10 - The Essentials of Patient Education in the Emergency Department

Editors: Peacock, W. Frank

Title: Short Stay Management of Heart Failure, 1st Edition

Copyright ©2006 Lippincott Williams & Wilkins

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10

The Essentials of Patient Education in the Emergency Department

Robin J. Trupp

Elsie M. Selby

Introduction

Heart failure is a complex chronic condition associated with great morbidity, mortality, and economic burden in the United States. The vast majority of health care expenses related to heart failure occur as a result of hospitalizations for decompensation.1 Identification of the reason for the decompensation, such as further deterioration in left ventricular function or a remedial cause, determines the treatment plan. Importantly, in most instances, these hospitalizations could be avoided with adherence to treatment regimens and/or careful monitoring and attention to changes in signs and symptoms of heart failure.2, 3 and 4 Although educational needs for the patient with heart failure are vast and include such topics as the pathophysiology and etiology of heart failure and necessary lifestyle modifications, in an observation unit education must be directed and succinct, given the short-term nature of the interaction. However, during times of stress, as would be expected in patients presenting to an emergency department, retention of any information given is limited.5 If the patient is ultimately hospitalized, the urgency for providing information is somewhat lessened, because the inpatient environment offers additional opportunity for, and reinforcement of, education. Because the majority of causes of worsening heart failure are directly attributable to nonadherence to the medication and/or dietary regimens, this chapter concentrates on these topics as essential elements of patient education.

Adherence to prescribed medical regimens, including both pharmacologic and nonpharmacologic interventions, significantly impacts both the short- and long-term management of heart failure. Such treatment strategies have been well proven to slow disease progression, reduce hospital admissions, and improve overall symptom control.6 However, despite the importance of these interventions, numerous barriers to adherence exist. Barriers may include lack of understanding of perceived benefit, lifestyle modifications, absence of social support, powerlessness, financial concerns,

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and time constraints. These barriers complicate patients' ability and willingness to adhere to the prescribed medical regimen. In addition, in the haste to shorten length of stay and reduce health care expenditures, clinicians may simply treat the symptoms and fail to identify nonmedical causes for the decompensation. By taking the time to do a thorough assessment to identify barriers and then target problem areas, clinicians can better use the time spent with each patient, leading to a more individualized treatment plan and enhanced adherence.7

Causes for Decompensation

Poor compliance with the medication regimen and volume overload, directly related to sodium indiscretion (willful or inadvertent) and/or excess fluid intake, are the major causes for decompensated, or worsening, heart failure.3,8 In many of these instances, improved communication between the patient and health care team could have provided an opportunity to intervene and avoid hospitalization. Using an organized multidisciplinary team affords greater opportunities for achieving treatment goals and outcomes. The success of multidisciplinary teams is well documented in the medical and nursing literature, and much of their success is directly related to enhanced communication, improved adherence, and increased attention to early warning signs of worsening heart failure.

Medication and Dietary Adherence

Diet and medication adherence have profound implications for the management of heart failure. Lack of adherence as a significant cause of decompensation and hospitalization has been well documented.3 Poor adherence also has significant economic repercussions. For example, if insufficient medication is taken for the treatment to be fully effective, as occurs when patients “ration” diuretics to extend the life of a prescription, subsequent health care costs are likely to be incurred as a result of hospital-based treatment. Not unexpectedly, better outcomes are seen with improved adherence to treatment plans.6

The role of education on medication and dietary adherence cannot be overemphasized and requires continual reinforcement. Clinicians working with heart failure patients are challenged to approach each patient as unique and to individualize strategies to increase adherence to diet and medication. One size does not fit all here.

