Health teachings on CHF

YOUR NEW PATIENT Viola McDonald has been admitted recently with a diagnosis of heart failure. Her signs and symptoms include dyspnea on exertion, a reported weight gain of 20 pounds in the last week, and constipation. Her assessment data include a respiratory rate of 24 breaths/minute at rest, 3-4+ edema bilateral lower extremities, and abdominal distension. What's your role as Ms. McDonald's nurse? The Institute for Healthcare Improvement has six interventions in its 5 Million Lives Campaign; one is "delivering reliable, evidence-based care for congestive heart failure to avoid readmissions." 1 Discharge teaching by a nurse educator, when it's targeted to the patient, has been shown to decrease the rate of readmission to the hospital for patients with left ventricular systolic dysfunction.2 Gaps in the discharge teaching process have been linked to deficiencies in self-care and readmission to the hospital.3 The Joint Commission in conjunction with several other organizations has come up with core measures, including six areas that must be covered in discharge teaching. 4 In this article, I'll discuss these six areas and how you can address them. But first, let's look more closely at who's affected by heart failure and how it's classified.

The heart of the matter

Approximately 5 million people in the United States have heart failure and more than 500,000 are diagnosed each year. Most of these patients are older than 65 years. 5,6 Heart failure occurs when the heart pumps too weakly to supply enough oxygen and nutrients to the body. Signs and symptoms of fluid overload or poor tissue perfusion indicate that a patient has this syndrome. Some common causes include hypertension, coronary artery disease, and valvular disease. 7 Two classification systems can be used to categorize patients with heart failure. The system developed by the American College of Cardiology with the American Heart Association (ACC/AHA) is based on a health continuum from prevention in at-risk patients to the advanced stages of heart failure. 5 The New York Heart Association stages are based on function and the ability to perform activities of daily living. Signs and symptoms of heart failure may differ depending on the type of heart failure and its cause. Knowing the type of heart failure (right-sided or left-sided failure) and its cause (including volume overload, a heart structure abnormality such as valvular disease, or hypertension) guides the clinician's treatment decisions. Managing the factors that contribute to heart failure progression can improve your patient's outcome.

The goals of treatment are to manage signs and symptoms and to delay its progression. Patient teaching is a key part of these goals.

Getting started
Begin the discharge teaching on admission so that your patient has time to absorb the information and to ask questions. By intervening early in the patient encounter, you'll have more time for reinforcing your teaching and for assessing whether the patient understands it. She'll be more likely to see the importance of an action or a medication if it's started in the hospital. Using an interdisciplinary approach will give her the chance to interact with multiple members of the patient care team. Now let's get down to the six key areas for patient teaching. * Weight monitoring. Most patients are weighed on admission, and hospitalized patients with heart failure are generally weighed every day to help monitor the effectiveness of their diuretics. While you're weighing your patient, you can emphasize the importance of monitoring her weight. Tell her to use the same scale every day at the same time, preferably in the morning after urinating and before eating and while wearing the same type of clothes, and to report a weight gain of 3 or more pounds in one day or 5 or more pounds in a week (or as directed by her healthcare provider). 6 Show your patient your hospital's system to track which scale weighs which patient. Ask your patient if she has a scale at home. * Discharge medications. An important aspect of patient teaching is to relay changes in the medication regimen so your patient will take the correct medications at home. See Teaching about drugs for heart failure. When your patient is taking a diuretic, you'll need to monitor her electrolytes. Diuretics act on the kidneys, causing water, sodium, potassium, or other electrolytes to be lost, depending on where in the kidney the diuretic is working. Many patients with heart failure believe that they can adjust the dosage of their diuretic themselves if they gain weight. They don't realize the drug's potential effect on their electrolytes, so be sure to include this information in your patient teaching. Teach your patient about the specific diuretic she's taking and the potential risks of increasing the dose or omitting a dose. For example, if your patient is taking furosemide and a potassium supplement, teach her that these two medications are related to each other. Increasing the dose of furosemide can cause potassium to be lost. Omitting a dose of furosemide while continuing to take the potassium supplement can lead to too much potassium. Either too much or too little potassium can cause problems including heart dysrhythmias. * Activity level. While she's in the hospital, your patient can consult with physical therapists. She can also start a cardiac rehabilitation program, which will provide a safe place to begin exercising. The staff of the program can provide supplemental education and a link for postdischarge education and referral.

