SELF-CARE EDUCATION

Readmissions for heart failure are caused by multiple factors, including failed self-care. Heart failure self-care education is therefore standard prior to hospital discharge and is included in a multidisciplinary cardiac rehabilitation program. HF patients who receive a focused education program before discharge are significantly more likely to be compliant with recommendations, have an improved quality of life, and promote their own health.

The quality of patient education in HF directly influences mortality and reduces risk-related behavior and the need for hospital readmissions (Salahodinkolah et al., 2020). Teaching the patient to focus on symptom monitoring, medication management, a low-sodium diet, activity tolerance, and psychosocial strategies promotes self-care that will reduce the frequency of hospital readmissions in HF patients (Bennett et al., 2020).

Several evidence-based educational interventions have proven effective in teaching HF patients how to progress in self-care. These interventions include face-to-face teach-back training, home visitation by follow-up phone call, group training, and e-learning.

A cohesive, multidisciplinary plan for education involves all the patient’s caregivers: physicians, nurses (including advanced practice nurses), medical social workers, respiratory therapists, physical therapists, occupational therapists, and discharge planners.

Principles of Patient Education

The following are necessary principles in successful patient and family teaching:

• The patient and caregivers are made aware of the need for learning by all members of the multidisciplinary team.
• A health literacy assessment is done to evaluate the ability to comprehend what is being taught. Health material should be written on a fifth-grade level to promote global comprehension. If necessary, the material is provided in the patient and family’s primary language.
• Goals are realistic.
• Teaching takes place after a crisis has passed and those involved are ready to receive learning; it takes place before discharge to allow time for family involvement, teach-backs, and re-demonstration.
• The use of medical terminology is limited.
• Anticipatory guidance gives the patient and caregivers a better idea of what to expect during recovery and rehabilitation.
• Perceived control allows the patient to make decisions about what actions are obtainable to achieve desired success.
• Follow-up visits and reassessments with healthcare personnel are important to evaluate progress and the need for any readjustments in the teaching plan.
  (Harding et al., 2020)

Medication Management Education

Medications are one of the most important treatment parameters in HF. Nonadherence to medication regimes is one of the two most commons reasons that patients with HF are rehospitalized. (The other is noncompliance with dietary restrictions.) Therefore, it is incumbent upon healthcare professionals to ensure patient and family understanding of every aspect of pharmacologic treatment modalities before discharge to home or a long-term care facility. Communication with potential caregivers should be included as well.

Good teaching standards require instructions to be given in a language that is well-understood by the person who will be responsible for dispensing the medications, whether that person is the patient, a family member, or a caregiver. Evidence also shows that patients are more likely to be compliant with medication schedules when they understand what they are for and are told how important they are. It is also suggestive of better effectiveness if the patient is told what outcome to expect.

The correct dosage of HF medications is essential to their effectiveness. Unless the importance of giving or taking the correct medication is understood, the patient may not benefit from the intended therapeutic effects. Due to the high cost of pharmaceuticals, the patient or family may occasionally try to reduce the medication dose in order to make the prescription last longer or to share the medications with another. Emphasis must be made about the possible outcomes if the correct dose is not taken as ordered.

Certain medications, such as antihypertensives, cannot be stopped suddenly without producing a rebound effect. This information must be explained to the patient and family.

Teaching Exercise (Activity) Tolerance

Exercise is a crucial component of daily activity for someone with HF. Exercise tolerance is the ability to obtain maximum workload and duration while moving. With the guidance of a physical therapist or exercise physiologist, a person with HF can stay as active as possible for as long as possible and potentially reap the resultant health benefits. The clinician teaches the patient and family specific exercises, within appropriate parameters, to optimize strength and endurance without causing an oxygen deficit secondary to exercise intolerance (Physiopedia, 2020). (See also “Cardiac Rehabilitation” earlier in this course.)

Oxygen consumption is the amount of oxygen used during activity. A certain amount of oxygen is consumed even while at rest. People with HF must pace themselves to ensure that using oxygen stores in the body too quickly does not cause shortness of breath or dyspnea. Medications to regulate heart rate and BP may be given to minimize oxygen consumption. Physical therapists and respiratory therapists work with other care team members to create a physical activity plan to keep the patient with heart failure active while minimizing symptoms of hypoxia (Harding et al., 2020).

Teaching Respiratory Management

Respiratory management is an indispensable aspect of patient and family teaching. Patients with moderate to severe HF may intermittently or permanently require oxygen supplementation or respiratory treatment to remain out of the hospital. Thus, a respiratory therapist is an extremely valuable member of the care team.

OXYGEN SUPPLEMENTATION

Oxygen supplementation may be needed for exacerbations of shortness of breath and dyspnea or may be a permanent feature. Some HF patients may require continuous oxygen even at rest, and others may require oxygen only while active. The supplementation may be in the form of portable oxygen by cylinder, small tank, or an oxygen concentrator. Cylinders and tanks must be refilled periodically, while a concentrator uses the 21% oxygen always available in the surrounding air and concentrates it to deliver a somewhat higher amount, usually measured in liters per minute (L/m).

A nonrebreather mask is a disposable, plastic oxygen mask that covers most of the face and is the only nonventilated oxygen device that can deliver 100% oxygen. But most patients prefer not to wear a mask covering their face and will wear a nasal cannula that can deliver no more than 6 L/m.

Oximetry devices measure the concentration of oxygen in the capillaries to evaluate the need for reduction of oxygen consumption, the need for oxygen supplementation, or the effectiveness of oxygen supplementation to maintain an oxygen saturation of 94% to 100% in the absence of respiratory disease.

(See also “CPAP/BiPAP/APAP” earlier in this course.)

POSITIONING

Many patients with HF are more comfortable sitting and even sleeping at a high angle up to 90 degrees (orthopnea). In this position, it is more possible to expand the bases of the lungs while inhaling, optimizing the amount of oxygen made available. For this reason, some patients commonly sleep in a chair or have a bed with a movable base in which the head of the bed can be elevated (Harding et al., 2020).

Teaching Weight Management

The closer a person with HF is to their optimal weight, the more active they can be, the less likely they are to need readmission to a hospital with a diagnosis of HF, and the longer their life expectancy. The person or persons in charge of the cooking for the patient may require instruction to promote weight loss and prevent fluid retention while maintaining adequate nutrition and hydration. A registered dietitian or nutritionist may be called in on consultation to help select menus and dishes that will accomplish these goals. Personal preferences, cost, availability, and cultural differences are all typical considerations when meal planning.

Prevention of fluid retention is a fundamental part of patient and family education for patients with HF. Fluid or volume overload can cause the patient to be rehospitalized. In the context of dietary noncompliance, it is the second most common cause for readmission with a diagnosis of HF (noncompliance with a medication regime being the first). Sodium and fluid restrictions are an essential part of self-care education.

(See also “Nutritional Therapy” earlier in this course.)