Caring for Patients with Congestive Heart Failure

Podcast Transcript

Carol Pehotsky (00:05):

A diagnosis of congestive heart failure begins a journey for patients and their loved ones. From the inpatient setting through the outpatient setting, nurses have many opportunities to support patients and their caregivers as they learn to manage medications, make lifestyle changes, and transition to a new normal. I'm joined today by Maureen Schaupp to learn more about the nursing care of patients with heart failure.

(00:30):

Hi, and welcome to Nurse Essentials, a Cleveland Clinic podcast where we discuss all things nursing from patient care to advancing your career, to navigating tough on-the-job issues. We're so glad you're here. I'm your host, Carol Pehotsky, associate chief nursing officer of Surgical Services Nursing.

(00:51):

Welcome back, everyone. Today, we're going to be talking about the best care for patients with congestive heart failure, whether that's inpatient or outpatient, or anywhere in between. As I was preparing for this episode, I was reflecting back on you know I didn't necessarily care for a lot of these patients in my actual nursing professional journey, but found myself gravitating towards them over, over again in nursing school. (laughs) To the extent that my professor said, somebody might be, ay, telling you something here, because it, it was many different patients all along their journey of their management, whether they were admitted for that reason or it was something else they were managing, but it wasn't their active diagnosis. So, it was almost a joke. (laughs)

[NEW_PARAGRAPH]It is. Of course, patients, Carol's patient has congestive heart failure. Thankfully, so much has changed since I took care of those patients 20 years ago. I am certainly not an expert in that (laughs) field at all, but I am so excited to welcome my friend and colleague, Maureen Schaupp. Maureen is our associate chief nursing officer for advanced practice nursing and nursing quality and practice at Cleveland Clinic. But you're here today to also be a subject matter expert for us in the care of patients with congestive heart failure. Welcome.

Maureen Schaupp (01:58):

Thanks, Carol. Thanks for having me today. I appreciate it.

Carol Pehotsky (02:00):

Of course. So, we'll get started like we do with every guest. I would love to have you share a little bit with our audience about your journey. What drew you to nursing and ultimately, what drew you to caring for this patient population?

Maureen Schaupp (02:11):

Absolutely. So, I have spent my whole career, my whole nursing career thus far with Cleveland Clinic.

Carol Pehotsky (02:16):

Mm-hmm.

Maureen Schaupp (02:16):

I started as a nurse in the cardiac ICU at Fairview Hospital.

Carol Pehotsky (02:20):

Okay.

Maureen Schaupp (02:21):

And from there I went on to get my nurse practitioner certificate and license and so on. And my first nurse practitioner job was on main campus.

Carol Pehotsky (02:30):

Okay.

Maureen Schaupp (02:30):

In J-34 in the outpatient heart failure department. And I have been seeing outpatient adult heart failure patients ever since. You know, I fell in love with them early on in those ICU days during kind of that acute phase of their illness and, you know, treating them and helping their families understand what was going on and what they might be able to expect...

Carol Pehotsky (02:30):

Mm.

Maureen Schaupp (02:50):

... moving forward. But it was really then becoming a nurse practitioner and working in that outpatient department that I was really able to see what this looks like full picture, right. From beginning to end, what it looks like at home and when-

Carol Pehotsky (02:51):

Yeah.

Maureen Schaupp (03:04):

... they come into the hospital and kind of help them also understand what this continuum of care would look like for them and help to improve the continuum of care for them. So, it's really just been a patient population that I have fallen in love with, you know, over the last 17 years or so, and just have a, a great amount of passion for.

Carol Pehotsky (03:23):

Wonderful. Well, we're thrilled to have you. So, knowing that we have audience members, some folks that are still in nursing school, some people who are mid to late career, so theirs probably isn't as flawed as mine when it comes (laughs) to the management of patients. It's been so long for me. Can you start us off by talking about some of the most common causes of CHF?

Maureen Schaupp (03:41):

Sure. Absolutely. So, we do have some updated statistics from the Heart Failure Society-

Carol Pehotsky (03:42):

Oh.

Maureen Schaupp (03:46):

... of America, and currently, approximately 6.7 million Americans over the age of 20 have heart failure.

Carol Pehotsky (03:54):

Wow.

Maureen Schaupp (03:55):

Yeah.

Carol Pehotsky (03:55):

Wow. Over the age of 20.

Maureen Schaupp (03:57):

Over the age of 20.

Carol Pehotsky (03:57):

Okay. All right.

Maureen Schaupp (03:59):

Right? And then it goes even further to tell us about what we can expect moving into the future...

Carol Pehotsky (04:04):

Okay.

Maureen Schaupp (04:04):

... which is not lovely. So, we expect this to rise to 8.7 million by 2030, 10.3 million in 2040, and 11.4 million by 2050.

Carol Pehotsky (04:17):

I assume they talk about what they're attributing that increase to.

Maureen Schaupp (04:21):

Yeah, so some of it is just as people age overall, right?

Carol Pehotsky (04:22):

Yeah. Sure.

Maureen Schaupp (04:25):

We've got a larger number of aging people, and we know that the older we get, the higher our likelihood to get heart failure is.

Carol Pehotsky (04:33):

Sure.

Maureen Schaupp (04:34):

But some of the most common causes overall for heart failure are coronary artery disease. It's up there on the list. People who have heart attacks, blockages, and it literally just kills part of that heart muscle.

Carol Pehotsky (04:44):

Yeah.

Maureen Schaupp (04:45):

And it makes it not able to work. People who have longstanding hypertension and high blood pressure, that extra workload on the heart over time really takes a toll. And we see that as well. And sometimes we just don't know what causes some people's heart failure.

Carol Pehotsky (04:59):

Oh gosh.

Maureen Schaupp (04:59):

We run them through the gamut of tests, and we end up just calling it idiopathic...

Carol Pehotsky (05:05):

Okay.

Maureen Schaupp (05:05):

... at the end of the day because we're never able to identify exactly what it was that triggered that. But that's one of the most interesting things about heart failure that I find is really trying to find the root cause.

Carol Pehotsky (05:17):

Okay.

Maureen Schaupp (05:17):

Because if we fail to find the absolute root cause, we may be throwing darts at the wrong target.

Carol Pehotsky (05:23):

Yeah.

Maureen Schaupp (05:24):

Right? Some of the treatments and some of the therapies are the same no matter what...

Carol Pehotsky (05:28):

Okay.

Maureen Schaupp (05:28):

... the root cause is, but sometimes the treatments are very different if you can find that root cause. So, it's always worth all of the time and effort to try to get there. And sometimes, despite our best efforts, we don't.

Carol Pehotsky (05:39):

Yeah.

Maureen Schaupp (05:40):

And then we use the tools that we know work across the board and do our very best to help those patients.

Carol Pehotsky (05:45):

So certainly, an aging population, but yeah. When we think about the health and wellness of our country and things that predispose us to coronary artery disease, that's certainly part of it too then.

Maureen Schaupp (05:56):

Absolutely. Right. Lifestyle is a huge factor, right?

Carol Pehotsky (05:57):

Mm-hmm.

Maureen Schaupp (06:00):

You know, we talk about the things we can modify.

Carol Pehotsky (06:00):

Yeah.

Maureen Schaupp (06:02):

And the things we can't. Right?

