recognizing heart failure symptoms can improve …low self-management instructions. mr. b recently...

www.AmericanNurseToday.com February 2015 American Nurse Today 1

DESPITE life-sustaining medicalmanagement for patients with criti-cally worsening symptoms, heartfailure (HF) prevalence continuesto rise. An estimated 5.7 millionadult Americans have HF, and theprevalence is expected to rise 46%from 2012 to 2030, resulting inmore than 8 million adults with HF.

The ability to recognize earlyand progressive HF signs andsymptoms is crucial for both pa-tients and clinicians. Yet even someexperienced nurses lack recognitionskills, so they’re unable to teachthese to patients. Patients who aredischarged without learning how tocare for themselves and when toseek timely treatment may need tobe readmitted repeatedly. It hasbeen estimated that 1 in 4 Medicarepatients with HF are readmittedwithin 30 days of discharge.

Current guidelines from theAmerican College of CardiologyFoundation/American Heart Associ-ation and the Heart Failure Societyof America focus on such care pri-orities as diet, discharge medica-tions, daily weights, fluid restric-tion, physical activities, symptomrecognition, what to do if symp-toms worsen, when and how toseek medical help, and requiredfollow-up.

Eliminating the disconnectNurses need to be more aware ofworsening HF symptoms reportedby patients. Studies show a dis-

connect between what patients re-port and how nurses respond. Lis-ten closely when HF patients re-port their symptoms. Takingappropriate action after assessmentmay prevent the need for immedi-ate readmission and improve self-management.

Make sure you know how torecognize early signs and symp-toms of HF decline—and stay alertfor them. Prompt recognition andaction can prevent undue pain andsuffering. Familiarize yourself withnew evidence and HF guidelines,such as the Heart Failure Society ofAmerica’s Comprehensive HeartFailure Practice Guidelines.

Teach patients how to recognizesymptoms of HF exacerbation andwhen to report them. Most HF pa-tients wait 2 to 7 days before seek-ing help, during which time theirsymptoms may get worse. Delaysmay contribute to additional suffer-ing, treatment, and costs.

Case studyNonadherence to self-managementis linked to increased readmissionsand mortality. In the case study be-low, the patient didn’t understandwhat might happen if he didn’t fol-low self-management instructions.

Mr. B recently visited the clinicafter multiple hospital readmis-sions for dyspnea, shortness ofbreath, and fatigue. A white malein his 50s, he had HF with uncon-

Recognizing heart failuresymptoms can improve

patient self-management To promote better outcomes, teach patients how to care

for themselves

By Sharon E. Vincent, DNP, RN, MSN, and Karen S. Mutsch, DNP, RN MSN

LEARNING OBJECTIVES

1. Identify why self-management isimportant in patients with heartfailure (HF).

2. State causes of nonadherence inpatients with HF.

3. Discuss interventions nurses canuse to enhance self-managementin patients with HF.

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Expiration: 2/1/18

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2 American Nurse Today Volume 10, Number 2 www.AmericanNurseToday.com

trolled diabetes, hypertension, andobesity. He didn’t adhere to self-management practices and jokedthat he ambulated to the vendingmachine without his wife’s knowl-edge to buy snacks while pushinghis I.V. infusion pump. Whenasked about his most severe prob-lems, Mr. B stated he was most af-fected by weight gain after HF di-agnosis because it impaired hisability to perform independent hy-giene measures. Yet he said he’dprobably continue to eat what tast-ed good, even though he knewadded fluid retention and weightcontribute to increased cardiomy-opathy, poor quality of life, andincreased symptoms of acute HF.

Reasons for nonadherenceWhy do some patients fail to ad-here to self-management plans?Reasons remain unclear. We knowcomorbidities, altered mental status,and poor literacy can affect adher-ence. Also, some patients mayavoid self-care as a means of cop-ing; others may fear acute-care set-tings or feel they’re a burden toothers. Yet reporting HF symptomspromptly is crucial if patients wishto avoid more suffering and longerhospital stays. They need to beable to recognize symptoms of de-terioration and seek help promptly.

Dealing with nonadherenceA patient like Mr. B who doesn’tadhere to the prescribed diet maybe in denial. In many cases, denialis a defense against stress. Devel-oping a trusting relationship withthe patient can lead to a usefuldiscussion. Be sure to take a care-ful approach when trying to buildtrust; otherwise the patient mightfeel threatened. (See the box below.)

RecommendationsPrimary care providers should thor-oughly assess patients’ medicationsand management plans and collab-orate with other interdisciplinarycare providers who are monitoringthe patient’s comorbid conditions.Question the patient about dailyweights as part of early symptomrecognition to help determine theseverity of his or her condition.

