W HAT TO TEACH TO PATI ENTS W I TH HEART FAI LURE AND W HY:
THE ROLE OF NURSES I N HEART FAI LURE CLI NI CS
En eida Rej an e Rabelo1 Gr aziella Badin Alit i2 Fer n an da Ban deir a Dom in gu es3 Kar en Br asil Ruschel3 Anelise de Oliv eir a Br un4
Rabelo ER, Alit i GB, Dom ingues FB, Ruschel KB, Brun AO. What t o t each t o pat ient s wit h heart failure and why: t he r ole of nur ses in hear t failur e clinics. Rev Lat ino- am Enfer m agem 2007 j aneir o- fev er eir o; 15( 1) : 165- 70.
The m ost im port ant obj ect ive of heart failure ( HF) t reat m ent is t o reach and preserve pat ient s’ clinical st abilit y. Several st udies have shown t hat program s aim ed at syst em at ic educat ion, developed by m ult idisciplinary t eam s, are posit ive st rat egies t o work wit h t hese pat ient s. Nurses act ive in HF clinics play a fundam ent al role in t he educat ional process and cont inuit y of pat ient care. The obj ect ives of t hese processes are t o t each, reinforce, im prove and const ant ly evaluat e pat ient s’ self- care abilit ies, w hich include w eight m onit oring, sodium and fluid r est r ict ions, phy sical act iv it ies, r egular m edicat ion use, m onit or ing signs and sy m pt om s of disease w or sening and ear ly sear ch for m edical car e. Ther efor e, educat ion t o under st and HF and t he dev elopm ent of self- car e abilit ies ar e consider ed k ey point s t o im pr ov e adher ence, av oid decom pensat ion cr ises and, consequent ly , t o m aint ain pat ient s clinically st able. This ar t icle pr esent s a car eful r ev iew of t he aspect s inv olv ed in t he pat ient educat ion process by nurses in t he cont ext of HF clinics.
DESCRI PTORS: hear t failur e; nur sing; educat ion; self- car e
¿QUÉ ENSEÑAR A LOS PACI ENTES CON I NSUFI CI ENCI A CARDI ACA Y POR QUÉ?:
EL PAPEL DE LOS ENFERMEROS EN CLÍ NI CAS DE I NSUFI CI ENCI A CARDÍ ACA
El principal obj et ivo del t rat am ient o de la insuficiencia cardiaca ( I C) consist e en obt ener y m ant ener la estabilidad clínica del paciente. Varios estudios dem ostraron que program as de educación sistem ática, desarrollados por equipos m ult idisciplinares, son est rat egias posit ivas para est os pacient es. Enferm eras que t rabaj an en clínicas de I C t ienen un papel fundam ent al en la educación y apoy o de los pacient es. Los obj et iv os del pr oceso son enseñar, reforzar, m ej orar y evaluar const ant em ent e la capacidad de aut oayuda, que incluye el cont rol de peso, rest ricciones al consum o de sodio y líquidos, act ividades físicas, el uso adecuado de m edicam ent os, la observación de señales y sínt om as de agr avam ient o de la enfer m edad y la búsqueda pr ecoz de los ser vicios m édicos. Los punt os principales para prom over el m ej or cum plim ient o de la t erapia y evit ar crisis de descom pensación serian ent onces la educación para el m anej o de la enferm edad y el desarrollo de la capacidad de aut oayuda. En est e artículo revisarem os en detalle aspectos de la educación para pacientes con insuficiencia cardiaca dada por enferm eros. DESCRI PTORES: in su ficien cia car diaca; en fer m er ía; edu cación ; au t oay u da
O QUE ENSI NAR AOS PACI ENTES COM I NSUFI CI ÊNCI A CARDÍ ACA E POR QUÊ:
O PAPEL DOS ENFERMEI ROS EM CLÍ NI CAS DE I NSUFI CI ÊNCI A CARDÍ ACA
O pr in cipal obj et iv o do t r at am en t o da in su f iciên cia car díaca ( I C) con sist e em alcan çar e m an t er a est abilidade clínica dos pacient es. Vár ios est udos dem onst r am que pr ogr am as m ult idisciplinar es par a educação sist em át ica sobr e a doença são est r at égias posit iv as par a est es pacient es. Enfer m eir os engaj ados em clínicas d e I C d esem p en h am p ap el f u n d am en t al n o p r ocesso d e ed u cação e acom p an h am en t o d os p acien t es. Os obj et ivos dest e processo são ensinar, reforçar, m elhorar e avaliar const ant em ent e as habilidades dos pacient es par a o aut ocuidado, que incluem a m onit or ização do peso, a r est r ição de sódio e de líquidos, a r ealização de at ividade física, o uso r egular das m edicações, a m onit or ização de sinais e de sint om as de pior a da doença e o con t at o p r ecoce com a eq u ip e assist en cial. Dest a f or m a, a ed u cação p ar a o en t en d im en t o d a I C, e o desenv olv im ent o de habilidades par a o aut ocuidado, são consider ados chav es par a m elhor ar a adesão, ev it ar cr ises de descom pensação e conseqüent em ent e m ant er a est abilidade clínica dos pacient es. Nest e ar t igo nos r ev isam os det alh adam en t e os aspect os en v olv idos n o pr ocesso de edu cação dispen sados aos pacien t es por enfer m eir os no cont ex t o das clínicas de I C.