Carol Pehotsky (06:02):

Yeah.

Maureen Schaupp (06:03):

We can't modify the genes that we get, and there are plenty of cardiomyopathies that are genetic based.

Carol Pehotsky (06:08):

Yeah.

Maureen Schaupp (06:08):

Right. And then we've just got to deal with what we can. We've come a long way in that realm because we've got a lot of genetic testing that we didn't have before.

Carol Pehotsky (06:15):

Okay.

Maureen Schaupp (06:16):

If we find out that people carry those genes, we can at least screen earlier, screen their relatives earlier and, you know, really help to manage the disease process overall. Or at least monitor it, get them maybe some prophylactic therapies over time.

Carol Pehotsky (06:16):

Okay.

Maureen Schaupp (06:29):

If they might need an ICD, something like that to help prevent detrimental events moving forward. But then those lifestyle modifications that we can make are huge. Right. Watching our weight, having the right diet, you know, watching the amount of sodium, limiting the amount of fats, all of those things that we know are so good for just health in general overall are pretty much those same things that help prevent heart failure over time.

Carol Pehotsky (06:54):

So that initial diagnosis or the initial suspicion that somebody might be starting to show signs of congestive heart failure, what are some of those early symptoms and signs? Do we see them more in an ambulatory basis, or are these patients that are coming into the hospital? Or is it one of those, it just kind of depends?

Maureen Schaupp (07:11):

Sure. You know, sometimes patients will come in with a very acute event.

Carol Pehotsky (07:15):

Yeah.

Maureen Schaupp (07:16):

For example, one large heart attack, right?

Carol Pehotsky (07:19):

Yeah.

Maureen Schaupp (07:19):

That'll be enough to start somebody's heart failure journey. Right?

Carol Pehotsky (07:22):

Okay.

Maureen Schaupp (07:22):

Come in with a large heart attack, they treat that, then they find that the muscle is weak, and you kind of go down that path. That can certainly happen. It happens often enough.

Carol Pehotsky (07:30):

Mm-hmm.

Maureen Schaupp (07:30):

Also, a good chunk of the time, people do start to experience symptoms at home...

Carol Pehotsky (07:36):

Okay.

Maureen Schaupp (07:36):

... before they're ever hospitalized but may chalk it up to something else.

Carol Pehotsky (07:40):

Sure.

Maureen Schaupp (07:41):

Right. Like they start to get a little more short of breath. Right. They used to be able to do all of the things they wanted to around the house, go to a large box store and they have no problem.

Carol Pehotsky (07:51):

Yeah.

Maureen Schaupp (07:51):

And suddenly they start to realize, "Oh man, like I want to have to sit down here for a minute."

Carol Pehotsky (07:56):

Mm.

Maureen Schaupp (07:57):

And it just comes on gradually. And so over time, they actually start to forget that you know what, just two months ago, I could do this without a problem.

Carol Pehotsky (08:05):

Oh, sure.

Maureen Schaupp (08:06):

And so over time though, it does start to get worse and worse. Then they may start going to their primary care doctor and say, "You know, I'm kind, I'm kind of short of breath. I don't..." Right, so...

Carol Pehotsky (08:06):

Tired. Yeah.

Maureen Schaupp (08:15):

... I'm tired. You go through these things, and you know, you get a chest x-ray and maybe it's bronchitis and you get treated for that once.

Carol Pehotsky (08:23):

Sure.

Maureen Schaupp (08:23):

And oh, those antibiotics didn't work. And so, we go (laughs)...

Carol Pehotsky (08:24):

Try something else.

Maureen Schaupp (08:27):

... and we try something else, but the patient is still short of breath. And then they either end up in the hospital, which is, I find in my clinic, a vast majority of the patients that their first diagnosis of heart failure actually happens during an inpatient admission.

Carol Pehotsky (08:43):

Oh, wow.

Maureen Schaupp (08:44):

Because things have gotten so bad, the symptoms started at home, they noticed it in the ambulatory setting, but it got so bad that they ended up needing to be hospitalized.

Carol Pehotsky (08:53):

Sure.

Maureen Schaupp (08:53):

And that's probably the first time somebody put a probe on their chest, did an echocardiogram, and noticed that they had some sort of underlying cardiomyopathy of some sort. And then that's where their journey begins.

Carol Pehotsky (09:03):

Sure. And you think about, yeah. All those symptoms that any of us could sort of ride off in our head as I, I'm fighting a bug.

Maureen Schaupp (09:09):

Yes.

Carol Pehotsky (09:10):

I, I walked a little too far, I'm out of shape.

Maureen Schaupp (09:12):

Mm-hmm. Yeah. You, you nailed it, you know?

Carol Pehotsky (09:15):

Yeah.

Maureen Schaupp (09:15):

You know, someone's like, "Oh, I just haven't, I haven't gotten on the treadmill in a couple months. That's what this is."

Carol Pehotsky (09:20):

Right.

Maureen Schaupp (09:21):

But it, you know, gets progressively worse to a point where they may not be able to lay flat at night.

Carol Pehotsky (09:26):

Oh, sure.

Maureen Schaupp (09:27):

And they have a hard time breathing there. So that's a, you know, a key sign. Also, any swelling anywhere.

Carol Pehotsky (09:32):

Yeah.

Maureen Schaupp (09:32):

Swelling in the ankles is very common. Swelling in the abdomen is something else that's-

Carol Pehotsky (09:37):

Hmm.

Maureen Schaupp (09:37):

... fairly common-

Carol Pehotsky (09:38):

Okay.

Maureen Schaupp (09:39):

... in patients that people don't seem to think of off the top of their head all the time.

Carol Pehotsky (09:41):

Sure. Yeah.

Maureen Schaupp (09:42):

Everyone's attention seems to go (laughing) the, but then that also goes with, "Oh man, it's summer and I ate too much pizza or..."

Carol Pehotsky (09:50):

Right.

Maureen Schaupp (09:50):

I'm a little...

Carol Pehotsky (09:51):

I'm bloated from whatever salty food I had last night and not...

Maureen Schaupp (09:55):

Exactly, but then it never goes away.

Carol Pehotsky (09:56):

Right.

Maureen Schaupp (09:57):

And then you, you know, kind of end up where you end up. So.

Carol Pehotsky (10:00):

All right. So, all right, so listeners, so another reminder that we all need to be listening to our bodies as well.

Maureen Schaupp (10:06):

Right.

Carol Pehotsky (10:07):

Always.

Maureen Schaupp (10:08):

Don't ignore it.

Carol Pehotsky (10:08):

And this and any other scenario. So, if you're listening and relating to some of these symptoms, maybe a time to go see a provider.

Maureen Schaupp (10:15):

Absolutely.

Carol Pehotsky (10:16):

Alright. Back to our regular scheduled programming. (laughs) So talking then about that initial admission and knowing that a lot of our listeners are working in an inpatient setting, what are some of those things that are being managed? What's the latest guidelines around how to help manage them? And what sort of things should nurses be anticipating as part of that initial stay?

Maureen Schaupp (10:35):

During the initial stay, I think it goes back to trying to find out what the underlying disease process is. That is always important, right. So, I would expect that your provider colleagues are working on that part simultaneously while managing the acute symptoms.

Carol Pehotsky (10:52):

Okay.