As she exercises, your patient will be monitored often. She'll have access to emergency care if she develops problems while exercising. With the guidance of the cardiac rehabilitation staff, she can learn how to exercise safely and what level of activity is appropriate. According to the AHA, she can "start slowly and gradually build up to at least 150 minutes of moderately vigorous physical activity per week" such as "30 minutes of activity, five or more times a week." She could try walking, biking, or swimming or some combination of these. 6 * Diet. Teach the patient to follow the diet her healthcare provider recommends. Encourage her to consult with dieticians while she's in the hospital. Teach her to avoid fats such as shortening, butter, and margarine and to eat only small amounts of olive and vegetable oil. She should also avoid fried foods and any food with more than 400 mg of sodium per serving. Teach her to read labels so she doesn't eat more than 2 grams of sodium per day. Check with her healthcare provider about alcohol consumption, but as a general rule women should have no more than one alcoholic drink a day and men should have no more than two. If she has high BP or diabetes, she should work with her healthcare provider to keep these under control. * What to do if heart failure symptoms worsen. Teach your patient how to realize her symptoms are worsening and when to call for help. Teach her to recognize increases in edema, shortness of breath, and weight. * Follow-up. Teach your patient to keep scheduled follow-up appointments. Consider assisting your patient with scheduling the first post-hospitalization follow-up appointment. This reinforces the importance of the follow-up visit. Document the date, time, and location of the follow-up visit on her discharge information form. In addition to these six key areas of patient teaching, patients are generally advised to quit smoking and lose weight if needed and to make sure they receive flu and pneumonia vaccines. Reinforce your teaching with written or other materials to enhance your patient's learning.

Tailoring your teaching

Let's return to Ms. McDonald. Although she's already been diagnosed with heart failure, you can still use preventive strategies to help her manage her symptoms and to possibly slow progression of her disease. If she has hypertension, high cholesterol, or diabetes, these need to be controlled. You should ask her what type of exercise she's doing: walking could benefit her heart failure and help to alleviate her constipation. Her abdominal distension could be caused by edema from heart failure and could also contribute to her constipation. Once her dyspnea improves enough so that she can tolerate exercise, encourage her to ambulate in the hallways. By starting patient education early in the course of her treatment, you can encourage Ms. McDonald to be a vital partner in her care and avoid preventable hospital readmissions. Refer your patient to the AHA Web site for information, connect her with local support groups, and encourage her to access the heart failure team for questions and concerns to help her stay out of the hospital and maintain her quality of life once she gets home.

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Diet and Congestive Heart Failure

Congestive heart failure (CHF) occurs when the heart does not pump efficiently and does not deliver enough oxygen to your body. Many diseases lead to CHF, such as high blood pressure and diseases of the heart and kidney. Treatment for CHF helps to prevent its complications and relieve its symptoms. The heart does not have to work as hard when you make some changes in your diet. If you eat too much salt or drink too much fluid, your body's water content may increase and make your heart work harder. This can worsen your CHF. The following diet will help decrease some of your symptoms.
Reduce the Salt in Your Diet

Enjoying what you eat is important. Even if you crave salt you can learn to like foods that are lower in salt. Your taste buds will change soon, and you will not miss the salt. Removing salt can bring out flavors that may have been hidden by the salt. Reduce the salt content in your diet by trying the following suggestions:
Choose plenty of fresh fruits and vegetables. They contain only small amounts of salt. Choose foods that are low in salt, such as fresh meats, poultry, fish, dry and fresh legumes, eggs, milk and yogurt. Plain rice, pasta and oatmeal are good low-sodium choices. However, the sodium content can increase if salt or other high-sodium ingredients are added during their preparation. Season with herbs, spices, herbed vinegar and fruit juices. Avoid herb or spice mixtures that contain salt or sodium. Use lemon juice or fresh ground pepper to accent natural flavors. Try orange or pineapple juice as a base for meat marinades. See "Salt-Free Herb Blends," below, for other ideas. Read food labels before you buy packaged foods. Check the nutrition facts on the label for sodium content per serving. Find out the number of servings in the package. How does the sodium in each serving compare to the total sodium you can eat each day? Try to pick packaged foods with a sodium content less than 350 milligrams for each serving. It is also useful to check the list of ingredients. If salt or sodium is listed in the first five ingredients, it is too high in sodium.