DESCRI TORES: in su ficiên cia car díaca; en fer m agem ; edu cação; au t ocu idado
1
RN, Doct or in Biological Sciences: Physiology, Adj unct Professor, Rio Grande do Sul Federal Universit y College of Nursing, Nursing Coordinat or, e- m ail: rabelo@port oweb.com .br; 2 RN, Port o Alegre Hospit al das Clínicas Heart Failure Clinic, M.Sc. in Cardiology Sciences; 3 RN, Port o Alegre Hospit al das Clínicas Heart Failure Clinic, Mast er St udent in Cardiology Sciences Rio Grande do Sul Federal Universit y; 4 RN, Port o Alegre Hospit al das Clínicas Heart Failure Clinic
I NTRODUCTI ON
H
e a r t f a i l u r e ( HF) i s a sy n d r o m e w h i ch i m p o se s m a r k e d f u n ct i o n a l l i m i t a t i o n , i m p a i r i n g im por t ant ly in pat ient s’ qualit y of life. I t s pr ev alence w or ldw ide appr oach es 1 t o 2 % . I n spit e of sev er al im port ant advances in HF t herapy, derived from bet t er physiopat hological underst anding, hospit al adm issions rat e cont inued t o increase in t he last decade( 1). Am ong t h e m ost im p or t an t cau ses of h osp it al ad m ission s, d e co m p e n sa t i o n e p i so d e s a r e d o m i n a n t , ca u se d m o s t l y b y p o o r a d h e r e n c e t o t r e a t m e n t , b o t h p h a r m a co l o g i c a n d n o n - p h a r m a co l o g i c( 1 - 4 ). So m e st udies indicat e t hat t hese aspect s respond for 15 up t o 6 4 % o f h o s p i t a l r e a d m i s s i o n s( 5 ). W i t h i n t h i s u n f a v o r a b l e s c e n a r i o , o n e t h e o b j e c t i v e s o f H F m anagem ent is t o reach and m aint ain clinical st abilit y o f p a t i e n t s, w h i ch i s b a se d o n a f a i r l y co m p l e x t herapeut ic regim en. I n t his review art icle, we discuss in det ails why and ways t o approach pat ient s and t heir fam ilies regarding educat ional aspect s in HF t o bet t er cop e w it h t h e b u r d en of t h e d isease. We sear ch ed MEDLI NE and BI REME for art icles cont aining t he t erm h ear t f ailu r e, n u r sin g ed u cat ion an d self - car e t h at w er e published bet w een 1988 and 2005.HF SYNDROME AND CLI NI CAL ASPECTS
I t is im p or t an t t o em p h asise t h at HF is a c h r o n i c a n d p r o g r e s s i v e s y n d r o m e , i n w h i c h ad j u st m en t s an d m od if icat ion s in lif est y le ar e v er y im port ant . Many pat ient s consider t hem selves healt hy an d sh ow lit t le ad h er en ce t o or ien t at ion s g iv en b y t h e m ed i ca l t ea m u n t i l t h ey p r esen t t h e f i r st HF decom pensat ion episode. The init ial appr oach w it h a HF p a t i e n t sh o u l d n o t i n cl u d e a l l o f t h e a sp e ct s regarding t he com plexit y of HF t reat m ent . Nurses m ust hav e t he abilit y t o ev aluat e indiv idual needs of each pat ient and proceed wit h t he educat ion m et hod based o n h i s/ h er p r ev i o u s l ev el o f k n o w l ed g e ab o u t t h e disease, on his/ her school level and also on