Heart Failure Management and Nursing Practice Initiative - Assignment Example

Literature Review on Patient Education: Heart Failure Management Introduction Heart failure is a cardiaccondition that occurs when the heart pumps less than the normal amount of blood through the circulatory system. The ineffective pumping causes blood flow inadequacy. This means the blood pumped by the heart is not enough to meet the metabolic demand of the body. Nicholson (2009) mentions that the heart failure can be systolic (heart failure with reduced ejection fraction), in which case there is a reduction in the contracting force of the heart (reduced cardiac contractility) or diastolic heart failure (heart failure with preserved ejection fraction) in which the heart relaxation is defective. When the heart failure is systolic, the blood is pumped at a force that is not enough to push it to distant organs, when the defect is in relaxation; the blood that returns to the heart is not accommodated in the heart chambers. Heart failure is usually a syndrome that results from other preexisting heart conditions such as coronary heart disease, myocardial infarction and myocardial under-perfusion. According to Stewart and Blue (2010), both types of heart failure have almost similar clinical manifestations and similar patient educational requirements. Heart failure is a condition common in older adults with a history of chronic hypertension, myocardial infarction or atherosclerosis. Other chronic diseases such as diabetes, cardiomyopathy and obesity are also known to increase the risks. As such, the risk factors for these conditions are the risk factors for heart failure and also impair the prognosis of the disease resulting to repeated hospitalization of patients with heart failure. Many patients are readmitted within three months after discharge (Mack, Smith & Dunlap, 2009, p. 134). In addition, heart failure is a chronic disease that is not fully curable. Treatment aims at maintaining the cardiac functions at a level that can support quality life. It is, therefore, regarded as a terminal illness and the patients require comprehensive care in the hospital and also at home. Due to the increased inefficiency of the pumping action of the heart, backflow of blood into the heart chambers and retention in the blood vessels occurs. This retention causes fluid overload in the body. This excess fluid leak into the interstitial space and in the lungs is causing clogging and congestion. Fluid filled lung tissues are ineffective in gaseous exchange. The major risk factors for congestive heart failure are uncontrolled hypertension, high salt diet, obesity, sedentary lifestyle and all factors that increase the likelihood of these (Flarey & Blancett 2011, p 486). Symptoms of cardiac failure result from reduced nourishment of body tissues, due to failure of the heart to meet the requirement; and also as a result of congested blood vessels, tissues and organs such as the lungs. These signs and symptoms include sudden gaining of weight due to fluid retention, edematous swelling of extremities where fluid is more likely to be retained, irregular heartbeats and periodic skipped beats, palpitations, difficulty in breathing even at rest, persistent cough and exhaustion. There is no complete cure for cardiac failure. Treatment aims at resolving the symptoms, reducing discomfort, reducing the hearts workload plus preventing complications. The treatment regime should be followed to achieve this (Barnett, 2012, p. 142). Management of heart failure in the healthcare facilities is directed towards reducing the risk of cardiac compromise through decompression therapy. This is required only during the initial stages. Thereafter, drug therapy, diet modification and lifestyle change reduce the progression of the disease. When these are adequately followed, the incidence of readmission significantly reduces and the prognosis is satisfactory. The implication of this observation is that understanding the disease and its current management will help the nurses to be at par with the new methods and apply evidence based practice in their work. (Melander 2009, p.85; Moser &Riegel2011, p.234). This paper seeks to provide more insight into the new terminology in heart failure management, heart failure with reduced ejection fraction and heart failure with preserved ejection fraction. Further, the paper will also look at the use of echo to assess ejection fraction, and treatments based on the new guidelines ESC 2012. Also, the aim is to enhance nurses’ knowledge and update on education in relation to the new terminology as currently used. Literature review The Search strategy The following databases were searched for relevant studies: CINAHL, Ebsco, Medline, Pubmed, MEDLINE, MEDSCAPE. The literature search used the following terms “heart failure, HFPEF and HFREF, nurses and education." The searches were not limited by study design or language of publication. Further studies were identified from the reference lists of all included articles, hand searching the journal heart failure and searching relevant websites. HPEF and HREF Previously, the symptoms of heart failure were only considered as a result of right ventricle systolic failure. In this case, the ejection fraction of the patient was reduced and the circulation thus compromised. However, the current research evidence shows that the heart failure can manifest with preserved ejection fraction. In this case, the defective function of the heart is left ventricle diastolic function. The result of this defect is preserved ejection fraction, but the circulation lagging is still present. Ejection fraction is the volume of blood that is pumped out of the left ventricle in a minute. When the systolic function of the heart is functioning normally, then the contractile power that pushes blood from the heart does not change. Patients with preserved ejection fraction also suffer severe cardiovascular abnormalities which worsen during exercise. This, therefore, means that different from the others with reduced ejection fraction, their symptoms are only felt mostly during exercise and severe compression. This