Nurse Driven Education for A Patient Diagnosed With Chronic Systolic Heart Failure Refusing Diagnostic and Interventional Procedures
Heather Horsley
Wilkes University School of Nursing

Abstract
Heart failure (HF) is a chronic progressive disease, arising from structural or functional disorders of the heart, in which incidence increases with age. This review attempts to describe the types and causes of HF while focusing on variable aspects of patient education that have a positive effect on patient outcome and quality of life. Specifically, the potential benefits of this education for a 55 year old male patient diagnosed by transthoracic echocardiogram with chronic systolic heart failure, who has refused physician deemed necessary diagnostic testing and treatment.
Keywords: heart failure, nurse driven education, heart failure, self-care

Nurse Driven Education for Patient Diagnosed With Chronic Systolic Heart Failure Refusing Diagnostic and Interventional Procedures
Heart failure (HF) is a major health care concern affecting over 5.7 million people in the United States. It is responsible for 1 in 9 deaths and costs the nation over 32 billion in health care expenses each year (Center for Disease Control, 2013). HF is the most common reason for hospitalization of people older than age 65 (Hinkle and Cheever, 2014). According to Hinkle and Cheever, HF is a “clinical syndrome resulting from structural or functional cardiac disorders that impair the ability of the ventricles to fill or eject blood.” There are two major types of HF, systolic heart failure in which there is an alteration in ventricular contraction, and diastolic heart failure, a less common type, in which there is a decreased ability for the ventricle to fill related to a noncompliant heart muscle. Many patients diagnosed with HF experience physical symptoms including dyspnea, fatigue, pulmonary or peripheral congestion, edema, and sleeping difficulties that decrease their health related quality of life. HF is often progressive with patients experiencing fluid overload or inadequate tissue perfusion, with one half of patients surviving less than 5 years from the time of diagnosis (CDC, 2013). Causes of HF include but are not limited to coronary artery disease, hypertension, cardiomyopathy, valvular disorders, and renal dysfunction (Hinkle and Cheever, 2014). The patient presented for discussion in this review is a 55 year old, obese male with chronic systolic heart failure who, in regards to financial concern and lack of health insurance, has refused any diagnostic testing or procedures beyond the initial transthoracic echocardiogram and expressed desire to leave the hospital as soon as possible to avoid any further financial responsibility. He has also expressed concern over the cost associated with medication and his ability to return to work as a self-employed landscaper/laborer.
Nurses Role One of the primary roles of a nurse in all aspects of heart failure, prevention through advanced disease, is patient education and advocacy. Nurses in the primary care setting have the opportunity to provide education related to primary prevention of heart disease, including lifestyle changes associated with modifiable risk factors. These include smoking cessation, diet modification, the incorporation of an exercise routine, and maintenance of a healthy weight. Nurses can also encourage the use of secondary prevention practices including blood pressure screenings, cholesterol level checks, diabetes screening and regular visits with their primary care physician to identify cardiovascular problems early, offering the best chances of successful treatment. For patients with existing symptoms of heart disease, the nurses role may include helping to identify risk factors and lifestyle habits that have led to the disease, as well as obtaining and documenting vital signs and diagnostic tests used to determine the extent of the disease. Education on identification of significant symptoms and the proper subsequent actions will play a major role in the patient’s ability to advocate for themselves and help them determine when it is necessary to seek care. Nursing responsibilities in caring for a patient already experiencing chronic heart failure, like the one being discussed in this review, include specialized cardiac monitoring, monitoring of vital signs and major organ function, post-procedure care, assessment and care of surgical incisions, administration of medications, managing patient anxiety and compliance, and patient education. Discharge is perhaps the most critical educational opportunity for nurses dealing with HF patients. The level of patient self care and symptom recognition and management after discharge is a significant factor relating to the prevalence of readmittance to the hospital and death in HF patients (Barnason, Zimmerman, and Young, 2011). Barnason, Zimmerman and Young (2011) reveal that one of the factors affecting the compliance with self care actions by heart failure patients is the amount of nurse directed education they receive. Nurse educators need to be skilled in their ability to assess a patient’s level of understanding and comprehension and to identify barriers to learning such as functional and cognitive limitations.
Patient Education and Plan Education relevant to HF patients includes information regarding the importance of compliance with medication, sodium and fluid restrictions, the recognition of signs and symptoms that indicate progression of the disease, and a physical activity regimen that increases activity at low to moderate intensity. This education is especially pertinent to the patient under review in that he has been diagnosed with chronic systolic heart failure with a lower than normal ejection fraction and hypertension, but has refused any further diagnostic test disallowing a complete assessment of the level of disease of his heart. He has agreed to maintain a medication regimen, fluid restriction, sodium-restricted diet and to monitor the amount of heavy lifting he performs. The first education topic discussed with the patient was the outpatient medication regimen he would be responsible for complying with and the possible side effects associated with his pharmacologic therapy. The patient was discharged with a medication list including: Apixiban, Aspirin, Carvedilol, Digoxin, Spironolactone, and Torsemide. Each medication, the justification and side effects were explained as follows. Apixaban is an anticoagulant used in the prevention of strokes and embolic events. Aspirin is used to decrease platelet aggregation and prevent transient ischemic attacks and myocardial infarctions. Carvedilol was explained as a medication to treat hypertension by decreasing heart rate and blood pressure and improving cardiac output; it was noted that it has the potential to cause dizziness, fatigue or even hypotension. Digoxin was described as an antiarrhythmic that increases the contraction of the heart and slows the heart rate down; side effects of fatigue, nausea and the potential for arrhythmias was explained. It was explained that Spironolactone is a diuretic and has been prescribed to prevent fluid retention and buildup while allowing the body to retain potassium. Finally, Torsemide was described as a loop diuretic also to help with fluid balance, preventing fluid retention and edema. Nonadhearance to medication regimens is common and, independent of the reasons behind the noncompliance, is associated with poor symptom control and higher hospitalization rates for HF patients (Ho, Bryson and Rumsfeld, 2009). The importance of taking medications as prescribed was reiterated verbally to the patient. Lenni et al. (2013) have demonstrated that patients with advanced HF who consume higher (>3g) sodium diets have a significantly greater chance of rehospitalization than those who follow a sodium restricted diet. Son, Lee and Song (2011) also agree that patients with a higher consumption of sodium exhibited greater symptom burdens and shorter cardiac event free time spans. The importance of a sodium restricted diet was clarified as increased sodium levels encourage the retention of water and intensify the workload of the heart as it is forced to move a greater systemic volume. The patient was encouraged to maintain a diet that avoids packaged, canned, processed, salted or smoked foods, and focuses on the consumption of fresh and raw foods. The patient was also informed that many condiments such as BBQ and soy sauces, dry seasonings and even ketchup are preservative rich and subsequently high in salts. The patient requested specific numerical dietary information regarding sodium intake, at which time a consult was initiated to a heart specific dietician; unfortunately the dietician was unavailable, and the patient was provided with written literature in the form of pamphlets describing appropriate sodium intake and other heart healthy dietary variables. A 2g sodium restriction as well as a 2L fluid restriction were advised to maintain fluid balance and prevent hypervolemia. Weight gain can be an early sign of fluid retention, and can be indicative that heart failure is worsening. In order to track his weight reliably, the patient was instructed to weigh himself everyday, on the same scale, at the same time while keeping a detailed diary of weights along with information regarding how he felt on that day. A gain of more than 2lbs in a day or 5lbs over a week is notable, and the patient was advised to call or be seen by his physician if this occurs. Understanding the signs and symptoms of worsening HF are important for the patient to acknowledge so they can be recognized and addressed as early as possible. The patient was advised that symptoms such as unusual or increasing shortness of breath, swelling of extremities, increasing cough, fullness in abdomen, dry mouth, muscle cramps, sudden weight gain or increasing fatigue are significant, may implicate worsening or recurring heart failure, and need to be addressed with their health care provider.
Physical activity is a major self-care variable in which, through compliance, patients can have a significant effect on their own heart health and the prevention of progression, or even reversal, of ventricular remodeling (Milligan, 2013). The benefits of upholding planned physical activity were explained to the patient to include: increased efficiency of the heart, increased muscle tone, decreased stress, increased energy, increased circulation, the lowering of cholesterol, lowering blood pressure, and increased ability to manage weight. It was also reinforced that exercise is important, but should be smart; the patient was informed that he should monitor his intensity level with the parameter that he be able to carry out a conversation while he is exercising and that if he is not able to he may be working too hard. He was instructed to start slowly and gradually build to a goal of 30 minutes per day, perhaps 3 ten-minute sessions, stopping to rest whenever he feels tired. The patient’s occupation, which he reported he planned to return to the next day, was taken into consideration and the physician ordered 10 pound lifting restriction was reinforced.
Referrals and Resources
By refusing any further diagnostic testing, this patient presents an unusual psychosocial demographic in which the importance of quality education cannot be understated. The patient was advised that he had a standing order at any facility- associated lab for follow up assessment and was provided directions to the lab closest to his home. Pamphlet-style information packets on location of other labs and operating hours were provided. The patient was also provided with the personal contact information of his physician, and a voucher for 30 days of his medication.

