Promoting Selfcare and Reducing Hospitalizations

1
Promoting Self-care and Reducing Hospitalizations
of Clients with CHF
Shannon M. Manning, Pacific Lutheran University
School of Nursing, Tacoma, WA 98477
Implementation
Introduction
Case Study
Patient Goals

• CHF CLINIC ENROLLMENT Hospitalized CHF
  patients should be referred to CHF clinic for
  further assessment, education and follow-up care
  (HFPG, 2006 Crowder, 2006)
• Educate on role and benefits of CHF clinics
  optimal drug therapy, early attention to warning
  signs, increased patient education and access to
  CHF specific health care providers (Crowder, 2006)

• Chronic Heart Failure (CHF) affects more than 5
  million
• Americans and averages 550,000 new cases a year
  (AHA,
• 2005)
• CHF is a chronic, terminal disease with a
  mortality rate of approximately 75 at 8 years
  (Rosamond et. at, 2008).
• CHF is the leading cause of hospitalization,
  accounting for 1 million admissions a year and an
  estimated 34.8 billion in direct and indirect
  cost (Anonymous, 1998 AHA 2008).
• Proper management to improve quality of life,
  reduce hospitalizations and medical costs, and
  slow progression of disease requires extensive
  lifestyle changes and a complicated therapeutic
  regimen (Searson, 2007)
• Up to 50 of re-hospitalizations are
  preventable and result from inadequate discharge
  instruction, noncompliance, and failure to
  follow-up with a PCP or enroll in a CHF specific
  program (Rutledge et. al, 2001)
• Nurses are at the forefront in providing
  education, support and guidance for self-care,
  enabling patients to effectively manage CHF,
  identify early warning signs seek treatment
  before hospitalization is necessary. This
  improves quality of life and reduces individual,
  family and societal cost (Yu et. al, 2006).

Short-term Patient will achieve fluid balance
and be free of dyspnea. Long-term Patient and
family will gain knowledge and skills necessary
to participate in self-care behaviors for CHF
patients
89 year old female admitted to Med-Surg Telemetry
Unit for dehydration and dyspnea secondary to
acute CHF exacerbation. She is legally blind and
lives at home by herself, completes most ADLs
independently with help from her children, who
live 45 minutes away, for grocery shopping. The
only exercise she participates in is water
aerobics twice a week. During initial
assessment, the patient asks why her ankles are
so swollen and why she is unable to complete her
water aerobics.
Implementation

• Patient education, medication review and CHF
  clinic enrollment can prevent up to 85 of CHF
  hospitalizations (Fonarow et. al, 1997).
• PATIENT EDUCATION Provide essential information
  reinforced in depth 1 week post-discharge and
  continued for 3-6 months with home health or CHF
  clinic (HFPG, 2006)
• Define CHF, etiology and symptom relationship
  Increases knowledge and empowers patient
  (Krumholz et. al, 2002)
• Diet 2 grams sodium - Sodium increases water
  retention, elevating BP and increasing workload
  on heart (AAHFN, 2008)
• Demonstrate how to read food labels (HFPG,
  2006)
• Patient will sort foods into high and
  low-sodium categories and identify products with
  hidden salt content (HFPG, 2006)
• Fluid Restriction 2 Liters Maintain fluid
  balance (Searson, 2007 HFPG 2006)
• Individualized plan for measuring intake
  (Searson, 2007).
• Patient records fluid intake during
  hospitalization Builds confidence in
  self-management (Nauman et al, 1999).
• Use of hard candy, chewing gum for dry mouth
  (Searson, 2007).
• Daily weights Increase of gt2lbs/day or gt5lbs/wk
  suggests fluid retention and worsening HF
  (Nicholson, 2007)
• Patient records daily weights in log every
  morning after urinating, demonstrating proper
  technique by discharge Patient takes active
  role in self-management (Caldwell et. al, 2005
  Krumholz et. al, 2002).
• Exercise Activity improves cardiac muscle
  strength, reduces breathlessness, and increases
  quality of life (Mondoa, 2004).