Dietary Instructions

In general, sodium intake should be limited to about 2,000 mg per day for all patients with heart failure, regardless of type of dysfunction or the use of diuretics. Because the average American diet consists of approximately 6,000 mg per day, this degree of sodium restriction is challenging for even the most dedicated patient. Counseling should include repeated in-depth

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instruction on the components of a 2-g sodium diet and should involve family members as well. Although patients not suffering from advanced disease may be able to tolerate more sodium, limiting intake to 2,000 mg sodium daily is advised because consumption will likely exceed the recommendations anyway. Salt substitutes and spices may be used to improve the palatability of food. However, some salt substitutes replace sodium chloride with potassium chloride and should be used with caution, given the potential risk of hyperkalemia.

In advanced heart failure, further dietary sodium restriction may be necessary to attenuate expansion of extracellular fluid volume and the development of edema. Although sodium restriction may assuage the development of edema, it cannot totally prevent it, because the kidneys are capable of reducing urinary sodium excretion to less than 10 mmol per day. Hyponatremia should not discourage compliance with a restricted sodium diet, because the hyponatremia is usually dilutional in nature and associated with total body sodium and water excess. Liberalized sodium intake or replacement, therefore, should be considered only in overt cases of severe excessive diuresis and dehydration.

Within the emergency department, simple questions about recent dietary intake may yield the cause of decompensation. Accompanying family members are also good sources of information regarding food or fluid intake. Patients should understand the relationship between fluid and sodium for managing volume and in controlling symptoms. Instructing patients to simply take an extra diuretic to relieve symptoms should not be encouraged, because diuretics contribute to increased neurohormonal stimulation and worsening renal function.7 Patients should understand that dietary indiscretion produces fluid retention and worsening symptoms. Thus, efforts should focus on helping patients make the association between behavior and symptoms. The challenge lies in doing this without preaching or condemning. Learning will not occur within that scenario. If a connection between a particular behavior and its negative consequences can be made, lifestyle changes are more likely. Behavioral changes do not happen overnight, but those who view the recommended changes as personal choices, rather than as edicts imposed by others, are more likely to make permanent lifestyle modifications.8

Recognizing obvious sources of sodium, such as the salt shaker or potato chips, is evident for most patients but in a typical diet constitutes less than 25% of total intake. Hidden sources of sodium play a major role in dietary intake yet are often unrecognized. Good heart failure clinicians are also good detectives. Common high-sodium-content items include, but are not limited to, canned soups and vegetables, pickles, cheese, softened water, tomato juice, antacids, and processed foods. Having the patient complete a food diary over the course of several days will give the clinician important insights into dietary habits and average fluid consumption and will likely reveal unexpected high-sodium sources. Starting this diary after treatment in the emergency department affords the clinician next evaluating the patient

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much-needed information and the ability to offer alternative lower sodium choices. Resources available for patients include pamphlets or booklets on the sodium content of foods, for use both at home and when dining out. These materials should be readily located and available within the emergency department. Another more commonly used resource is the Internet, where numerous web sites related to low-sodium food choices and recipes can be located.

Medications

Pharmacologic interventions are vital to managing symptoms and halting disease progression in heart failure. Yet, medications for heart failure are both complex and costly. Polypharmacy, or the need for multiple medications, is a normal consequence of an evidence-based approach to managing heart failure, because beta-blockers, angiotensin-converting enzyme (ACE) inhibitors and/or angiotensin receptor blockers, aldosterone inhibitors, electrolyte supplements, and diuretics must all be taken at different times throughout the day. No wonder patients become confused and fail to comply. Potential barriers to adherence should be identified and addressed. Besides financial barriers, other frequently missed obstacles include real or perceived side effects, forgetfulness, and understanding the importance of the medication.5,6 To improve patient adherence, ongoing discussions must occur between clinicians and patients to reach understanding and agreement on the necessity for medications and the appropriate regimen.6 Rather than mandated or imposed views, this discussion may require some compromise from both parties, as patients agree to take more medications than they initially wanted or as the clinician acknowledges the patient may be taking less than is ideal. What is most important is that the actual medications being taken are known.