increases their exercise intolerance. The clinical picture in HFPEF is due to diastolic dysfunction. This is different from those of HFREF which are due to systolic dysfunction. The clinical progression of these two conditions are the same, only varying in the quantitative contribution of the signaling events and some symptoms. The use of Echo in assessment of ejection fraction Ejection fraction an important marker for mortality and prognosis in heart failure. The procedure is becoming increasingly crucial because the selection of patients who benefit from an internal cardiac defibrillator is based on LVEF. Currently, echocardiography is an imaging modality often used to assess EF. However, echo is limited by high intra- and inter-observer variability. Reliable contour detection of the diastolic or systolic failure is only visible during end-systole and end-diastole. Although echo improves ejection fraction better compared to fundamental imaging, even in good quality echocardiograms it is sometimes difficult to delineate the endocardium in the still frames whereas with LVO this may be more reliable. Due to the consecutive character of patient inclusion in our study (no patient was excluded because of image quality) our SHI result seems worse than those reported by others. Although some authors showed an improvement in LV endocardial border detection with SHI compared to FI, optimal intra- and inter‐observer variability in LV-EF can only be achieved when contrast is added to SHI imaging. In a study by Hoffmann et al., inter-observer variability between three readers from different institutions was best (even compared to MRI images and cineventriculography) with contrast-enhanced echocardiography and worst with unenhanced echocardiography. Nurses Knowledge on Heart Failure In a study conducted by a group of nurses researchers on the knowledge level of nurses on heart failure, the researchers identified that most nurses are not adequately educated in heart failure management principles. Out of the 300 nurses included in the study, more than 28% of the licensed practical nurses were not able to answer at least 40% of the questions regarding the care of heart failure patients. This was, however, not the case for the registered nurses. The latter had a better understanding. Because nurses are the direct caregivers to patient these results indicate that more education focused on the nurses is required. Education Models Education is the process that is aimed at improving the knowledge, skills and attitudes of the target learner with the aim of effecting a change of behavior and improving the activities related to the topic. The traditional model of education related knowledge empowerment with health promoting activities. Such activities included adherence to pharmacological and non-pharmacological therapies as well as self-care behaviors (Echlin & Rees 2012, p. 42). According to Chelf (2011), this model of learning assumes that the main aim of health education process is to reduce the disease burden, mortality rate and healthcare cost. The critiques of this model argue that traditionally, patients comply with medication even without knowing the names of the drugs. However, it is agreeable that lack of knowledge can be a problem especially in self-care and self-manipulated environments and therapies. As such, the learning model adopted presently is that which will involve reflections, interaction understanding and interpretations in a way that the patient and the family can relate to their own living conditions. In health education, the educator must become a facilitator rather than an expert. In this way, the patient will have the opportunity to express themselves and provide a suitable goal direction for the education. Besides, active involvement will enhance the identification of the education needs of the patient and family and this will increase the relevance of the education provided (Barsevick, Sweeney, Haney & Chung 2012, pp.73-83). Determining Education Needs The education needs of the nurses must first be determined through the active involvement of the care of patients with heart failure. This will require the assessment of the nurse’s level of knowledge concerning the disease and its management (Mack, Smith & Dunlap, 2009, p. 105). This will help identify the knowledge gap and hence effectively plan the education process. The desired knowledge of the client and family should be assessed in order to ensure that the education meets the client’s needs and is relevant from the client point of view. From this assessment of the knowledge gap of the client and the family, it is possible to relate the needs to the community and make possible community diagnosis that can be addressed in a community health forum. Education goals such as avoidance of a sedentary lifestyle, dietary modification and stress management can be well extended to the community (Matzo & Sherman 2010). Issues in Education Nurses and other medical practitioners have always regarded health education as their most important responsibility. However, according to a journal article published in 2011, the provision of comprehensive patient education has become increasingly difficult to accomplish. Various reasons have been cited to be the cause of this including the huge workload, tightly scheduled clinic visit, lack of enough and adequate educational material and language and other barriers to effective communication. The article describes a study conducted in a hospital setting among caregivers. Of the 243 nurses and clinicians interviewed, at least all of them recognized the importance of health education in improving health outcomes of chronically ill patient. However, less than half (38%) of them were aware of the requirements of comprehensive patient education and further only a few (12%) of them admitted practicing a bit in the 12 months period prior to this study (Krouse 2011, p. 752). The implication of comprehensive education has been found to affect the whole management of heart failure and to go beyond the patient to affect their life and their family and by extension the community. In a study involving 53 heart