cognit ive funct ions( 3, 5). I t is convent ionally assum ed t hat when pat ient s lear n about t heir disease t hey under st and it bet t er an d, in con sequ en ce, ar e m or e adh er en t . At t im es, how ev er, t her e r em ains lack of under st anding bet w een w hat is t aught about self- car e and w hat is absorbed or ret ained by t he pat ient s; even when t here is supposedly a bet t er knowledge of t he disease, which n o t n e c e s s a r i l y m e a n s b e t t e r a d h e r e n c e( 5 ). Th e
orient at ions m ust , t herefore, be given repeat edly and posit iv ely r einfor ced. Nur ses, phy sicians, nut r it ionist s as well as ot her m em bers of t he m ult idisciplinary t eam play im port ant roles on t he educat ion of HF pat ient s. Th e r e a r e s e v e r a l t o o l s t o p r o v i d e b e t t e r underst anding of HF aspect s t o pat ient . I t is possible t o design specific st rat egies t o obt ain bet t er out com es regarding pat ient educat ion in HF( 1,3,6- 7).
Risk fact or s pr edict iv e of hospit alizat ion and r eadm ission du e t o HF in clu de poor k n ow ledge an d a d h er en ce t o t h e r eco m m en d a t i o n s f o r sel f - ca r e, involving rest rict ion of fluid int ake, rest rict ion of sodium int ak e in t he diet , daily w eight m onit or ing, phy sical act ivit y and t he regular use of m edicat ions( 1,3). Wit hin t his cont ext , a st udy wit h 113 am bulat ory pat ient s in a HF clinic, det ect ing failures in relat ion t o w hat w as t aught t o t he pat ient s and what t hey really underst ood and apply in t heir daily life. The poor adherence was also r elat ed t o lit t le k n ow led g e of t h e d isease an d self - car e p r in cip les, t o liv in g alon e an d t o t h e f act t hat pat ient s had not had previous hospit alizat ion due t o decom pensat ed HF( 5).
DAI LY W EI GHT MONI TORI NG
The or ient at ion of t he HF pat ient about t he h om e con t r ol of t h e daily w eigh t h as an im por t an t r ole on t h e id en t if icat ion of h y p er v olem ia sig n s( 8 ). Pat ient s m ust be inst r uct ed t o check t heir w eight in t h e m or n in g af t er u r in at in g an d b ef or e b r eak f ast , w ear in g ligh t clot h es an d u sin g t h e sam e scale. An incr ease of 1.3 kg in body w eight in t w o days, or of 1.3 - 2.2 Kg in one week, m ay indicat e fluid ret ent ion( 9). A r ecent m ult icent r ic r andom ized st udy w it h pat ient s class I I I or I V of t h e New Yor k Healt h Associat ion in v est igat ed w h et h er a t ech n ologic sy st em for daily m on i t or i n g of w ei g h t an d sy m p t om s cou l d r ed u ce h osp it alizat ion s ( p r im ar y ou t com e) , m or t alit y or t o im pr ov e life qualit y ( secondar y out com es) . Alt hough n o d i f f e r e n c e s i n r e h o s p i t a l i z a t i o n r a t e s w e r e det ect ed, t he st udy show ed a significant decr ease in m ort alit y in 6 m ont hs in t he int ervent ion group( 8).
