Educate CHF patients about home management
A congestive heart failure (CHF) patient who is not followed closely or noncompliant with taking medications may show up in the ED with exacerbations including chest pain/tightness, shortness of breath, difficulty sleeping, abnormal swelling, and edema of the lower extremities. It’s up to you to educate patients about home management of CHF, stresses Victoria L. Mugica, RN, BSN, clinical program coordinator for the center for heart failure management at the University of Chicago Hospital.
There is no cure for heart failure, Mugica notes. "In most cases, there is nothing we can do to reverse the damage to the myocardium, because it is a progressive disease," she explains. "Home management is key to prevent exacerbations and causing further damage."
Studies have shown that home management of CHF decreases hospital admissions, so chronic patients can be managed in the outpatient setting. "There is a better quality of life for patients, since they don’t have to spend a majority of their time in the hospital or doctor’s office," she stresses.
With proper education, patients also have an increased functional capacity, Mugica says. "If they are managed long enough, in some cases they can increase their strength and return to Class I function."
Here are some things to consider when educating patients about home management of CHF:
• Signs and symptoms can’t be repeated enough.
Patients must weigh themselves every day. If they have increases of two pounds overnight or three to five pounds in a couple days, they need to notify whoever is managing their condition, says Mugica.
Patients with moderate to severe heart failure are placed on a 2-gram (approximately 1 teaspoon) sodium diet. "This is a very strict diet and can be difficult to follow," says Mugica. "Patients may not understand the importance or the severity of the restriction."
Patients should not wait until they are so volume overloaded that they have to come to the ED, urges Mugica. "I cannot stress enough the importance of education in reducing the number and severity of exacerbations," she says. "As health care providers we may feel like broken records, but the more times and ways information is given, the chances increase that it will be understood and put to use."
Home monitoring available
• New home monitoring equipment places a system in the patient’s home.The patient can be hooked up to EKG leads while blood pressure and pulse can be checked in a remote location. "The patient plugs it into the phone and sends it to a central monitoring station, where any unusual data is immediately forwarded to the nurse or physician," says Mugica.
Lifesigns Systems, a home management program portable bedside monitoring system, is available from Alaris Medical Systems in Hillsboro, OR. (For more information, see Resource, p. 147.)
• New software programs are available for management of CHF that allow two-way interaction.
CHF patients log into a Web site using a password, and enter their vital signs and symptoms. A nurse at the receiving end will review the data, look for trends, talk with the patient, and notify the doctor of changes in the patient’s condition," says Gradman.
"A home or outpatient visit may be warranted for a dose of IV Lasix or a dobutamine infusion," she says.
• Patients should be alerted to seasonal exacerbations of CHF.
Heat and humidity can exacerbate CHF patients and bring them to the ED during the summer.
"Also, the day after Thanksgiving, many CHF patients come in because of dietary indiscretion and salt overloading. That trend continues through the holiday season," notes David Wilcox, MD, FACEP, medical director for ConnectiCare, an HMO in Farmington, CT, and associate professor of emergency medicine at University of Massachusetts Medical School in Worcester.
• Understand why patients may not be compliant with taking medications. Patients may be noncompliant because they don’t fully understand the dosing or purpose of the medication, Mugica explains. "They may not have transportation to the pharmacy or adequate means to pay for the prescriptions. There may be unpleasant side effects which have not been addressed."
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