failure patients under care of their family, Semple and Mcgowan (2009), found that those who received comprehensive education on dietary modification and exercise besides the drug compliance and follow-up education were implementing these with the family. This not only improved the psychological wellbeing of the patients and their caregivers but also enhanced the health of the family and the caregivers, as well. Of the 53 families under the study, 41 of the caregivers reported having personally benefitted from the patients regime in exercise and dietary modification (Semple, &Mcgowan, 2009). Literature synthesis The educational needs in heart failure are massive and specific. For education to be effective in any situation, the educational needs must be first assessed. This, as research indicates helps in planning for the resources that are required for the program and also planning for the best approach. Heart failure patients are mainly the elderly adults. Adult education has to be effectively planned to ensure retention and concern for individual attitudes and needs (Schillinger et al. 2012, pp 135-153). The article by Krouse provides relevant information regarding the perceived roles of the healthcare providers in the provision of health education. It also helps the healthcare providers, which are that target audience to identify the failures in the process of delivery of care. The implication of this study is that for the educational benefits to be realized, the nurses and other healthcare providers should be ready to plan for the patients and family education well before discharge. The findings are affirmed by the research conducted to compare the coping and readmission rates of the two groups of patients. Although the study was conducted on a small sample size the evidence from this research suggests that the education provided at home is costly and time is consuming, yet the healthy education provided in the course of patient care is cheap and more effective (Farmer et al. 2013, p. 234). Provision of comprehensive care to patients has been found to focus more on pharmacological therapy compliance even when the disease is directly related to lifestyle. There should be a change in priority whereby the education provided should focus more on comprehensive coping and behavioral change. For the education process to meet its goals, the collaboration of the health practitioners, the patient and the family is necessary. The education given will have an impact on all these players directly or indirectly (Eysenbach2013). From the study conducted on nurses, it is clear that there is increased need for education focus on nurses to improve their caregiving knowledge attitudes and skills. This enhances their confidence and helps in meeting the health goals of management. Resource Tool implementation and evaluation The resource tool developed for health education will be used as a guide or a checklist by nurses and students in the provision of health education to heart failure patients. The tool will be used develop the health education plan as part of the patient discharge plan. During health education, the nurse will use the resource tool to identify the basic items of health education that should be covered in comprehensive health education. This will include the assessment of the patient’s educational needs and preparedness as well as identifying the response of the patient (Redman 2013, p.807). By using this tool, the nurse will be in a position to track the educational achievement of the patient and also identify areas that need more emphasis each educational encounter. Further, the tool will also be used to improve itself through obtaining feedback from the users. From their feedback, a review of the tool can be done periodically to cover more specific items and hence increase its effectiveness. As a resource tool, the developed document will form part of the important health documents of the patient allowing for continuity of care (Fagerlin et al. 2009, p 153). Possible obstacle during the implementation is the lack of sufficient time for nurses to study the poster and lack of interest to apply. This can be triggered by interpersonal factors (Blumenthal &Diclemente2011, p. 765). Timeframe for implementation To determine the effectiveness of this tool, it will be required that the tool is in use for two months. Review documents will be issued every week. This will give at least eight documents for each patient (one for each week). These documents will then be analyzed to identify the flow of the process of patient education and the changes in educational needs and patients understanding. The implementation will require a brief introduction in the form of simple demonstration to the nurses and students in the wards after permission is granted by the hospital management. After the eight weeks timeframe, questionnaires will be issued to the participating nurses to help obtain the evaluative feedback and determine if the format used helps achieve the objective of ensuring that the patient is discharged from the hospital with adequate health literacy to enhance the quality of life and reduce the rate of readmission. Advantages and disadvantages of using posters Posters are the easiest tools to use in education for change. The advantage of the poster in change is that there is an increased attention tracking when the poster is well designed and placed on the wall. Posters are extremely eye catching and can be manipulated to focus on the intended issue and offer visual stress on the importance points by bolding or color mixing. They are also cheap to format and apply. However, the disadvantage of using posters is that the intended audience may not be literate enough to comprehend the content of the posters and sometimes they require elaboration for them to be effective in effecting change. The space allowable on a poster is also small and this limits the details that can be included in the poster. Lewin’s Change Model The change model proposed by Lewin involves three stages; the unfreezing stage, the change stage and then refreezing stage. The three stages are connected in such a way that, for a change to be effective, the organization and the individuals must first break the norm and create space for the development of new ideas. This is followed by affecting the change process. During the change process, the individual adopts the change and practice it to perfection. The third stage involves refreezing the system at the new level of change. 