The Continuing Education You Want.

Therapeutic Management of
Heart Failure
Management Strategies to Maximize Outcomes, Increase Patient
Independence, and Reduce Hospital Readmissions

Presented by Amy Shevlin, PT, DPT

Learning Objectives
1. Examine the pathophysiology of heart failure and identify symptoms and clinical manifestations of a patient in
decompensated heart failure.

2. Apply evidence-based assessment strategies including assessment of heart and lung sounds, medication
reconciliation, outcome measures.

3. Identify programs and strategies designed to reduce hospital readmission and key factors that have been shown to
reduce hospital readmission.

4. Analyze patient self-management strategies and techniques clinicians can use to facilitate improved adherence with
medical recommendations and treatments.

5. Utilize evidence-based interventions to maximize patient independence and increase physical activity levels.

6. Apply heart failure case studies with application of principles to physical and occupational therapy practice.

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 Amy Shevlin, PT, MS, DPT, GCS Therapy Management of
Relevant Financial Relationships
Amy Shevlin is compensated by Summit as an instructor.
Heart Failure
Relevant Nonfinancial Relationships
Therapists role in the management of heart failure in order to
Amy Shevlin has no non-financial relationships to disclose. maximize outcomes, increase patient independence, reduce
hospital admission and increase patient self-management of
heart failure

Learning Objectives What’s the problem with Heart Failure?

1. Examine the pathophysiology of heart failure and identify symptoms and clinical manifestations of
a patient in decompensated heart failure. • Heart Failure is a global pandemic, affecting at least 26 million people
worldwide
2. Apply evidence-based assessment strategies including assessment of heart and lung sounds,
medication reconciliation, outcome measures. • Prevalence is increasing related to the aging of the population along
with improvements in survival rates
3. Identify programs and strategies designed to reduce hospital readmission and key factors that
have been shown to reduce hospital readmission. • Heart failure places a huge economic burden on our healthcare
system
4. Analyze patient self-management strategies and techniques clinicians can use to facilitate
improved adherence with medical recommendations and treatments. • Median cost for managing a patient with heart failure per year is
estimated to be around $24,383 in the US.1
5. Utilize evidence-based interventions to maximize patient independence and increase physical
activity levels. • Cost of hospitalization for heart failure annually is twice the amount
spent on all forms of cancer. 2
6. Apply heart failure case studies with application of principles to physical and occupational therapy
practice.
3 4

What is heart failure?

• Heart failure is a condition in which the ability of the heart to pump blood
to the lungs and body steadily decreases because of a weakening and/or
thickening of the heart muscle.
What is Heart Failure? • With the weakening or thickening of the heart muscle, the heart loses its
ability to eject blood with each contraction or fill with blood between
contractions. This leads to a decrease in the amount of blood that is
Symptoms, Causes, and Pathophysiology ejected with each contraction, leading to a decrease in the amount of
blood that is ejected each minute. This results in a decreased blood flow
and oxygen delivery to the body, resulting in the heart being unable to
meet the demands of the body.
• The American Heart Association and American College of Cardiology
defined heart failure as a complex clinical syndrome that can result from
any structural or functional cardiac disorder that impairs the ability of the
heart to fill with blood or eject blood 3 .

5 6

3
 Pathophysiology Review of Cardiopulmonary Circulation
• Heart failure is considered a secondary condition. It is caused • If we follow a drop of blood coming back to the heart from the
as a result of any disease process that causes the death of the periphery, what chamber of the heart does the blood reach first?
cardiac muscle cells or cardiomyocytes.
• Potential causes 3
RA
• CAD
• MI PERIPHERY RV
• Cardiomyopathy
• Congenital heart disease
• DM
• Hypertension
• Arrhythmia
• Kidney disease
• Obesity
• Tobacco or recreational drug use
• Medications such as chemotherapeutic drugs
LV LA LUNGS
7 8

Typical Heart Failure Symptoms 4

Diagnostic Challenges in the Geriatric Patient 5
• Weight gain of greater than 2 to 3 pounds in one day • Geriatric patients may have an atypical presentation of heart failure
• Dyspnea • Predominant symptoms in the geriatric patient
• Fatigue • Anorexia
• Generalized weakness
• Nocturia • Fatigue
• Dry, hacking cough • Less common- mental disturbances and anxiety
• Activity or exercise intolerance • An added challenge in diagnosing heart failure in the geriatric patient
• Fluid retention is they may limit their activity level to the point of becoming relatively
comfortable and asymptomatic, making it difficult to recognize a
worsening in their condition.

9 10

Terminology Review Ejection Fraction Versus Stroke Volume

• Ejection Fraction is an important term to understand regarding heart failure. It

refers to the portion of the total blood that is ejected from the heart chamber You have a water bottle with
when the heart contracts. EF= amount of blood ejected with each contraction
(stroke volume)/amount of blood in the chamber of the heart (end diastolic 8 ounces of water in the
volume) x 100. Normal ejection fraction is considered 50 to 70%. Some patients bottle. You take your hand,
with heart failure will have a reduced ejection fraction and some will have a
preserved ejection fraction. squeeze the bottle and
%EF = SV/EDV x 100 squeeze out 4 of your
• Cardiac output is the total amount of blood that is ejected by the heart over the original 8 ounces of water.
course of a minute. It is a product of the stroke volume times the heart rate. • What is your ejection
Patients with both types of heart failure (reduced ejection fraction, preserved
ejection fraction) will have a reduced stroke volume and cardiac output. fraction?
CO=SV x HR • What is your stroke
volume?
11 12

4
 Systolic Heart Failure- Khan Academy Systolic Heart Failure
• Systolic heart failure is a pumping problem, the heart muscle is weakened
• https://youtu.be/FL3Q5Q6IdAY and the ventricle can’t generate enough force to squeeze out a sufficient
amount of blood. Thus, the heart can’t meet the demands of the body.
Because of this, fluid begins to build up in either the periphery or the
lungs, depending on which side of the heart is affected. Systolic heart
failure usually begins in the left ventricle.
• Would a patient with systolic heart failure have a reduced or preserved
ejection fraction?
• Patients with systolic heart failure are said to have an EF of <40%6.
Reduced ejection fraction is considered to be 40 to 50%
• Systolic heart failure is also known as heart failure with reduced ejection
fraction, or HRrEF
13 14

Diastolic Heart Failure-Khan Academy Diastolic Heart Failure

• https://youtu.be/rGAIHFB9FL0 • Diastolic heart failure is a filling problem. It occurs when the heart chambers are
unable to adequately fill with enough blood. Think of the water bottle analogy,
you squeeze the bottle with the same amount of force, there just isn’t as much
water in the bottle to be squeezed.
• There are two main reasons this can occur
• thickening of the heart muscle results in less room in the chamber to fill with blood
• the ability of the heart muscle to relax is decreased or slowed, making it difficult for the
ventricle to fill with enough blood.
• Diastolic heart failure results in a reduced stroke volume and cardiac output.
• Would a patient with diastolic heart failure have a reduced or preserved ejection
fraction?
• Patients with diastolic heart failure will have an EF of >50%7
• Diastolic heart failure is also known as heart failure with preserved ejection
fraction, or HRpEF

15 16

Systolic versus diastolic heart failure Signs/symptoms of left sided heart failure 8

8 ounces of water 4 ounces of o Pulmonary crackles, productive cough

in bottle. water in bottle. o Orthopnea
Decreased force Normal force o Paroxysmal nocturnal dyspnea
when squeezing used when o Fatigue
bottle, resulting in squeezing o Chest pain
2 oz/8 oz = ? EF bottle, resulting o Heart murmur
What is Stroke in 2 oz/4 oz = o S3 and S4 heart sound
Volume? ?EF o Tachycardia
What is Stroke o Weakness, fatigue, confusion, restlessness
Volume? o Cool, pale lower extremities
o Diminished peripheral pulses
***keep in mind, your patient may have a combination of systolic and diastolic
heart failure 17 18

5
Signs/Symptoms of right sided heart failure 8 ACC/AHA Stage A and B “at risk” stages 3
Stage A Patients at risk of These are patients with a
o Ascites, jaundice, enlarged liver developing heart failure history of conditions that
o Edema in the abdomen and lower extremities can put them at increased
o Nausea, vomiting, indigestion, anorexia risk of developing heart
o Nocturia failure such as CAD,
hypertension, or DM. No
o Right ventricular heave current symptoms of heart
failure.
Stage B Patients who have This group includes those
developed structural heart individuals who have had
**As a reminder, your patient may have a combination of both left and disease but have not a previous cardiac incident
right sided heart failure, although it usually starts in the left ventricle, shown signs/symptoms of such as an MI or LVH (left
leading to right sided heart failure heart failure ventricular hypertrophy)
19 20

Stage C and D NYHA Classification of Heart Failure 4

Stage C These are patients that
have current or prior
symptoms of heart failure
with underlying structural
disease of the heart
Stage D These are individuals with
advanced structural
disease of the heart,
marked symptoms of
heart failure at rest. End-
stage heart failure
These individuals are
currently undergoing
heart failure treatment
These are individuals with
frequent heart failure
hospitalizations, possible
referral to hospice services
• NYHA Classification system is based upon how the heart function
affects daily functional activities and activity tolerance
• Class I (mild) puts no limits on physical activity. Everyday activity does not
cause fatigue, shortness of breath, or palpitation.
• Class II (mild) shows slight limitation with physical activity. Patient is
comfortable at rest but may experience fatigue, shortness of breath, or
palpitation with everyday activity.
• Class III (moderate) shows obvious limitation with physical activity. Patient
shows no symptoms at rest but displays fatigue, palpitations, and shortness of
breath with less than ordinary activity.
• Class IV (severe) patient in discomfort with any physical activity. At rest, there
are signs of cardiac insufficiency.