Focus on teaching patientssymptom-monitoring skills to helpthem recognize elevated HF risk.Existing practices include increas-ing patient knowledge and helpingpatients understand the importanceof seeking help at the first sign ofworsening symptoms. Instruct pa-tients about dietary and weight rec-ommendations and activities of dai-ly living. Stress the importance oftaking daily weights, and advise

patients on how to integrate thispractice into daily life.

Ideally, use the teach-back ap-proach. With this technique, askthe patient to explain what youhave presented, so you can deter-mine the level of understanding.This helps you gauge what addi-tional teaching to provide. For in-stance, if you say to a womanwith HF, “Please explain how youplan to weigh yourself” and shesays, “I’ll weigh myself every otherday after I get dressed,” you knowyou need to reinforce the need forher to weigh herself every daywearing the same clothes to en-sure consistency.

Some discharged patients maynot know they’re supposed to dis-continue a medication they weretaking before hospitalization. In-stead, they keep taking it after dis-charge—in addition to a newly pre-scribed drug with similar effects.To prevent this, review the pa-tient’s medications at discharge andhave the patient rewrite the infor-mation you’ve taught on a walletcard to demonstrate understanding.Provide handouts on symptommanagement and instruct patientsto reread the information once theyget home. If you’re a home-carenurse, review all medications andtreatment protocols with patientsduring home visits.

Psychodynamic approach toteachingInstead of simply telling or askingpatients to perform a certain self-management task, try to inspireand motivate them. It’s not enoughto get their teach-back verbaliza-tion of what it means to take dailyweights. Instead, describe out-comes of daily weight patternsthoroughly to help them under-stand how weight gain can lead toworsening symptoms. This can mo-tivate them to set goals for mainte-nance and to seek help promptlywhen needed.

Using a psychodynamic ap-

Building trust with patientsHere some ways to work effectively with a patient like Mr. B: • Ask him to describe his understanding of HF in his own words.• Work to build a more effective therapeutic partnership: “How could we ap-proach this more effectively?” or “What are some obstacles that have stopped usfrom dealing with this better?”

• Ask if he understands the purpose of his prescribed diet and possible conse-quences of not following it: “I’m concerned that if your diet isn’t better con-trolled, you could develop serious complications.”

• Use open-ended questions: “Are you comfortable following the goals we’vetalked about for diet, or do you see any problems?”

• Work with the patient mutually to find solutions to identified adherence prob-lems.

• If you’re having trouble identifying causes of nonadherence, consider screeningthe patient for depression, dependence, or dementia.

• Enlist the patient’s family and friends, colleagues, case managers, and outsideagencies for support.


proach to lifestyle changes, a psy-chotherapist can work to improvethe patient’s health behaviors andreadiness to change by offeringguidance in affective and physicalactivity behaviors. The therapistand patient set goals for what theyhope to achieve. They identifysuch barriers as negative thinkingand stressors, as well as healthylifestyle choices that can improvephysical status (such as walkingrather than driving or riding in acar). Interventions aim to motivate,inspire, and encourage patients tobe more caring about themselves,as reflected in improved health be-haviors—especially more physicalactivity or supervised strength-train-ing activities. Physical outcomes ofgains in aerobic capacity and phys-ical endurance may be used tomeasure improvements in lifestylechoices, along with improved anxi-ety and depression scores.

Practical tools that boostadherencePractical tools can improve patientadherence, enhance quality of life, and reduce the need for read-mission.

Symptom and event diaryUsing a symptom and event diarycan help patients recognize symp-toms. This strategy is recommend-ed by the Patient Care Committeeof the Heart Failure Association ofthe European Society of Cardiolo-gy. Instruct patients to record theirsymptoms and other events in thediary, along with a description andthe date and time of each symptomor event. Advise them to rate thesymptom or event on a scale of 1to 5 (with 1 indicating mild and 5indicating severe) and to add anyrelevant notes. Instruct patients totake the diary with them to theirnext medical visit and discuss itwith their healthcare provider. (Foran example of a symptom diary,visit www.heartfailurematters.org/static_file/HeartFailureMatters/

Documents/EN/Symptoms_and_events_diary.pdf.)

Warning signs instruction sheetProvide an instruction sheet to pa-tients at the time of discharge. Sug-gest they post it on their refrigera-tor along with their prescribedmedication regimen and emergencynumbers to call. Instruct patients tocall their primary care provider im-mediately if they experience warn-ing signs (such as worsening andpersistent shortness of breath orchest pains unrelieved by nitroglyc-erin) or if they need more pillowsto sleep, continue to wake up shortof breath, or have worsening palpi-tations. Urge them to contact theirprovider if they experience extremefatigue or gain 2 lb in one day ormore than 5 lb in a week.

Stoplight tool to improve symptom recognitionFor active symptom monitoring, pa-tients must be able interpret theirsigns and symptoms well enough toprevent further deterioration andreadmission. A recent study used a“stoplight” tool to aid patients’ symp-tom recognition. (See Green, yellow,red: Heart failure action plan.)

