Despite life-sustaining medical management for patients with critically worsening symptoms, heart failure (HF) prevalence continues to rise. An estimated 5.7 adult Americans have HF, and the prevalence is expected to rise 46% from 2012 to 2030, resulting in more than 8 million adults with HF.
The ability to recognize early and progressive HF signs and symptoms is crucial for both patients and clinicians. Yet even some experienced nurses lack recognition skills, so they’re unable to teach these to patients. Patients who are discharged without learning how to care for themselves and when to seek timely treatment may need to be readmitted repeatedly. It has been estimated that 1 in 4 Medicare patients with HF are readmitted within 30 days of discharge.
Current guidelines from the American College of Cardiology Foundation/American Heart Association and the Heart Failure Society of America focus on such care priorities as diet, discharge medications, daily weights, fluid restriction, physical activities, symptom recognition, what to do if symptoms worsen, when and how to seek medical help, and required follow-up.
Eliminating the disconnect
Nurses need to be more aware of worsening HF symptoms reported by patients. Studies show a disconnect between what patients report and how nurses respond. Listen closely when HF patients report their symptoms. Taking appropriate action after assessment may prevent the need for immediate readmission and improve self-management.
Make sure you know how to recognize early signs and symptoms of HF decline—and stay alert for them. Prompt recognition and action can prevent undue pain and suffering. Familiarize yourself with new evidence and HF guidelines, such as the Heart Failure Society of America’s Comprehensive Heart Failure Practice Guidelines.
Teach patients how to recognize symptoms of HF exacerbation and when to report them. Most HF patients wait 2 to 7 days before seeking help, during which time their symptoms may get worse. Delays may contribute to additional suffering, treatment, and costs.
Nonadherence to self-management is linked to increased readmissions and mortality. In the case study below, the patient didn’t understand what might happen if he didn’t follow self-management instructions.
Mr. B recently visited the clinic after multiple hospital readmissions for dyspnea, shortness of breath, and fatigue. A white male in his 50s, he had HF with uncontrolled diabetes, hypertension, and obesity. He didn’t adhere to self-management practices and joked that he ambulated to the vending machine without his wife’s knowledge to buy snacks while pushing his I.V. infusion pump. When asked about his most severe problems, Mr. B stated he was most affected by weight gain after HF diagnosis because it impaired his ability to perform independent hygiene measures. Yet he said he’d probably continue to eat what tasted good, even though he knew added fluid retention and weight contribute to increased cardiomyopathy, poor quality of life, and increased symptoms of acute HF.
Reasons for nonadherence
Why do some patients fail to adhere to self-management plans? Reasons remain unclear. We know comorbidities, altered mental status, and poor literacy can affect adherence. Also, some patients may avoid self-care as a means of coping; others may fear acute-care settings or feel they’re a burden to others. Yet reporting HF symptoms promptly is crucial if patients wish to avoid more suffering and longer hospital stays. They need to be able to recognize symptoms of deterioration and seek help promptly.
Dealing with nonadherence
A patient like Mr. B who doesn’t adhere to the prescribed diet may be in denial. In many cases, denial is a defense against stress. Developing a trusting relationship with the patient can lead to a useful discussion. Be sure to take a careful approach when trying to build trust; otherwise the patient might feel threatened. (See the box below.)
Building trust with patients
Here some ways to work effectively with a patient like Mr. B:
Primary care providers should thoroughly assess patients’ medications and management plans and collaborate with other interdisciplinary care providers who are monitoring the patient’s comorbid conditions. Question the patient about daily weights as part of early symptom recognition to help determine the severity of his or her condition.
Focus on teaching patients symptom-monitoring skills to help them recognize elevated HF risk. Existing practices include increasing patient knowledge and helping patients understand the importance of seeking help at the first sign of worsening symptoms. Instruct patients about dietary and weight recommendations and activities of daily living. Stress the importance of taking daily weights, and advise patients on how to integrate this practice into daily life.
Ideally, use the teach-back approach. With this technique, ask the patient to explain what you have presented, so you can determine the level of understanding. This helps you gauge what additional teaching to provide. For instance, if you say to a woman with HF, “Please explain how you plan to weigh yourself” and she says, “I’ll weigh myself every other day after I get dressed,” you know you need to reinforce the need for her to weigh herself every day wearing the same clothes to ensure consistency.