21 22

Compensation 9 Compensation

• During the early stages of heart failure, the decrease in cardiac output stimulates the
sympathetic nervous system (SNS) to increase heart rate and contractility of the
heart in order to preserve the cardiac output.
CO= HR X SV
• Over time, the SNS receptors on the heart become desensitized and decrease in
density, leading to dysfunction of these receptors and a decreased ability to
compensate
• Additionally, the increase in contractility of the heart causes a thickening of the
myocardium. This increases the oxygen demand of the surviving cardiac muscle
cells. The combination of the decreased blood flow and increased oxygen
demand leads to myocardial ischemia and death of further cardiac myocytes.
This causes heart failure to continue to worsen.
23
• Low cardiac output also leads to stimulation of the renin angiotensin system.
• Antidiuretic hormone and aldosterone are secreted. This leads to vasoconstriction along
with sodium and water retention to increase blood volume in order to increase the
ventricular filling volume or preload. Aldosterone has been shown to increase coronary
inflammation, cardiac hypertrophy, myocardial fibrosis, ventricular arrhythmias, and ischemis
and necrotic lesions
CO = SV x HR
• The increased preload leads to increased pressures, leading to an increased stroke volume.
This is known as the Frank Starling Law, the higher the preload, the higher the stroke volume
• With the increased stroke volume, heart muscle cells require more oxygen and with time can
lead to the death of these cardiac muscle cells. Surviving muscle cells compensate by
elongating and growing, contributing to a thickening of the heart muscle.
24

6
 Decompensation 9 Heart Failure Zone Tool 10
Zone Symptoms Action
Green No shortness of breath Continue daily weight checks
Physical Activity levels are normal Continue medications as ordered
• Decompensation happens when the heart is no longer able to No New Swelling Continue low sodium diet
compensate for the decrease in cardiac output and is defined as the Weight gain is stable Continue with physician follow-up
No chest pain visits
presence of new or worsening symptoms that can result in
Yellow Dry, hacking cough Contact physician, patient may need
hospitalization or unscheduled medical care. Worse shortness of breath a change in medications
Increased swelling in legs, ankles and feet
• Patients who are decompensated will present with signs/symptoms Sudden weight gain of >2-3 pounds/24 hours or >5 pounds/week
such as dyspnea, fatigue, weight gain, edema and/or chest pain Discomfort or swelling in abdomen
Trouble Sleeping
• Use of Heart Failure Zone tools can allow patient to monitor for Red Frequent, dry hacking cough Call physician or 911 for immediate
worsening symptoms and possible decompensation Shortness of breath at rest medical evaluation
Increased discomfort or swelling in lower body
Sudden weight gain of >2-3 pounds/24 hours or >5 pounds/week
New or worsening dizziness
Loss of appetite
Increased trouble sleeping/cannot lie flat
25 26

Monitoring for decompensation during

therapeutic interventions Imaging to diagnose heart failure 4

• The goal is to identify decompensation as early as possible, refer back to
physician with symptoms of decompensation
• Vital signs must be monitored before, during, and after therapy treatments
and progression of treatments. If patient doesn’t have the expected vital
sign reaction to exercise, this information needs to be reported to the
patient’s physician
• In order to ensure patient safety, we need to monitor for a worsening of
symptoms, monitor body weight or edema measurements with each
therapy session. Ask your patient about their daily “dry weight”. If patient
is capable of monitoring weight and isn’t, educate patient on importance of
monitoring daily weights using zone tools as a reference.
• Echocardiogram-can be used to determine ejection fraction as well as
determine if it is systolic or diastolic dysfunction by visualizing the
heart size, valves, blood flow, heart shape and pumping action of the
heart
• Chest x ray which may help to identify pleural effusion, pulmonary
edema or enlargement of the ventricles
• ECG is also recommended for detection of other abnormalities than
may either cause or worsen heart failure

27 28

Why should therapists care about

medications?
The medications a patient is taking can have a direct effect on a patient’s ability to perform
and progress with therapy treatments
• Common adverse drug reactions related to use of cardiac medications include increased
urination, dizziness, low blood pressure, nausea, headache, fatigue, and weakness
Heart Failure Medications • Medication administration is considered an IADL 11. “Occupational Therapy practice
framework identifies medication management as an aspect of health management which
places addressing this occupation in the scope of practice of an occupational therapist”
AOTA, 2020
• APTA House of Delegates statement: “Physical therapist patient and client management
integrates an understanding of a patient’s or client’s prescription and nonprescription
medication regimen with consideration of its impact on health, function, movement, and
disability. It is within the physical therapist's professional scope of practice to administer and
store medication to facilitate outcomes of physical therapist patient and client
management.” 12
29 30

7
 Role of therapists ACE inhibitors 13
Older adults experience changes in their ability to metabolize and
eliminate medications and may require adjustments in dosing. ACE inhibitors (ACEI) help manage heart failure as a vasodilator. By dilating the
• Other than therapists, who else spends as much time with their coronary arteries, this helps to increase blood flow to the cardiac muscle cells. In
patients and asks them to do as much as we ask them to do? the periphery, the vasodilation helps to reduce blood pressure in the periphery,
thereby decreasing the workload on the heart
• Assessing ADLS/functional mobility/cognition when medication
changes occur. Notify physician of any adverse effects. Examples Enalapril, lisinopril and captopril
• Medication reconciliation should occur at various timepoints
throughout the plan of care and clinicians should routinely ask their
patients if they have had any medication changes. Possible Low blood pressure, low white blood cell count, and kidney or liver
side problems
effects

31 32

Angiotension II Receptor Blockers (ARBS) Beta Blockers

Beta blockers work by inhibiting the sympathetic nervous system, thereby
helping to preserve the SNS receptor density and sensitivity
ARBS work as a vasodilator like ACEI, but are more tolerable than ACEI. Examples propranolol, metoprolol, acebutolol, atenolol
These medications typically work well for patients with chronic kidney
Possible side fatigue, cold hands and feet, weight gain, shortness of breath,
disease
effects trouble sleeping, and depression
Examples Losartan, Irbesartan, and Valsartan Other clinical • Should be avoided in patients with asthma secondary to
considerations medication may trigger asthma attacks
Possible Side Effects Low blood pressure, elevated • May block signs/symptoms of low blood sugar in patients with
potassium levels, muscle or joint diabetes, including increased heart rate. Diabetic patients
pain, dizziness, drowsiness, should monitor blood sugar
headache, and nausea/vomiting • May blunt heart rate and blood pressure response to exercise.
Clinicians should use additional methods to measure response
to exercise

33 34

Medications used to treat heart failure Direct-Acting Vasodilators16 Shah

Diuretic medications help to reduce fluid retention by ridding the body of sodium
and water11
These medications also work as a vasodilator. Additionally, they
Types inhibit vasoconstriction, leading to an increase in blood flow to the
• Thiazide diuretics heart muscle and decrease workload on the heart
• Examples: include chlorothiazide, chlorthalidone, hydrochlorothiazide, indapamide, metolazone
• Possible side effects: hyponatremia, hypokalemia, decline in renal function, gout, or Examples Hydralazine, nitrates such as isosorbide
hyperglycemia mononitrate, minoxidil
• Loop diuretics
• Examples: bumetanide, furosemide, torsemide Possible side compensatory tachycardia, headache, angina,
• Possible side effects: hypokalemia, hyponatremia, low magnesium levels, and high levels of effects shortness of breath and fluid retention
calcium. These can lead to weakness and possible abnormal heart rhythms
• Potassium sparing diuretics Clinical work well for patients that are unable to tolerate an
• Examples: amiloride, triamterene, spironolactone (higher doses) Considerations ACE inhibitor or an ARB or if ACEI or ARB don’t
• Possible side effects: feeling faint, dizzy, confused, sleepy, and hyperkalemia
manage symptoms
35 36

8
 Aldosterone Antagonists 14 AGS Beers Criteria 15

These medications work by blocking the response of the • List of medications known to have an increased risk of having an
adverse event on the older adult, created by the American Geriatrics
sympathetic nervous system and the release of aldosterone in Society
response to decreased renal blood flow • Included in the Beers Criteria are medications that should be avoided
Examples Two commercially available- Spironolactone and in the geriatric population, referred to as Potentially Inappropriate
Medications (PIM), medications to be used with caution, medications
Eplerenone that should be used with caution in certain older adult populations
(i.e. patients with heart failure), and medications with potential drug-
Possible side Hyperkalemia, cough, dizziness, headache or drug interactions in the older adult population
effects diarrhea • Original list published in 2012 with updates published in 2015 and
2019.

37 38

American Geriatrics Society

Treatment of Heart Failure by AHA Stage 4
Beers Criteria 15
• Digoxin is listed as a PIM for the treatment of heart failure, may cause • Stage A (at risk stage, no signs or symptoms, no history of cardiac
toxicity and be associated with increased mortality in older adults with
heart failure. Most recent update to AGS Beers Criteria recommends event)
digoxin not be used as a first line medication, and when it is used, dosages • Recommend regular exercise
should be below .125 mg. • Low sodium diet
• In patients with heart failure, it is advised that NSAIDs are used with • Recommend smoking cessation if appropriate
caution in patients with asymptomatic heart failure, and avoided in
patients with symptomatic heart failure secondary to they can promote • Treatment of high blood pressure if present
fluid retention and exacerbate heart failure. • Treatment of high cholesterol if present
• Disopyramide should be avoided in patients with heart failure as it may • Limit use of alcohol or recreational drugs
induce heart failure in older adults
• Treatment with an ACEI or ARB if vascular or cardiac condition present
• Dronedarone and cilostazol have potential to increase mortality in heart
failure • Treatment with a beta blocker if hypertension is present

39 40

Treatment of Heart Failure by AHA Stage 4 Treatment of Heart Failure by AHA Stage 4

• Stage B (at risk, no signs or symptoms, structural heart disease • Stage C (structural heart damage present, current or prior symptoms
present) of heart failure)
• Stage A treatment • Stage A and B treatment
• ACEI or ARB if not currently taking • Beta Blocker if not currently taking
• Beta Blocker if history of MI or EF <40% if not currently taking • Diuretic medication
• Aldosterone antagonist if history of MI or DM with an EF of <35% • Aldosterone Antagonist if not currently taking and ACEI or ARB and beta
• Possible surgery to treat cause of heart problem (valvular surgery, treatment blocker don’t manage symptoms
of blockage, etc) • hydralazine/nitrate combination if other meds don’t manage symptoms
• Medications to reduce HR if >70 bpm
• Tracking weight daily
• Possible fluid restrictions

41 42

9
 Treatment of Heart Failure by AHA Stage 4

• Stage D (end stage heart failure, patient symptomatic at rest with

advanced structural damage to heart muscle)
•
•
Treatment of Stage A, B and C
Possible Ventricular Assist Device Common Lab Tests
• Possible heart transplant
• Possible Palliative or Hospice Care

43 44

Lab values 16 BNP 7,16

• BNP BNP Level Interpretation

• B-type natriuretic peptide is secreted by the heart to help
regulate our blood pressure and maintain proper fluid >Normal to <200 pg/dl Likely compensated heart failure
balance. It is released in response to increase in
ventricular volume and pressure overload. Levels are
elevated with fluid retention associated with CHF due to > 200 to < 400 pg/dl Likely moderate CHF
pressure overload and increase in ventricular volume.
• Normal BNP levels are relative to age and gender, but > 400 pg/dl Likely moderate to severe CHF
roughly 35 to 93 pg/dl in males and 64 to 167 in females

45 46

BNP and NYHA Classification System 16 Pro BNP and Troponin 7

Functional class 5th to 95th Median • Updated AHA guidelines also advocate for the use of Pro BNP to
screen for heart failure as it is also a natriuretic peptide. Values will
percentile be different and cannot be used interchangeably
I 15 to 499 pg/ml 83 pg/ml • Elevated troponin levels can be elevated in acute or chronic
decompensated heart failure and is present due to myocardial cell
II 10 to 180 pg/ml 235 pg/dl injury or death

III 38 to >1300 pg/ml 459 pg/dl

IV 147 to >1300 pg/ml 1119 pg/ml

47 48

10
 Complete Metabolic Panel (CMP) in Heart
Complete blood count in heart failure 7
Failure 17
Patient with heart failure can present with anemia. Iron
deficiency anemia has been associated with reduced exercise • Kidney function tests: BUN and Creatinine levels indicate worse
mortality. Elevated BUN levels >45 mg/dl at discharge have a higher
capacity in heart failure. Patient may have CBC completed to readmission rate.
determine hemoglobin levels
• Low sodium and potassium levels also associated with worse
mortality along with resistance to diuretic medications. Patients with
low sodium levels have also been found to have longer hospital stays
Na Cl Bun
GLUC
K HCO3 Cr