At every encounter with the patient and family caregivers orothers support persons, discusseach component of the patient’sself-management, including diet,weight, medications, activities of daily living, and worsening of symptoms. See (Examples of HF self-management components.)

Self-management is the keyNurses are responsible for helping

This “stoplight” tool uses green, yellow, and red zones and short instructions to helppatients recognize symptoms and take appropriate action.

GREEN: ACTION:You are doing well. Continue current medications, diet:• No shortness of breath • Weigh yourself daily.• Stable weight • Limit fluids to 2 liters/day.• Little or no swelling • Limit sodium to 2,300 mg/day.• Able to maintain usual activity• No chest pain

YELLOW: CAUTION. ACTION:Symptoms indicate you may need to Continue yellow treatment plan.talk to your provider.• Increased shortness of breath • Medications (list each)____________• Trouble sleeping, or having to use • Instructions: If you gain 2 lb in a day, more pillows take an extra diuretic dose.• Sudden weight gain of 2 lb in 1 day • Watch your salt intake. or 5 or more in 1 week • Increased abdominal or foot or leg swelling• Decreased energy RED: ACTION:YOU MAY NEED HELP IMMEDIATELY! Call provider at once. This is a Symptoms very unstable; you may need MEDICAL EMERGENCY!to be evaluated by provider NOW if • If appropriate, call 911!actions haven’t helped. • Don’t wait to see if symptoms • Extreme difficulty breathing even at rest improve, or try to treat this yourself.• Weight gain of 4 lb or more in 1day• Wheezing or chest pain Provider telephone #: _______________• Severe weakness, dizziness, or fatigue.

Adapted from resources at hnfs.gov

Green, yellow, red: Heart failure action plan

4 American Nurse Today Volume 10, Number 2 www.AmericanNurseToday.com

HF patients improve their self-man-agement strategies, including recog-nizing symptoms that could lead todeterioration or readmission. Thesestrategies improve when nurses ex-plain how patients’ actions can helpthem retain an acceptable quality oflife and avoid readmission. To pro-vide accurate information, keepyour HF knowledge base up-to-dateand stay current with updated car-diac guidelines. Make sure you’re

familiar with medications used totreat HF and know how to recog-nize and intervene for worseningsigns and symptoms. Taking everyopportunity to teach patients howthey can better care for themselvesat home can lead to better out-comes. �

Selected referencesClark AM, Savard LA, Spaling MA, et al. Un-derstanding help-seeking decisions in peo-

ple with heart failure: a qualitative system-atic review. Int J Nursing Stud. 2013;49(12):1582-97.

Heart Failure Matters. Usefool tools.www.heartfailurematters.org/en_GB

Heart Failure Society of America; LindenfeldJ, Albert NM, Boehmer JP, et al. HFSA 2010Comprehensive Heart Failure Practice Guide-line. J Card Fail. 2010;16(6):e1-194.

Hunt SA, Abraham WT, Chin MH, et al. 2009focused update incorporated into theACC/AHA 2005 Guidelines for the Diagnosisand Management of Heart Failure in Adults:A Report of the American College of Cardiol-ogy Foundation/American Heart AssociationTask Force on Practice Guidelines; devel-oped in collaboration with the InternationalSociety for Heart and Lung Transplantation.Circulation. 2009;119(14);e391-479.

Jaarsma T, Nikolova-Simons M, van der WalMH. Nurses’ strategies to address self-careaspects related to medication adherence andsymptom recognition in heart failure pa-tients: an in-depth look. Heart Lung.2012;41(6):583-93.

Lainscak M, Blue L, Clark AL, et al. Self-caremanagement of heart failure: practical rec-ommendations from the Patient Care Com-mittee of the Heart Failure Association of theEuropean Society of Cardiology. Eur J HeartFail. 2011;13(2):115-26.

Mozaffarian D, Benjamin E, Go AS, et al.Heart disease and stroke statistics—2015 up-date: a report from the American Heart Asso-ciation. Circulation. 2015;131.

Mutsch KS, Herbert M. Medication dischargeplanning prior to hospital discharge. QualManag J. 2010;17(4):25-35.

Prasun MA, Casida J, Howie-Esquivel J, et al.Practice patterns of heart failure nurses.Heart Lung. 2012;41(3):218-25.

Yancy CW, Jessup M, Bozkurt B, et al; Amer-ican College of Cardiology Foundation;American Heart Association Task Force onPractice Guidelines. 2013 ACCF/AHA Guide-line for the Management of Heart Failure: AReport of the American College of Cardiolo-gy Foundation/American Heart AssociationTask Force on Practice Guidelines. Circula-tion. 2013;128:e240–e327.