Av ailab le d at a, h ow ev er, in d icat e t h at it is difficult for pat ient s t o correlat e a sudden increase in weight wit h HF worsening( 10). Adherence t o inst ruct ions abou t w eigh t m on it or in g v ar y in t h e lit er at u r e fr om
12( 11) t o 75%( 12). According t o nat ional and int ernat ional
t o con t act t h e m ed ical t eam or ad j u st t h e d iu r et ic d o se. Th e ad j u st m en t o f t h e d i u r et i c d o se f o r HF pat ient s by nur ses t hr ough st r uct ur ed pr ot ocols has been recom m ended in t he lit erat ure. The em ploym ent of t hese prot ocols has result ed in 90% adherence by t h e p a t i e n t s a n d a 5 0 % r e d u c t i o n i n t h e r ehospit alizat ion r at e due t o decom pensat ed HF( 6). I t is im port ant t o point out t hat t he flexibilit y of t he use of t hese m edicat ions depends on t he self- car e abilit y of t he pat ient , as w ell as on t he or ganizat ion of t he m e d i ca l se r v i ce , si n ce t h e r e i s n e e d o f co n st a n t m onit or ing and follow - up.
MON I TORI N G DECOMPEN SATI ON SI GN S
AND SYMPTOMS
Lit erat ure dat a show t hat HF pat ient s t olerat e som e sy m p t om s su ch as ed em a, w ei g h t g ai n an d f at igu e f or 7 day s, an d dy spn ea f or 3 day s, bef or e seeking for m edical care, and only 5% of t he pat ient s associat e weight gain wit h hospit alizat ion( 3). Wit hin t his co n t e x t , n u r si n g i n t e r v e n t i o n m u st f o cu s o n t h e educat ion of pat ient s and t heir fam ilies for t he ear ly r ecogn it ion of t h ese sign s an d sy m pt om s, av oidin g d ecom p en sat ion ep isod es.
EDUCATI ON FOR THE USE OF MEDI CATI ON
Drugs em ployed in t he t reat m ent of m ost HF p at ien t s ar e b ased on g u id elin es r ecom m en d at ion s from Am erican Heart Associat ion and Brazilian Societ y of Car diology, u sin g com bin at ion of f iv e m ain dr u g t y p e s : d i u r e t i c , a n g i o t e n s i n - c o n v e r t i n g e n z y m e i n h i b i t o r s , b e t a b l o c k e r s , e s p i r o n o l a c t o n e a n d digit alis( 1 3 - 1 4 ). Th e am ou n t of m edicat ion em ploy ed, t he m aint enance of t he t herapeut ic regim en, and t he num ber of daily doses ar e fact or s of gr eat influence on adherence t o t reat m ent . The larger t he am ount of drugs, num ber of doses and changes in t he t herapeut ic r eg im en , t h e g r eat er ar e t h e p r ob ab ilit ies t h at t h e p a t i e n t w i l l st o p u si n g t h e m , w i t h a co n se q u e n t increase in t he decom pensat ion risk( 3). A recent review show ed t hat adherence t o m edicat ion varies bet w een 20 t o 58%( 15). The syst em at ic educat ion of t he pat ient h as t h u s been sh ow n as t h e k ey com pon en t in t h e search for a bet t er adhesion t o HF t reat m ent( 1,3,5).
The m edicat ion regim en m ust be reviewed wit h t he pat ient and present ed t o him in a schem at ic way,
w it h em phasis on t he m edicat ion nam es, indicat ions, doses, schedules and possible side effect s( 3). A sim ple st rat egy, w hich has been em ployed for several year s by our group, involves t he drawing of a t able wit h t he nam e and t im e of m edicat ions, which is placed in a sit e easily seen by t he pat ient and relat ives. The pat ient s m ust be advised t o always t ake t heir m edicat ion, even when t hey feel well, since t hat is a consequence of an efficient t reat m ent . The nurse’s role is t o inst ruct t he pat ient t o bring t he t able or t he prescript ions t o every appoint m ent in t he HF clinic or w hen r eadm ission is necessar y, since it m akes easier t o ident ify possible om issions, dose increase or confusion.
PHYSI CAL ACTI VI TY AND REST
Th e i n c r e a s i n g k n o w l e d g e o n t h e p h y si o p a t h o l o g y o f t h e d i se a se , a n d t h e e v i d e n t benefit s of physical act ivit y observed in clinical st udies, est ablished an im port ant t herapeut ic role for physical ex er cise on t h e st ab le ch r on ic car d iac d y sf u n ct ion . HF r e su l t s i n f a t i g u e sy m p t o m s a n d p r o g r e ssi v e dyspnea at st ress or rest which is frequent ly t he m ain r eason for seek ing ur gent m edical help.
