Introduction to Microsystem
Clinical nurse specialist helps patient manage their heart failure while in the hospital. Also helps to coordinate care between patient, doctors, specialties and other services
Clinical nurse specialist is floor specific. Care will be passed on from one nurse specialist to another when patient is transferred.
A clinical nurse specialist has many different roles within the hospital microsystem. The CNS is responsible for all education and teaching that is needed on the unit, for both nurses and patients alike. The bedside nurse will be the main contact for a patient who needs education, but the CNS can help provide additional details and an also find other resources that may be applicable. The CNS typically works Monday to Friday, so they can help facilitate things during the week, and can be a constant in the patient’s care.
Heart Failure Overview
“Heart failure “is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood.” (Aguanno & Samson, 2018, page 1).
Fluid retention which can lead to difficulty breathing and shortness of breath
Can be caused by pregnancy, infection, heart attack and trauma
Heart failure “is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood.” (Aguanno & Samson, 2018, page 1). Not all patients who have heart failure exhibit the same symptoms. As heart failure progresses, the shortness of breath can happen all the time (even at rest), not just with exercise. When the patient is being evaluated for heart failure, the ejection fraction is measured and evaluated. An echocardiogram will be done, usually described as an ultrasound of the heart, which will provide caregivers with an estimate of the patients’ ejection fraction. “Ejection fraction is the fraction of blood ejected from a ventricle of the heart with each heartbeat.” (Aguanno & Samson, 2018, page 2). A “normal” ejection fraction is 55-70%, reduced is less than 50% and less than 40% is considered heart failure. Treatment for heart failure typically involves angiotensin-converting enzyme inhibitors (ACE) or an angiotensin receptor blockers (ARBs) if the ACE is contraindicated and loop diuretics.
Admitted to cardiac floor or intensive care unit, depending on reason for admission
Followed by cardiologists and nurses who specialize in heart failure
May also be followed by case management, social services, dietary, cardiac rehabilitation
Discharged home (or to rehab/facility) with care plan that includes medications, daily weight checks, and most likely visiting nurse appointments
Whether the patient is admitted via the emergency room or from a doctor’s office for evaluation of their presumptive heart failure, they will be admitted to one of the cardiac or medicine floors, and will be followed by a team of cardiologists and nurses who are knowledgeable in heart failure. As mentioned before, the patient will undergo an echocardiogram, where the function of the heart and the flow of blood can be traced and analyzed. Medications will be titrated for maximum effect and the patient will be discharged home with a care plan in place. The patient will follow up with the cardiologist, and may also be enrolled in some cardiac rehabilitation, which will help them get back into shape and help the patient deal with the symptoms of heart failure.
Key Leadership Positions
Clinical nurse specialist (CNS) is a key part in patient education
Helps patient connect with other services, such as nutrition, chaplain, case management
CNS works with registered nurses, doctors, other care members to assure that the patient receives the care needed and desired
The CNS can also help connect the patient to other services within the hospital, such as dietary, case management, social work, and/or the chaplaincy if the patient so wishes. The CNS, bedside nurse, and medical team will work together to make sure that the patient has the care that they need, deserve and want to receive. Advocacy leadership was created to make sure that patients receive the care that they want. Many patients may wish to have a visiting nurse come to their home to help them manage the new diagnosis and to make sure that things are going ok. The nurse can help the patient monitor for swelling, changes in breathing or activity level and will help the patient maintain a daily weight chart. Dietary can help the patient develop and maintain a low sodium diet, which will help in reducing the risk of fluid retention.
Positive feed forward should be given to those patients who do not understand what needs to be done (language barrier, mentally challenged, unmotivated). These patients need constant education and reminders of what is needed. These patients may need a translator or integration of different learning styles.
Feedback will work best for the patients who understand what is needed from them and are compliant.
Try to maintain caregivers when in the hospital, for consistency in care
The effectiveness of the leadership style will be determined based on how the patient does at home, caring for themselves. If the leadership style is working, then the patient will have few, if any, complications and will be able to successfully manage their heart failure on an outpatient basis. If the plan is not working for the patient, then he or she may have an increased number of doctor visits and or hospital visits, and may have fluctuations in their weight, depending on their diet, adherence to the medication regimen, or other side effects of not following the plan.