Patient Outcomes
Patient provided basic definition of CHF and
verbalized how symptoms related to her heart
failure. Family identified heart healthy, low
sodium foods to buy and a daily fluid intake
schedule was in place. She was encouraged to
enroll in St. Josephs CHF clinic and a referral
for home health was made. Patient was discharged
with normal fluid balance and planned to return
to her water aerobics the following day.
Assessment
Labs/Diagnostics

• Patients understanding of CHF and treatment
  regimen - Identifies knowledge gaps/misconceptions
  (Krumholz et. al, 2002)
• Learning needs - Teaching tailored to each
  individual and family (Pichert, 1990 Jaarsma,
  1999).
• Sensory impairments Requires modification in
  teaching methods and self-care behaviors (HFPG,
  2006)
• Cognitive impairments (Have patient draw clock
  from memory) - 30-80 of CHF patients are
  cognitively impaired and require adjustments in
  teaching methods (Bennett, 2003)
• Reading ability (Have patient read and
  interpret prescription instructions) - 20 of
  US population reads at 4th-5th grade level most
  information provided at 8th grade level (Fischer,
  1999 Williams et. al, 1998)
• Functional abilities (Assess Patients ability
  to complete ADLs) Functional limitations
  require adaptive changes in skills required to
  promote effective self-care and adherence to
  treatment regimen (HFPG, 2006).
• Perceived barriers and motivation to change
  (HFPG, 2006)
• Emotional well-being (BDI) - 20-70 have
  depressive symptoms that impair learning
  (Johansson et. al, 2006).
• Discuss patients cultural practices/preferences
  Individualized plans tailored to lifestyle,
  cultural preferences and environment maximize
  patient adherence and treatment effectiveness
  (Rutledge et. al, 2001).
• Have patient identify support system -HF patients
  often suffer from cognitive, functional or
  emotional impairments that limit comprehension
  and implementation of learned material without
  others help (HFPG, 2006).
• Current CHF classification Intensive education
  has negative effects in patients with less
  complicated CHF (Reigle et. al, 2000)

Signs
Evaluation

• Repeated exposure using different methods of
  teaching is imperative in learning and retention
  of complex self-care behaviors (HFPG, 2006).
• Effective patient education increases
  knowledge, motivation and self-efficacy, enabling
  patients to take an active role in disease
  management with less reliance on nurses and
  physicians (Krumholz et. al, 2002).
• CHF clinics decrease ER visits, hospital
  admissions and duration while increasing
  functional capacity and quality of life (Crowder,
  2006 Rutledge, 2001).
• Patients enrolled in CHF clinics report higher
  satisfaction related to increased physical and
  mental well-being and improved self-care
  abilities (Crowder, 2006).

Pathophysiology

• CHF is an inability of the heart to fill or
  pump effectively, resulting in decreased cardiac
  output (CO) and deficient delivery of oxygen and
  nutrients to meet metabolic demands of the body
  (Copstead Banasik, 2005).
• Classic signs/symptoms result from fluid volume
  overload and impaired oxygenation of tissues
  (Lewis et. al, 2007).
• Common risk factors include HTN, DM, CAD, drug
  and alcohol use, sedentary lifestyle, obesity,
  and excessive stress (Lewis et. al, 2007)

Future Interventions
1) CHF clinic Home health by cardiovascular
nurse Decreased hospital admissions, duration,
and mortality with increased quality of life
(Hamner, 2005). 2) Peer support groups
Preliminary studies show increased self-care but
low enrollment rate and increased readmission
rates (Reigel Carlson, 2004). 3) Decreased
diuretic use IV diuretics increase ICU
admissions, length of stay and mortality rates
(ADHERE, 2004). 4) Risk of Hospital
Readmission sheet Use of evidence-based,
standardized tool to assist nurses in early
identification of potential problems allowing for
individualized care plans and discharge services
(Anderson et. al, 2006)
Nursing Diagnosis

Acknowledgements
Knowledge Deficit CHF self-care r/t cognitive
and sensory impairment, lack of information about
disease process management Ineffective
therapeutic regiment management r/t complexity of
regimen, knowledge deficit, social support
deficit, and sensory impairment
Thanks to PLU for a great undergraduate learning
experience. Thanks to April Rhodes and 11B
staff at St. Josephs for an amazing
preceptorship. References on attached sheet.
Figure 1. Common signs and symptoms of CHF