49 50

Normal vital sign response to exercise 18

• Increase in systolic blood pressure relative to MET level of exercise
• We can expect a 10 mm increase in systolic blood pressure for every MET of activity.
Precautions and Response is decreased with patients taking vasodilators, calcium channel blockers, ACEI
and beta blockers.
Contraindications • Light activity (leisurely walking, standing/performing basic ADLs) is 3 METs.
• Moderate activity (walking at a brisk pace, heavy cleaning such as mopping,
washing windows) is 6 METS
• Vigorous activity (hiking, participation in sports, shoveling) is greater than 6 METs.
• Increase in heart rate at a rate of around 10 beats per minutes for every 1 MET of activity.
**This response is blunted for patients on beta blockers
• A post-exercise decrease in heart rate by at least 12 beats during the first minute after
exercise or 22 beats by the end of the second minute after exercise. Failure of the heart
rate to reduce normally after exercise is strongly associated with an increase in mortality.
51 52

Precautions/Relative contraindication to exercise 19 Precautions/Relative Contraindications to exercise 19

• Body mass increase > 2 to 3 pounds in 24 hours or > 5 pounds over • NYHA Class IV HF status
a week
• Continue to monitor vital signs and patient status, repeating vital • Use of IV dobutamine in the acute care setting
sign measurements as needed. Stop exercise and contact physician • Heart rate > 100 bpm in supine at rest
if patient has
• Hypertensive response to exercise with a SBP of > 250 mm hg • Complex ventricular arrhythmia present at rest or with
• Systolic blood pressure decrease with exercise exertion
• Decrease in SBP below the pre-exercise resting value or > 10
mm Hg is abnormal and is often associated with myocardial • Moderate aortic stenosis
infarction, left ventricular dysfunction and has been • Abnormal response to exercise
associated with an increased risk of subsequent cardiac
events
• Systolic blood pressure > 180 mm hg or diastolic blood pressure
> 110 mm hg18
53 54

11
 Absolute Contraindications to Exercise 19
• Decompensated heart failure
• New onset of atrial fibrillation
• Uncontrolled Diabetes (if blood sugar < 100 mg/dl increase carbohydrate intake
and recheck, if blood sugar is > 250 mg/dl exercise with caution, if blood sugar is

•
>18 300 mg/dl hold exercise until confirmation of no presence of ketones in urine)
Acute illness or fever
Patient Evaluation
• Symptomatic aortic stenosis
• High degree AV block
• Untreated life-threatening cardiac arrhythmias
• Untreated thrombophlebitis or embolism
• Pericarditis or myocarditis
• Further reduction in exercise tolerance, or increased dyspnea at rest/upon
exertion over the last few days
• Exercise-training induced hypotension
55 56

Patient evaluation Patient evaluation

• Proceed with patient evaluation as normal, keeping in mind key areas
of assessment in patients with heart failure
Assessment of lung sounds
• Daily weight, what is your patient’s daily dry weight? Is it safe to proceed
with evaluation? • When patient has fluid build up in the lungs, you will typically hear fine
inspiratory crackles, also known as rales
• Assess patient’s ability to obtain and track a daily weight • Lung sounds in heart failure
• Edema Assessment of heart sounds
• Are circumferential measurements necessary?
• Normal heart sounds (lub-dub) are referred to as the S1 and S2 heart
• Pitting edema measurement 20 sounds
Grade Indentation depth Rebound time • In heart failure, we may hear an extra heart sound, either the S3 or the S4
1+ Barely visible Immediate
heart sound
• S3 and S4 can be best heard using the bell of the stethoscope
2+ 3-4 mm 15 seconds or less • S3 heart sound video
3+ 5-6 mm 15 to 30 seconds • S4 heart sound video
4+ 8 mm or more > 30 seconds

57 58

Patient evaluation Modified Borg dyspnea scale

• Dyspnea
• Assess for dyspnea. Initially, patients with heart failure will experience dyspnea just
with exertion, but as the heart failure worsens, they may become short of breath even
at rest.
• Patients with heart failure may experience orthopnea, or positional shortness of
breath any may have difficulty lying flat. Have patient demonstrate ability to transfer
supine <> sit and assess for dyspnea
• Use Modified Borg dyspnea scale or other scale to assess severity of dyspnea before
activity, after activity and in different positions.
• Does the patient require use of oxygen?
• Sleep disturbances
• Number of waking/night, where does patient sleep, how many pillows required to
sleep in bed
• Document history of sleep apnea, increased prevelance in patients with heart failure
and can contribute to increased mortality and morbidity risk
59 60

12
 Patient evaluation Borg Rating of perceived exertion

• Assess patients’ cardiorespiratory function and endurance

• Monitoring blood pressure, heart sounds, lung sounds, heart rate,
O2 saturation levels, and perceived exertion levels at rest, with
activity, and after activity as needed to monitor for normal
response to exercise. If patient doesn’t have the expected vital
sign response, communication with physician may be needed.
• Use of the Borg Rating of Perceived Exertion as a clinical tool to
assess patient response to exercise may be helpful to monitor
response to exercise if patient is taking a medication such as a
beta blocker and should be used in combination with heart rate.21

61 62

Past Medical History Patient-Centered Goal 24

• Obtain thorough medical history, including any prior heart failure
hospitalizations, cardiac events or surgeries
• Elevated depressive symptoms is common in heart failure with
symptoms present in up to 75% of patients 22
• COPD commonly present in heart failure with 20 to 30% of chronic HF
failure patients having COPD as a comorbidity 23
• In order to help increase patient engagement and adherence with
self-care measures and therapy interventions, it is important to have
the patient establish a goal
• Patients are most likely to make the greatest gains in therapy when
the interventions are related to something meaningful to the patient.
Collaboration with patient is essential and goals should be functional
and related to disabilities or functional limitations and not
impairments

63 64

Patient-Centered Goal 24

• Questions that may help patient determine functional goal

• What do you currently need help completing that you would rather do for
yourself?
• What problems do you anticipate regarding your return to work, hobbies, or
leisure activities?
Outcome Measures
• What are some normal activities that you like to complete at home?
• What are some of your normal hobbies or leisure activities that you are
unable to complete at this point?
• Imagine it’s several months down the road, what would you like to be doing?

65 66

13
 Outcome measures appropriate for patients
6-minute walk test25
with cardiopulmonary dysfunction
• When choosing an appropriate outcome measure, it’s • Considered the gold standard of tests for measuring cardiopulmonary
endurance
important to consider
• What is it that I need to measure with this patient • Equipment needed: blood pressure cuff, stethoscope, Borg Rating of
Perceived exertion scale, dyspnea scale, stopwatch, orange cones and
to capture evidence of decline? portable chair
• How much space/time will this test require? • You will need a hallway > 100 feet in length, marking end of course
• Do I need any special tools to perform test? with orange cones

67 68

Testing guidelines-6MWT Absolute/relative contraindications 26

• Test can be performed indoors. If performing outdoors, can be • Absolute contraindications

administered if weather is appropriate on a flat surface. Choose same
location for repeat testing • unstable angina during the previous month
• Patients can use their usual assistive devices when test performed • myocardial infarction during previous month
• Repeat testing should occur around the same time of day to decrease the • Uncontrolled arrhythmias causing symptoms
effect of fatigue • Acute myocarditis
• If patient has oxygen ordered, oxygen should be worn during testing • Uncontrolled acutely decompensated heart failure
• Allow patient to rest and obtain a set of resting vitals prior to administering • Acute pulmonary embolism
test
• Relative contraindications
• Monitor patient status during test and immediately stop test if patient
experiences chest pain, intolerable dyspnea, leg cramps, diaphoresis, • resting heart rate > 120
staggering, or pale or ashen appearance • SBP > 180 mm Hg
• DBP > 100 mm Hg
69 70

Administering test-6MWT Administering 6MWT

• Obtain resting vitals including pulse oximetry
• Have patient stand and give a baseline dyspnea score utilizing Modified Borg
Dyspnea scale
• Instruct patient as follows: “The object of this test is to walk as far as possible for 6
minutes. You will walk back and forth in this hallway. Six minutes is a long time to
walk, so you will be exerting yourself. You will probably get out of breath or
become exhausted. You are permitted to slow down, to stop, and to rest as
necessary. You may lean against the wall while resting, but resume walking as
soon as you are able. You will be walking back and forth around the cones. You
should pivot briskly around the cones and continue back the other way without
hesitation. Please watch the way I turn without hesitation (demonstrate). Are
you ready to do that? I am going to use this counter to keep track of the number
of laps you complete. I will click it each time you turn around at this starting line.
Remember that the object is to walk as far as possible for 6 minutes, but don’t run
or jog. Start now, or whenever you’re ready”
71
• After the first minute, tell the patient “you are doing well. You have 5 minutes to
go”
• After two minutes, tell the patient “keep up the good work, you have 4 minutes to
go”
• After three minutes, tell the patient “You are doing well. You are halfway done”
• After four minutes, tell the patient “keep up the good work. You have only 2
minutes left”
• After five minutes, tell the patient “You are doing well. You have only 1 minute to
go”
• When 15 seconds remain, tell patient “In a moment I’m going to tell you to stop.
When I do, just stop right here you are and I will come to you.”
• Tell the patient to stop at end of timer. Mark the spot they stopped
• Record a post test dyspnea score.
72

14
 6 MWT Outcomes 26 Short Physical Performance Battery (SPPB) 27,28
• Requires 5 to 10 minutes to administer
• Minimal detectable change for geriatric patients is 58 meters • 3 areas are assessed
• Increased mortality risk and hospitalization risk with patients with • Balance- patients are asked to balance with feet together, then semi-tandem,
reduced performance in 6MWT and then tandem position
• Feet together- 1 point if patient able to hold 10 seconds
• Most studies agree that a 6MWT distance of < 300 meters is
• Semi-tandem-1 point if patient able to hold 10 seconds
indicative of a poor prognosis • Tandem- 1 point if patient can hold 3 to 9.9 seconds, 2 points if can hold > 10 seconds
• Distance of < 200 meters for stable HF patients may indicate an • Gait speed- patients complete a 3- or 4-meter walk test, 0 to 4 score
increased risk of death depending on speed
• Weakness- patients are asked to complete 5 times sit to stand as quickly as
• Stable performance of 6MWT over a year suggestive of increased possible, 0 to 4 score depending on time required
survival rates
• Total score ranges from 0 to 12

73 74

SPPB and 6MWT in heart failure 2-minute step test 29

• FRAGILE-HF study looked at the prognostic value of SPPB and the 6MWT 28
• Retrospective study looking at older patients hospitalized with acute exacerbations of
heart failure and prognostic value of the SPPB and 6MWT
• Patients with lower SPPB scores had a worse prognosis
• Patients with lower SPPB scores (<7) also had an increased risk of adverse events
• Patients with shorter 6MWD had worse outcomes (less than the median value, or
242 meters)
• 6MWT demonstrated a better risk prediction than the SPPB and also showed
better prognostic value over conventional heart failure risk factors.
• Administering test
• To determine the appropriate height of step: determine the point midway
between the patella and iliac crest. Use a marker on the wall to mark this
point
• Ask the patient to march in place for 2 minutes, instructing patient on
appropriate step height
• Instruct patient to rest as needed or stop test as needed
• Count the number of times the patient raises the right knee during the test
• Use of Borg RPE or Modified Borg before and after administration of test can
be beneficial as well. Monitoring vital signs before and after test is
recommended.
• Multiple studies have allowed patient to utilize assistive device during the test