Patients should be instructed to bring their medications whenever seeking or receiving health care. Doing so provides an accurate record of current medications and prevents duplicate prescriptions. A variety of aids to enhance adherence are available and may be helpful to some. These aids include pill boxes, medication trackers, or timers, to name few. For those with financial constraints, most major pharmaceutical companies offer assistance programs for individuals unable to afford medications. Documentation of medical necessity is required from the prescribing clinician, and patients may need to submit documentation of financial need as well. Although this process is unlikely to be initiated in the emergency department, it is important to recognize resource options and to make the necessary referrals.

Worsening Signs and Symptoms

Despite advanced warning signs and symptoms of decompensation, many patients either fail to recognize them or fail to react. For example, Friedman reported that 90% of patients hospitalized due to decompensation experienced dyspnea 3 days prior to hospitalization.9 Additionally, 35%

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reported edema and 33% had cough 1 week prior to admission.10 A survey by Carlson and Riegel11 revealed that most patients had experienced multiple symptoms of worsening heart failure in the previous year, yet their knowledge of the importance of these signs and symptoms was poor. Even though patients who had lived with heart failure for years were more likely to use appropriate self-care strategies than newly diagnosed patients, they were uncomfortable in evaluating the effectiveness of their own actions.11 Thus, when patients fail to recognize or acknowledge worsening signs and symptoms, clinicians lose the chance to intervene and potentially avert hospitalization. Therefore, educating patients and their families on both the signs and symptoms associated with worsening heart failure and what actions to take provides an excellent opportunity to reduce hospitalizations and ultimately reduce health care expenditures. Establishing self-efficacy, or belief in the ability to control heart failure, is essential for patients to participate in their own care and better manage their disease.

Patients experiencing decompensated heart failure exhibit a constellation of signs and symptoms, including increased dyspnea and/or fatigue, weight gain, orthopnea, and paroxysmal nocturnal dyspnea (PND). Essential aspects of education are presented in Table 10-1. Patients need simple advice on what changes in symptoms are important and clear endpoints that should prompt them to seek help. Whenever special equipment is involved, instruction on proper use and when to seek help are required. For example, daily weights require that the patient owns a scale, that the scale has numbers that can be read by the patient with a stable base large enough for them to stand on, and that the weights be obtained at approximately the same time each day. Education on when to call with weight changes is determined by the clinician and should be provided in written format and then reinforced frequently. In all cases, patients and families should be diligent in monitoring physical signs and symptoms. Establishing plans for notifying health care providers of any changes is the logical next step and should include the identification of emergency contact numbers for doing so.

Respiratory Symptoms

The majority of patients with decompensated heart failure have evidence of excess extracellular volume or congestive signs and symptoms. However, typical respiratory complaints, such as dyspnea, have poor sensitivity and are nonspecific to heart failure.12 In addition, many patients with heart failure also have significant comorbidities that may further limit respiratory function, such as chronic pulmonary disease or obesity. When such comorbidities are present, the clinical importance of these alterations from everyday respiratory limitations becomes the measure for pending decompensation. For example, using three pillows to sleep may be a normal sleep pattern for some and should not be considered as evidence of orthopnea, but for others, a change from one pillow to two pillows may be indicative of worsening heart failure. Further questioning about sleep patterns can also

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provide additional insight. Patients may report sleeping on one pillow but fail to mention that one pillow is used in their recliner, because they cannot tolerate lying flat in bed without severe respiratory distress.

