Heart Failure Heart failure is the most common Medicare diagnosis and more Medicare dollars are spent on it than for any other diagnosis. Currently, nearly 6 million Americans have heart failure and 1 in 9 deaths lists heart failure on the death certificate. There are 915,000 new cases of heart failure diagnosed in the US each year. On average, a heart failure client lives 4 years following diagnosis. Heart failure is a large economic burden on the United States due to the frequent hospitalizations that these patients endure. It was estimated that heart failure will cost the United States nearly $70 billion dollars by the year 2030. It has also been reported that Medicare spends more money on heart failure treatment than it does on MIs and all forms of cancer combined. These statistics underscore the need for quality care for all clients who are diagnosed with heart failure, as well as highlight the economic burden that will continue to plague the United States should effective means of managing heart failure not be established. What is Heart Failure? Many people mistakenly believe that heart failure means that the heart has stopped or is about to stop. Heart failure simply means that the heart is not pumping blood through the body as well as it should. As the heart’s pumping action weakens, blood backs up into the blood vessels around the lungs and causes seepage of fluid into the lungs. The fluid causes congestion and makes it hard to breathe. Sometimes the heart pumping is normal but there is an increase in pressure inside the heart. This can also cause problems with breathing. Many people with heart failure also have swollen legs and feet. That is why heart failure is sometimes called
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congestive heart failure. Unfortunately, millions of people are living with heart failure but are unaware of it because the symptoms are often mistaken for signs of “just getting older.” Heart failure is not a heart attack, but a progressive condition in which the heart’s muscle becomes weakened after it is injured from something like a heart attack or high blood pressure and gradually loses its ability to pump enough blood to supply the body’s needs. While there is currently no known cure for heart failure, early diagnosis and proper treatment can offer patients a more normal life expectancy. Usually by the time heart failure has been diagnosed, the heart has already little by little, lost some of its pumping capacity. If the heart becomes less able to pump well, the body will try to compensate for this by using hormones and nerve signals to increase blood volume by initiating water retention. Less blood flow to the kidneys can also lead to increased fluid retention. This extra fluid leads to fluid build-up in the heart, lungs and body. Also the weakened pumping action of the heart can lead to less oxygen getting to critical areas of the body, such as the brain. This can result in more fatigue and even confusion or cognitive impairment. Symptoms: The cardinal symptom associated with heart failure is usually shortness of breath, which in the early stages is associated with activity. As the disease progresses, the shortness of breath occurs even at rest. At times, the difficulty in breathing is associated with reclining due to the increase in venous return to the heart. This phenomenon is called
Heart Failure orthopnea. Clients may also have night time shortness of breath that awakens them from sleep. All of the previous symptoms are related to pulmonary congestion with accumulation of fluid that occasionally might lead to the development of acute pulmonary edema. Other symptoms common in patients with CHF are swelling or edema in the lower extremities or abdomen, fatigue, anorexia, loss of appetite, liver congestion, confusion, sleeping disorders, and frequent awakenings throughout the night in order to urinate. Why it occurs: The prevalence of heart failure approximately doubles with each decade of life. Heart failure usually occurs when another problem makes the heart weak or stiff so that it doesn’t pump or fill normally. Six of every 7 clients hospitalized with heart failure have a history of coronary artery disease or a heart attack. Three out of 4 have high blood pressure, and more than half have defective heart valves or a history of diabetes. Individuals with diabetes have 2-4 times the risk of dying of heart disease. A heart attack does its damage by suddenly shutting off blood flow to part of the heart muscle, which can cause damage to the heart. Hypertension, defective heart valves, and diabetes all make the heart work too hard. A weakened heart also can be inherited or the result of an infection, thyroid disease, and alcohol or drug abuse. Sometimes the exact cause of heart failure is not known.
