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Heart failure (HF), predominant in adults older than 65, is a chronic and progressive
syndrome frequently associated with the burden of distressing symptoms. HF symptom
management is directed at treating the underlying causes of acute decompensation,
which commonly relate to lack of medication adherence or dietary restriction. Therefore, for older adults capable of managing their health care needs, promotion of selfcare is essential for symptom management. Using the Model of Heart Failure Self-Care
as a guide, the purpose of this article is to discuss the relationship between self-care
and HF symptom management and to provide nursing strategies for assessment and
promotion of self-care in older adults with HF.
Corrine Y. Jurgens, PhD, RN, ANP-BC, FAHA; Kathleen M. Shurpin, PhD, RN, ANP-C;
and Kellie A. Gumersell, MS, RN, ANP-C
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2010 /iStockPhoto.com
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80
70
60
50
40
30
20
10
0
Dyspnea
on exertion
Fatigue
Cough
Edema
Increased
girth
Weight
gain
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(Jurgens, Moser, et al., 2009). Furthermore, differentiating changes associated with HF from those of aging is
challenging. Systemic physiological
changes associated with aging and HF
blur patients perception and interpretation of symptoms (Ahmed, Allman, DeLong, Bodner, & Howard,
2002; Woo, Macey, Fonarow, Hamilton, & Harper, 2003). Comorbid
illness, common in older adults with
HF, further complicates determining
the source and meaning of symptoms
(Braunstein et al., 2003; Havranek et
al., 2002; Krumholz et al., 2000) (See
Table 1 for an abbreviated list of the
most common comorbid illnesses in
older HF patients, reported in a crosssectional sample of 122,630 Medicare
beneficiaries (Braunstein et al., 2003).
As a result, correctly labeling symptoms is problematic for patients, and
hospitalization for symptom management is common, with costs estimated
to be more than $39.2 billion for 2010
(American Heart Association, 2010).
Clearly, symptom recognition and
response are important components
of self-care for nurses to target when
educating HF patients.
The value of self-care was highlighted in a systematic review of randomized trials of multidisciplinary
strategies to improve outcomes for
HF patients. The authors concluded
that patients managed by a multidisciplinary team providing specialized
follow up were 24% less likely to be
readmitted at least once to the hospital
(McAlister, Stewart, Ferrua, & McMurray, 2004). However, the analysis
reported multidisciplinary strategies
that included enhanced self-care were
more effective. Those who had enhanced patient self-care activities were
34% less likely to be readmitted. Preventing hospitalization by enhancing
self-care is important, as hospitalization for HF is associated with poor
prognosis postdischarge. Readmission
within 6 months is common, and mortality is reported to be as high as 11.3%
at 30 days postdischarge (Fonarow,
Adams, Abraham, Yancy, & Boscardin, 2005; Kosiborod et al., 2006).
Psychosocial factors,
health beliefs
and behaviors,
and cultural
influences affect the
management and
outcomes of older
adults with heart
failure.
Self-Care Maintenance:
Symptom Monitoring and
Treatment Adherence
Symptom Monitoring
Stage 1 of self-care involves selfcare maintenance activities of daily
symptom monitoring and treatment
adherence. The basics of symptom
monitoring include recording daily
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Table 1
Common Comorbid
Illnesses in Heart
Failure Patients
Alzheimers disease/dementia
Asthma
Cerebrovascular disease
Chronic obstructive pulmonary
disease/bronchiectasis
Chronic renal failure/renal
insufficiency
Depression/affective disorders/
anxiety
Diabetes mellitus
Hypercholesterolemia
Hypertension
Intravertebral injury, spondylosis, or other chronic back
disorders
Ocular disorders (e.g.,
retinopathy, macular disease,
cataract, glaucoma)
Osteoarthritis
Osteoporosis
Peripheral and visceral
atherosclerosis
Prostatic hyperplasia
Thyroid disorders
Source. Braunstein et al. (2003).
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Treatment Adherence
Treatment adherence to prevent
decompensation of HF status is the
other essential component of selfcare maintenance. Treatment adherence includes following the advice of
health care providers, taking medications as prescribed, restricting dietary
sodium, restricting alcohol, initiating
or maintaining smoking cessation,
and engaging in preventive behaviors
(e.g., yearly influenza vaccine) (Riegel et al., 2009). Although all of the
self-care maintenance behaviors are
important, this article will focus on
factors and strategies related to medication adherence and dietary sodium
restriction.
Medication therapy for HF relates
to the clinical severity of the syndrome. The goal of this therapy focuses on improving patient function
and symptoms, as well as the reversal
of ventricular remodeling. Diuretic
agents, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin
receptor blockers, and beta-adrenergic blockers are the primary drug classifications used in the management of
HF. Other drug classes may be added
when symptoms are severe and persistent. Medication therapy is outlined
by the American College of Cardiology and American Heart Associations Guidelines for the Diagnosis
and Management of Heart Failure in
Adults (Hunt et al., 2009).
Diuretic medications are used in
the treatment of HF to achieve euvolemia (fluid balance) and to prevent
edema. Diuretic selection can be difficult with patients with severe HF,
and these patients must be closely
observed for serum electrolyte abnormalities. ACEIs may be prescribed
at all stages of HF. ACEIs slow the
remodeling process of the abnormal
ventricle and thus can prevent the development of HF in patients with left
ventricular dysfunction without HF
as well as improve exercise performance. ACEIs also reduce mortality
and hospital readmissions for patients
with HF. For those patients who experience severe persistent cough sec-
Table 2
Self-Care Management:
Symptom Recognition,
Evaluation, and Treatment
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Table 3
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keypoints
Jurgens, C.Y., Shurpin, K.M., & Gumersell, K.A. (2010). Challenges and Strategies for
Heart Failure Symptom Management in Older Adults. Journal of Gerontological Nursing,
36(11), 24-33.
2
3
4
A sedentary lifestyle and comorbid illness complicate the assessment and meaning of HF symptoms in older adults.
Assessing symptom burden with activity versus at rest as activity
tolerance is one indicator of symptom impact.
Older HF patients and their families need specific education on
when and how to access support from health care providers for a
change in symptoms.
Conclusion
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G.F.,
Gerstenblith, G., Weller, W., Niefeld, M.,
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beneficiaries with chronic heart failure.
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