I n 1999, a first random ized st udy wit h 99 HF st able pat ient s dist ribut ed in int ervent ion ( wit h exercise) an d con t r ol ( w it h ou t ex er cise) g r ou p s, assessed if m oderat e long- t erm exercise would increase funct ional a b i l i t y a n d l i f e q u a l i t y. Bo t h p a r a m e t e r s sh o w e d significant im pr ov em ent in t r ained pat ient s aft er 1 4 m ont hs follow - up. The sust ained effect of funct ional i m p r o v e m e n t s e e m s t o b e a s s o c i a t e d t o a l o w r eh ospit alizat ion r at e du e t o HF an d a low er deat h rat e( 16). Pr esent ly, phy sical act iv it y for pat ient s w it h left v en t r icu lar dy sfu n ct ion w it h pr ev iou s or cu r r en t s y m p t o m s ( s t a g e C) r e c e i v e s g u i d e l i n e s r ecom m endat ion gr ade I I a and evidence level A( 14).
ORI ENTATI ONS FOR PHYSI CAL ACTI VI TY
Th e o r i e n t a t i o n sh o u l d b e i n d i v i d u a l i z e d according t o t he HF grade and pat ient age( 13). A hom e-based w alk in g pr ogr am is t h e best opt ion t o av oid t h e n e g a t i v e p h y s i o l o g i c a l a n d p s y c h o l o g i c a l co n se q u e n ce s o f i n a ct i v i t y. Th e w a l k e d d i st a n ce should be gr adually incr eased, if possible( 3,13).
m easu r es f or HF t r eat m en t an d sh ou ld alw ay s b e included in nur sing consult at ions. I n spit e of it s w ell est ablished im port ance and frequent recom m endat ion, lit er at u r e r epor t s sh ow t h at ph y sical act iv it y is n ot perform ed by 41 - 58% of t he pat ient s( 5,10).
Rest - Physical act ivit y w as consider ed, unt il t h e 1 9 8 0 ’s, r elat iv ely or absolu t ely con t r a- in dicat ed for individuals wit h increased cardiac area, decreased lef t v en t r icu lar sy st olic f u n ct ion an d HF( 1 7 ). St ab le pat ient s were advised t o avoid physical act ivit y in order t o pr eser v e car diac funct ion. I n a st udy published in 2001, 30% of t he pat ient s were shown t o have st opped phy sical ex er cise aft er hav ing HF diagnosed( 10). This fin din g m ay be an ev iden ce t h at t h e old con cept is st ill v alid f or m an y p at ien t s. Rest w as con sid er ed b e n e f i c i a l f o r i n c r e a s i n g r e n a l b l o o d f l o w a n d im proving urinary debt( 17). Prolonged rest or inact ivit y, h o w e v e r, m a y c a u s e a t r o p h y o f t h e s k e l e t a l m u s c u l a t u r e , e x a c e r b a t i o n o f H F s y m p t o m s , t h r o m b o e m b o l i s m a n d d e c r e a s e d e x e r c i s e t oler an ce( 1 4 , 1 7 ). Rest is p r esen t ly in d icat ed on ly in ep isod es of acu t e d ecom p en sat ion , an d ev en t h en according t o each pat ient ’s lim it at ion( 13- 14).
WORK
Th e g u i d e l i n e s f o r t h e d i a g n o s t i c s a n d t r eat m ent of HF r ecom m end w or k ing act iv it ies w hich d o n o t d e m a n d g r e a t e f f o r t s, a n d t h e d e f i n i t i v e ret irem ent is r est rict ed t o severe HF cases( 13- 14).
DAI LY PHYSI CAL TRAI NI NG
Ex e r c i s e i n t o l e r a n c e , d e p e n d e n t o n t h e disease sever it y, m ay be one of t he lim it ing fact or s for daily life act ivit ies. The pat ient is advised t o ident ify t he pr esence or absence of fat igue and shor t ness of breat h when doing daily chores and, from t hen on, t o m o n i t o r t h e i m p r o v e m e n t o r a g g r a v a t i o n o f t h e sy m pt om s. Many of t he pat ient s r epor t car r y ing out daily chores slow ly and w it hout m uch effort( 13- 14).