TABLE 10-1 Essentials of Heart Failure Patient Education

  • Daily weights every day of your life.
    • [check mark] Use the same scale at the same time of the day wearing comparable clothing.
    • [check mark] Weigh first thing in the morning after going to the bathroom.
    • [check mark] Notify your health care provider if you gain 3 or more pounds overnight or 5 pounds over 3 days OR if you lose weight and experience dizziness on standing up.
  • Maintain a low sodium diet to help avoid fluid retention.
    • [check mark] A dietary intake of 2,000 mg of sodium per day is recommended.
    • [check mark] Ask for written materials to help you make healthier choices.
    • [check mark] Salt is everywhere. Learn to read labels.
  • Be conscious of fluid intake.
    • [check mark] Do not drink 8 glasses of water per day if taking a diuretic (water pill). This defeats the purpose of that medication.
    • [check mark] Drink small sips when thirsty or when taking medications.
    • [check mark] Do not carry liquids with you.
    • [check mark] Fluid comes in a variety of formats: soup, Jell-O, ice, watermelon.
  • Be as active as possible.
    • [check mark] Engage in physical activity at least 3–4 times per week.
    • [check mark] Appropriate activities include walking or biking.
  • Avoid any form of heavy lifting or isometric exercises.
    • (Isometric exercises are those in which a force is applied to a resistant object, such as pushing against a brick wall.)
    • [check mark] Treatment of heart failure is directed at reducing the workload in your heart not straining it. Do not lift anything heavier than 10 pounds.
  • Notify your health care provider of changes in your symptoms or weight.
    • [check mark] This includes weight gain of 3 or more pounds overnight or 5 pounds over 3 days, increased fatigue or shortness of breath, dizziness, or fever, to name a few.
    • [check mark] Your physician or nurse will give you additional, specific information to follow.
    • [check mark] Keep their emergency number available in case of need.

Patients with chronic heart failure live with dyspnea, and breathlessness becomes “normal” or a part of everyday life.13 Adjustments to constant dyspnea usually center on reducing physical activities to reduce breathlessness. Seeking help occurs only when the usual strategies, such as rest or fresh air, fail to relieve symptoms and the patient becomes anxious or frightened. Initial treatment is aimed at rapidly alleviating the air hunger and hypoxia. It is important to remember that substantial pulmonary congestion can occur without rales or jugular venous pressure being evident.14

Changes in Weight

Just as diabetics monitor glucose levels to better manage their disease, so should heart failure patients monitor their weight. Daily weights comprise the gold standard for the outpatient care and management of heart failure and are indicated to permit the use of lower and safer doses of diuretics and for the titration of diuretics. As previously discussed, daily weights will not occur or be accurate if the patient does not own a scale, devalues the necessity of performing the task, or fails to do so consistently and appropriately.

Although the focus of weight monitoring is to detect weight gain, indicating fluid retention, patients should also pay attention to weight loss. Excessive weight loss can result in dehydration, electrolyte imbalances, or worsening renal function and produces symptoms of dizziness, fatigue, and shortness of breath. In advanced heart failure, when the patient's appetite and caloric intake decline, excess volume may take place in the absence of any apparent weight gain, as true body mass is lost through muscle and fat catabolism.

Fatigue

Patients with heart failure experience chronic fatigue and reduce their physical activity to mitigate exhaustion. However, worsening or increasing fatigue, in the absence of increased physical activity, can be an early indicator of decompensation. Any increased fatigue that lasts longer than 2 to 3 days should be a source of concern for the patient and should prompt closer attention to sodium and medication adherence. Should additional symptoms develop or the fatigue continue or worsen, health care providers should be notified immediately, to intervene and possibly avoid hospitalization. However, as with dyspnea, fatigue is a vague symptom that is difficult to quantify and can be included in the differential diagnosis for many other conditions and diseases.

Nocturia

One of the earliest symptoms of excess extracellular fluid is nocturia. To maintain homeostasis, the heart attempts to eliminate excess volume

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through the secretion of natriuretic peptides from the atrial and ventricular myocytes. These endogenous peptides act by dilating the renal afferent arteriole, preventing sodium reabsorption, and counteracting vasoconstriction effects. Atrial natriuretic peptide (ANP) is secreted primarily at night, when right atrial pressures are highest as a result of supine positioning. Consequently, urinary volume is increased, and the patient is awakened to void. Patients should pay attention to new onset or increasing nocturia that occurs in the absence of changes in the medication or dietary regimen.

