1. Benbow, Denise A. RN, CMSRN, MSN

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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.



Table. Teaching abou... - Click to enlarge in new windowTable. 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.




1. Institute for Healthcare Improvement. Deliver reliable, evidence-based care for congestive heart failure. [Context Link]


2. Koelling TM, Johnson ML, Cody RJ, Aaronson KD. Discharge education improves clinical outcomes in patients with chronic heart failure. Circulation. 2005;111(2):179-185. [Context Link]


3. AHRQ Health Care Innovations Exchange. Innovation Profile. Transition home program reduces readmissions for heart failure patients. February 16, 2009. [Context Link]


4. The Joint Commission. Performance Measurement Initiatives. Heart Failure Core Measure Set. Update February 2009. [Context Link]


5. McPhee S, Papadakes M. Current Medical Diagnosis and Treatment 2008. New York, NY: McGraw-Hill Professional; 2007. [Context Link]


6. American Heart Association. Heart failure. Update April 30, 2009. [Context Link]


7. Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner and Suddarth's Textbook of Medical-Surgical Nursing. 11th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2008. [Context Link]