....if it were my family member, I would just call them and have her sent to the ER for a complete eval. I would find out what really is going on with my mom and I wouldnt wait another day.

I've been thinking about this since I read your first post and how I would handle this at work (I do LTC).

She needs answers and it sounds like your grandmother needs closer observation until her edema resolves. Your mom is the POA. She can have this done today.

I hope your grandmother gets better soon!

begalli

Specializes in Critical Care/ICU.

Thanks brat! :)

I'm calling mom right now.

begalli

Specializes in Critical Care/ICU.

*sigh* Mom called LTC after I called her. They told her that gramdma's not in congestive heart failure? They said she's on a couple of GI meds, cardizem, lopressor, synthroid, and 40mg lasix/day (no potassium!?). They did chest xray and said it was okay. Didn't draw labs, but will next week?

So I asked mom if she thought that they might talk to me. Nope, didn't think so, HIPPA. Then I asked her when she was going over there today and to please ask grandma if she would give permission to have them talk with me. Grandma was more than happy BUT the RN who needed to fill out the paperwork for this "permission" was in a meeting and mom had to leave for her own DR appt and grandma needed to lie down.

Boy, I'm feeling kind of dumb here knowing nothing about how LTC works.

Mom's report on grandma today: Changed soaked socks once while she was there for less than an hour, still very edematous. Grandma just got done with OT and was asking for her 02 and to lie down because she was "just so tired."

I dunno, sounds like CHF to me. What the heck else could it be? I read an article recently in Critical Care RN where it talks about the chest xray not being a great predictor of heart failure. Something about the lymphatic system increases drainage and so the picture may look relatively dry and upon auscultation, no crackles are present. Sounds to me the only diagnostic criteria this doctor used was a chest xray, perhaps listened to her lungs and examined her legs while she was still lying in bed very early in the am (apparently the weepiness goes away when she's supine all night long, but not the pitting edema).

I plan to call and just let my feelings, my thoughts, and my experience be known to the nurse (in a nice professional way of course). I don't expect her to tell me anything, I just want it to be known what I'm thinking. I'll call my mom when she returns from her Dr appt and see if anything comes of it. If nothing does, then mom and I have to have a serious discussion about what to do next.

Thanks for letting me bounce this around here.

begalli

Specializes in Critical Care/ICU.

AH HA! FINALLY some satisfaction.

The RN who cares for my grandmother directly was able to get the permission she needed to talk with me. She agreed completely with everything I had a concern with and said it was her nursing supervisor, going on the docs opinion, who was holding back on getting my grandmother more difinitive care. This RN flat out said, if it were my mother or grandmother, I'd....

Grandma's on her way to the ER.

UM Review RN, ASN, RN

Specializes in Utilization Management.

Yay! Just finished reading this and I agree, a trip to the ER is certainly warranted.

Have them do a BNP. Have had an amazing number of folks who have clean CXRs but the BNP level is way out there. Here's more about the BNP from The Cleveland Clinic website: http://www.clevelandclinic.org/heartcenter/pub/guide/tests/labtests/bnp.htm

BNP levels below 100 pg/mL indicate no heart failure

BNP levels of 100-300 suggest heart failure is present

BNP levels above 300 pg/mL indicate mild heart failure

BNP levels above 600 pg/mL indicate moderate heart failure.

BNP levels above 900 pg/mL indicate severe heart failure.

Here's an article on the topic from Reviews in Cardiovascular Medicine, since CHF is so common in the elderly:

http://www.medreviews.com/pdfs/articles/RICM_42_72.pdf

begalli

Specializes in Critical Care/ICU.

Thanks Angie O.

I also read about BNP as well as "proportional pulse pressure" in that journal article I mentioned ealier. I asked the LTC nurse about this, but she didn't know what I was talking about.

There is something that's really bothering me though right now. When I spoke to the nurse about how my mom goes about getting my grandmother to the hospital, she gave me all the info, again collaborating all of my concerns, BUT said (paraphrased), tell your mom when she talks to the nursing supervisor here not to say that I told you any of this or that I agreed with you that your grandmother needs to go to the hospital.

WHAT?!

She urged me to get my mom to take grandma to the ER and have her checked out. I wonder why she would not advocate for her patient on her own? Is there some loss a LTC place takes when a patient goes out to the hospital? I can't imagine this nonaction by an RN when the RN feels that something is wrong.

It makes me worry that in the future things will not be addressed and it will be up to my investigative work of gently coaxing information out of my mom about my grandmother's condition, from 2000 miles away!

