Congestive heart failure is a cardiac disease that causes many complications and affects many individuals in multiple ways. Aspects of one’s life that are impacted by CHF are: activities of daily living, including social, family, and spiritual involvement. It can be very difficult for someone with heart failure to manage the disease and deal with the complications both physically and emotionally. However, there are some preventative measures that can be taken to avoid such extremes. Nurses play a huge roll when caring for a patient suffering from heart failure. It is important that they understand how this disease is affecting their patient beyond the cardiovascular system, and to be aware of interventions that will improve the outcome of their patient’s health.
A patient presents to the clinic complaining of dyspnea, fatigue, weakness, swelling in his feet so bad that he is unable to put his shoes and he has a persistent cough. The nurse quickly assesses the patient and expresses her concerns of the probability of heart failure to the physician. The physician further assesses the patient and begins to get a history of the patient’s onset of symptoms. It is discovered that the patient has gained about five pounds in the last three days despite not being able to eat very much food. As the doctor auscultates heart sounds, he notes that his patient’s heart rate is very rapid. After careful consideration the physician diagnoses the patient with heart failure. Now what? The nurse must anticipate the level of care her patient is going to require while considering the many effects the diagnosis of heart failure is going to have on the patient. We would like to take this opportunity to now explain exactly what heart failure is, the details of its diverse effects, and describe the care expected.
Heart failure is a clinical syndrome that results from the progressive process of remodeling, in which mechanical and biochemical forces alter the size, shape, and function of the ventricle’s ability to fill and pump enough oxygenated blood to meet the metabolic demands of the body. Seventy five percent of heart failure cases are caused by systemic hypertension (Grandinetti, 1974/2010). A third of patients experiencing a heart attack will also develop heart failure; another common cause is structural heart changes such as: valvular dysfunction especially pulmonic or aortic stenosis which leads to pressure or volume overload on the heart. (Grandinetti, 1974/2010).
However, those are not the only risk factors. Other serious risk factors that nurses should be aware of are: coronary artery disease, irregular heartbeats, diabetes, medications used to treat diabetes such as Avandia or Actos, sleep apnea, congenital heart defects, viruses, alcohol, certain kidney conditions, and of course, genetics (Mayo Clinic, 2010).
As you can see, CHF is a very intricate disease process that involves more than just the heart muscle itself. Complications from chronic heart failure take a serious toll on a patient’s ability to perform ADLs without becoming short of breath or easily exhausted. The patient may have activity limitations demonstrated by the avoidance of walking long distances, walking up stairs, or exerting themselves because they become dyspenic very easily. The nurse must assess the patient’s ability to perform minor tasks such as putting on shoes. Since heart failure can lead to severe swelling especially in the feet and ankles, the patient may not be able to put his or her shoes on without assistance or in some cases a specially designed shoe may be necessary. It is also important that the nurse inquire the patient about the ability to perform simultaneous arm and leg work, such as carrying groceries. This type of activity may place an intolerable demand on the failing heart (Ignatavicius, 1991/2010).
Congestive heart failure does not solely affect the patient’s ability to perform activities of daily living, yet it affects other portion of life such as their family, social, and spiritual lives. Patients with advanced CHF often require help with daily tasks (i. e. making food, getting dressed, running errands, housekeeping); and family members often help out by doing these tasks for their loved ones. If the patient lives with a family member, that person may also be responsible for further management of cares in the home. This requires the family to be willing to learn about the disease process, and when it is necessary to call the health care provider or bring the patient into the hospital. This can cause a great amount of stress on the family member due to the responsibility of managing care. The fact that the patient may not be able to perform tasks on their own may lead to frustration which can further lead to self isolation due to the fact that they don’t want to be bothersome nor embarrassed by their deficits. This is damaging to their social life and may cause depression.
While the patient may be struggling with managing their social lives and trying to remain as independent from family members as possible the patient may turn to their religion. They may turn to their faith and pray more in hopes that it will benefit them and make it easier for them to deal with losing their independence. Spiritual well-being is an important, modifiable coping resource for depression, but little is known about the role of spiritual well-being in patients with heart failure (Bakelman, 2010). However, hope is a major indicator of one’s wellbeing. This is especially true for patients with heart failure. Those who are hopeful tend to feel better and are more socially involved (Ignatavicius, 1991/2010).
Another factor that plays a major role in how patients with heart failure manage their care is the cultural background which they are from. For instance, those in minority communities may require more direct contact and consistent encouragement to follow the recommendations for treating their disease. A 2006 study concluded that:
“ Nurse management can improve functioning and modestly lower hospitalizations in ethnically diverse ambulatory care patients who have heart failure with systolic dysfunction. Sustaining improved functioning may require continuing nurse contact” (Sisk, 2006).