Summary
Heart failure is an increasingly common issue, especially among older individuals in the United States. Diagnosis and treatment of HF is accomplished by an experienced interdisciplinary team, of which nurses play a vital role through assessment, patient monitoring, direct care, and particularly education. Patient education relating to self care activities after discharge is exceedingly important and is comprised of the importance of medication compliance, recommendations for diet, fluid restriction, activity level, and recognition of signs and symptoms of progressing or recurring disease. This education may prove to be especially imperative for patients who, for various reasons, feel that full diagnostic assessment or procedural intervention is not their best option.

References
Barnason, S., Zimmerman, L., & Young, L. (2011). An integrative review of interventions promoting self-care of patients with heart failure. Journal of Clinical Nursing, (21), 448-475.
Heart Failure Fact Sheet. (2013, December 3). Retrieved March 17, 2015, from http://www.cdc.gov/DHDSP/data_statistics/fact_sheets/fs_heart_ failure.htm
Hinkle, J., & Cheever, K. (2014). Management of Patients With Complications From Heart Disease. In Brunner & Suddarth's textbook of medical-surgical nursing (Edition 13 ed., pp. 795-810). Wolters Kluwer Health, Lippincott Williams & Wilkins.
Ho, P., Bryson, C., & Rumsfeld, J. (2009). Medication Adherence: Its Importance In Cardiovascular Outcomes. Circulation, 119, 3028- 3035.
Lennie, T., Moser, D., Biddle, M., Welsh, D., Bruckner, G., Thomas, D., ... Bailey, A. (2013). Nutrition intervention to decrease symptoms in patients with advanced heart failure. Research in Nursing & Health, (36), 120-145.
Milligan, F. (2013). Using exercise to improve quality of life for people with heart failure. British Journal of Nursing, 22(21), 1242-1246.
Son, Y., Lee, Y., & Song, E. (2011). Adherence to a sodium-restricted diet is associated with lower symptom burden and longer cardiac event-free survival in patients with heart failure. Journal of Clinical Nursing, (20), 3029- 3038.

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