Anyway, haven't heard from my mom yet since they went. I can just see the poor thing now, sitting in the ED for hours. NOT something she wants or needs to be doing right now, but does it anyway out of love for her mother and the fear of losing her too. :o

I have worked at 2 facilities in the last 5-6 years - sometimes its like trying to pull teeth to get the doc to respond to anything, other times it is quite easy - depending on the doc. I have had families take their loved one to the ER (at my encouragement) themselves, especially if the doc involved was not listening to me or was not even bothering to call back. DNR does not mean 'do not treat'. A lot of nurses and docs need reminding of this. I hope all goes well for you, your mom and your grandma.

medsurgnurse, RN

Specializes in Me Surge.

Thanks Angie O.

I also read about BNP as well as "proportional pulse pressure" in that journal article I mentioned ealier. I asked the LTC nurse about this, but she didn't know what I was talking about.

There is something that's really bothering me though right now. When I spoke to the nurse about how my mom goes about getting my grandmother to the hospital, she gave me all the info, again collaborating all of my concerns, BUT said (paraphrased), tell your mom when she talks to the nursing supervisor here not to say that I told you any of this or that I agreed with you that your grandmother needs to go to the hospital.

WHAT?!

She urged me to get my mom to take grandma to the ER and have her checked out. I wonder why she would not advocate for her patient on her own? Is there some loss a LTC place takes when a patient goes out to the hospital? I can't imagine this nonaction by an RN when the RN feels that something is wrong.

It makes me worry that in the future things will not be addressed and it will be up to my investigative work of gently coaxing information out of my mom about my grandmother's condition, from 2000 miles away!

Anyway, haven't heard from my mom yet since they went. I can just see the poor thing now, sitting in the ED for hours. NOT something she wants or needs to be doing right now, but does it anyway out of love for her mother and the fear of losing her too. :o

yes, the facility may loose money. After you grandmother is managed in the hospital, do not send her back to that facility. Her legs are weeping and they said she is not in heart failure. hello! there's more than one kind of heart failure. Once the dependant edema gets that bad she could get cellulitis. The facility nurse could have at least contacted the physician when the edema started.

medsurgnurse, RN

Specializes in Me Surge.

I hope your grandmother gets well.

snowfreeze, BSN, RN

Specializes in ICU, CCU, Trauma, neuro, Geriatrics. Has 16 years experience.

If this was my patient she surely would have had quicker treatment. If she has poor renal function then dobutamine IV 3 or 4 times a week does help. Good renal function, lasix or bumex. The legs need to be kept elevated when possible and wrapped with stretch bandages, we have healed stasis ulcers many times this way. Accurate Intake and output each shift will help to see if you need to limit fluid intake. Does the POA truly understand the treatments and consequences? The nurse caring for this patient should try to educate the family and especially the POA on what is happening. How involved is the doctor, many facilities have more than one doctor available, ask staff for names of other doctors that can be used and interview them if possible.

And I am sorry that you are having such trouble with LTC, I work in that type of facility now and am appalled at what goes on in other facilities.

Always call your social worker at the facility if things are becoming a problem. They are your advocate and liason to all other departments.

snowfreeze, BSN, RN

Specializes in ICU, CCU, Trauma, neuro, Geriatrics. Has 16 years experience.

As far as what the patient wants and family wants, where I work I just send the patient to the hospital according to what their POLST says when their medical condition becomes something beyond what I can treat effectively where they are. If they desire hospitalization and will accept treatments for problems then they go, I page the doc and send em. Most of our docs call before the ambulance arrives but sometimes they don't. I write it as a verbal order from the doc anyhow as the POLST is my standing order for what the patient desires and it is signed by the doc. I also document my findings and what I am doing, this shows me being a patient advocate.

This is an outrage......

Until your Mom is able to add you to the list....your grandma can designate you as the family advocate....I would call that charge nurse every hour on the hour until I am satisfied...that this is done.

If I where you I would call the Facilities Administrator and the Medical Director of the facility....ASAP regardless if they won't release any information is not the case you are partially aware of your grandmother's condition and you as a concerned family member you have the right to voice your concerns. We never turned away concerns of family members period, POA or not this is your Grandmother. The Administrator must hear you...You are advocating for your elderly grandmother on your family's behalf, as concerned family representative. Tell them either they talk to you or you will ask the state to intervene, if need be tell them the next call they recieve will be from your Grandmother's attorney. It is abvious that she needs medical attention that the LTC is unable to provide. Make sure your use lots of words like Family advocate, Resident rights. Your Grandma is not able to speak for herself and pass this info to your Mom She should go straight to Facilities administrator. Do what ever you have to, to get your grandma to the hospital. Alot of time this about $, if they are not treating as they should and she sent to the hospital w/ the same dx the LTC will be made to pay that hosp bill. All the nurse has to do is call the MD on call stating that the family (your Mom) is here and demanding her mother be seen in the ER with those s/s they have to be able to get the order....Best of luck.... sorry if I got carried away...