Inability to maintain daily routine
Inability to pay for medications
Patient may not be able to understand what is going on, due to language, education, or other issues
Patient may be noncompliant
Lose of insurance, benefits or support system
Common barriers that arise when dealing with any disease, not just a chronic disease, is the constant maintenance that is needed to make sure that there are no relapses or disturbances in care. For instance, heart failure patients need to maintain a low sodium diet, check their weight daily and log it, stick with a medication regimen and make sure that the patient keeps all medical appointments. Patients need to know who to call when issues arise, so they must have emergency numbers and office numbers handy. Having a visiting nurse is a good idea for most patients who are suffering from a chronic disease, as they can help keep things in order. Patients may not be able to afford their medications, or they may have side effects when taking the medication, which can lead to a change in the care plan. A social worker and a case manager can help the patient deal with any issues regarding insurance, payments, or needing to find services close to home.
Solution for each barrier
Continued vigilance to make sure that there is no lapse or disturbance in the care.
Heart failure patients need to maintain
Low sodium diet
Daily weight checks
Doctor appointments & visiting nurse appointments
Maintain contact with social worker, case manager, nutritionist
The barriers and solutions will be different for each patient. If a patient is cooperative and willing to make the necessary changes in lifestyle, then they will have an “easier” time with the care plan, than someone who does not have a support system, does not wish to participate or simply just doesn’t understand what is going on. The patient should always be included in the choices of treatment, to make sure that they are fully aware of what is happening (or not happening) and why.
Ensure that each patient has a medical team that they can reach 24/7
Connect patient with any services needed, such as translators, case management, financial services, nutrition, nursing services
Help patient develop a care plan that they feel comfortable with and can maintain
Please see previous slides for more information on barriers and solutions.
Leadership changes, such as not having consistency with caregivers, can lead to the patient receiving information that may be different or misinterpreted, which can cause confusion and frustration on the patient’s part. When the patient is in the hospital, it is important to maintain consistency with the nursing staff whenever possible.
New relationships & educational opportunities
The nurse will be the main contact between the patient and his/her caregivers.
CNS will have complete record of who has been following the patient, make sure that all parties are up to date
The patient will develop new relationships with the staff on the units, and with whichever services they need
Education will be provided from all sources. It may be helpful to keep a binder of what has been reviewed, and invite the patient to participate in teaching back what they have learned to ensure accuracy
When the patient is in the hospital, it is important to maintain consistency with the nursing staff whenever possible. Many case managers, social workers, and dieticians only work on 1 or 2 floors, so they can follow the patient throughout their time in the hospital. Patients who use these services on an outpatient basis will most likely have the same person caring for them. The same goes for visiting nurses, it should be kept to one or two nurses who regularly follow the patient to ensure consistency and comfortability. Every nurse and caregiver has their own style, and sometimes that style doesn’t “mesh” with the patients’ style. There may also be communication and learning barriers that need to be identified to ensure effective communication.
Solutions affect on microsystems
Including more caregivers can potentially lead to information being lost or misunderstood
The patient may become overwhelmed with all the care teams and keeping people straight
If patient doesn’t have a family member that can assist in taking care of them, they may feel overwhelmed and want to give up
Increased demand on hospital staff, services
Health promotion activity
Patients must maintain a healthy weight.
This can be done via
Low/no salt diet
Daily weight monitoring
Keeping doctor and visiting nurse appointments
Patient should have a “person” who is a designated caregiver, who goes through all teaching/appointments and helps patient stay on track with treatment regimen
Ensuring that the patient is willing and cooperative is a major part in making sure that a care plan will be successful.
Resources needed for Microsystem
The patient will need clear and concise information, provided by many different treatment teams.
The information should be presented so that the patient can understand it
Information may need to be repeated many, many times.
A binder, or another way to keep information organized, may help the patient have a better understanding of what is going on and not feel so overwhelmed
Summary for microsystem
Clear and concise information
Keep patient informed and “in the loop”
CNS will coordinate other care teams and make sure patient is comfortable with current care plan
Patient must be accountable for his or her involvement in the care plan (compliant, organized, reliable)
As time goes on, homecare should become easier requiring fewer home nurse visits. Patient should become more independent with care plan duties
Doctor appointments will become less frequent and shorter
Plan effectiveness & Communication
If the patient is able to stay out of the hospital, then the plan is successful.
The patient may see hospitalizations as a set back, but it may just mean a minor change in care plan
To see if the care plan is working, there are certain marks that should be met. These goals will be discussed while developing the care plan. These goals could be:
A specific amount of weight loss
Improved lab values
Weaning off/changing medication regimen
Aguanno, J., & Samson, L. (2018). Diagnosis and management of patients with heart failure. MLO: Medical Laboratory Observer, 50(1), 6-12.