Heart Failure and Patient Education

At the age of 36, I was diagnosed with hypertension, hyperlipedemia and weighed 280 lbs. I was started on Norvasc for hypertension and Lipitor for hyperlipidemia. Like a good patient, I took my medications religiously, and did all of the things that my doctor told me to. At the age of 37, I entered the emergency room with chest pain radiating down my left arm. The crushing pressure on my chest made every breath a fight to survive. Statistically five million people over the age of 65 are admitted to the hospital due to poor management of their heart failure. Every year, about 500,000 new cases of heart failure are diagnosed. This number is expected to increase as the age of the American population increases (Rodgers, 2002). When we’re younger, we think we’re invincible. The reality is that every choice we make in life has a consequence. Good or bad, it’s a consequence that we will face some day. Although heart failure may show after the age of 65, the cause can be traced back to the choices we make when we’re younger. By applying some of nursing’s fundamental tasks, such as a basic knowledge base and patient teaching, patients learn that through consistent life style changes they can decrease the frequency of congestive heart failure (CHF) exacerbations, improving their quality of life. These changes include medication management, diet, exercise, and weight management.
Congestive Heart Failure Defined
Nurses are charged with acquiring a basic knowledge base for providing patient teaching. Before we can appreciate the effect that CHF has on the heart, it’s important to understand the normal function of the heart. Over the years, I have learned that in a healthy heart, blood enters through the right side of the heart, passing through the ventricles and into the lungs exchanging carbon dioxide for oxygen. Blood returns from the lungs to the left ventricle exiting the left side of the heart providing nutrients to the body. The heart operates through a fine balance of timing, fluid volume, blood pressure, and muscle elasticity and contraction. Compromised function to any one of these areas will not cause heart failure. However, if one area is compromised the other areas are taxed in an attempt to compensate for the area failing. According to J.M. Black, this persistent strain can cause a chain reaction resulting in the heart becoming an ineffective pump. With left sided CHF, the left ventricle is unable to push blood out to the body resulting in blood back flowing into the lungs. This causes congestion of the lungs and is referred to as systolic failure. If the patient has diastolic failure, the right ventricle is unable process blood returning from the extremities resulting in peripheral edema (Black, 2000). Damage to heart muscle, which leads to heart failure (HF), can occur from a myocardial infarction (MI), viral or bacterial infection, valvular disease, hypertension, or coronary artery disease (Rosenthal, 2004). Now that the cornerstone has been laid, the next step in the education process is a basic knowledge base on medication.