1. Unfreezing This stage involves the use of information to create a desire for change. For a practice to stop, or for development to be realized, the current situation must first be considered as unsatisfactory and a desire for improvement created. This will be applied through educative seminars in which evidence base will be created for the nurses to realize the need for change and hence improve the possibility of acceptance of the change. 2. Movement This is the second stage that involves the actual training. It follows the creation of the desire, from which motivation to learn the new thin arises. Using the poster, new information will be provided and the nurses will be ready to acquire the new kind of information. From this information, they will develop skills for a new care and management guidelines. 3. Re-freezing In this stage of change, the training results are assessed and if they fall within the expected change, a new practice in considered the norm and future management based on this new level of management. During the education process for nurses, the following basic rules should be observed. a) Adults learn best when there is a perceived need for the information. This means that the facilitator of health education must first establish the need for information for it to be received. b) Teaching of adults should move from the known to the unknown. Engaging the adults in discussion kind of learning helps to identify their entry behavior and helps in topic development and planning. c) Teaching of adults should progress from the simpler concepts to more complex topics. The knowledge and educational level of the patient should be assessed to avoid giving complex information that deters concentration. d) Adults learn best using active participation. They should therefore be actively involved e) Adults require opportunities to practice new skills. Demonstrations and return demonstrations should be used to reinforce learnt information f) Immediate feedback and correction of misconceptions increases are learning. Learning the perception and myths related to the topic from the patient enhances this principle (Ellenbogen&Auricchio2009, p.549). The use of poster will possibly use this change model. After the initial introduction of the differences between the two forms of heart failure, their management and the required patient education for each, it is expected that the nurses will have a willingness to change which will make them unfreeze from their initial level of performance and yearn for a change. When a change is made the norm, the nurses will refreeze at the new level of performance. The advantage of the poster in change is that there is an increased attention tracking when the poster is well designed and placed on the wall. However, to unfreeze the situation will require more than just a poster. It may call for seminars to enhance the need for change References Barnett, D. B. (2012). Congestive cardiac failure: pathophysiology and treatment. New York: Marcel Dekker, Inc. Barsevick, A. M., Sweeney, C., Haney, E., & Chung, E. (2012). A systematic qualitative analysis of psychoeducational interventions for depression in patients with cancer. 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Information needs and information-seeking behaviors of men with prostate cancer and their partners: A review of the literature. Cancer Nursing,25(1), 35-41. Eysenbach, G. (2013). The impact of the Internet on cancer outcomes. CA: Cancer Journal for Clinicians,53(6), 356-371. Ellenbogen, K. A., &Auricchio, A. (2009). Pacing to support the failing heart. Chichester, UK, Wiley-Blackwell. http://search.ebscohost.com/login.aspx?direct=true&scope=site&db=nlebk&db=nlabk&AN=267081. Fagerlin, A., Rovner, D., Stableford, S., Jentoft, C., Wei, J.T., & Holmes-Rovner, M. (2009). Patient education materials about the treatment of early-stage prostate cancer: a critical review. Annals of Internal Medicine,140(9), 721-728. Farmer, A.P., Légaré, F., McAuley, L.M., Thomas, R., Harvey, E.L., McGowan, J., Grimshaw, J.M., & Wolf, F.M. (2013). Printed educational materials: effects on professional practice and health care outcomes. The Cochrane Database of Systematic Reviews 2003, Issue 3. 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Improving outcomes in heart failure: an interdisciplinary approach. Gaithersburg, Md, Aspen Publishers. Neal-Boylan, L. (2011). Clinical Case Studies for the Family Nurse Practitioner. Hoboken, John Wiley & Sons. http://public.eblib.com/EBLPublic/PublicView.do?ptiID=822495. Nicholson, C. (2009). Heart failure a clinical nursing handbook. Chichester, West Sussex, John Wiley & Sons. http://search.ebscohost.com/login.aspx?direct=true&scope=site&db=nlebk&db=nlabk&AN=213967 Redman, B. K. (2013). Measurement tools in patient education. New York, Springer Pub. Schillinger D, Grumbach K, Piette J, Wang F, Osmond D, Daher C, et al. (2012). Association of health literacy with diabetes outcomes. JAMA;288:475-482. Semple, C. J., &Mcgowan, B. (2009). Need for appropriate written information for patients, with particular reference to head and neck cancer. Journal of Clinical Nursing,11(5), 585-593. Stewart, S., & Blue, L. (2010). Improving outcomes in chronic heart failure specialist nurse intervention from research to practice. London, BMJ. http://onlinelibrary.wiley.com/book/10.1002/9780470750551. Appendix 1 Ward Poster Draft Ward Poster HFPEF vs. HFREF How are they different? Define each Give the differences How do we treat each? Brief explanation of treatment regimen Differences in treatment approach What are the differences in patient educational needs? List the educational needs of each How are these needs met? Briefly explain thenursing roles What are the current management guidelines? Attach a section of the guidelines Read More