Maureen Schaupp (10:52):

Usually, the acute symptoms are a result of too much fluid overall.

Carol Pehotsky (10:58):

Yeah.

Maureen Schaupp (10:58):

Right. So, we try to decongest the patient, most often using diuretics.

Carol Pehotsky (11:04):

Mm-hmm.

Maureen Schaupp (11:05):

Right. Your IV Lasix, it could be a mix of other medications. And if the patient has heart failure with reduced ejection fraction...

Carol Pehotsky (11:12):

Mm-hmm.

Maureen Schaupp (11:13):

... where their left ventricular ejection fraction is lower than you would expect, you know, less than 40, they will also start on guideline-directed medical therapy.

Carol Pehotsky (11:23):

Okay.

Maureen Schaupp (11:23):

So there are four pillars of guideline-directed medical therapy in... for those patients with heart failure with reduced ejection fraction that are outlined in the guidelines that are put out by the Heart Failure Society of America, the American Heart Association, and the American College of Cardiology. They put together joint guidelines.

Carol Pehotsky (11:42):

Oh, that's beautiful.

Maureen Schaupp (11:42):

Yes. Every couple of years.

Carol Pehotsky (11:44):

We have one source of truth. Yay.

Maureen Schaupp (11:45):

It was not always that way, but we are there.

Carol Pehotsky (11:47):

(laughs)

Maureen Schaupp (11:47):

We're there now. So, and you know, kind of four different primary medication classes that we use.

Carol Pehotsky (11:54):

Okay.

Maureen Schaupp (11:54):

And so, you'll also see your provider colleagues start to put those medications on board. And I think for nurses working at the bedside, it's most important to understand what those medications are, why we're using them.

Carol Pehotsky (11:54):

Yeah.

Maureen Schaupp (12:08):

Because remember, these are probably going to be all new for the patient.

Carol Pehotsky (12:11):

Yeah. Yeah.

Maureen Schaupp (12:12):

So, making sure the patient understands what they're for, how important they are, and how they actually work to affect their entire disease course. Right.

Carol Pehotsky (12:22):

Yeah.

Maureen Schaupp (12:22):

Diuretics are not one of the four. (laughing)

Carol Pehotsky (12:27):

Okay.

Maureen Schaupp (12:28):

Diuretics are not one of the four. These four drug classes essentially help to reduce morbidity and mortality.

Carol Pehotsky (12:35):

Okay.

Maureen Schaupp (12:35):

Right. By affecting the disease process overall. Diuretics only work to decongest.

Carol Pehotsky (12:35):

That short period of time. Okay.

Maureen Schaupp (12:41):

So, we use them when we need it, but they actually have no long-term effect-

Carol Pehotsky (12:42):

Hmm.

Maureen Schaupp (12:46):

On the outcomes for the patient...

Carol Pehotsky (12:48):

Okay.

Maureen Schaupp (12:48):

... overall. Right.

Carol Pehotsky (12:49):

All right.

Maureen Schaupp (12:50):

So, there is nothing that says over time, you should always be on some dose of basics. If you don't have to be on some dose of diuretic, that's the best case.

Carol Pehotsky (12:50):

Yeah. (laughs)

Maureen Schaupp (13:01):

The best-case scenario.

Carol Pehotsky (13:01):

Yeah. Yeah.

Maureen Schaupp (13:02):

So as the bedside nurse, I would look out for those, medications, monitor what the side effects may be, and educate the patient and their family members because this is a lot...

Carol Pehotsky (13:13):

Yeah.

Maureen Schaupp (13:13):

... to take in all at once. A lot. And they usually come in pretty sick that first time.

Carol Pehotsky (13:14):

Yeah.

Maureen Schaupp (13:18):

Because they've limped along for a while and now, they can't limp anymore. And so, they're here, they're trying to take this all in and monitoring their eyes and nose is another very important thing to do that very closely. And also, their daily weights.

Carol Pehotsky (13:32):

Yeah.

Maureen Schaupp (13:32):

Which is really hard with the beds and the pillows and the sheets-

Carol Pehotsky (13:32):

Yeah.

Maureen Schaupp (13:35):

... and all of the other stuff. But if I could stress to recognize the importance of that in this patient population, getting them up on a standing scale is best case...

Carol Pehotsky (13:47):

Sure.

Maureen Schaupp (13:48):

... scenario. Best case scenario.

Carol Pehotsky (13:48):

Not easily done but yes.

Maureen Schaupp (13:48):

Not easily done.

Carol Pehotsky (13:50):

Yeah.

Maureen Schaupp (13:51):

But best-case scenario, because you're going to be teaching them the same thing as they're getting ready for discharge. So, if we show them how important it is while they're here as an inpatient, it'll make it more likely that they do it as an outpatient as well.

Carol Pehotsky (14:04):

Okay. I hadn't thought about that, but absolutely. So, the four pillars without a whole lesson in pharmacology. (laughing). That's another episode. As that inpatient nurse, what types of medications or what medications would fit into one of those four pillars? What are their effects and what are s... You mentioned side effects.

Maureen Schaupp (14:04):

Yeah.

Carol Pehotsky (14:23):

What should I be looking for as that nurse who's starting somebody on these medications probably for the first time?

Maureen Schaupp (14:27):

Yeah, absolutely. So, one of the first pillars is your beta blockers.

Carol Pehotsky (14:31):

Ah, okay.

Maureen Schaupp (14:31):

So, medications like metoprolol succinate or TOPROL is the brand name of that medication. Carvedilol...

Carol Pehotsky (14:38):

Okay.

Maureen Schaupp (14:38):

... COREG, right, those types of medications, they can affect blood pressure. They will lower the blood pressure.

Carol Pehotsky (14:39):

Yeah.

Maureen Schaupp (14:44):

So, you always want to monitor that, and they will lower your heart rate as well. So those are the two big things to look out for in regard to somebody's vital signs.

Carol Pehotsky (14:52):

Right.

Maureen Schaupp (14:53):

The other very interesting thing about beta blockers, if you look way back in the literature...

Carol Pehotsky (14:58):

Mm-hmm.

Maureen Schaupp (14:58):

... beta blockers used to be absolutely contraindicated-

Carol Pehotsky (14:58):

Really?

Maureen Schaupp (15:02):

... in patients with heart failure.

Carol Pehotsky (15:02):

(laughs)

Maureen Schaupp (15:04):

Right.

Carol Pehotsky (15:05):

Okay. (laughs)

Maureen Schaupp (15:05):

But what we learned over time was that they are still contraindicated in certain spots in the disease process.

Carol Pehotsky (15:12):

Oh, okay.

Maureen Schaupp (15:13):

So, if somebody is still acutely fluid overloaded...

Carol Pehotsky (15:17):

Ah.

Maureen Schaupp (15:18):

... or in a low flow state, you don't want to start or increase a beta blocker at that point in time because it can be more detrimental-

Carol Pehotsky (15:27):

Ah.

Maureen Schaupp (15:27):

... to the patient.

Carol Pehotsky (15:28):

So, get them a little less fluid overloaded first.

Maureen Schaupp (15:30):

Decrease their contra... Exactly. So, you got to bring that fluid level down. So, I wouldn't expect that your patient-

Carol Pehotsky (15:31):

Day one.