75 76

2 minute step test, EF and NYHA functional Atlanta Heart Failure Knowledge Scale 31
impairment levels • The Atlanta Heart Failure Knowledge Test was created to measure patient and
family knowledge about heart failure, treatment and self care strategies.
• Wegrzynowska-Tedorczyk et al 2016 study 29
• It is a 30-question instrument to assess patient knowledge in areas such as diet
• Mean age of participants 59 with a mean left ventricular EF 32% and nutrition, pathophysiology, medications, symptoms, daily weighing and
NYHA class Mean number of steps physical activity behaviors. Studies have shown that patients and caregivers lack
knowledge regarding the actions of heart failure medications.
I-II 92
• Decreased knowledge in relation to self care activities in heart failure such as
III-IV 79 adherence to a low sodium diet, daily weights and adherence with daily
Group 88 medications is a contributor to rehospitalization in heart failure.
• Alosco et al 2013 study • Studies of telephone education and counseling in patients with heart failure have
demonstrated a 46% reduced rehospitalization rate at 3 months and 48% at 6
• Mean age 68 with a mean left ventricular EF 42% 30 months
Gender Mean number of steps • Emory University has created an answer key along with recommended education
Male 70 for each question that is answered incorrectly
Female 57
Group 65
77 78

15
Patient evaluation-Quality of life and Self-Care
Measurements
• Consists of Mini-Cog and the Medication Transfer Screen-Revised
• Kansas City Cardiomyopathy questionnaire is free to use and designed
to measure health related quality of life for patients living with HF. It
is a 12-item questionnaire (KCCQ-12) that has been shown to be valid
and reliable. Original instrument was 23 items. Studies have shown
a high KCCQ-12 score at discharge from hospital associated with a low
readmission rate 32
• Self-Care of Heart Failure Index (SCHFI) assesses adherence to
recommended self-care instructions, recognition of symptoms of
decompensation and actions required to control these symptoms,
and confidence in ability to perform self-care activities. Overall score
of 0 to 100, with scores >70 indicating adequate self-care 33
79
Interventions
81
Exercise Guidelines
• Exercises need to be tailored to the patient’s individual
level of tolerance with continuous monitoring of patient
including appropriate vital sign response.
• If patient’s exercise tolerance is very limited
• Begin with intervals of 5 to 10 minutes of exercise, 2-3 times
per week.
• Progress minutes of exercise gradually, as tolerated, to 20 to 30
minutes, 3 or more times per week.
• Educate patient on self monitoring of blood pressure, heart
rate, oxygen saturation, and Borg RPE. 35
83
16
Revised Medi-Cog ( Medi-Cog R) 34
• Mini-Cog
• Three word recall at two minutes- banana, sunrise, chair. Each word is worth 1
pount
• Clock drawing task- patient is asked to draw a clock showing 10 minutes after 11,
worth 2 points
• Medication Transfer Screen-Revised
• Patient is given a pill planner and 4 fake prescription bottles. Patient is asked to
organize prescriptions into the pill planner. Final task is for the patient to count
the number of pills in Saturday row and report to examiner.
• Total of score of 5 points, one point for correct distribution of each medication
and one point for correct pill count
• Cut-off score of <8 indicates impairment and demonstrates good
sensitivity and specificity
80
Changes to Exercise Tolerance and Adherence
to Exercise Program 18
• Exercise capacity is reduced by around 30 to 40%
• Lower peak HR, peak stroke volume, and peak cardiac output response to
exercise
• Vasodilation of the larger blood vessels is decreased, limiting blood flow to
the body
• Changes in biochemistry of skeletal muscle limiting oxidative capacity
• Exercise adherence for patients with heart failure is approximately
40% at one year mark
82
MET levels and Recommended Maximal
Activities 36
• MET, or Metabolic Equivalent levels are based upon the amount of energy
expenditure required to complete a task. Resting MET levels are
considered to be 1 MET, light activity is 3 METs, and moderate activity is
considered 6 METs
• MET levels in a particular patient is relative to that patient’s current health
status. A patient heart failure may be working at a vigorous level while
performing just basic ADLs.
• Patients with heart failure should be taught to monitor exertion levels with
the use of the Borg RPE and dyspnea scale along with monitoring of vital
signs. Patients should also be taught energy conservation and work
simplification techniques such as limiting the amount of work, planning
ahead, organizing work, using appropriate equipment, using effective
biomechanical methods, and resting as needed
84
 Recommended MET levels NYHA Stages 36 Recommended MET levels NYHA Stages 36

• Stage IV • Stage II
• Recommended MET level 1.5 • Recommended MET level is 4.5
• Examples of Occupations and Activities 1.5 METs • Examples of Occupations and Activities at 4.5 METs
• Grooming and bathing in a seated position
• House cleaning
• Dressing in a seated position
• Moderate effort walking
• Stage III • Grocery shopping
• Recommended MET level is 3.0 • Gardening
• Examples of Occupations and Activities at 3 METs
• Dressing
• Stage I
• Cooking • Recommended MET level is 6.5
• Light house cleaning • Examples of Occupations and Activities at 6.5 METs
• Making a bed • Stationary cycle
• Bathing in a standing position • Climbing stairs
• Leisurely walking
• Carrying groceries
85 86

HF-ACTION Study37 Strength Training 38

• Study looking at 2331 HFrEF patients between the years 2003 through
2007
• Participants completed 3 months of supervised exercise at moderate
intensity 3 times a week
• Study found exercise was associated with a reduction in mortality and
heart failure hospitalizations
• Study confirmed safety and clinical benefit of exercise with HFrEF patients
and aided in CMS approval and coverage of cardiac rehab for HFrEF
patients
• Study also demonstrated aerobic exercise results in improvements in
skeletal muscle, vascular function, respiratory function, and neuro-
hormonal systems
• Strength training for upper and lower extremities and trunk using light
weights, resistance band, weight machines or body resistance begin
with low resistance and high repetitions, avoiding the Valsalva
maneuver
• May begin strength training with 1 set and progress to 3 sets of each
exercise, performing 10 to 15 repetitions per set 2 to 3 days per week
• Once patient able to lift a weight 10 to 15 repetitions without muscular
fatigue, increase amount of weight lifted to an amount the patient can
lift only 8 to 10 reps without having to stop due to muscular fatigue
• Older persons with heart failure have an increased risk of skeletal
fracture (e.g. hip fracture) and require supervision or restrictions for
exercise modalities that can cause increased risk for falls

87 88

Aerobic training 18,38 Flexibility Exercises 18

• Patients can initially work with light intensity (40 to 50% of VO2 max),
progressing to moderate intensity (60 to 80% of VO2 max).
• Moderate intensity aerobic training has strong evidence to support
use in therapy programs to decrease mortality in patients with heart
failure.
• Protocols include gradually progressing to a frequency of 3 to 5 times
per week, with a duration of 20 to 45 minutes of continuous exercise
or interval training.
• Types of exercise recommended include treadmill or free walking and
stationary cycling
• Recommendations
• Minimal frequency of 2 to 3 days a week with daily flexibility program most
effective
• Muscles should be stretched to the point that patient feels tightness or slight
discomfort
• Hold time should be 10 to 30 seconds for static stretching, 2 to 4 repetitions
of each stretch
• Types of stretching include static, dynamic, and/or PNF stretching

89 90

17
 Cardiac Rehab 39
• Rehabilitation services after HF hospitalization that includes exercise,
education, and psychological counseling aimed at reducing mortality.
It is divided into 3 phases
• Phase 1: occurs up to 4 weeks after hospitalization, includes breathing
exercises, peak flow spirometry, and walking exercises
• Phase 2: early outpatient services that includes physical exercise and
respiratory exercise aimed at improving exercise capacity and improving
quality of life
• Phase 3: long-term outpatient services that includes physical activity,
mindfulness education, counseling, and heart failure education
91
High Intensity Interval Training (HIIT) 42
• Studies have been showing an improvement in cardiovascular health and
clinical outcomes with high intensity interval training
• Systematic review of studies utilizing high intensity interval training in
heart failure patients
• HIIT showed improvements in VO2 peak greater than other forms of exercise,
however, improvements were not maintained at one year follow-up
• HIIT showed no difference in LVEF, vascular function, blood pressure and adverse
events when compared to other forms of exercise
• HIIT showed similar improvements in quality of life when compared to other forms
of exercise
• Concerns about feasibility of this form of exercise with HF patients due to intensity.
Recommend a gradual increase in intensity and shorter duration of high intensity
intervals
93
Inspiratory Muscle training
• Protocols include beginning training with light resistance (30% max
inspiratory pressure) and gradually progressing to moderate
resistance (60% max inspiratory pressure).
• Optimal frequency including performing two 15-minute sessions daily
or 30 minutes once daily, taking rest breaks as needed
• Patient will need to gradually increase reps and take rest breaks as
needed. Instruct patient to take rest breaks as needed, but perform
as many reps as possible during time frame
• If your patient also has a history of COPD, be sure to include
expiratory muscle training in your therapy program to avoid trapping
of air.
95
18
Interval Training 40
• Many patients with heart failure are unable to tolerate continuous
exercise. These patients may benefit from interval training in one
session, or even possible multiple sessions over the course of a day if
your setting allows (Long term care)
• Patients want to perform a warmup and cool down period of light
intensity activity
• Optimal protocol appears to consist of short intervals of moderate
intensity exercise with recovery periods consisting of light activity.
• Interval training has been shown to produce greater improvements in
VO2 peak, LVEF, and 6MWD when compared to continuous exercise in
patients with heart failure. 41
92
Inspiratory Muscle Training
• Patients with heart failure can experience weakness of respiratory muscles, as
well as increased airway resistance. Patients may experience early onset of
fatigue with exercise training, and patients may benefit from inspiratory muscle
training. 43
• Due to changes in ventricular function, reduced lung compliance, increased
airway resistance, patients with HF have an altered breathing pattern. This could
lead to patient’s experiencing increased respiratory muscle fatigue, leading to
decreased respiratory muscle function and decreased activity and exercise
tolerance
• A systematic review of 13 eligible studies found inspiratory muscle training
resulted in an improvement in inspiratory muscle strength, functional capacity
and quality of life. Greatest improvements found in studies that utilized training
loads of >60% max inspiratory pressure and longer intervention times.44
• Use of a respiratory muscle trainer with threshold device has been found to be
most beneficial. Example is the Respironics Threshold IMT Device.
94
Aquatic Therapy 45
• During swimming, the hydrostatic pressure compresses superficial veins,
particularly in the lower extremities and the abdomen, causing a blood
volume shift to the chest and heart
• Decompensated heart failure is an absolute contraindication to aquatic
therapy
• Patient with severe HF should remain in upright position and submerge
body in water no deeper than the xiphoid process.
• Obtain physician’s clearance, as well as recommendations for water
temperature and time spent in pool.
• Patient should be closely monitored for cardiac symptoms and changes in
vital signs.
96