Medication Management
Medication is paramount to the treatment of any cardiac disorder. The primary goal of medication management is to reduce the overall workload on the heart while maintaining or even improving the hearts current level of function. This is accomplished through two avenues, symptom relief and improved cardiac function. Symptom relief is obtained through diuretic therapy resulting in reduced fluid volume. With left sided failure, reduced fluid volume results in improved gas exchange and improved ejection of blood to the body. With right side failure, a reduction in the fluid volume can reduce peripheral edema. According to Cayley, management of CHF symptoms through diuresis promotes improved gas exchange and tissue perfusion. Compared with other active medications, diuretics can improve exercise capacity in patients with heart failure by about 30 percent. Withdrawal of diuretic therapy from patients with heart failure may increase the risk of hospital readmission or death. About eight deaths are prevented for every 100 patients treated (Cayley, 2006). Cox points out, improved cardiac function can be obtained through the proper application of angiotensin converting enzyme (ACE) inhibitors, beta blockers, or aldosterone blockers. ACE inhibitors maintain circulating fluid in the body through vasoconstriction. Beta blockers influence the sympathetic nervous system through management of the bodies fight or flight response resulting in decreased fluid volume. Aldosterone blockers ultimately reduce the amount of sodium in the blood reducing fluid overload. Coordination between diuretic therapy and medications that directly impact cardiac function are the best option for effective sustained congestive heart failure management (Cox, 2007). Once the actions of medications are understood, the ability to provide safe and adequate patient teaching is underway
Diet Management
The first focus of the heart failure diet is to teach the client to manage their sodium intake (Rodgers, 2002). Education must be practical and safe. With today’s increased awareness of heart disease, an abundance of alternatives have been made available. With this abundance, education is more vital than ever. Caution must be taken when dietary education is provided. Replacing salt with salt substitutes can simply replace sodium with potassium resulting in heart failure exacerbations. Teaching the patient how to read food labels aides the patient in not only making safe decisions but places control of their diet within reach, ensuring the continuation of safe decisions. Involving a dietician can assist with dietary management through guidance surrounding: safe seasoning alternatives, food preparation, and appropriate food choices. This involvement only seeks to strengthen decisions by providing favorable alternatives. Patient education is vital in achieving decreased cardiac stress and improved CHF management.
Exercise
Patient education must contain a well balanced exercise program if positive outcomes are to be attained. According to Rodgers, exercises, such as walking, improve peripheral circulation resulting in improvement of tissue perfusion. Studies show that bed rest and limited activity are detrimental. Patients with stable heart failure should be encouraged to do regular light aerobic exercise or participate in a formal cardiac rehabilitation program (Rodgers, 2002). The New York Heart Association has broken heart failure down into four classifications. “Class I—No limitation of physical activity. Ordinary activity doesn’t cause undue fatigue, dyspnea, palpitation, or anginal pain. Class Il—Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in heart failure symptoms, including fatigue, dyspnea, palpitation, or anginal pain. Class Ill —Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes heart failure symptoms. Class IV—Severe limitation. Symptoms of heart failure (including anginal pain) are present at rest. If any physical activity is undertaken, discomfort is increased (Bosen 2003). To maintain continued and progressive exercise, it is vital to remember exercise requires balance. Self awareness of breathing patterns, energy levels, heart rates, and faintness can help control how much or how little exercise can be safely performed. For a severe heart failure client, passive range of motion may be required in the beginning. Other clients may require assistance walking a few feet while still others may be able to do more. Moderate exercise (i.e., at 60 percent of maximum exercise capacity) improves quality of life, decreases mortality, and decreases hospital readmissions for heart failure in patients with stable chronic heart failure (McConaghy, Smith, 2004). Without proper patient education, the patient is placed at risk of cardiac failure. Balance between cardiac taxing and cardiac limits
Weight Management
According to Mair, the primary focus of weight management centers on fluid retention. A weight gain of 1.35 to 2.25 kg (3 to 5 lb) can be an early indicator of deterioration which may require intervention. Because fluid and weight management go hand in hand, all patients with heart failure should obtain a bathroom scale and monitor their weight each morning. Tracking daily weights provides visual reinforcement, increased awareness, and promotes responsibility of cardiac management. Increased patient awareness of early indicators of deterioration can reduce hospitalizations (Mair, 1996). As medication, diet, and exercise are coordinated through the application of the lessons learned, a level of weight management is achieved. This chain reaction results in the heart being able to increase it’s output reducing the progression of the disease process.
Barriers
In a perfect world, patients take heed to the warnings and follow the advice presented before them. Well, we live in the realm of reality. Although there are many different barriers to consider with many different approaches to each barrier, there are four different barriers that if properly addressed can help with your goal of patient teaching. These barriers are knowledge, religion, socioeconomics, and inadequate insurance.
Knowledge
The Nursing Code of Conduct Provision Seven states: the nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development (ANA, 2007). Failure to possess a competent understanding of the heart and its function places patients at risk of injury or even death. This knowledge deficit can be influenced by many things that we may not even recognize. Arrogance or compliance with one’s current level of knowledge, home interference or even work ethics can silently push our responsibility as a nurse to the back. By general definition, negligence is the failure to do something (omission] which a reasonable person, guided by considerations which ordinarily regulate human affairs, would do or it is the doing of something (commission) under those same considerations which a reasonable person would not do (Collins, 2007). Whether the nurse omits a treatment or the knowledge base required to provide safe care to a patient, nurses are responsible for their actions and how we face these responsibilities define us.
Religion
So, where does the patient’s religion fall into this equation? As our world grows smaller and more cultures are brought closer, how does the nurse overcome barriers to provide the education that is required? A short example from Beth L. Rodgers puts it plainly. “A smart and eager university professor comes to an old Zen master for teachings. The Zen master offers him tea and upon the man’s acceptance he pours the tea into the cup until it overflows. As the professor politely expresses his dismay at the overflowing cup, the Zen master keeps on pouring: ‘A mind that is already full cannot take in anything new’, the master explains. ‘Like the cup, you are full of opinions and preconceptions’. In order to find happiness, he teaches his disciple, he must first empty his cup (Rodgers, 2002). To provide competent care, nurses must remove any prejudice or preconceived ideas. Our chosen task is to care for people and to do that, it is vital to meet patient’s where they are. Failure to do this only serves to build walls and barriers.
Socioeconomics
Poor compliance with medication is a key reason people with HF fail at their disease management. Many times, this is due to incomplete patient teaching. Often, we fail to consider the patient’s socioeconomic status. Many HF patients are primarily older and do not have the resources necessary to manage their disease process effectively. For some people it truly is a choice between food, heat for a loved one or themselves, or the medication that the doctor has prescribed. Thus, even persons with coverage, particularly sicker persons with greater need for medications, may face substantial financial barriers to obtaining essential medications (Saver, 2004). Alternatives approaches are available. Generic forms of medications, contacting a pharmacist to find alternatives for the patients to present to their physician, or government grants provided to contractors specifically for finding alternatives for patients who are defined as needy are just a few. Failure to assist the patient with maneuvering through these obstacles sets up the patient for failure.
Inadequate Insurance
Many times, it is assumed that because patients have insurance they can afford the services that are being provided or required. As a nurse, it is part of our responsibility to discuss these issues with our patients. Patients have a knowledge deficit of the continuum of health care. Being mindful of a patient’s insurance gives insight into the limitations faced by the patient. Most patients have limited resources and many services require copays. Understanding their limitations allows the nurse to facilitate the resolution of needs in a time frame preventing the development of barriers with lasting consequences.
Conclusion
Management of CHF requires effort, continuity, and determination. Lifestyle changes through medication management, diet, exercise, and weight management can decrease CHF exacerbations. This change requires the nurse to be educated knowledgeable and able to instill this knowledge to the patient. In a study performed by the Ahmanson University of California at Los Angeles Cardiomyopathy Center, 214 patients discharged with severe CHF were examined. They were treated aggressively with ACE inhibitors and diuretics, and advised to change diet and exercise habits. In six months, hospital readmissions dropped 85% among these patients (Southwick, 1998). This study and studies like it support not only how fragile the action of the heart is, but also how through simple changes, we can manage the consequences of those choices we made when we were younger. Changes that when pursued can improve not only the quantity of life but the quality of life. These changes made possible through a knowledge base and the ability to articulate that knowledge to a patient in a competent approach. Basic physiologic education is the cornerstone of patient care. Without it, the nurse lacks the understanding of the physiological changes throughout the disease process. This knowledge base allows the nurse to guide patients down the path of wellness and disease management. As the nurse develops a deeper knowledge of the physiological process, the information is passed on providing the patient the potential for optimal cardiac output.