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Managing Heart Failure Managing heart failure will reduce symptoms and improve how a client feels. An episode of heart failure can be brought on by eating too much salt, not taking their medications correctly, high blood pressure, not getting enough rest or exercise and/or drinking large amounts of fluids. Although medications are important in the management of heart failure, dietary and lifestyle changes are essential and recommended to all patients with heart failure. Some of the recommendations are:
Smoking cessation Dietary restriction of sodium Fluid restriction (if ordered) Limit alcohol Weight management Exercise, as ordered
When a client has heart failure, it is very important that they change their diet. Very often, the doctor will recommend that they eat a heart healthy diet. This generally means they should limit red meats, butter, dairy products, and saturated fats and replace them with foods high in fiber, whole grains and fruits and vegetables. The doctor may also have prescribed your client a low sodium (salt) diet, generally around 1500 mg of sodium. They may also have their fluids restricted. You should familiarize yourself with the amount of salt and fluids your client is allowed each day so that you can help them make the appropriate choices. Sodium helps regulate fluid balance and blood pressure. The kidneys naturally balance the
Heart Failure amount of sodium stored in the body for optimal health. When sodium levels are low, the kidneys essentially hold on to the sodium. When sodium levels are high, kidneys excrete the excess in urine. But if for some reason the kidneys can't eliminate enough sodium, the sodium starts to accumulate in the blood. Because sodium attracts and holds water, blood volume increases. Increased blood volume makes the heart work harder to move more blood through blood vessels, which increases pressure in arteries. This can make it hard for the kidneys to keep sodium levels balanced. Some people's bodies are more sensitive to the effects of sodium than are others. If a client is sodium sensitive, they may retain sodium more easily, leading to fluid retention and increased blood pressure. If this becomes chronic, it can lead to heart disease, stroke, kidney disease and congestive heart failure. The Institute of Medicine of the National Academy of Sciences, the Department of Agriculture, the Department of Health and Human Services and the World Health Organization, and the CDC have all supported lowering daily sodium intake to no more than 2,400 mg and many of those agencies have said that most people should consume less than 1,500 mg. According to these organizations, adults, who are middleaged, elderly, already have hypertension or prehypertension, or who have a family history of hypertension should consume less than 1,500 mg. of sodium. It has been reported that many Americans consume as much as 3100-4700mg of sodium daily.
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New CDC data show that only 9.6% of the U.S. adults limit their daily sodium intake to recommended limits. Most of the sodium we eat comes from packaged, processed, storebought and restaurants foods. Only about 5% comes from salt added during cooking and about 6% comes from being added at the table. Most of the sodium in processed canned and packaged foods is added as a preservative to extend the shelf life of the item or as added flavor. A CDC 2010 report identifies foods that give Americans most of their sodium:
Yeast Breads and grains contribute 37% of our daily sodium. Meats, including chicken contribute 28% of our daily sodium Vegetables contribute more than 12% of daily sodium (due to canned vegetables and vegetable soups and vegetable sauces that are full of sodium) Pizza Pasta dishes Cold cuts
To put it in perspective, ¼ teaspoon of salt = 600mg sodium, ½ teaspoon of salt = 1,200mg sodium, ¾ teaspoon of salt = 1,800mg sodium, and 1 teaspoon of salt = 2,400mg sodium. It’s easy to see how you can exceed the recommended amount. You can determine the sodium content per serving by looking at a food’s nutrition label. If the sodium percentage per serving is not listed, read the ingredient list and look for the words monosodium glutamate (better known as MSG), baking soda, baking
Heart Failure powder, disodium phosphate, sodium alginate, sodium nitrate, or any other compound that has sodium or “Na” in its name. This will indicate that even though the sodium percentage is not listed, there is added sodium. Because many canned and frozen foods contain 1,000 mg or more of sodium in an eight-ounce serving, you must read food labels very carefully to help client select lower sodium products. Often such products are difficult to find or cost more. Restaurant meals, which are not labeled, often contain 3,000 mg of sodium or more, added without the consumer’s knowledge. Tips to help your client reduce salt:
Take the salt shaker off the table Help the clients read the food labels and pay attention to portion size Avoid processed foods and canned soups and vegetables when preparing meals for heart failure clients Avoid processed meats, like bacon, ham, bologna or hot dogs for the client When the client goes out to eat, they should ask the cook to prepare without sodium
In addition to restricting salt intake, very often your client will need to monitor the amount of fluid they drink daily. It is important to know if your client is on a fluid restriction plan. If so, help the client plan out their fluid intake to include the amount of water needed to take their medications, as well as a drink with meals. When helping them account for their fluid intake, don’t forget to include the fluids in the foods they are eating, particularly soups and broths.