Other Exercise Modalities 40
• Tai Chi- shown to improve quality of life in patients with HF. More research
needed to demonstrate positive effects on clinical factors as well as
exercise tolerance
• E-stim- for patients with unstable HF, may be a good alternative for muscle
strengthening. Has been shown to improve muscle sympathetic nerve
activity, vasoconstriction, exercise tolerance, muscle strength and quality of
life in patients with HF
• REHAB-HF study- patient received exercises in the following 4 domains:
balance, strength, mobility and endurance. Exercises were tailored to
patient’s individual level of exercise tolerance and progressed as patient
able. Study showed improvements in SPPB score along with fewer
rehospitalizations. Patients who were rehospitalized had shorter hospital
stays. 46
Medication Management Interventions and
Strategies 47
• Study of 61 patients with NYHA Class II and Class III heart failure with an
average of 16.9 medications including prescription, over the counter, and
herbal medications
• Strategies utilized
• Simplifying medication management by use of a pill box or marking medications to
ease organization
• Synchronizing medication schedules with daily activities such as ADLs
• Use of a caregiver to assist with medication management
• Use of a chart or a log to track when medications were taken
• Increased awareness of the value of medications. An example would include a
patient understanding frequent trips to the bathroom indicated diuretic medications
were working and helping keeping their heart healthy

97 98

Medication Management Strategies 48

• APTA Clinical Practice Guidelines (CPG) recommended treatments for HF
• Provide patient a written list of current medications to be used as a
reference
• During care transitions, a updated list of medications should be
provided to the subsequent provider
• All clinicians should reconcile medications at different timepoints,
inquiring about any new or changed medications
• Education should be provided including purpose of each medication,
changes in dose or frequency and which meds to stop, start or
change, when to take medications, and possible side effects
APTA Clinical Practice Guidelines 9
• Advocate for increased total daily physical activity. Recommendation is 150 minutes
per week of moderate-intensity physical activity OR 75 minutes per week of vigorous-
intensity physical activity
• Educate on chronic disease management behaviors
• Daily weight measurement and report increases greater than 2 to 3 pounds in 24 hours or 5
pounds over 3 days
• Recognition of signs and symptoms that may indicate worsening of heart failure
• Utilizing Red-Yellow-Green zone tool and following action plan
• Follow a nutrition plan with low sodium diet
• Medication management and medication reconciliation at various points during the continuum of
care. Reconciliation includes comparing all medications the patient is taking to an updated
medication list from patient’s physician

99 100

APTA Clinical Practice Guidelines

APTA Clinical Practice Guidelines
• CPGs continued
• CPGs continued
• Prescribe aerobic exercise training for stable, NYHA Class II or III HF • Prescribe high-intensity interval exercise training in stable, NYHA Class II to
patients III HFrEF patients
• 20 to 30 minutes per day • > 35 total minutes of 1 to 5 minutes of high intensity exercise (>90%) alternating with
• Intensity: 50% to 90% peak VO2 1 to 5 minutes of rest at 40 to 70%. Rest intervals should be shorter than the work
intervals
• Frequency: 3 to 5 times per week • Frequency 2 to 3 times per week
• Duration: at least 8 to 12 weeks • Duration: at least 8 to 12 weeks
• Mode: walking, treadmill, bicycle or dancing • HIIT has been shown to reduce HF-related hospital admissions and hospital days, but
not better than other intensities of exercise training
• Aerobic training has been shown to reduce HF-related hospital admissions as well
as hospital days • Prescribe upper and lower body resistance training
• Time: 45 to 60 minutes per session
• Meta-analysis demonstrated no deaths in 60,000 exercise hours along with a
• Intensity: 60 to 80% 1RM
reduced risk of adverse events in exercising patients when compared to controls
• Frequency: 3 times per week
• Duration: at least 8 to 12 weeks
101 102

19
 Occupational Therapy for Individuals Living
APTA Clinical Practice Guidelines
with Heart Failure-AOTA 36
• CPGs continued
• Prescribe inspiratory muscle training
• Time: 30 minutes/day or less if using higher intensity training (>60% max inspiratory • Purpose of article is to identify education and strategies for best
pressure) practice for Occupational Therapy when working with heart failure
• Intensity: >30% max inspiratory pressure patients
• Frequency: 5 to 7 days a week
• Duration: at least 8 to 12 weeks • Recommended interventions
• Utilization of threshold or similar device is recommended (one that provides consistent • Provide strategies designed to allow patients with heart failure to acquire
resistance such as the Respironics threshold IMT by Phillips)
• Prescribe neuromuscular electrical stimulation habits and behaviors shown to promote positive disease management
• Time: 30 to 60 minutes per session • Educate patient and caregivers to increase physical activity through ADL and
• Waveform: biphasic symmetrical pulses at 15 to 50 hz IADL participation
• Intensity: on/off time 2/5 seconds, pulse width for larger LE muscles should be 200 to 700 • Modify and adapt daily tasks to allow continued activity engagement as the
ms and .5 to .7 ms for smaller muscles
• Frequency: 5 to 7 days/week disease progresses. Throughout disease progression, ensure participation in
• Duration: at least 5 to 10 weeks daily physical activity and maximize independence with ADLs.

103 104

Occupational Therapy for Individuals Living
with Heart Failure-AOTA 36
• Recommended interventions
• Incorporate stress management and coping activities to help to protect the
body from known stressors
• Positive self-task-changing negative thoughts to positive thoughts
• Emergency stress-stoppers-actions performed at the moment the
stressful activity is being performed. Activities performed are situation
based and vary dependent upon type of activity, intensity, and number of
stressors present. Problem solve with patient stress-stoppers to be used
when stressors are encountered
• Counting to 10 before speaking or reacting
• Break down bigger problems into smaller parts or tasks, taking one step at a
time
• Stress-busting activities-educating patients to engage in a meaningful
hobby or occupation that will have a positive impact on their health-
sharing coffee with a friend, going for a walk, reading a book
Occupational Therapy for Individuals Living
with Heart Failure-AOTA 36
• Recommended interventions
• Educate on energy conservation and work simplification techniques such as
limiting the amount of work required to complete task, planning ahead,
organizing, using appropriate equipment, utilizing appropriate biomechanical
methods, and resting as needed
• Instruct on lifestyle modifications including avoiding tobacco, being more
active, and choosing good nutrition
• Educate on medication management strategies
• Assess for caregiver burden and train to recognize signs and symptoms of
caregiver burnout
• Promote development of a recommended exercise program that includes
aerobic exercise, flexibility, and strength training

105 106

Heart Failure Hospitalization 48

• More than 1 million people are hospitalized with heart failure annually
• Studies have found that a single intervention to prevent hospital
readmission may not be effective and transitions of care should be
Heart Failure Hospitalization individualized and multi-faceted
• Hospital to home initiative has successfully reduced hospital readmission
rates. 3 out of 10 of the key practices of the program are centered around
medication management- education on purpose of medications, changes in
dose or frequency, which to stop, which to start and how to take them
correctly
• Poor adherence to discharge instructions can lead to worsening HF and
readmissions. The recommended 1 hour of comprehensive patient
education has been difficult to put into practice

107 108

20
 System-based readmission factors 48 System-based readmission factors 48
Decreased readmission risk from a long-term care facility • Coordination of care between disciplines
• Hospitalization occurred at a hospital with dedicated HF services • Should include a handoff to subsequent providers
• Follow-up visit scheduled prior to discharge from hospital • Effective transitions of care with 8 common themes
• Use of teach back method bundled with prompt follow-up appointments and • Planning for discharge
phone calls • Multiprofessional teamwork, communication and collaboration
• Post hospital follow up phone calls as close to discharge date as possible • Timely, clear, and organized information
• determine if patient had medication prescriptions filled • Medication reconciliation and adherence
• Access whether or not patient has obtained the appropriate DME • Engaging patient in social and community support groups
• Clinicians should also check on patient well-being, review or reinforce discharge • Delivering patient education on monitoring and managing signs and
instructions, and address any new or worsening problems that could lead to an adverse symptoms after discharge
event • Outpatient follow up
• Clinician should report any worsening in condition to the appropriate provider
• Advanced Care Planning and End of life care

109 110

System-based readmission factors 48 System-based readmission factors 48

• Palliative care with improvement in symptom management
• Palliative care can be initiated much sooner than hospice care and use Increased readmission risk
is independent of prognosis or goals of treatment.
• Patients receiving palliative care have shown an improvement in • Admitted to a teaching hospital
symptom burden, quality of life, and self-efficacy • Patient left hospital against medical advice
• Nurse home visits along with follow up with disease • Discharged to home
management clinics with multidisciplinary HF team • Medicaid payor source

111 112

Patient-centered readmission factors 48 Patient-centered readmission risks 48

Increased readmission risk Decreased readmission risk
• Elevated troponin levels
• Serum Creatinine 1.0 – 2.5 mg/dl • Normalization of sodium levels at discharge to 135-140 mEq/dl
• Systolic Blood Pressure > 130 • Predischarge BNP level < 430 pg/ml
• African American ethnicity • Medication adherence
• History of kidney disease • Participating in social and community support groups
• History of diabetes • Monitoring for signs and symptoms of worsening heart failure after
• Previous HF hospital admission within one year discharge
• Advanced age • Adherence with self-care recommendations
• History of atrial fibrillation • low sodium diet
• Poor health-related quality of life
• Presence of depression • staying physically active
• Poor adherence to hospital discharge instructions • monitoring weight
• taking medications as prescribed
113 114

21
 Decreased health care literacy and heart
failure hospital readmissions 31
• Frequent hospital admission in heart failure has been directly
associated with decreased adherence with medication regimen and
recommended lifestyle modifications
• Lack of health care literacy and knowledge is a contributor for
hospital readmission
• Use of teach back method and instruments to measure health care
literacy in heart failure after education delivery is essential to assess
patient understanding of education provided
• Factors that may negatively impact a patient’s health literacy include
fewer years of schooling, old age, and greater number of years living
with chronic illness 49
115
Praise of the HRRP 51
• CMS has stated that the program has helped to reduce hospital
readmission rates for heart failure
• Medicare has saved millions of dollars through penalties since the
beginning of the program. Between 2014 and 2016, Medicare saved
$564 million.
• It has been instrumental in the development of programs to increase
awareness of heart failure management as well as programs to assist
patients during care transitions. Poor care transitions between health
care settings have been linked with increased hospital readmission
risk
117
Trends since program initiation2,50,51,52,53
• Multiple studies have looked at HF readmission rates since program
implementation. Gupta et al reported a modest improvement in
readmission rates during the time period 2010 through 2014. Khan et
al also showed improvement through 2013, no change in 2014, and
then an increase since 2015.
• Khan et al study looking at HF readmission trends from 2010 to 2017
• There was a .59% increase in HF related 30-day readmission rates (a .1%
increase in the study represented >10,000 patients)
• There was a 1.2% increase in HF related 90-day readmission rates
• Wadhera et al looked at ED visits and observation stays and found an
increase in stays for those conditions targeted by the HRRP 53
119
22
Hospital Readmission Reduction Program
(HRRP) 50
• Nearly 1 in 4 heart failure patients admitted to the hospital are readmitted
to the hospital within 30 days. 60-day readmission rate is nearly half.
• It is estimated that one-fourth of hospital readmissions could be
prevented.
• In 2009, CMS started publicly reporting 30-day hospital readmission rates
for heart failure, among other conditions.
• In 2010, CMS added a financial penalty for those hospitals with higher-
than-expected readmission rates (up to 3% of their annual Medicare
reimbursement)
• Penalty phase implemented in 2012
116
Criticism of the HRRP
• Some feel hospitals are being unfairly punished for things beyond their
control
• There is concern that the program incentivizes readmission avoidance over
patient safety
• Additional concerns about “gaming” the system by up-coding claims
• Improvement in readmission rates began before HRRP was started and
improvements have mostly been stagnant since implementation of the
penalty phase in late 2012
• Program wasn’t tested before it was initiated.
• Some believe the program should have additionally measured ED visits
along with observation stays
118
Trends since implementation2
• There has been a disproportionate rise in observation status stays for
medical conditions that are a part of the HRRP with a financial
penalty for hospital readmission
• The HRRP utilized risk adjustment strategies to help even the playing
field. However, the adjusted readmission rates were not risk adjusted
for socio-economic factors. Because of this, the “safety net” hospitals
that care for the most vulnerable patients have had more financial
penalties when compared to non safety net hospitals.
120
 Chris Traeger versus Ron Swanson
management styles
• Chris versus Ron management style
https://www.youtube.com/watch?v=5FjxchiwDzY
Self-care and Adherence to
Medical Instructions