Some discharged patients may not know they’re supposed to discontinue a medication they were taking before hospitalization. Instead, they keep taking it after discharge—in addition to a newly prescribed drug with similar effects. To prevent this, review the patient’s medications at discharge and have the patient rewrite the information you’ve taught on a wallet card to demonstrate understanding. Provide handouts on symptom management and instruct patients to reread the information once they get home. If you’re a home-care nurse, review all medications and treatment protocols with patients during home visits.
Psychodynamic approach to teaching
Instead of simply telling or asking patients to perform a certain self-management task, try to inspire and motivate them. It’s not enough to get their teach-back verbalization of what it means to take daily weights. Instead, describe outcomes of daily weight patterns thoroughly to help them understand how weight gain can lead to worsening symptoms. This can motivate them to set goals for maintenance and to seek help promptly when needed.
Using a psychodynamic approach to lifestyle changes, a psychotherapist can work to improve the patient’s health behaviors and readiness to change by offering guidance in affective and physical activity behaviors. The therapist and patient set goals for what they hope to achieve. They identify such barriers as negative thinking and stressors, as well as healthy lifestyle choices that can improve physical status (such as walking rather than driving or riding in a car). Interventions aim to motivate, inspire, and encourage patients to be more caring about themselves, as reflected in improved health behaviors—especially more physical activity or supervised strength-training activities. Physical outcomes of gains in aerobic capacity and physical endurance may be used to measure improvements in lifestyle choices, along with improved anxiety and depression scores.
Practical tools that boost adherence
Practical tools can improve patient adherence, enhance quality of life, and reduce the need for readmission.
Symptom and event diary
Using a symptom and event diary can help patients recognize symptoms. This strategy is recommended by the Patient Care Committee of the Heart Failure Association of the European Society of Cardiology. Instruct patients to record their symptoms and other events in the diary, along with a description and the date and time of each symptom or event. Advise them to rate the symptom or event on a scale of 1 to 5 (with 1 indicating mild and 5 indicating severe) and to add any relevant notes. Instruct patients to take the diary with them to their next medical visit and discuss it with their healthcare provider. (For an example of a symptom diary, visit www.heartfailurematters.org/static_file/HeartFailureMatters/Documents/EN/Symptoms_and_events_diary.pdf.)
Warning signs instruction sheet
Provide an instruction sheet to patients at the time of discharge. Suggest they post it on their refrigerator along with their prescribed medication regimen and emergency numbers to call. Instruct patients to call their primary care provider immediately if they experience warning signs (such as worsening and persistent shortness of breath or chest pains unrelieved by nitroglycerin) or if they need more pillows to sleep, continue to wake up short of breath, or have worsening palpitations. Urge them to contact their provider if they experience extreme fatigue or gain 2 lb in one day or more than 5 lb in a week.
Stoplight tool to improve symptom recognition
For active symptom monitoring, patients must be able interpret their signs and symptoms well enough to prevent further deterioration and readmission. A recent study used a “stoplight” tool to aid patients’ symptom recognition. (See the box below.).
This “stoplight” tool uses green, yellow, and red zones and short instructions to help patients recognize symptoms and take appropriate action.
At every encounter with the patient and family caregivers or others support persons, discuss each component of the patient’s self-management, including diet, weight, medications, activities of daily living, and worsening of symptoms. See the box below.
Be sure to cover the following topics when teaching HF patients and their family caregivers how to manage their disease.
Self-management is the key
Nurses are responsible for helping HF patients improve their self-management strategies, including recognizing symptoms that could lead to deterioration or readmission. These strategies improve when nurses explain how patients’ actions can help them retain an acceptable quality of life and avoid readmission. To provide accurate information, keep your HF knowledge base up-to-date and stay current with updated cardiac guidelines. Make sure you’re familiar with medications used to treat HF and know how to recognize and intervene for worsening signs and symptoms. Taking every opportunity to teach patients how they can better care for themselves at home can lead to better outcomes.
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Heart Failure Matters. Usefool tools. www.heartfailurematters.org/en_GB
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Yancy CW, Jessup M, Bozkurt B, et al; American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240–e327.
Sharon E. Vincent is a clinical assistant professor at the College of Health and Human Sciences School of Nursing, University of North Carolina, Charlotte. Karen S. Mutsch is an associate professor at the College of Health Professions, Department of Advanced Studies, in Northern Kentucky University, Highland Heights.