Sharon E. Vincent is a clinical assistant professor atthe College of Health and Human Sciences School ofNursing, University of North Carolina, Charlotte.Karen S. Mutsch is an associate professor at theCollege of Health Professions, Department ofAdvanced Studies, in Northern Kentucky University,Highland Heights.

Be sure to cover the following topics when teaching HF patients and their familycaregivers how to manage their disease.

Self-management component Examples and suggestions

Diet • Restrict sodium intake to 2,300 mg/day (or less if prescribed). Substitute basil, cilantro, or rosemary for salt. • Measure serving sizes. • Keep fruits and vegetables available for snacks. • Avoid canned fruit in heavy syrup and fried or breaded vegetables. • Consume whole-wheat, whole-grain, high- fiber breads, pasta, and cereals. • Limit saturated fats to less than 14 g in a 2,000-calorie diet. • Limit solid fats (butter, margarine, shorten- ing). Use olive or canola oil instead. • Consume only low-fat protein foods, such as fish, beans, low-fat dairy, and soybeans.

Weight • Weigh yourself daily at the same time and place, wearing the same clothes, after urinating and before drinking. • Know your dry and wet normal weights.

Fluid restrictions • Record your daily fluid intake.

Medications • Take prescribed medications as ordered. • Discuss your medications at each visit with your provider.

Activities of daily living • Get at least 2½ hours of exercise weekly.

Worsening of symptoms • If your symptoms worsen, contact your primary care provider or call 911. Refer to the “Green, yellow, red: Heart failure action” tool.

Note to clinicians: Give patients information about signs and symptoms of complica-tions related to their comorbidities. Examples include pulmonary embolus, stroke,electrolyte disturbances, diabetic ketoacidosis, and repeated implantable cardiovert-er defibrillator firings.

Examples of HF self-management components


Please mark the correct answeronline.

1. The incidence of heart failure (HF) isexpected to increase by what percentagefrom 2012 to 2030?

a. 23%b. 33%c. 46%d. 56%

2. What is the estimated number ofMedicare patients with HF readmittedwithin 30 days of hospital discharge?

a. 1 in 2 b. 1 in 4c. 1 in 8d. 1 in 10

3. Which statement about self-management of HF patients andreadmission is correct?

a. Nurses should listen closely topatients’ reports of signs andsymptoms to reduce readmission.

b. Patients who have had HF for 5 ormore years are able to engage in self-management.

c. Nurses should give patients time todevelop their own strategies forreporting signs and symptoms.

d. Studies show that nurses listen wellwhen patients report their signs andsymptoms of HF.

4. The average number of days HFpatients wait before seeking help afterthey begin to experience exacerbation ofsymptoms is:

a. 1 to 2.b. 3 to 5.c. 2 to 7.d. 5 to 10.

5. Which of the following is not acommon reason why HF patients don’tfollow a self-management plan?

a. Comorbiditiesb. Altered mental statusc. Poor literacyd. Positive coping

6. A way to build trust with patients is to: a. limit the time for them to ask questions

about HF.b. ask them to describe their

understanding of HF.c. ask questions that require a yes or no

answer to save time.d. avoid working with the patient’s family.

7. Mrs. Smith has had HF for the pastyear. She currently weighs 140 lb. Which ofthe following values should prompt her tocontact her healthcare provider?

a. Weight of 140.5 lb the next dayb. Weight of 141 lb the next dayc. Weight of 146.5 lb in a weekd. Weight of 143 lb in a week

8. In general, Mrs. Smith should limit herfluid intake to:

a. 1 L/day.b. 2 L/day.c. 3 L/day.d. 4 L/day.

9. Which of the following symptomsshould prompt Mrs. Smith to seek helpimmediately?

a. Increased leg edemab. Decreased energy c. Having to use an extra pillow to sleepd. Wheezing

10. Which of the following should indicateto Mrs. Smith that she might need to talkto her provider?

a. Decreased abdominal swellingb. Having to use an extra pillow to sleepc. Stable weightd. Decreased leg swelling

11. You should instruct Mrs. Smith torestrict her sodium intake to:

a. 1,000 mg/day or less if prescribed.b. 1,200 mg/day or less if prescribed.c. 2,300 mg/day or less if prescribed.d. 3,500 mg/day or less if prescribed.

12. Mrs. Smith typically consumes a 2,000-calorie/day diet. You should instruct her tolimit her saturated fat intake to:

a. less than 14 g.b. less than 18 g.c. less than 20 g.d. less than 24 g.

13. How often should you recommend toMrs. Smith that she exercise in a week?

a. 2½ hoursb. 3½ hoursc. 4 hoursd. 5 hours

POST-TEST • Recognizing heart failure symptoms can improve patient self-management Earn contact hour credit online at http://www.americannursetoday.com/continuing-education/

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