121 122

Heart Failure and adherence to self-care Difficulty with adherence with self-care
instructions strategies
• All patients with heart failure should adhere to the following self-care
• Meta-Synthesis completed to assess barriers to adherence to self-
strategies to reduce their risk of hospitalization 48 care strategies in heart failure 54
• Patients with heart failure need to know how to monitor and report their • Difficulty recognizing symptoms of heart failure exacerbation, especially
symptoms and weight fluctuations complex symptoms such as dizziness, fatigue, sleepiness, cognitive
• Patients should adhere to follow up appointments decline and loss of consciousness
• Patients should restrict sodium intake
• Patients should adhere to their prescribed medication regimens • Difficulty adhering to dietary guidelines
• Patients should stay physically active • Lack of knowledge and misconceptions about heart failure
• Studies have shown a reduction in mortality and hospitalization risk • Cultural beliefs and personal values
with adherence to self-care strategies. Additionally, studies have • Lack of social support leads to poor self-care adherence. One study
shown improvements in quality-of-life measurements with self-care found males have stronger social support than females
strategies.

123 124

Adherence and depression 48 Therapy Strategies to help manage depressive

• Patients with depression or elevated depressive symptoms have a higher rate of
hospital readmission. One study showed the likelihood of readmission to be
doubled with high levels of depressive symptoms
• Prevalence of depression among patients with heart failure is reported to be
between 13% to 77.5%
• Patient with depression are less likely to adhere to discharge instructions including
medication regimens and lifestyle recommendations
• The AHA recommends screening all patients with cardiovascular disease for
depression, as the presence of depression has been associated with heart failure
disease progression. Use of PHQ-2, PHQ-9, or Geriatric Depression Scale can be
helpful
• Multi-disciplinary approach to treating depression is recommended
• Patients and families should be educated on the importance of social support
following hospitalization for HF to help manage symptoms of depression
symptoms
• The largest study of exercise and depression, the REGASSA
trial, 55 showed an improvement of depressive symptoms of
50% by incorporating physical activity
• Other studies found no difference improvement between light,
moderate, and high intensity exercise
• ADL dependency associated with increased depressive
symptoms after hospitalization
• Improved ADL participation associated with improvement in
depressive symptoms at 1.5 month and 3 month follow up 56

125 126

23

Transtheoretical Model of
Health Behavior Change (TTM)
127
Stages of Change 57
• According to the transtheoretical model of health behavior, or stages
of change model, all persons go through the same 6 stage process
when making a health behavior change
• Precontemplation: patient is not intending on making a health behavior
change in the foreseeable future. Example: patient admitted to hospital for
CHF exacerbation and not adhering to low sodium diet and unwilling to
change behavior
• Contemplation: patient is willing to make a change in foreseeable future and is
aware of pros and cons of making change. Example: after admission, patient
becomes more aware of need to change diet
• Preparation: Patient intends to make a change and has a plan of action in
place. Example: patient asks for help creating a diet and exercise plan once
discharged from the hospital
129
Contemplation
• It is estimated that 40% of patients will be in the contemplation stage.
• At this stage, patient is aware of a need to change the behavior and is aware of
the potential benefits of change and the consequences of the continued
behavior
• Patient is not ready for change and has mixed feelings about the need for
change. Additionally, patient may perceive more barriers than benefits to
change.
• Interventions should include working with patient to determine if barriers are
perceived or actual. Continue to provide patient education on benefits of
change. Provide patient resources to support behavior change and help patient
problem solve overcoming barriers to change.
• Example of intervention: patient aware of the need to exercise and increase ADL
participation, but doesn’t feel able or ready to increase activity levels. Discuss an
identified barrier to performance of an exercise program and problem solve ways
to overcome barrier with patient.
131
24
Transtheoretical Model of Health Behavior
Change 57
• Gives clinicians a model to assess a patient’s willingness to change a
health behavior and provides strategies to help patients to change
health behaviors.
• TTM allows clinicians to match interventions with the stage of change
a patient is currently experiencing. TTM has been shown to improve
patient adherence by targeting interventions to a patient’s stage of
change rather than mismatching interventions to a patient’s current
stage of change.
• 4 main parts: stages of change, self-efficacy, decisional balance, and
processes of change
128
Precontemplation
• Precontemplation:
• It is estimated that 40% of patients are in the pre contemplation stage.
• At this stage, patient is unaware they have a problem with this particular
behavior.
• Interventions for this stage are to provide information as to the benefits
of the health behavior change and the consequences of the continued
behavior.
• Example of intervention: patient unaware of high sodium dietary
choices; determine patient-centered goal and educate patient on types
and benefits of low sodium diet and how it may help patient achieve
their goal (i.e. staying out of the hospital)
130
Preparation
• It is estimated that 20% of patients will be in the preparation stage.
• At this stage, patient has made some changes to the behavior, but is
inconsistent in performing desired behavior. Patient has desire to continue
behavior change and wants to become more consistent with behavior change.
• Interventions should include continued problem solving to overcome barriers
to performance of behavior change. Work with patient on establishing a goal
for performance of behavior with a targeted end date.
• Example of intervention: patient has begun aerobic exercise program, but
hasn’t progressed program from a light intensity to a moderate intensity as
directed. Therapist works with patient to determine what is causing patient to
not progress intensity of exercise and asks patient to set a goal for performing
moderate intensity exercise over the next two weeks.
132
 Action
• Patient has made consistent progress with targeted behavior change
and is adherent to desired behavior change.
• Patient is aware of benefits of behavioral change and is motivated to
continue with desired behavior.
• Interventions should include providing continued support for patient
to continue maintaining behavior change. Teach patient, caregivers
techniques to problem solve overcoming potential future barriers to
continued adherence to program
• Example of intervention: patient discharged from outpatient therapy
and therapist has scheduled future check in phone calls with patient
to provide ongoing support for the next 6 months
133
Self-Efficacy
135
Self-efficacy 58
• Study completed by Sarkar et al looked at the relationship between a
patient’s sense of self efficacy and risk for hospitalization in heart failure.
Outcomes based on scores on self-efficacy measurement scale.
• Participants in study were followed for an average of 4.3 years.
• Researchers found that patients with lower baseline self efficacy scores
were more likely to be hospitalized, up to 40% more likely to be
hospitalized and 30% more likely to die.
• Self-efficacy is one of the main components of TTM and is believed to be
one of the most influential factors in determining Stage of Change
• Many studies have found that self-efficacy is the most important factor in
health behavior change
• Self-efficacy is modifiable
137
25
Maintenance and Termination
• Maintenance
• Lapses can still occur in maintenance stage. One study showed long
term exercise adherence for patients in this stage was 67%.
• Patients may benefit from participating in support groups.
• Follow up phone calls may also be beneficial during maintenance stage
• Termination
• Patient has 100% self efficacy and confidence in their ability to
maintain behavior change, despite potential future barriers to
adherence. Interventions are no longer needed for patients in this
stage.
134
Heart and Soul Study 58
• Heart and Soul Study looked at the relationship between baseline self-
efficacy scores and heart failure severity and rehospitalization rates
• Defined self-efficacy in heart failure as the amount of confidence a
patient has to perform self-care behaviors. Level of self-efficacy
impacts engagement in and performance of these behaviors.
• Used the Maintain Function measure to determine baseline cardiac
self-efficacy scores
• 5 item measure that asks the patient level of confidence of ability to
participate in daily life activities, such as work and social activities.
Patient rate confidence from 1 to 5 with total possible score of 20
• Study found that patients with lower baseline cardiac self-efficacy
had lower LVEF scores along with higher rehospitalization rates
136
Modifying Self-efficacy
• Patients need to be provided with physical activity experiences in
which they are able to succeed. However, avoid making activities too
easy in which there isn’t any challenge.
• Train patients on setting realistic, but moderately challenging goals.
Achieving goals helps to increase self-efficacy. Additionally, if a
patient is overly optimistic with his or her goals, it can lead to
disappointment when the goal is not achieved and lead to
nonadherence
• Actual and perceived barriers to health behavior change are
associated with lower sense of self-efficacy
• Discuss perceived barriers to adherence and possible solutions to
overcoming barriers
138
 Helping patients overcome barriers to change
• Help patient improve self-efficacy by discussing barriers to adherence,
and problem solve with patients on how to help remove these
barriers. 57 Parish
• Step 1: describe the barrier to change
• Discuss with patient actual and perceived barriers to change. Determine one specific
barrier chosen by patient to determine a possible solution
• Step 2: help the patient to brainstorm a possible solution
• Clinician should aid patient in determining a few possible solutions to barrier, clinician
should act as facilitator but allow patient to determine solutions
• Step 3: ask the patient to list the pros and cons of each possible solution
• Step 4: patient should choose the best option to be implemented for a certain
amount of time
• Step 5: evaluate the results. If the option didn’t work, the process should be
repeated with patient choosing one of the other possible solutions.
Decisional Balance 57
• Simply, this is a patient going through the process of weighing the pros and cons of
behavior change.
• A patient’s health literacy and perceived/actual barriers to adherence are an
integral part of the process of decisional balance. The better a patient understands
the appropriate management of heart failure and how it relates to their own
health and well being, the more the patient will understand the value of behavior
change.
• The idea behind decisional balance is a patient will initiate a change if the
perceived pros of a change outweigh the costs of initiating the change. For
example, once the patient understands the personal benefits of engaging in an
exercise program to help them achieve their goals than they do barriers to
exercising, they will become more physically active.
• Patients in the contemplation and precontemplation stages of change perceive
more barriers (cons) to change than benefits (pros) of changing
• The cross-over point, or balance point, in which a patient perceives more pros than
cons to behavior change occurs in the preparation stage.
Cognitive Processes of Change
Cognitive Typically work better for patients in pre-contemplation and
Processes contemplation stages of change
Consciousness Seeking new information about exercise-tailor education to
Raising patient’s goals and how exercise/activity can impact goals
Dramatic Relief Experience and express intense feelings about being inactive-
allow patient to express how they feel about being inactive
Environmental Assess how being inactive affects physical and social
Re-evaluation environment-allow patient to explore how inactivity has
affected their day-to-day environment
Self re-evaluation Re-appraise values about inactivity-is patient happy with
current lifestyle? Is inactivity in line with patient’s goals and
values?
Social-liberation Process of taking advantage of things in one’s environment to
become more active, such as taking the stairs.
Overcoming barriers to change
• Identify what is important to the patient (patient-centered goals), and
tailor education to allow patient to see how that goal can be enhanced
by therapy interventions
• Example: Patient’s goal is to live alone, but patient needs assistance with getting
dressed in the morning. Educate patient on the role of participation in ADL
activities to increase independence with dressing and being able to return to
independent living
• Education is a process and not limited to single therapy session, patients will
need ongoing education and education will need to be modified dependent
upon what barriers are encountered
• Work with your patient to determine if barriers are actual or perceived.
If you perceive a strong enough benefit (pro), the barriers to change
can be dissolved.
139 140
Processes of Change 57
• One of the main components of the TTM and considered to be one of the two
most influential factors in progressing through Stages of Change
• Strategies and processes used to support efforts to progress through the stages of
change
• Strategies and processes used vary based on the stage of change a patient is in.
• According to the TTM, there are 10 distinct processes a patient goes through when
making a health behavior change that are internally focused on emotions, values,
and cognition. There are 5 cognitive processes, and 5 behavioral processes.
• In general, patients in the earlier stages of change tend to place greater emphasis
on cognitive processes, and patients in the later stages place greater emphasis on
behavioral processes.
141 142
Behavioral Processes of change
Behavioral Typically work better for patients in preparation, action and maintenance
Processes stages of change
Counter Substitute alternate behaviors for sedentary ones-help patient to brainstorm an
Conditioning active behavior for a previously sedentary behavior
Helping Use support from others to be more active-educate patients and caregivers on
relationships the importance of positive reinforcement and avoiding negative reinforcement
Reinforcement Changes contingencies, reward physical activity-allow patient to choose a
management reward for adherence to physical activity or ADL performance
Self-liberation Choose and commit to being more active; believe that change is possible-
continue to discuss overcoming barriers to change as they arise and highlight
progress towards change thus far
Stimulus control Controls situations and cues that support inactivity- what needs to be removed
or modified in patient’s environment to support change?
143 144
26