SEXUAL ACTI VI TY
St able pat ient s are encouraged t o keep sexual act i v i t y, w i t h t h e n ecessar y ad j u st m en t s t o av o i d ex cess ef f or t an d t h e ap p ear an ce of sy m p t om s( 1 4 ).
Th e s u b j e c t s h o u l d b e a p p r o a c h e d b y t h e m u lt idisciplin ar y t eam in a n at u r al an d in f or m at iv e w ay du r in g t h e fir st con su lt at ion an d w h en ev er t h e pat ient present s quest ions or difficult ies. Psychological sy m pt om s der iv ed f r om t h e HF, phy sical lim it at ion , si d e ef f ect s o f d r u g s ( d i u r et i c an d b et ab l o ck er s) , pr esence of diabet es m ellit us, and hy per t ension ar e som e of t he fact ors which can be involved wit h erect ile dy sf u n ct ion . Class I an d I I pat ien t s can m ak e saf e u se of silden af il, bu t m u st be in f or m ed t h at , w h en using nit r at es, sildenafil can be used only 24 h aft er it s int errupt ion( 13- 14).
DI ET AND SOCI AL ACTI VI TI ES
Sodium rest rict ion - A recent st udy( 18) wit h a 19- years follow - up show ed t he correlat ion bet w een a diet w it h no sodium r est r ict ion and t he incidence of HF. This cross- over epidem iologic st udy included 10362 individuals wit h no HF hist ory and wit h norm al weight o r o v e r w e i g h e d . Th e r e su l t s i n d i ca t e d t h a t h i g h sodium consum pt ion is an independent risk fact or for HF an d lef t v en t r icu lar h y per t r oph y in ov er w eigh ed indiv iduals ( BMI = 25) . I n spit e of t hese conclusions, t h er e is n o con sen su s abou t t h e v alidit y of a st r ict so d i u m r est r i ct i o n f o r HF p a t i en t s. So d i u m ( sa l t ) ingest ion am ong t he Brazilian populat ion is in average around 8 t o 12 g/ day, which is over five- fold t he daily needs( 13). Sodium r est r ict ion lev els = 2g/ day should be prescribed for pat ient s wit h severe HF( 13- 14) whereas a diet w it h 3 - 4 g sodiu m / day is a m or e r eason able and realist ic goal for pat ient s wit h m ild and m oderat e HF(13).
Th e p r e s e n t c o n s e n s u s , h o w e v e r, i s t o recom m end t hat t he pat ient s be inst ruct ed not t o add s a l t t o a l r e a d y p r e p a r e d f o o d a n d t o a v o i d i n d u st r i a l i ze d a n d ca n n e d f o o d w h i ch a r e r i ch i n sodium . A r ecent r ev iew( 3) show ed a non- adher ence r at e t o sod iu m r est r ict ion of 5 0 t o 8 8 % . Self - car e a d h e r e n ce , i n cl u d i n g d i e t r e st r i ct i o n , w a s a g a i n significant ly cor r elat ed t o k now ledge.
con t r ol of in gest ed flu ids m ay also be ex plain ed by t h e g r eat er in t er f er en ce in t h e au t on om y an d lif e qu alit y of t h e pat ien t r epr esen t ed by t h is m easu r e
( different ly from salt rest rict ion and drug prescript ion, which are bet t er est ablished as part of t he t reat m ent ) .
Fluid r est r ict ion fr equent ly or iginat es t hir st , w hich is one of t he less well t olerat ed sym pt om s for m oderat e
t o sev er e HF( 19). Many believ e t hat t he r at e of fluid in t ak e sh ou ld b e lef t f r ee accor d in g t o t h e p at ien t
n e e d s, w i t h t h e a v o i d a n ce h o w e v e r o f e x ce ss o r insufficient consum pt ion. I n severe HF cases, in which
t he concent r at ion of cir culat ing ant idiur et ic hor m one can be increased and t he capacit y t o elim inat e wat er can be com prom ised, fluid rest rict ion is recom m ended
in order t o avoid plasm a sodium t o fall t o levels below 130 m Eq/ L( 13). A european st udy report ed t he design
of a r an dom ized, cr oss- ov er an d pr ospect iv e st u dy in which t he cont rol group is inst ruct ed t o com ply wit h
a m a x i m u m f l u i d i n t a k e o f 1 . 5 0 0 m L, a n d t h e in t er v en t ion gr ou p h as in div idu alized flu id in t ak e of 30- 35 m L/ kg/ day. The aut hors believe t hat fluid int ake
based on phy siological needs cor r ect s t he feelings of
dry m out h and t hirst , saving t he pat ient from anot her s o u r c e o f s t r e s s i n t h e n o n - p h a r m a c o l o g i c a l t reat m ent( 19). Am ongst our am bulat ory pat ient s, 56%
h ad n ev er been in st r u ct ed abou t f lu id r est r ict ion( 2 0 ) whereas lit erat ure result s show t hat adherence t o t he
cont rol of fluid int ake is 23%( 21).
