NON PHARMACOLOGICAL MANAGEMENT

After the initial evaluation and diagnosis, follow up of the heart failure patient should focus on repeated and ongoing education involving the patient and family. During the education process, the health care provider, the patient, will develop a plan of care specific to the needs of that patient. This plan of care should include ways to optimize their pharmacological therapy, improve their quality of life and prevent recurrent or worsening symptoms.

This portion of care is best done by a non-physician personnel, such as trained nurses.

Benefits of ongoing and repeated education:

• Patient compliance will increase if they are knowledgeable about their illness.
• Family members who are encouraged to actively participate will likely support the patient.
• Recognition and reporting of early sign and symptoms by the patient will reduce acute hospitalizations.

EDUCATION

1. All patients (and their families) need to be educated about heart failure at their level of understanding using words that are easy for them to grasp. Be sensitive to their level of education, reading ability, language and culture. Stress the importance of keeping all scheduled clinic appointments.
2. Patients should have a general understanding of what heart failure is. Example: Heart failure is a medical condition in which the heart pumping chamber is weakened and cannot pump blood as efficient as a normal heart. Possible causes of heart failure include coronary artery disease, hypertension, heart valve disease, excessive alcohol intake, some types of chemotherapy, and unknown causes, referred to as idiopathic dilated cardiomyopathy, and unknown causes, referred to as idiopathic dilated cardiomyopathy. Patients should be taught about causes that are specific to their condition.
3. There should be definitive instructions given on symptoms that might herald an exacerbation of heart failure. Include: shortness of breath, difficult breathing when lying down, cough decreased appetite, fullness in abdomen, weigh gain, swelling of lower extremities. Patients should be taught to take their pulse and report significant slow or fast heart beat.
4. Written instruction should be given to the patient and reinforced at each visit.
5. Provide the patient and their family with contact numbers they can use to report changes and ask questions.
6. Those patients who smoke or use tobacco products must be encouraged to stop. Second hand smoke should be avoided.
7. It is essention that patients weigh themselves daily first thing in the morning before breakfast with minimal clothing on. Instruct them to write their weight down every day and report a gain of 2-3 lbs overnight or 5 lbs in a week. Ask them to bring this information with them to each visit.
8. Educate the patient regarding prevention of common infectious illnesses. Emphasize the need to stay away from others with cantagious illnesses. Cold, flu etc. Offer influenza and pneumococcal vaccinations.
9. An evaluation of the patient's level of comprehension should be assessed and documented with each education session.
10. Assess the patient's ability to cope with a chronic illness. Offer support groups or other health care professionals who may assist them in coping.
11. Both patients and families must understand the full scope of the disease, its often silent progression, and mortality including incident of arrhythmic events. Physicians should discuss prognosis with the patient and his or her family. Advanced directives should be reviewed and documented.

MEDICATIONS

Because of the advanced age of this population and the complexity of medication regimes, every effort should be made to simplify and clarify a patient's medications.

Benefits:

(See Pharmacological Management section)

Education:

1. All medication instruction needs to be in writing.
2. A medication list supplying the name of the medication as it is listed on their bottle (generic and brand name). The dosage they need to take, and how and when to take. It should be given to the patient and updated at each visit. Question thoroughly on all over-the-counter medication they use including herbal and vitamin supplements.
3. Keep the same list in the patient chart so it can be referred to when the patient calls in to report symptoms.
4. It should be explained in detail that treating heart failure requires multi-pharmacy treatment and that adjustment to medications may need to be done over time to fine-tune the treatment specific to that patient.
5. Explain possible side effects they may experience. Emphasize the need to report side effects before stopping any medication.
6. Try to prescribe cost effective medications whenever possible. Splitting tablets can often be done in order to reduce cost. (Most of pharmaceutical companies have an indigent program to assist those patients that cannot afford their medications).
7. Attempt to group medications together. Use once daily dosing when possible to promote better compliance.
8. Insist they bring all their medication bottles and their list with them to all office visits or hospital admissions.
9. Instruct patients to report any new medications they may receive from other healthcare providers.

DIET

Dietary indiscretion remains a common cause of exacerbation of CHF and reinforcement of the importance of dietary compliance should occur at each interaction.

Benefits:

• Reduce sodium intake to less than 3 gm to prevent fluid retention and lower blood pressure.
• Reduce fats to control risk of developing new cardiac injury. (Specific to individual needs).
• Reduction in weight to lower blood pressure and control risk of developing new cardiac injury.
• Restrict fluid intake to prevent fluid retention. (Specific to individual needs).
• Discourage alcohol use to avoid further reduction in cardiac function.

Education:

1. Whenever possible, suggest dietary counseling for the patient to tailor a diet specific to that patient's needs. (Weight reduction, low sodium, low fat, fluid restriction).
2. Instruct the patient to read all food labels for sodium, fat and carbohydrate content.
3. Remove the salt shaker from the table.
4. Avoid canned and prepared foods including packaged luncheon meats and "fast foods" due to their high sodium content. Use fresh fruit and vegetables whenever possible.
5. Replace salt with non-salt based spices in cooking.
6. Do not use salt substitute products unless approved by your doctor. Sodium chloride is replaced by potassium chloride in salt substitute products.
7. Avoid pop, which contains very high sodium. Be aware that milk contains high sodium.
8. Avoid condiments high in sodium. (Soy sauce, ketchup, mustard, steak sauce etc.).
9. If fluid restriction is necessary, avoid foods high in fluid content such as water, juice, soda, milk, coffee, tea, soup, ice cream, sherbet, yogurt, pudding, gelatin, oranges , melons, grapefruits.
10. Instead of drinking liquids, suggest chewing gum, sucking on hard candy, or rinsing mouth with water.
11. Alcohol use should be discouraged. In severe heart failure complete abstinence is recommended.

EXERCISE

Benefits:

• Improve the flow of blood through the body.
• Help strengthen the heart and body.
• Tones the muscle.
• Help control weight
• Increases energy level.
• Helps manage stress.

Education:

1. All patient will benefit from aerobic-type activities such as walking, swimming and biking.
2. The amount of exercise a patient can do is limited by the degree of heart failure.
3. Low-intensity exercise programs are beneficial even in the most clinically impaired group of patients. Low-level resistive training can add muscle strength and flexibility, improve function for activities of daily living, and increase strength.
4. Encourage patients to set realistic goals individualized to their condition.
5. Suggest they keep a record of their exercise to see their progression.
6. Encourage alteration between rest and activity.
7. Avoid exercise shortly after eating, or in extreme weather conditions. Avoid heavy lifting.
8. Always use common sense.
9. A warm-up and cool-down session should occur with all exercise.
10. Exercise should be stopped if they become unusually fatigued or develop chest pain or extreme shortness of breath.
11. Suggest a formal exercise program if you think your patient would benefit. On average, a good exercise program involves 20-30 minutes of exercise done 3-4 times a week.