Maureen Schaupp (15:35):

... comes in for the first time. Right. Exactly. You know, with their neck veins up to their ears and you know...

Carol Pehotsky (15:35):

(laughs) Yeah.

Maureen Schaupp (15:40):

All swollen and the whole thing. And that someone would give them a beta blocker out of the gate.

Carol Pehotsky (15:44):

Okay.

Maureen Schaupp (15:44):

Because that might be a bit detrimental. But as they get closer to discharge-

Carol Pehotsky (15:45):

Ah.

Maureen Schaupp (15:48):

... and we see those fluid levels come down, it would be a very appropriate thing at that point, as long as they're not low flow, to start a beta blocker. Because that will be key in their long-term therapy.

Carol Pehotsky (16:00):

Oh, sure. Okay.

Maureen Schaupp (16:00):

Essentially what the beta blockers do is allow the heart to rest a little bit and recover.

Carol Pehotsky (16:07):

Mm-hmm.

Maureen Schaupp (16:07):

Right. If we think about how beta blockers work without getting into the big pharmacology (laughing) lecture, right. They block the fight or flight response on the heart.

Carol Pehotsky (16:16):

Yeah.

Maureen Schaupp (16:17):

To a degree, right?

Carol Pehotsky (16:18):

Mm-hmm.

Maureen Schaupp (16:18):

So, if you think about it, when we're really acutely sick and ill, we need...

Carol Pehotsky (16:22):

Yes.

Maureen Schaupp (16:23):

... the fight or flight response...

Carol Pehotsky (16:23):

Yes.

Maureen Schaupp (16:24):

... to keep us going.

Carol Pehotsky (16:25):

Mm-hmm.

Maureen Schaupp (16:25):

So, you don't want to block it. That's why we don't use them when they're acutely fluid overloaded or in a low flow state. But over time, you can't keep running that fast.

Carol Pehotsky (16:34):

No. No. (laughs) Right.

Maureen Schaupp (16:36):

Especially if you're a bit broke. Right?

Carol Pehotsky (16:36):

Yeah. Hmm.

Maureen Schaupp (16:38):

So, you can't keep running that fast. And so, the beta blocker kind of helps protect the heart in that matter.

Carol Pehotsky (16:43):

Okay.

Maureen Schaupp (16:44):

So over time it reduces morbidity and mortality. The next kind of group of drugs is inclusive of a couple classes.

Carol Pehotsky (16:51):

Oh, okay.

Maureen Schaupp (16:51):

Are drugs that interact with the RAS system overall.

Carol Pehotsky (16:56):

Okay.

Maureen Schaupp (16:56):

The drug of choice here, we only currently have one FDA-approved in the United States. It's a combination medication. It's called sacubitril/valsartan.

Carol Pehotsky (16:56):

Okay.

Maureen Schaupp (17:06):

So, as you can see, there's a portion of an ARB in there.

Carol Pehotsky (17:06):

Mm-hmm.

Maureen Schaupp (17:09):

The brand name for this is ENTRESTO. Okay. And sacubitril/valsartan falls into a class of drugs called ARNIs.

Carol Pehotsky (17:09):

Okay.

Maureen Schaupp (17:15):

Right. (laughs) So it's an angiotensin receptor blocker, that's the valsartan part.

Carol Pehotsky (17:22):

Mm-hmm.

Maureen Schaupp (17:23):

And then the neprilysin inhibitor and the neprilysin inhibitor is a sacubitril portion of that. And so, what this does is it blocks some of the harmful effects of hormones and neurotransmitters that come from the kidneys that make us retain...

Carol Pehotsky (17:41):

Ah.

Maureen Schaupp (17:41):

... water-

Carol Pehotsky (17:42):

Okay.

Maureen Schaupp (17:43):

... and vasoconstrict vessels. It blocks those effects. So, it opens up our blood vessels and also helps make sure that we're not retaining more sodium and things at the kidneys so that it can help us...

Carol Pehotsky (17:43):

Okay.

Maureen Schaupp (17:55):

... you know, make sure that we-

Carol Pehotsky (17:56):

Everybody out of the pool.

Maureen Schaupp (17:57):

Yeah, exactly. It does, it does multiple things. Every time I give a lecture to some of the advanced practice providers, I do it a couple times a year, and I pull up the picture of the RAS system and where-

Carol Pehotsky (18:08):

Ah.

Maureen Schaupp (18:08):

... in particular these medications work.

Carol Pehotsky (18:10):

Yeah.

Maureen Schaupp (18:10):

But I feel like everybody gets a little bit of PTSD (laughs) when it happens (laughs) because it's, you know, it brings you right back to school-

Carol Pehotsky (18:17):

(laughs)

Maureen Schaupp (18:18):

... and it's trying to memorize the whole thing. So, we'll sum it up that way. That medication, the sacubitril/valsartan has been proven to be superior compared to ACE inhibitors or ARBs alone.

Carol Pehotsky (18:31):

Okay.

Maureen Schaupp (18:32):

Those used to be the primary drugs in that choice, but since this one came out in the market, it has been proven superior over the other two.

Carol Pehotsky (18:40):

Oh, okay.

Maureen Schaupp (18:40):

Now, if a patient cannot tolerate that medication for some reason or another, it does have a more profound effect on the blood pressure tends to than the ACE inhibitors or the ARNIs, that might be a reason you would change them to an ACE inhibitor, which is a perfectly acceptable thing to do.

Carol Pehotsky (18:59):

Yeah.

Maureen Schaupp (19:00):

In the case of all three medications, you're watching blood pressure because it can go too low.

Carol Pehotsky (19:05):

Yeah.

Maureen Schaupp (19:05):

You're watching the kidney function.

Carol Pehotsky (19:07):

Okay.

Maureen Schaupp (19:07):

Because it can have an, an effect on the kidney function. And you're also, in particular, looking at the potassium levels.

Carol Pehotsky (19:13):

Yeah.

Maureen Schaupp (19:13):

Because they all tend to increase potassium levels as well.

Carol Pehotsky (19:13):

Okay.

Maureen Schaupp (19:15):

So those would be some of the key things.

(19:17):

Next part, also part of the RAS system, is the mineral corticosteroid receptor antagonists.

Carol Pehotsky (19:23):

Okay.

Maureen Schaupp (19:23):

So here-

Carol Pehotsky (19:24):

Say that five times fast.

Maureen Schaupp (19:24):

Exactly, right.

Carol Pehotsky (19:25):

(laughs)

Maureen Schaupp (19:26):

So here we have spironolactone and/or eplerenone.

Carol Pehotsky (19:29):

Okay.

Maureen Schaupp (19:29):

Aldactone and Inspra would be the brand names for those. And those work, you know, in the same sort of fashion, blocking harmful effects of aldosterone on the heart and those neurotransmitters that come with it. And then last but not least are the SGLT inhibitors as well. So dapagliflozin and empagliflozin, one example of which would be FARXIGA.

Carol Pehotsky (19:51):

Okay.

Maureen Schaupp (19:52):

Or JARDIANCE-

Carol Pehotsky (19:52):

Oh okay.

Maureen Schaupp (19:53):

... would be the other two that we see here in the United States. And those medications also help us block some of the harmful neurotransmitters and things like that, as well as helps us get rid of some more glucose and sodium. And with that, also comes more fluid.