Motivational Interviewing
145
4 main principles of MI 60
1. Express empathy
• Clinicians should use careful listening techniques and nonjudgemental
curiosity in order to truly understand the patient’s problem or barriers to
change
• MI utilizes the term accurate empathy, which is a sincere desire by the
clinician to truly understand what is happening with the patient and how it
relates to their barriers to change. It goes beyond simply expressing empathy
and it is not the same as providing sympathy to the patient
• MI theory recommends the clinician play the role as the guide, not the expert,
and help guide the patient to discover what needs to change and facilitate
change talk, or arguments for change, rather than sustain talk, or arguments
against change
147
4 Main Principles of MI
3. Rolling with resistance
• Clinician should not directly oppose resistance and should avoid arguing for
change. Patient should be the source of potential solutions to overcome
barriers
• Avoid the “righting reflex”, which is our desire to convince someone to avoid
an action we feel is taking them off course. MI principles state this automatic
response to meet resistance head on often leads to further resistance
4. Supporting self-efficacy
• Self-efficacy is crucial for change. Clinicians should provide support as
patients explore their perceived ability to make the determined change.
Allowing patient to choose action plan can help to facilitate patient’s sense of
self-efficacy.
149
27
Motivational Interviewing (MI) 59
• Incorporates the TTM of health behavior change and consists of
client-centered counseling to help patients become successful with
health behavior change. It is a cognitive behavioral therapy along
with a social cognitive therapy.
• Interviewer must maintain a non-judgmental approach throughout
intervention.
• With motivational interviewing, patient must determine the need for
the behavior change
• Motivational interviewing explores ways to implement behavior
change once a patient determines the need to make a change. Goal
is to overcome resistance or ambivalence to change
146
4 Main Principles of MI
2. Develop discrepancy
• Allow the patient to discuss how their current behavior is in conflict with their
health goals. First step is for the patient to identify what their values are and
how those values relate to their goals
• Clinicians should ask open-ended questions to elicit change talk and to better
understand the discrepancy between their goals and their current behavior.
As an example, asking the patient why they would want to make this type of
change.
• Clinician should facilitate the patient talking about the change versus the
clinician telling the patient why they should change
148
MITI-HF Study
• Purpose of study was to determine the feasibility and efficacy of motivational
interviewing techniques in patients with heart failure
• Intervention group received one at home counseling session lasting 60 minutes
along with 3 to 4 follow up phone calls over the course of 90 days. Control group
received usual care.
• Interventions during in person session included working with patients to resolve
resistance or ambivalence to change on specific aspects of heart failure self care.
Interventions then turned toward developing an action plan. Interventions
during follow up phone calls included following up on action plan and providing
support and guidance with the action plan
• Outcomes studied were improvements in self care scores utilizing the Self Care of
HF index (SCHFI) and quality of life utilizing the Kansas City Cardiomyopathy
questionnaire (KCCQ-12)
• Study found statistically significant and clinically meaningful improvements in self
care measure, but no statistically significant change in quality of life
150
 MOTIVATE-HF Study 61 MOTIVATE-HF Study
• Patients were eligible for study if there was evidence of insufficient self care
based on Self Care of HF Index (SCHFI) score
• Score 0 to 100, higher score indicates better self care. Scores > 70 indicate
• Known as the Motivational Interviewing to Improve Self-Care in Heart adequate self care. Participants had an initial SCHFI score of <70
Failure Patients trial. Trial was conducted in Italy.
• Outcomes were measured based on improvements of SCHFI score
• Three groups within trial
Improvement in SCHFI score % of patients with adequate self-care
• Motivational interviewing techniques with patient only
Timepoint MI with MI with Usual care MI with patient MI with pt/caregiver Usual care
• Motivational interviewing techniques with patient and caregiver patient pt/caregiver
• Usual care 3 months 6.99 7.42 2.58 29.8% 28.5% 22.5%

• Intervention included a 60-minute face to face MI intervention 6 months 9.6 10.15 4.69 25.3% 28.8% 14.3%
utilizing MI along with 3 follow up phone calls lasting 15 minutes 9 months 13.84 15.96 7.81 31.6% 36.2% 19%
within 3 months of enrollment. Interviewers used MI principles
12 months 21.19 18.84 14.65 42.5% 39.3% 30.3%
during face-to-face intervention and follow up phone calls

151 152

Study Looking at Adherence to Physical

CONNECT-HF Study 62
• Known as the CONNECT-HF, or the Care Optimization Through Patient and
Hospital engagement Clinical Trial for Heart Failure
• Randomized study completed involving 5647 patients throughout 161
hospitals across the US.
• Intervention group received educational sessions provided by coaches that
attended the CONNECT-HF academy and education provided was based on
recommendations of the National Heart, Lung and Blood Institute.
• Patients were studied for a year to determine if intervention of receiving
clinical education would result in fewer heart failure rehospitalizations in
patients with HFrEF
• No significant difference in heart failure readmission rates for the
intervention group versus the control group.
Activity Programs 63
• Meta analysis looking at 20 different studies from 1999 through 2018 which included
monitoring adherence of physical activity programs at 6- and 12-months post
intervention
• Effective interventions
• Provide prompts or cues: promote or cueing behavior with a social stimulus such as a phone
call or email reminder
• Provide a credible source: explicit and detailed advice from a health professional to engage in
physical activity
• Add objects to the environment: provide a treadmill, weights, steps or stationary bicycle
• Generalize target behavior: advice patient to add the desired behavior in another situation,
such as performing a home program along with exercise in the clinic
• Monitor behavior with other forms of feedback: let participants know you will be observing or
recording adherence to program using items such as an exercise tracker or telehealth
monitoring equipment

153 154

Heart Failure Adherence Study Case Study #1

• Effective interventions
• Educate patient on self monitoring with use of a outcome tracker. For example, having patient record
pain levels as a result of physical activity
• Instruct on graduated activity progression: start with easy tasks, gradually increasing difficulty of task
until desired level is achieved
• Practice behavior: promptly practice the desired behavior
• Teach action planning: create a detailed plan of when and where behavior will be performed along with
quantity and intensity of the desired behavior.
• Teach effective goal setting: help patient create a goal for the desired behavior
• Study also found center- and group-based programs along with programs facilitated by a
therapist (compared to nurse, lay person, researcher, or exercise physiologist) to be more
beneficial
• Group based programs are believed to contribute to behavior change due to factors such as
participants comparing themselves to others in the group, changing their beliefs, and identifying as a
group member.
155
• Patient is a 75-year-old male who is a retired farmer. Patient has a primary
diagnosis of systolic heart failure. Patient has a PMH of COPD, GERD and
hypertension. Patient lives at home with his wife with 4 stairs with one
handrail to enter home. Prior level of function was independent with gait
throughout home with use of wheeled walker, SBA for bathing,
independent with toileting, and activity tolerance around 15 minutes.
• Patient recently hospitalized due to exacerbation of heart failure and fluid
overload. Patient reports they removed 15 pounds of fluid from him
during hospital admission.
• What are some potential side effects of removing a large amount of fluid
during hospital admission?
156

28
 Case Study #1 Case Study #1
• Patient’s discharge medications. Patient reports several medication changes since hospital
admission
• Albuterol sulfate nebulizer every 4 to 6 hours as needed • Patient reports 2 falls since return home from the hospital. Patient reports once
• Losartan his legs “just gave out” while he was walking and another fall occurred when he
• Aspirin was in a hurry to sit down and missed his chair.
• Biofreeze topical as needed • What is a possible reason that his legs “gave out” while he was ambulating?
• Pulmicort inhaler 2 x a day • Patient’s functional status upon evaluation
• Oxygen 4 liters continuous
• 30 second chair rise test 1 repetition
• Lasix
• 2-minute step test 20 steps.
• Metoprolol
• min to mod assist for bed mobility and transfers
• Nitrostat sublingual as needed for chest pain
• Potassium • ambulating just to bathroom (around 10 feet) only with assistance of adult son.
• Spironolactone • Mod assist for toilet transfers and toileting hygiene
• Sponge baths at side of bed with mod assist
• What are potential side effects of patient's medications?
• Currently using urinal for urination, only using toilet with riser for bowel movements
• What type of screening assessment could we perform to determine patient’s ability to safely
manage medications? • Are there any other outcome measures you would utilize during your evaluation?
• What type of medication management strategies might we include in our interventions?
157 158

Case Study #1 Case Study #1

• When therapist asks patient what his goal is, patient asks therapist to
please not ask him to do that, because it is too depressing. Tells therapist
she can write whatever she wants, but that he is not going to talk about his
goals. Spouse tells therapist patient is “crabby” all the time and doesn’t
want to do anything.
• Are there any other outcome measures or screening tools that you believe
may be applicable at this point?
• Any other disciplines that we may want to get involved in patient’s care?
• What stage of change do you think this patient might be in?
• Which principles of MI might be helpful in facilitating change talk with this
patient?
• Patient is currently ambulating with a 2-wheeled walker, using a toilet riser
without arm rests over toilet, and sponge bathing at side of bed (tall bed)
• Any DME recommendations?
• Any ADL recommendations as far as increasing safety?
• Patient reports he is unable to walk any farther than he currently is
because of his shortness of breath. Additionally, he reports he gets very
winded when getting dressed each morning and has to take a lot of rest
breaks.
• Patient reports his best time of day is mid morning, reports that he takes a
long time to get ready in the morning and gets very tired in the afternoons.
• When building his care plan, what interventions would we want to include?