Bibliography

Black, J.M., Hawks, J.H., (2005). Medical surgical nursing, (7th ed.). St Louis, Elsevier
Saunders, (13). 1650.

Bosen, D. (2003). What makes the new heart failure guidelines tick. Nursing Management.
(2003, February). Retrieved July 12, 2007, from Research Library database EBSCO Host.

Cayley, W. E. (2006). Diuretics for treatment of patients with heart failure. American
Family Physician. 74, 411-413. Retrieved August 7, 2007, from Research Library database
Ebsco Host.

Cox, B. (2007). Pharmacological management of heart failure. Practice Nurse. 36b, 49–
54. Retrieved July 19, 2007, from research data base Ebsco Host.

Mair, F. S., (1996). Management of heart failure. American Family Physician. 54, 245-
254. Retrieved August 7, 2007, from Research Library database Ebsco Host.

McConaghy, J. R., Smith, S.R. (2004). Outpatient treatment of systolic heart failure.
American Family Physician. 70, 2157-2164. Retrieved August 7, 2007, from Research
Library database Ebsco Host.

Rodgers, J.M., Reeder, S.J. (2002). Managing heart failure. Nursing Management,
(2002, Oct), 48A-48F. Retrieved July 15, 2007, from Research Library database. EBSCO
Host.

Rosenthal, K. (2004). Case study: Using ultrafiltration to manage CHF. Nursing
Management, 35, 41-46. Retrieved July 12, 2007, from Research Library database.
ProQuest,

AMA, (2007) The American Nurses Association, Inc. Retrieved 10/28/2007 from
http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/
EthicsStandards.aspx

Collins, S. E., (2007). Criminalization of negligence in nursing: a new trend. The Florida
News, 3, 28. Retrieved October 28, 2007, from Research Library database EBSCOHost.

Rogers, B. L., Yen, W. J., (2002). Re-thinking nursing science through the understanding of
Budism. Nursing Philosophy, 3, 213, Retrieved October 28, 2007 from EBSCOHost.

Saver, B.G., Doescher, M. P., (2004), Seniors with chronic health conditions and prescription
drugs: benefits, wealth, and health. Value in Health, 7, 134. Retrieved Oct 28, 2007, from
Research Library database EBSCOHost