As far as what the patient wants and family wants, where I work I just send the patient to the hospital according to what their POLST says when their medical condition becomes something beyond what I can treat effectively where they are. If they desire hospitalization and will accept treatments for problems then they go, I page the doc and send em. Most of our docs call before the ambulance arrives but sometimes they don't. I write it as a verbal order from the doc anyhow as the POLST is my standing order for what the patient desires and it is signed by the doc. I also document my findings and what I am doing, this shows me being a patient advocate.

begalli

Specializes in Critical Care/ICU.

Grandma got to the ED within an hour after my mom demanded she be evaluated and the hospital is keeping her. CXR showed "severe left lung fluid" - my mom's words. EMT's and RN's were shocked at the degree of edema that was present and without palpable pulses! She got a hit of IV lasix and already put out almost a liter in urine since arriving to the ED a few hours ago.

:angryfire You better believe that this facility is going to hear from me, fuerza757. There is some culture of fear going on there wherein the direct care RN was AFRAID to advocate for her patient - "don't tell my nursing supervisor" - but KNEW very well that something was VERY wrong.

My mother was told by the nursing supervisor that the CXR done this am was completely clear and that there was no chf and that no hospital would take her if they sent her out?!?!?!??!?!

Okay. I spoke with both mom and grandma just a few minutes ago. Still in the ED but will be admitted within the next couple of hours. Grandma's got her cardiologist there and from what it sounds like, a really great nurse. I feel that things are safe at this point. Grandma sounded in good spirits (she's such a tiny sweet little old lady!) I told mom to go home and now I can take a deep breath too.

You know, maybe tonite was the night that with a little exertion, grandma would have had a flash pulmonary edema (and then what? she's a dni/dnr), maybe she would have hit her leg on the side of the bed and tore 4 inches of skin off or maybe her heart would have given out because of working so hard for so long in chronic afib no less! Maybe that won't happen now and there's absolutely NO excuse that this place didn't try to prevent this ealier!

begalli

Specializes in Critical Care/ICU.

OH! I almost forgot...the posters here at Allnurses are the BEST! Thank you so much for your thoughts and support through this rocky day!

:flowersfo

p.s. Mom and I already talked briefly about this...grandma's NOT going back to that facility.

UM Review RN, ASN, RN

Specializes in Utilization Management.

Is there some loss a LTC place takes when a patient goes out to the hospital?

Yeah, it costs money to send a resident out to the ER, but my understanding was it only costs money if the resident is sent back without being admitted. I could be wrong, it's been a long time since I did LTC.

I'm surprised and puzzled that her doc didn't get involved sooner. The facility can't override his order to send her out to the ER, after all. I'd definitely get the doc on the phone and discuss this. And a telephone conference sounds like a great idea. You should be involved in that, begalli. It's not like you're just an interested bystander here after all.

Might be a good idea to get a copy of her chart before she leaves the facility.

TracyB,RN, RN

Specializes in jack of all trades, master of none. Has 14 years experience.

Ditto to getting a copy of her chart. There was a definite lack of BASIC nursing care for your Gram, LTC or not.... & a nurse, afraid to send a pt out? Sorry, no peripheral pulses, severe weeping edema? HEELLLLLLLLOOOOOO!?!?!?!? Anyone with a license working here? Doesn't sound like it. I am wondering, though, about the CXR.. was it portable, where the company brought it to the facility... Sometimes, I think some of those clowns, that I have experienced while working LTC didn't even really DO an xray. I would follow them, watch them position my resident, & step out, when they were ready for the picture... No wonder I always got "talked to" about OT. Sorry, part of my job, & 8 hrs IS NOT enough to adequately assess, chart, medicate, provide dressing changes, assist my CNA's with boosts, passing trays, etc, etc, etc... So, when you will hire another competent nurse to split these 40 medicare patients that are ALL in desperate need, with families present, asking ??'s, etc, don't complain about the OT, b/c you know I am doing my job 200%. End of story.

Sorry, got a little off topic.... what i am trying to say, any nurse should have known better, to get the appropriate medical eval for your Gram.

Good luck to you. Prayers for Gram & your mom, especially, to get some rest......

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