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A common misconception among patients with heart failure is that any sort of physical activity may worsen their symptoms; however, research from the American Heart Association (AHA) reveals that physical exercise may not only decrease symptoms, but it may also improve exercise tolerance and quality of life. The AHA recommends that adults living with heart failure build endurance to exercise for 25 to 40 minutes at least three to five times each we have. You may work with PT, the client and their family in helping the client begin moving and exercising as possible Monitoring Client Progress Client management of heart failure primarily focuses on optimizing drugs, diet, exercise, and early detection of decompensation. Early management is difficult because early symptoms are subtle and treatment regimens are complex. In the elderly, the initial change may be decreased mental function. Patients with heart failure frequently are cognitively impaired, making family preparation especially important. So, what can you do? You can assist the client and family in recognizing worsening symptoms and empower them in obtaining a nutritious diet and exercise program, as ordered by their doctor. It has been determined that common reasons for re-hospitalization for heart failure results from just a few common reasons:
54% are readmitted due to missed or skipped medication doses 30% due to medication running out 41% due to nonadherence to a low sodium diet 50% due to worry or stress 45% due to getting sick
Heart Failure Recognizing the common reasons that clients often require hospitalizations will help you better assist the client and family in observing for these common issues. If you observe any change, particularly with breathing, diet, exercise tolerance, weight, or swelling, contact your supervisor immediately. Clients are instructed to monitor signs of fluid buildup or edema in their body after they are diagnosed with heart failure. Weight gain can indicate the body is retaining fluid, which is dangerous for a person with heart failure and will make the heart work harder. Most often, patients are told their weight the day of their discharge, and this weight is referred to as their “dry weight,” or weight without any extra fluid in their body due to heart failure. Clients are encouraged to weigh themselves daily, ideally at the same time each day so they are able to keep track of any weight gain. If clients gain more than 2-3 pounds in a day, or 4-5 pounds in a week; or they notice more swelling than usual, they are instructed to call their doctor for further instructions or evaluation. You may be asked to assist clients in observing and recording their daily weights. If you notice a sudden weight increase, contact your supervisor. Many agencies use a tool for the family to assist them in knowing when they should notify the physician of changes. An example of such a tool to recognize worsening heart failure symptoms is attached. This form, or one such as this, can assist the client and family in better recognizing their worsening symptoms. Generally, a physician will have
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very specific parameters for when to call the office, which may be similar to the attached form, or may be slightly different. It is important that the client understand exactly when their physician wishes to be notified for any changes in condition. As a direct care provider in the home, you should observe the client and family to see if they are following these established guidelines. It is important to be familiar with the symptoms that may indicate that the heart failure is worsening. Any change in client condition should be reported to your supervisor immediately.
Heart Failure Green Zone = “All Clear”
No shortness of breath No swelling No weight gain No decrease in your ability to maintain normal activity level
Green Zone Means:
Yellow Zone = “Caution” If you have any of the following signs or symptoms: Increased weight (2-3 lbs, in one day or 4-5 lbs in the past 5 days) Increased cough Increased swelling of legs, ankles and/or feet Increased shortness of breath with activity Chest Pain Increased number of pillows needed to sleep or need to sleep in a chair Anything else unusual that bothers you
Unrelieved shortness of breath Unrelieved chest pain Wheezing or chest tightness at rest Chest pain not relieved or reoccurs after taking _______ Nitro tablets Mental changes
Your symptoms are under control Continue taking your medications Continue to follow your diet Keep physician appointments
Yellow Zone Means:
Your symptoms indicate that you may need an adjustment in your medications Call your physician
Primary MD:_____________________________________ Phone Number:__________________________________
Red Zone = “Medical Alert”
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Red Zone Means:
This indicates that you need to be evaluated by a physician right away If unable to catch breath or chest pain is unrelieved, call 911
Primary MD:_____________________________________ Phone Number:__________________________________