Carol Pehotsky (20:09):

Sure.

Maureen Schaupp (20:09):

And so, you end up diuresing out more of that through a natriuretic process. Right. So oftentimes when those medications are started, we can actually back off a little bit...

Carol Pehotsky (20:20):

Mm-hmm.

Maureen Schaupp (20:20):

... on the diuretics.

Carol Pehotsky (20:21):

Yeah.

Maureen Schaupp (20:21):

Because they have a diuretic effect on their own. And so, we always watch out for that.

Carol Pehotsky (20:22):

Yeah.

Maureen Schaupp (20:25):

So those medications, in particular, they were developed for use in diabetic patients.

Carol Pehotsky (20:29):

Oh well, yeah.

Maureen Schaupp (20:30):

Right. We've been using them in diabetes for a really long time.

Carol Pehotsky (20:31):

Yeah.

Maureen Schaupp (20:34):

They should not be used in type 1 diabetics at all.

Carol Pehotsky (20:38):

Okay.

Maureen Schaupp (20:38):

So always contraindicated there. And in patients with type 2 diabetes, you do want to continue to monitor their blood sugar as they have been. But I have to be honest, I was really scared when these were approved for the use in heart failure-

Carol Pehotsky (20:39):

Yeah.

Maureen Schaupp (20:50):

... because I thought I was going to drop everybody's blood sugar.

Carol Pehotsky (20:54):

Sure. Yeah.

Maureen Schaupp (20:54):

Right? But really, it has been an absolute game changer in these heart failure patients. And I have not personally seen negative profound effects-

Carol Pehotsky (21:02):

Okay.

Maureen Schaupp (21:02):

... in regard to hypoglycemia. And so, it's really been very well tolerated in these patient populations. So those are the four, you know-

Carol Pehotsky (21:09):

Yeah.

Maureen Schaupp (21:10):

... kind of pillars of guideline-directed medical therapy and watching out for renal function as well with the SGLT inhibitors.

Carol Pehotsky (21:17):

Yeah. So, patients have had their, their first admission related to this progression of their heart. They're on all these new medications, there's a lot of other changes of diet, of lifestyle, et cetera. So, appreciating that as nurses, we should receive of course discharge instructions, but there's so much. I can't even imagine. "Mrs. Pehotsky, it's time to discharge you." What recommendations do you have for nurses? It's time to do those discharge instructions. Hopefully, it's not the first time of course that patient and their loved ones have heard about these things.

Maureen Schaupp (21:17):

Sure.

Carol Pehotsky (21:48):

But now things are getting real and it's time for me and my loved one to go home and manage this on our own. What are some tips and tricks or, or what, what, what have you for the nurses that are doing that discharge instruction?

Maureen Schaupp (22:00):

Yeah, absolutely. I would try to focus on those things that are of the utmost importance first.

Carol Pehotsky (22:07):

Okay.

Maureen Schaupp (22:07):

Right. There, to your point, there is a lot, and they will not take it all in during their hospitalization.

Carol Pehotsky (22:13):

No.

Maureen Schaupp (22:13):

(laughs) So I would focus, one, on the medications. That is very, very important that they clearly understand the medications that they're on, when they're supposed to take them, what they're for.

Carol Pehotsky (22:25):

Mm-hmm.

Maureen Schaupp (22:26):

The next thing would be what are the things they should do every day at home to help them monitor themselves.

Carol Pehotsky (22:33):

Okay.

Maureen Schaupp (22:34):

And you have to take that one step further though, because it's great that they're monitoring themselves, but if they don't know what bad looks like...

Carol Pehotsky (22:42):

Yeah.

Maureen Schaupp (22:43):

... or who to call when bad happens, then we've done them no good.

Carol Pehotsky (22:46):

Right.

Maureen Schaupp (22:47):

And so that's kind of a three-step process, right? So, I use daily weights as the example here.

Carol Pehotsky (22:47):

Okay.

Maureen Schaupp (22:53):

Right. That they should weigh themselves every day in the morning, after they go to the bathroom, before they have anything to eat or drink.

Carol Pehotsky (22:59):

Okay.

Maureen Schaupp (23:00):

And do it in the same amount of clothing that you would, right, every day.

Carol Pehotsky (23:04):

Yeah, yeah.

Maureen Schaupp (23:04):

Whether it's your pajamas or whatever you want. So that's important. And they need to write that down.

Carol Pehotsky (23:09):

Yeah.

Maureen Schaupp (23:10):

Because just like I talked about before, how the symptoms kind of creep up and you start to not notice...

Carol Pehotsky (23:14):

Yeah.

Maureen Schaupp (23:14):

... that it's different. Same thing can be said for the weight.

Carol Pehotsky (23:16):

It's not that much, it's just a little bit.

Maureen Schaupp (23:18):

Yeah. No big deal.

Carol Pehotsky (23:18):

Until it's several days of a little bit.

Maureen Schaupp (23:20):

Exactly. And then you have to define what several days of a little bit is.

Carol Pehotsky (23:24):

Right.

Maureen Schaupp (23:24):

Right.

Carol Pehotsky (23:25):

Yeah.

Maureen Schaupp (23:25):

And so, what we say here at the clinic is four pounds from your dry weight. So, you establish that dry weight for them and it's usually the provider group that will do that. Right. Because they may not leave here completely dry.

Carol Pehotsky (23:37):

Right.

Maureen Schaupp (23:38):

And that's okay.

Carol Pehotsky (23:39):

Mm-hmm.

Maureen Schaupp (23:39):

Right. They can continue the diuresis at home as long as everything else is stable. But if they go up or down four pounds from their dry weight, that's when they should call.

Carol Pehotsky (23:39):

Okay.

Maureen Schaupp (23:49):

And we got to give them a very clear number...

Carol Pehotsky (23:52):

Yes.

Maureen Schaupp (23:52):

... to call and who to get hold of.

Carol Pehotsky (23:52):

Mm-hmm.

Maureen Schaupp (23:54):

Because a lot of different people took care of them while they were in the hospital.

Carol Pehotsky (23:57):

Yeah.

Maureen Schaupp (23:57):

They may have many different numbers listed on their discharge summary. And so, making it very clear to them who to call and when.

Carol Pehotsky (24:05):

And I mean, thinking about making sure that they have a reliable scale at home.

Maureen Schaupp (24:09):

Yes.

Carol Pehotsky (24:10):

Even starting with, do you have a scale at home? Is it in good working order?

Maureen Schaupp (24:14):

Mm-hmm. Absolutely.

Carol Pehotsky (24:15):

Really making no assumptions that people are prepared for this and, and maybe they are, but really making sure as the nurse that you're going over-

Maureen Schaupp (24:22):

Right.

Carol Pehotsky (24:22):

... all of that. Again, in the, in the cosmos of things, there's so many things to think about, but it's discharge time. How much information should we be sharing about diet changes and that approach as well?

Maureen Schaupp (24:32):

Yeah.

Carol Pehotsky (24:33):

Knowing that we don't want to completely overwhelm our patients.

Maureen Schaupp (24:35):

Absolutely. I would say in the acute period, leaving the hospital, the most important thing to drive home is their sodium intake.

Carol Pehotsky (24:44):

Yeah.

Maureen Schaupp (24:45):

And decreasing the amount of sodium. Now, to your point, not making any assumptions and kind of meeting them where they're at is the best thing you can do.