When Checking Labels:

Use the nutrition information included on packaged foods. Be sure to notice the number of servings per container. Here are tips for using this information.
Nutrient List The list covers nutrients most important to your health. % Daily Value This number shows how foods meet recommended nutrient intake levels for a 2,000 calorie reference diet. Try to eat no more than 100 percent of total fat, cholesterol and sodium. Daily Values Footnote Some food labels list daily values for 2,000 and 2,500 calorie daily diets. Calories Per Gram Footnote Some labels give the approximate number of calories in a gram of fat, carbohydrate and protein. Sodium Content Always check the sodium content. Look for foods with a sodium content less than 350 milligrams for each serving.

When Cooking or Preparing Food:

Shake the habit. Remove the salt shaker from the kitchen counter and table. A 1/8 teaspoon "salt shake" adds more than 250 milligrams of sodium to your dish. Be creative. Instead of adding salt, spark up the flavor with herbs and spices, garlic, onions and citrus juices. See the recipes for salt-free herb blends, below. Be a low-salt cook. In most recipes, you can cut back on salt by 50 percent or even eliminate it altogether. You can bake, broil, grill, roast, poach, steam or microwave foods without salt. Skip the urge to add salt to cooking water for pasta, rice, cereal and vegetables. It is an easy way to cut back on sodium. Be careful with condiments. High-sodium condiments include various flavored salts, lemon pepper, garlic salt, onion salt, meat tenderizers, flavor enhancers, bouillon cubes, catsup, mustard, steak sauce and soy sauce. Stay away from hidden salt. Canned and processed foods, such as gravies, instant cereal, packaged noodles and potato mixes, olives, pickles, soups and vegetables are high in salt. Choose the frozen item instead; or better yet, choose fresh foods when you can. Cheeses, cured meats (such as bacon, bologna, hot dogs and sausages), fast foods and frozen foods also may contain a lot of sodium.

When Eating Out: A low-sodium diet does not need to spoil the pleasure of a restaurant meal. However, you will have to be careful when ordering. Here are some tips for meals away from home:
Move the salt shaker to another table. Ask for a lemon wedge or bring your own herb blend to enhance the food's flavor. Recognize menu terms that may indicate a high sodium content: pickled, au jus, soy sauce or in broth. Select raw vegetables or fresh fruit rather than salty snacks. Go easy on condiments such as mustard, catsup, pickles and tartar sauce. Choose lettuce, onions and tomatoes. Remember that bacon and cheeses are high in sodium.

Request that the cook prepare foods without adding salt or MSG. Or ask for sauces and salad dressings on the side since they are often high in sodium. For a salad, use a twist of lemon, a splash of vinegar or a light drizzle of dressing. Salt-Free Herb Blends

Instead of seasoning your food with salt, enhance the flavor of food with these salt-free herb and spice combinations. To make 1/2 cup, combine the ingredients in a jar. Cover tightly and shake. Keep in a cool, dry place. Then rub or sprinkle them on food for flavor. Chinese 5-Spice For chicken, fish or pork:
1/4 cup ground ginger 2 tablespoons of each: ground cinnamon, ground cloves 1 tablespoon of each: ground allspice, anise seeds

Mixed Herb Blend For salads, pasta salads, steamed vegetables, vegetable soup or fish:
1/4 cup dried parsley flakes 2 tablespoons dried tarragon 1 tablespoon of each: dried oregano, dill weed, celery flakes

Italian Blend For tomato-based soups, pasta dishes, chicken, pizza, focaccia and herbed bread:

2 tablespoons of each: dried basil, dried marjoram, thyme, crushed dried rosemary, crushed red pepper 1 tablespoon of each: garlic powder, dried oregano

Easy Dip Blend For mixing with cottage cheese, yogurt, or low-fat sour cream:
1/2 cup dried dill weed 1 tablespoon of each: dried chives, garlic powder, dried lemon peel and dried chervil