Reinforcement of Education

Because high levels of relapse are likely to occur after short-term behavioral interventions, plans for reinforcement of the education must be established to improve long-term adherence and as relapse prevention.15 Patients must be given instructions to schedule a follow-up visit with the primary care physician or other clinicians managing the heart failure within days of receiving treatment in the emergency room. This quick appointment serves two purposes. The first is to ensure that treatment has been adequate in resolving the patient's signs or symptoms and that no new issues have developed. Second, reinforcement of education can be provided, especially information specific to the cause of the decompensation. If the cause for the exacerbation was not identified, health care providers more familiar with the patient may be able to discern the cause at this appointment and provide the requisite education.

Because patients prefer information to be presented in different formats, a variety of educational materials must be accessible within the emergency department. Some examples of materials available include videotapes or CDs, pamphlets, or printed pages specifically printed and distributed by the institution. Having these materials at hand provides patients and families the opportunity to read and have questions answered, resulting in an expedited education process.

Summary

For many, episodes of decompensated heart failure may be largely avoidable through self-monitoring of symptoms and enhanced adherence to treatment regimens. Unfortunately, during incidents of worsening heart failure, it can be difficult, if not impossible, to provide education to patients on better managing their disease. A better plan in the emergency department is to begin by treating the excess volume and alleviating the symptoms. Once stabilized and in the observation unit, there is an important opportunity and a teachable moment. Education and counseling that address specific concerns may provide the knowledge, support, and impetus to adherence to treatment plans and to recognize early signs of worsening heart failure and ultimately to reduce hospitalizations. Importantly,

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discharge instructions should include prompt follow-up with the established primary care physician. In advanced or complex cases, referral to a heart failure specialist is warranted.

References

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2. Evangelista LS, Dracup K. A closer look at compliance research in heart failure patients in the last decade. Progr Cardiovasc Nurs 2000;15(3):97–03.

3. Dunbar SB, Clark PC, Deaton C, et al. Family education and support interventions in heart failure. Nurs Res 2005;54(3):158–166.

4. Ni H, Nauman D, Donna Burgess D, et al. Factors influencing knowledge of and adherence to self-care among patients with heart failure. Arch Intern Med 1999;159:1613–1619.

5. Dominique JF, de Quervain DJF, Roozendaal B, et al. Acute cortisol administration impairs retrieval of long term declarative memory in humans. Nat Neurosci 2000;3:313–314.

6. Compliance or concordance: is there a difference? Drugs Ther Perspect 1999;13(1):11–12.

7. National Heart Lung and Blood Institute web site. NHLBI working group. Available at http://www.nhlbi.nih.gov/meetings.workshops.cardiorenal-hf-hd.htm (accessed August 16, 2005).

8. Ryan RH, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol 2000;55:68–78.

9. Friedman M, Griffin JA. Relationship of physical symptoms and physical functioning to depression in patients with heart failure. Heart Lung 2001;30:98–104.

10. Vinson J, Chin MF, Goldman L. Factors contributing to the hospitalization of patients with congestive heart failure. Am J Public Health 1997;87:643–648.

11. Carlson B, Riegel B. Self-care abilities of patients with heart failure. Heart Lung 2001;30: 351–359.

12. Maisel AD, Krishnaswany P, Nowak RM, et al. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med 2002;347:161–167.

13. Edmonds PE, Rogers A, Addington-Hall JM, et al. Patient descriptions of breathlessness in heart failure. Int J Cardiol 2005;98:61–66.

14. Young JB, Mills RM. Clinical management of heart failure. West Islip, NY: Professional Communications Inc, 2001.

15. Rutledge DN, Donaldson NE, Pravikoff DS. Patient education in disease and symptom management in congestive heart failure. Online J Clin Innovations 2001;15(2):1–52.