Carol Pehotsky (24:45):

Yeah.

Maureen Schaupp (24:54):

Right. We use the old adage all the time, if you tell a diabetic not to eat cake, are going to go home and eat cake. (laughing) If you tell a heart failure patient to not eat any chips, oh, they're going to want to have chips.

Carol Pehotsky (25:06):

All they're going to have is chips. (laughs)

Maureen Schaupp (25:07):

All they want. So, I start with trying to figure out what their current sodium intake might be.

Carol Pehotsky (25:13):

Oh sure. What does a normal day look like?

Maureen Schaupp (25:14):

What does a normal day look like for you?

Carol Pehotsky (25:14):

Yeah.

Maureen Schaupp (25:14):

Right?

Carol Pehotsky (25:14):

Mm-hmm.

Maureen Schaupp (25:16):

Find out if they eat a lot of pre-prepared foods, do they have a lot of canned goods? Right.

Carol Pehotsky (25:16):

Yeah.

Maureen Schaupp (25:22):

It's not even coming up with the number of milligrams they have per day. Right. Don't even start there.

Carol Pehotsky (25:26):

Yeah.

Maureen Schaupp (25:27):

Just start with like kind of what does this look like for you.

Carol Pehotsky (25:27):

Mm-hmm.

Maureen Schaupp (25:29):

Do you have a salt shaker? Do you use it? Okay. Right.

Carol Pehotsky (25:33):

Because must have both questions today.

Maureen Schaupp (25:35):

Exactly. Because first step would be-

Carol Pehotsky (25:36):

Yeah.

Maureen Schaupp (25:37):

... stop using the salt shaker.

Carol Pehotsky (25:39):

Yeah.

Maureen Schaupp (25:40):

Right.

Carol Pehotsky (25:40):

Yeah.

Maureen Schaupp (25:40):

And then continue to work with them on what it is. And of course, always giving them as many materials and references that they can take home with them...

Carol Pehotsky (25:40):

Mm-hmm.

Maureen Schaupp (25:49):

... as possible so that the patient and their family, their caregivers, whomever is with them, can reference those after they've left the hospital when they probably are better prepared to start to intake some more of that information.

Carol Pehotsky (26:00):

Yeah. So, you know, you think about any chronic disease, right? And so, it's, I came into the hospital and now I have this stack of paper, (laughs) this new diagnosis, a list of pills, and myself and my loved one are trying to sort of wrap our heads around this. Knowing that that outpatient management is so very important, what does that transition look like? And nurses working in the outpatient setting, what are some things that they need to be reinforcing or perhaps educating anew to patients and their loved ones as they're coming back in for follow up appointments.

Maureen Schaupp (26:30):

Absolutely. One of the most important things, just as I said, when the patient is discharged when they come in, is to get a good clear medication list from them.

Carol Pehotsky (26:39):

Mm. Yeah.

Maureen Schaupp (26:39):

Right. And oftentimes we see the patient just hand back the discharge summary.

Carol Pehotsky (26:44):

(laughs)

Maureen Schaupp (26:44):

Right. Thinking about it's like-

Carol Pehotsky (26:45):

I know. You wrote this week ago.

Maureen Schaupp (26:46):

Right, here it is.

Carol Pehotsky (26:46):

Yeah.

Maureen Schaupp (26:47):

Like this is what I'm taking, which may very often be true, but I think asking them some really pointed questions about the medications to get a feel, you know, have they really started to learn them or not and find out where they are. Again, you have to meet them where they are.

Carol Pehotsky (27:02):

Yeah. Are you taking it-

Maureen Schaupp (27:04):

Absolutely.

Carol Pehotsky (27:05):

... as prescribed. If not-

Maureen Schaupp (27:06):

Have you picked this up from the pharmacy?

Carol Pehotsky (27:08):

Well sure. Yeah.

Maureen Schaupp (27:09):

Right?

Carol Pehotsky (27:09):

Mm-hmm.

Maureen Schaupp (27:09):

Because they'll tell you like, here's my list of things.

Carol Pehotsky (27:09):

(laughs)

Maureen Schaupp (27:12):

And if you just say, okay, and you mark them up, it's going to match exactly what they were discharged on, assuming you're on the same EMAR, right. But what you find out oftentimes is, oh, I didn't pick that one up yet. They called me yesterday and said it was ready.

Carol Pehotsky (27:25):

Sure.

Maureen Schaupp (27:26):

Right.

Carol Pehotsky (27:26):

Yeah.

Maureen Schaupp (27:26):

And so really asking kind of those pointed questions to really get to, are you taking these every day? Is it going okay? And cost.

Carol Pehotsky (27:36):

Yeah.

Maureen Schaupp (27:36):

With some of these medications-

Carol Pehotsky (27:37):

Yeah.

Maureen Schaupp (27:38):

... is also something, right? While they're here in the hospital for many patients, they're covered or we don't know if they're covered or not, but they get them while they're here.

Carol Pehotsky (27:46):

Mm-hmm.

Maureen Schaupp (27:47):

Then they go home only to find out that they cost a lot, and they may qualify for some assistance programs and those sort of things, but that does take a little while.

Carol Pehotsky (27:47):

Yeah.

Maureen Schaupp (27:56):

And so, between their discharge from the hospital and their follow up appointment, hopefully within seven days-

Carol Pehotsky (28:03):

Yeah.

Maureen Schaupp (28:03):

... from, you know, right.

Carol Pehotsky (28:04):

Mm-hmm.

Maureen Schaupp (28:05):

That short window is so important for these patients. They may not have gotten that medication yet.

Carol Pehotsky (28:09):

Sure.

Maureen Schaupp (28:10):

And so, asking them those questions about where are they with the patient assistance program, how can we help? And you know, being knowledgeable in those areas too becomes very helpful. But I think for the outpatient nurse, that really good medication review, really understanding what the patient is or is not taking...

Carol Pehotsky (28:28):

Yeah.

Maureen Schaupp (28:29):

... is good. The accurate weight, again.

Carol Pehotsky (28:31):

Yeah.

Maureen Schaupp (28:32):

To help and to talk to them about their weights at home. Have you been weighing yourself daily?

Carol Pehotsky (28:37):

When?

Maureen Schaupp (28:37):

Do you have that list with you? Exactly.

Carol Pehotsky (28:39):

Yeah.

Maureen Schaupp (28:39):

When? Right. And just reinforcement of all of those things. And do you know who to call? Do you know when to call? So, it goes back to all of those same things that were just as important at discharge. Now it comes to reinforcing in the outpatient area. And at that first visit, I don't know if those key points are any different than they were when the patient was discharged.

Carol Pehotsky (28:59):

Okay.

Maureen Schaupp (28:59):

It's such a short window of time. They have been through so much.

Carol Pehotsky (29:03):

Yeah. They're still probably processing.

Maureen Schaupp (29:05):

Exactly. That we, you know, kind of reinforce those important things again. And then just work our way through with each visit, more and more, more and more, pointing them to the different resources that they have available at home so they can be reading and learning in between visits and pointing them to reliable resources-

Carol Pehotsky (29:21):

Ah.

Maureen Schaupp (29:22):

... is-

Carol Pehotsky (29:24):

Yeah.