It is not well understood why this is, but it may be likely that those patients who reside in minority communities do not have access to the types of health promotion and prevention programs as those who reside in a more socioeconomically stable community.
Moving on now to the psychological effects that disease casts upon its victims; many patients with heart failure are at risk for anxiety and frustration. They may experience symptoms such as dyspnea, which further complicates their anxiety level. Those who are dealing with an advanced disease are certainly at high risk for depression. It is not certain whether the function impairment contributes to the depression or the depression affects functional ability. It is thought that those who are rehospitalized for an acute episode of heart failure are more likely to be depressed (Ignatavicius, 1991/2010). Nurses may help these patients with alternative coping methods.
It is important to keep in mind that nurses have a great amount of responsibility when it comes to prevention and treatment for those suffering from heart failure. Preventative measures that can be taught and reinforced to clients are: to quit smoking, control certain conditions such as hypertension, stay physically active, eat healthy foods, maintain a healthy weight, and tips for reducing and managing stress (Mayo Clinic, 2010). Treatment for these clients is generally directed by the physician, but the nurse reinforces the treatment plan and continues to guide the care throughout its course.
Treatment often starts with conservative measurements such as treating the underlying cause, for example, a rapid heart rate or repairing a heart valve (not as conservative). But for most people, treatment involves a balance between the right medications and in some cases devices that help the heart beat and contract properly. Medications often used are: ACE inhibitors, ARBs, Digoxin, beta blockers, diuretics, and aldosterone antagonists. If medications alone are unable to treat the disease, other forms of treatment such as coronary bypass surgery or heart pumps may be used (Mayo Clinic, 2010).
Furthermore, nurses must continue to intervene and assess the patient’s response to prescribed treatments. As mentioned before, nurses can educate their clients on the measures taken to prevent heart failure. Even more so, if the patient already has heart failure, the nurse shall administer medications as prescribed, place the patient on physical and emotional rest, while continuing to monitor for their therapeutic response to the medication and reducing the workload of the heart to increase its reserve. The nurse shall also monitor for complications such as excessive fluid volume, by weighing the patient daily and carefully assessing for lung sounds that would indicate fluid buildup (i. e. crackles in the lung fields) (Grandinetti, 1974/2010).
Another nursing intervention that may be useful in helping the patient to manage their care at home is to teach them about MAWDS, an acronym that stands for Medications, Activity, Weight, Diet, and Symptoms. This module is an easy way to teach patients about medication usage, recommended activity level, maintaining weight and the boundaries for weight loss and weight gain, a heart healthy diet, which includes low sodium (2-3gms) and fluid restrictions, as well as symptoms that should be noted and reported to the physician immediately (Ignatavicius, 1991/2010). This is a very concise and understandable tool that is beneficial to both the nurse providing the education and the patient required to remember and comply with the self-management techniques.
It is critical for nurses to understand the care needed to manage the patient with heart failure. They must be able to comprehend all aspects of its affect upon the patient in order to know how to direct them toward the right health choices and to know when to intervene to prevent complications. As we have discussed heart failure affects more than just the patient’s cardiovascular system, and there are many other factors that are involved in the disease process as well. Lifestyle changes must be made and maintained, those in minority communities may need more frequent contact to manage their care, and the health care provider must also remain aware of the psychosocial effects such as depression. Once these factors are understood to the best of their knowledge then improvement and management of this dynamic disease can be attained. Even if this means aggressive treatment because the conservative course did not serve its purpose as expected. Sometime drastic measures must be done. Either way nurses shall continue to provide teachings and management strategies to improve the outcome of their patients care. References
References
Bakelman, D. B. (2010). Spiritual Well-Being and Depression in Patients with Heart Failure. Journal of General Internal Medicine, 22(4), 470-477.
Grandinetti, D. (Ed.). (2010). Lippincott Manual of Nursing Practice (9th ed.). Ambler, PA: Wolters Klewer Health, Lippincott Company. (Original work published 1974)
Ignatavicius, D. (2010). Medical Surgical Nursing: Patient-Centered Collaborative Care (6th ed.) (L. Henderson, Ed.). St. Louis, MO: Saunders Elsevier. (Original work published 1991)
Mayo Clinic. (2009, December 23). In Mayo Foundations for Medical Education & Research (Eds.), Heart Failure. Retrieved February 19, 2011, from Mayo Clinic: http://www. mayoclinic. com/health/heart-failure/DS00061
Sisk, J. E. (2006). Effects on Nurse Management on the Quality of Heart Failure Care in Minority Communities. Annals of Internal Medicine, 145(4), 273-283.