Alcoh ol an d t obacco u se - Accor din g t o t h e r e c o m m e n d a t i o n s o f A m e r i c a n a n d B r a z i l i a n associat ions, t he excessive use of alcoholic drinks and t obacco should be av oided in v iew of t heir negat iv e
e f f e ct s o n t h e ca r d i o v a scu l a r sy st e m( 1 3 - 1 4 ). No n -adher ence t o t he t obacco and alcohol r est r ict ion w as
si g n i f i can t l y asso ci at ed t o t h e n u m b er o f h o sp i t al adm issions due t o HF in a st udy published in 2000( 22).
Al co h o l r ed u ces m y o ca r d i a l co n t r a ct i l i t y a n d m a y cause ar r y t hm ias( 13- 14) .
Vaccin at ion - An n u al im m u n izat ion ag ain st in flu en za m u st be r ecom m en ded t o all HF pat ien t s,
accor ding t o nat ional and int er nat ional guidelines(
13-1 4 )
. I m m u n i za t i o n r ed u ces t h e r i sk o f r esp i r a t o r y i n f e c t i o n s , p r e v e n t i n g t h u s e p i s o d e s o f d i s e a s e
d e c o m p e n s a t i o n . I n 2 0 0 2 a s t u d y s h o w e d t h a t adher ence t o v accinat ion w as 6 8 % am ong pat ient s,
w i t h h i g h e r a d h e r e n c e r a t e s a m o n g e l d e r s a n d w om en( 23).
CONCLUSI ONS
Self- car e educat ion, including t he cont r ol of non- pharm acological m easures, should be part of t he daily m anagem ent of HF pat ient s at bot h hospit al and
a m b u l a t o r y se t t i n g s. HF p a t i e n t s i n t h e h o sp i t a l environm ent represent t he best sit uat ion t o st art t he
edu cat ion al pr ocess an d t r ain in g of t h e pat ien t an d t heir caregivers, using t he im pact represent ed by t he
adm ission t o t h e h ospit al an d by t h e sy m pt om s of d ecom p en sat ion t o est ab lish t h e ad h er en ce t o t h e t r e a t m e n t . Th e d a y s f o l l o w i n g r e c o v e r y a r e
par t icu lar ly u sefu l t o t h e adapt at ion of t h e pat ien t s
and t heir fam ilies t o t he underst anding and assessm ent of t h ese m easu r es f or m ain t en an ce of t h e clin ical st ab ilit y. Th e ear ly p lan n in g of t h e h osp it al leav e,
w hich includes daily v isit s t o ev aluat e and r einfor ce adherence, give t he pat ient s and t heir fam ily support ,
and em phasise t he recognit ion of signs and sym pt om s of worsening, is an approach which can be successfully
em ploy ed t o r each t hose obj ect iv es.
Finally, nurses at HF clinics t oget her wit h t he ot h er pr of ession als in t egr at in g t h e m u lt idisciplin ar y
t eam h av e a fu n dam en t al r ole in t h e follow - u p an d m anagem ent of pat ient s. This appr oach aim s at t he
per m anent t r aining, r einfor cem ent , im pr ov em ent and ev aluat ion of self- car e abilit ies, w hich include w eight
m o n i t o r i n g , so d i u m an d f l u i d r est r i ct i o n , p h y si cal act iv it ies, r egular use of m edicat ions, m onit or ing of
si g n s a n d sy m p t o m s o f w o r se n i n g a n d t h e e a r l y seek ing of m edical help.
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