Maureen Schaupp (29:24):

... so important.

Carol Pehotsky (29:24):

Yeah.

Maureen Schaupp (29:25):

So important. Because they'll go down a rabbit hole.

Carol Pehotsky (29:27):

Mm-hmm.

Maureen Schaupp (29:27):

We all, we all have-

Carol Pehotsky (29:27):

I talked to my neighbor, and you know, he's on-

Maureen Schaupp (29:29):

Right. We all have, right?

Carol Pehotsky (29:30):

Yep.

Maureen Schaupp (29:31):

He takes this, you know, vitamin supplement. Oh my gosh. No, you're also on Coumadin. So, (laughs) you know, pointing them towards really reliable resources, you know from other... I know Cleveland Clinic, we put our own healthcare resources out there for the public, okay, to reference, which is great. I know some other large, very respectable health systems do the same. And so those are wonderful places to go for resource as well. Some of our websites from like Heart Failure Society of America-

Carol Pehotsky (29:56):

Okay.

Maureen Schaupp (29:57):

... also has patient-facing...

Carol Pehotsky (29:58):

Oh, nice.

Maureen Schaupp (29:58):

... resources. So that's another wonderful place to go to get some really reliable information to our patients.

Carol Pehotsky (30:04):

One I think about, especially that first visit, everybody's still processing things. They're just hitting the grieving process of my life has to look different now. The, the caregiver's life has to look different.

Maureen Schaupp (30:16):

Hmm.

Carol Pehotsky (30:16):

With each subsequent visit, what should nurses be thinking about to provide that compassion and that, that support really for the caregiver as well as the patient?

Maureen Schaupp (30:25):

I think always being in tune to everybody in the room.

Carol Pehotsky (30:31):

Mm. Okay.

Maureen Schaupp (30:31):

Right. So often, we talk about making sure we're talking to the pa... Right?

Carol Pehotsky (30:31):

Yeah, of course.

Maureen Schaupp (30:36):

Because the patient's the patient.

Carol Pehotsky (30:37):

Yes.

Maureen Schaupp (30:37):

That's the person here for treatment today, here for... Right. But being in tune to what they're doing, the body language of the patient as well as the body language from all of the other people who have now accompanied the patient in the room as well.

Carol Pehotsky (30:53):

Yeah.

Maureen Schaupp (30:54):

Right. And if there's nobody accompanying the patient, asking those questions. Is there anybody at home that's helping you?

Carol Pehotsky (31:00):

Mm. Mm-hmm.

Maureen Schaupp (31:02):

Do you need any other help at home? Right. What is most challenging for you?

Carol Pehotsky (31:02):

Okay. Mm-hmm.

Maureen Schaupp (31:06):

Right, uh, asking some more open-ended questions to help get there. But I think paying attention to the cues, the non-verbal cues...

Carol Pehotsky (31:14):

Yeah.

Maureen Schaupp (31:14):

... has been what becomes really telling in a room as well. Right. Some people come in and they're just very stubborn. They just aren't ready to accept the diagnosis. They want to be able to do all of the things that they used to be able to do and they might get back there. Right.

Carol Pehotsky (31:15):

Yeah.

Maureen Schaupp (31:33):

If they've just been diagnosed, that may very well happen. But we have to help them through this. And sometimes the caregivers need the help and guidance to help them get through it as well, because they also-

Carol Pehotsky (31:33):

Yeah.

Maureen Schaupp (31:43):

... don't know-

Carol Pehotsky (31:44):

Right.

Maureen Schaupp (31:45):

... what to expect moving forward. And so, involving everybody in the room in the conversation as the patient allows...

Carol Pehotsky (31:53):

Of course. Yeah.

Maureen Schaupp (31:53):

... is always, you know, just a wonderful way to kind of get at it.

Carol Pehotsky (31:57):

Who normally prepares the food at home?

Maureen Schaupp (31:59):

Mm-hmm. Also, very important. Who prepares the food?

Carol Pehotsky (32:01):

Oh, even salt I add to the soup counts too?

Maureen Schaupp (32:02):

Right.

Carol Pehotsky (32:05):

Yes. It all counts.

Maureen Schaupp (32:06):

Yes.

Carol Pehotsky (32:06):

Yeah.

Maureen Schaupp (32:06):

Yeah.

Carol Pehotsky (32:07):

Sure.

Maureen Schaupp (32:07):

We threw away the salt shaker. I bought this no salt, you know, replacement.

Carol Pehotsky (32:12):

Mm-hmm.

Maureen Schaupp (32:12):

Oh, well, it's got a lot of potassium in it. Could we talk about that?

Carol Pehotsky (32:15):

Sure. Well, yeah, that's a great point.

Maureen Schaupp (32:16):

Exactly.

Carol Pehotsky (32:16):

There's the good intent there. But does everybody in the room understand...

Maureen Schaupp (32:20):

Exactly.

Carol Pehotsky (32:20):

... what's happening?

Maureen Schaupp (32:21):

And sometimes I even notice when patients, it's obvious they've come with someone when I go out to the waiting room to-

Carol Pehotsky (32:27):

Yeah.

Maureen Schaupp (32:27):

... you know, call the patient and they're like, "Oh, you can stay here," right? And you see that there's a, a gaggle of people-

Carol Pehotsky (32:27):

(laughs)

Maureen Schaupp (32:32):

... who stay and the patient comes back. But then once they sit down, I'm like, "I saw you had people out there. Who are they? You know, are they assisting you at home? We're going to talk about some things. Say, do you want them to come back?" "Oh, okay. I just thought it was-

Carol Pehotsky (32:46):

Oh, sure. Yeah.

Maureen Schaupp (32:46):

Right. And so, to always offer that as well.

Carol Pehotsky (32:48):

Wow. So, we could keep talking for a long time about this. I, I want to circle back to, to just one last question. So, with any chronic disease, we want to avoid readmission as much as possible.

Maureen Schaupp (32:58):

Mm-hmm.

Carol Pehotsky (32:58):

And with heart failure, that's something that hospitals are measured in their success in avoiding that.

Maureen Schaupp (33:04):

Yes.

Carol Pehotsky (33:04):

Knowing that, again, patients are on their own journey. What are some things that we as nurses can do to hopefully minimize that readmission?

Maureen Schaupp (33:13):

Sure. I think on the inpatient side...

Carol Pehotsky (33:15):

Mm-hmm.

Maureen Schaupp (33:15):

... right, before the patient is discharged, really listening to the patients and their family members or whomever is accompanying them, you know, at times during their visit.

Carol Pehotsky (33:24):

Mm-hmm.

Maureen Schaupp (33:25):

Helping to identify what their barriers may be to successful care once they leave the hospital. Right. And those can be multiple things.

Carol Pehotsky (33:34):

Yeah.

Maureen Schaupp (33:34):

Right. It can be anything from cost to transportation is another big one.

Carol Pehotsky (33:39):

Mm-hmm.

Maureen Schaupp (33:39):

And food insecurity.

Carol Pehotsky (33:41):

Gosh. Yeah.

Maureen Schaupp (33:42):

Right. And-

Carol Pehotsky (33:43):

Do you have access to low-sodium food?

Maureen Schaupp (33:44):

Exactly.

Carol Pehotsky (33:45):

Yeah.