159 160

Case Study #1 Case Study #2

• What tools can we teach patient to use to monitor his
dyspnea/desaturation during ambulation in home and during ADL
performance?
• Any equipment you would recommend for patient to purchase?
• For respiratory muscle training, what tool would you recommend patient
purchase to work on strengthening respiratory muscles?
• When should we try to time our therapy sessions?
• What ideas do you have to help improve patient adherence?
• Patient receives a referral to Palliative Care Services and eventually
transitions to hospice services. Patient expired after 2 months of receiving
hospice services.
• Patient is a 70-year-old female recently hospitalized secondary to
hyperkalemia.
• Past medical history includes hypertension, osteoarthritis, CAD, depression,
history of falls, Type 2 Diabetes, and systolic heart failure. Patient has had 2
prior hospitalizations for heart failure in the past year.
• Patient lives alone, and her primary caregiver and medical power of attorney
is her niece. Niece is involved in care and is primary contact for nursing and
therapy staff to schedule visits.
• Medications at time of hospital admission: aspirin, Lipitor, Ferrous Sulfate,
Prozac, Advair Diskus, furosemide, Neurontin, Levimer Flexpen, Novolog,
lactobacillus, Losartan, and metoprolol
• What medication discussed today might have contributed to reason for
hospital admission?
• Would patient have a reduced or preserved ejection fraction?

161 162

29
 Case Study #2
• Patient being seen by home health PT, OT and nursing. The niece is present and
brings you back into patient’s bedroom where patient is lying in bed. Niece
reports to you that therapy is very important, as patient had a fall getting up to go
to the bathroom at 2 am. Patient fell out of bed onto the floor. Injury apparent
to you is bruised toes.
• When you enter the room, you notice a lot of clutter throughout patient’s
bedroom and narrow pathways. Most notable to you is the condition of the
patient’s bed. Patient has located multiple items on her bed, including multiple
packs of pens, multiple crossword puzzle books, snacks including boxes of snack
crackers, and several blankets. Several layers of blankets are on the bed and
pushed to the side of the patient, with some blankets balled up on bed creating a
physical barrier which prevents patient from lying in the center of bed. Patient
has an approximate 18- inch section of bed in which to lie.
• What stage of change do you think this patient might be in at this point? What
would be a primary intervention for this patient at that stage of change?
163
Case Study #2
• When you question the patient about her fall, she reports it wasn’t a big deal.
She slid onto the floor after sitting up on the side of the bed as she was
attempting to walk to the bathroom. She had to crawl on the floor to reach a
phone to call the EMS. She reports the bruises on her toes are likely due to
hitting the cedar chest directly across from her bed. When you notify the patient
that agency policy requires you to notify her physician about her fall, she states
that she prefers you didn’t contact her physician and asks you why it is necessary.
• What are some assumptions we can make regarding patient’s health literacy?
• What may be something patient is fearful of happening/barrier to proper patient
care? Was it helpful to tell patient that you were notifying the physician about
the fall? What might happen in the future when patient falls?
• What processes of change might we incorporate to help move patient through
the stages of change?
• What other disciplines might you want to get involved in this patient’s care?
165
30
Case Study #2
• On the way back to the bedroom, the niece tells you she is doing her best
to take care of the patient, but that she is overwhelmed as her husband is
ill as well.
• After you enter the room, the niece comes into the room asking patient
about her morning meds. Patient reports she took her medications, but
pills are still present in the mediplanner. Niece states that she called
patient this morning to remind her to take her meds, and patient told her
she took medications, even though they are still present in mediplanner.
Niece reports that they will just skip the morning dose of the blood
pressure medication and tells patient to not take two pills at once.
• What comes to mind when you hear this information?
• Are there any suggestions you would make to help patient manage
medications better?
164
Case Study #2
• Therapist discusses patient’s goals with patient with niece present. Patient reports her goal is to
stay in her own home and not move to an Assisted Living Facility or a Nursing home.
• When you are selecting your outcome measures, what do you want those tools to specifically
measure? Which tools would you select?
• In regard to her diagnosis of heart failure, what specific items would you want to assess during
your evaluation?
• Patient is seen by PT and OT for a period of 3 weeks. Interventions focused on fall prevention,
strengthening, program to increase cardiopulmonary endurance, ADL training and standing
balance training.
• Social work involved in care of this patient, with patient referred to the local Senior Services
program to help facilitate increased help in home. Niece was able to recruit additional family
members to assist patient with care throughout they day with a master schedule for all helpers.
Patient also received medical alert button.
• Patient progresses with therapy with improved Two Minute Step Test, improved ambulation
endurance, improved safety and independence with ADLs. and improved adherence with daily
weights and medication regimen with assistance of niece and other family members.
166
 Lab Values 64

Lab Value Reference Values Clinical Implications

BUN (Blood Urea Nitrogen) 6-25 mg/dl • Causes include high protein diet, renal failure, CHF.
• Symptoms of BUN trending upward may include HTN, fluid
retention, fatigue, poor appetite, nausea/vomiting,
itchy/dry skin, decreasing cognition, dyspnea, or bone pain
• Patients with BUN outside of reference range may have
decreased activity tolerance
Serum Creatinine Male: 0.7 – 1.3 mg/dl • Causes include renal disease, CHF, dehydration,
Female: 0.4 – 1.1 mg/dl rhabdomyolysis
• Presentation of creatinine trending upward may include
decreasing urine output, dark colored urine, edema, back
pain, dyspnea, fatigue, low fever, loss of appetite,
headache, confusion
• Presentation of creatinine trending downward may include
fatigue, although this is uncommon
• Patients with creatinine outside of reference range may
have decreased activity tolerance
Hemoglobin Male: 14-17 g/dl • Hemoglobin values trending upward may occur in
Female: 12-16 g/dl congenital heart disease, severe dehydration, COPD, CHF,
severe burns or high altitude
• Symptoms of trending upward hemoglobin may include
orthostasis, presyncope, dizziness, arrhythmias, CHF
onset/exacerbation, seizure, symptoms of TIA, symptoms
of MI, or angina
• Hemoglobin values trending downward may occur in
hemorrhage, nutritional deficiency, lymphoma, renal
disease, sarcoidosis

31
 • Patients with low hemoglobin levels may present with
decreased endurance, decreased activity tolerance, pallor,
tachycardia, orthostatic hypotension
• If hemoglobin < 8g/dl, collaborate with interdisciplinary
team to determine appropriateness of mobilization
• Monitor O2 sat levels with low hemoglobin levels
• Low critical values (<5.7 g/dl) can lead to heart failure or
death
• High critical values (>20 g/dl) can lead to clogging of
capillaries as a result of hemoconcentration
Sodium 130-145 mEq/L • High sodium levels, or hypernatremia is >145 mEq/L
• Causes of upward trending levels of sodium include
increased sodium intake, severe vomiting, CHF, renal
insufficiency, Cushing’s Syndrome, and Diabetes
• Symptoms of hypernatremia include impaired cognitive
status, irritability, agitation, seizure, coma, hypotension,
tachycardia, and decreased urinary output
• Hyponatremia is < 130 mEq/L.
• Causes of downward trending sodium levels include
diuretic use, GI impairments, burns/wound, and cirrhosis.
• Symptoms of hyponatremia include impaired cognitive
status, headache, lethargy, decreased reflexes, nausea and
vomiting, diarrhea, seizure, coma, orthostatic hypotension,
and pitting edema
• Check standing bp with patients with hyponatremia
secondary to risk of orthostatic hypotension
Potassium 3.7- • High potassium levels (hyperkalemia) is > 5 mEq/L
5.1 mEq/L • Causes of upward trending levels of potassium include
renal failure, metabolic acidosis, Diabetic ketoacidosis,
Addison’s Disease, excessive potassium supplements,
blood transfusion

32

BNP Normal males 35 to 93 pg/dl
females 64 to 167 pg/dl
• Symptoms of hyperkalemia include muscle
weakness/paralysis, paresthesia, bradycardia, heart block,
v fib, cardiac arrest
• Low potassium levels (hypokalemia) is < 3.5mEq/L
• Causes of downward trending levels of potassium include
diarrhea/vomiting, GI impairment, diuretics, Cushing
Syndrome, malnutrition, restrictive diet, ETOH abuse
• Symptoms of hypokalemia include extremity weakness,
paresthesia, decreased reflexes, leg cramps, EKG changes,
cardiac arrest, hypotension, constipation
• Elevated in CHF with increased ventricular pressures and
volume overload

NYHA Functional Class Median Value 13

Class I 83 pg/dl
Class II 235 pg/dl
Class III 459 pg/dl
Class IV 1119 pg/dl
Troponin 0 to 0.04 ng/ml • Levels elevated due to damage of heart muscle and may be
elevated in CHF due to myocardial cell injury or death

33
Borg Rating of Perceived Exertion

6 No Exertion at all

7 Extremely Light

9 Very Light

10

11 Light

12

13 Somewhat hard

14

34
15 Hard

16

17 Very Hard

18

19 Extremely Hard

20 Maximal Exertion

35
 Modified Borg Dyspnea Scale

0 Nothing at all
.5 Very, very slight (just noticeable)
1 Very slight
2 Slight
3 Moderate
4 Somewhat severe
5 Severe
6
7 Very severe
8
9 Very, very severe (almost maximal)
10 Maximal

36
 Possible Medication Side Effects
Medication Type Examples
Beta Blockers metaprolol, atenolol
Ace Inhibitors Enalapril, lisinopril and captopril
Angiotensin 2 Receptor Blockers Losartan, Irbesartan, and
Valsartan
joint pain, dizziness, drowsiness,
Thiazide Diuretics chlorothiazide, chlorthalidone,
hydrochlorothiazide,
indapamide, metolazone
Loop Diuretics bumetanide, furosemide,
torsemide
Potassium Sparing Diuretics amiloride, triamterene,
spironolactone (higher doses)
Direct-Acting Vasodilators Hydralazine, nitrates such as
isosorbide mononitrate,
minoxidil
Aldosterone Antagonists Spironolactone and Eplerenone
37
Common Side Effects
Fatigue, cold hand and feet,
weight gain, can trigger asthma
attacks, diarrhea
Low blood pressure, low white
blood cell count, and kidney or
liver problems
Low blood pressure, elevated
potassium levels, muscle or
headache, and nausea or
vomiting
Low sodium, low potassium,
decline in renal function, gout,
or hyperglycemia
Low sodium, low potassium,
low magnesium, high levels of
calcium
Feeling faint, dizzy, confused,
sleepy, and high levels of
potassium
compensatory tachycardia,
headache, angina, shortness of
breath and fluid retention
Hyperkalemia, cough, dizziness,
headache or diarrhea
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