Maureen Schaupp (33:45):

Right. And low-sodium food oftentimes is more expensive-

Carol Pehotsky (33:48):

Yeah.

Maureen Schaupp (33:49):

... than some of the food that comes higher in sodium, some of the canned goods and things like that. And so, kind of just spending time to get to know them, build that trusting relationship first, and then working from there to best understand them and then notifying your other care team members of the things that you're noticing as well.

Carol Pehotsky (33:49):

Yeah.

Maureen Schaupp (34:08):

Right. Speak up.

Carol Pehotsky (34:09):

Yeah.

Maureen Schaupp (34:09):

Right. Somebody may come in the room and be like, "Okay, we've got this in line and this in line and this in line and we're ready to go." But in your head and in your gut, you're like, "Man, I know I talked to him about that yesterday and he told me the car's broke."

Carol Pehotsky (34:22):

Mm.

Maureen Schaupp (34:23):

Right. And so, it may or may not be appropriate to say in front of the patient, it depends on the rapport that you've built with them-

Carol Pehotsky (34:23):

Sure.

Maureen Schaupp (34:30):

... and that sort of thing, but always making sure to speak up and say, "You know what, I'm not quite sure that that's going to work. Do we have another option?"

Carol Pehotsky (34:38):

Right.

Maureen Schaupp (34:38):

Right. Here's why.

Carol Pehotsky (34:39):

Mm-hmm.

Maureen Schaupp (34:39):

Right. And really being that advocate-

Carol Pehotsky (34:42):

Always.

Maureen Schaupp (34:42):

... that we all strive to be...

Carol Pehotsky (34:43):

Yeah.

Maureen Schaupp (34:43):

... for our patient, right?

Carol Pehotsky (34:43):

Mm-hmm.

Maureen Schaupp (34:44):

That's a huge part of our role as nurses is advocating for the patient and their well-being. So really letting everybody else on the team know as well when you see something that-

Carol Pehotsky (34:53):

Absolutely.

Maureen Schaupp (34:54):

... might just not be conducive to them coming back on short term. One of the most important things about reducing readmissions, right. And even it's important for the hospital. It is a way that we are measured, but it's not good for the patient either...

Carol Pehotsky (35:08):

Right.

Maureen Schaupp (35:08):

... at the end of the day, right, is it really what we're trying not to do.

Carol Pehotsky (35:08):

That's why we measure it. Yeah.

Maureen Schaupp (35:08):

Exactly.

Carol Pehotsky (35:08):

Mm-hmm.

Maureen Schaupp (35:12):

And so, one of the most important things is very close outpatient follow up...

Carol Pehotsky (35:15):

Yeah.

Maureen Schaupp (35:16):

... when the patient has been discharged. So, we recommend an outpatient visit in less than seven days.

Carol Pehotsky (35:21):

Wow. Yeah.

Maureen Schaupp (35:22):

From the time they're discharged.

Carol Pehotsky (35:23):

Mm-hmm.

Maureen Schaupp (35:24):

For many patients, like, I don't want to be anywhere near...

Carol Pehotsky (35:26):

Right. (laughing) You want me to do what? (laughs)

Maureen Schaupp (35:30):

Anywhere near this place for much longer than a week.

Carol Pehotsky (35:33):

Yes.

Maureen Schaupp (35:33):

You want me to do what?

Carol Pehotsky (35:33):

(laughs)

Maureen Schaupp (35:34):

So also helping to explain to the patient throughout the course why that is so important.

Carol Pehotsky (35:39):

Yeah.

Maureen Schaupp (35:39):

Right. We've made a lot of changes while you're here in the hospital, we've changed things significantly for you. We need to make sure that this is going the right way and-

Carol Pehotsky (35:48):

Yeah.

Maureen Schaupp (35:49):

... you know, trust me, if you give them (laughs) the options of getting admitted to the hospital, coming to see us in the outpatient department, you know, or staying at home, you know, they'll always choose staying at home, of course.

Carol Pehotsky (36:01):

(laughs)

Maureen Schaupp (36:01):

But if coming to the outpatient appointment more frequently...

Carol Pehotsky (36:04):

Mm.

Maureen Schaupp (36:04):

... we'll keep them at home more...

Carol Pehotsky (36:07):

And not back in the-

Maureen Schaupp (36:07):

... than getting admitted to the hospital.

Carol Pehotsky (36:09):

Sure.

Maureen Schaupp (36:09):

It's usually a pretty easy sell.

Carol Pehotsky (36:11):

Okay. Well, I've learned so much. So, thank you very much.

Maureen Schaupp (36:16):

Thank you.

Carol Pehotsky (36:16):

So, before we call it a day, want to switch the topic a little bit. Those of you who have been listening a while know we normally do a speed round, but we're going to try something a little different. We have already spent, and we'll continue to spend this year at Cleveland Clinics talking a lot about purpose and, and what our why is. I'm hoping you're willing to share with us a little bit about your why.

Maureen Schaupp (36:34):

Absolutely. So, I became a nurse and became passionate. We talked a little bit about my passion towards chronic cardiac disease (laughs), overall.

Carol Pehotsky (36:34):

Mm-hmm.

Maureen Schaupp (36:42):

But even before I was passionate about that, I had a passion for chronic disease.

Carol Pehotsky (36:45):

Okay.

Maureen Schaupp (36:46):

So, my mom had multiple sclerosis and she's no longer with us, but so many good things came from that experience. And my purpose to become a nurse and to become a nurse practitioner really was because of the care that she received.

Carol Pehotsky (37:03):

Oh.

Maureen Schaupp (37:04):

And so, she had this lovely nurse practitioner over at the Mellon Center. Her name was Danny.

Carol Pehotsky (37:04):

Mm-hmm.

Maureen Schaupp (37:09):

She's retired now but-

Carol Pehotsky (37:10):

Shout out to Danny, everybody.

Maureen Schaupp (37:11):

Just shout out to Danny...

Carol Pehotsky (37:12):

Yeah.

Maureen Schaupp (37:12):

... because what an inspiration.

Carol Pehotsky (37:16):

Mm.

Maureen Schaupp (37:16):

Just like my chronic heart failure patients, this was a chronic disease. Right. We knew where it was going to end up. How long? No one knew. Right. But you just did everything in the meantime. But Danny was always so attentive and listened and you know, helped my mom and then helped all of the rest of us through the whole thing. And so, Danny and the care that she provided was really what gave me purpose because I wanted to help other families just the way she was able to help us.

Carol Pehotsky (37:46):

And clearly, you are.

Maureen Schaupp (37:48):

Thank you.

Carol Pehotsky (37:49):

Thank you so much for joining us today.

Maureen Schaupp (37:50):

You're welcome. Thanks Carol.

Carol Pehotsky (37:55):

As always, thanks so much for joining us for today's discussion. Don't miss out. Subscribe to hear new episodes wherever you get your podcasts. And remember, we want to hear from you. Do you have ideas for future podcasts or want to share your stories? Email us at nurseessentials@ccf.org. To learn more about nursing at Cleveland Clinic, please check us out at clevelandclinic.org/nursing.

(38:21):

Until next time, take care of yourselves and take care of each other.

(38:29):

The information in this podcast is for educational and entertainment purposes only and does not constitute medical or legal advice. Consult your local state boards of nursing for any specific practice or questions.