Helping an elderly patient live with CHF I was working the 3-to-11 shift in our hospital’s busy CCU when I first met Esther Saver. This 69-year-old woman had just been transported to our unit from the emergency room. She was pale and short of breath, with a puffy face and 2+ pitting edema of both ankles. The diagnosis: congestive heart failure.
We managed to stabilize Esther without much difficulty. But that was only the beginning of our task. The real challenge was to prevent another cardiac emergency.
Congestive heart failure kills countless people every year, and sends many others rushing to the hospital for treatment of one cardiac crisis after another. To help your CHF patients break this vicious cycle, you’ll need to coach them on individualized exercise and nutrition regimens. You’ll also need to address the ways in which aging affects the body’s response to the medications that are prescribed for CHF.
The history and physical exam
A thorough nursing history will allow you to establish realistic goals for your elderly CHF patient. In order to accurately assess the physical and psychosocial status of a patient like Mrs. Saver, you will need to learn the answers to questions such as these:
* Does she live alone or with her family?
* What is her daily dietary intake? What are her food preferences and mealtimes?
* How many hours does she sleep at night? Does she have difficulty falling asleep?
* How much and what kinds of physical activity does she usually engage in?
* What prescribed medications and over-the-counter drugs does she use? Does she take these drugs every day or only occasionally?
* Does she have any financial problems?
* Is there a family member or a close friend whose advice she trusts?
Also ask your patient about recent deaths among her friends or relatives and any physical disabilities she has that might interfere with her ability to care for herself. The deaths of friends and personal disabilities, both frequent causes of depression in the elderly, can bring on fatigue, loss of appetite, difficulty sleeping, and lack of interest in personal hygiene and appearance. Such symptoms, if mistakenly attributed to the patient’s hearth condition, can complicate nursing care.
It’s also important to distinguish physical findings related to CHF from those attributable to some other cause. For example, dependent edema–a common sign of CHF–can also stem from protein deficiency or decreased venous return. Shortness of breath on exertion–another sign of CHF–can result from iron deficiency or a sedentary lifestyle.
An individualized exercise program
To combat the harmful effects of immobility on Mrs. Saver’s cardiovascular system, we designed an exercise program for her. Such a program can also relieve anxiety and depression, help maintain ideal weight, and reduce the need for anti-hypertensives and sedatives.
To determine whether it was safe for Mrs. Saver to exercise alone, we observed how her pulse rate and blood pressure responded when she walked around her room. These vital signs should increase with exercise unless the patient is taking a beta blocker. Falling blood pressure or failure of the heart rate to increase with exercise usually indicates severe cardiac disease requiring strict medical supervision. If the vital signs of a patient who’s not taking beta blockers fail to increase, warn her to avoid unsupervised exercise, including walking.
Any exercise program must, of course, take into account the patient’s physical limitations. The patient with severe arthritis, for example, should be advised to stick to swimming and riding a stationary bicycle, which don’t put undue pressure on weight-bearing joints.
To avoid overexertion, tell your patient to space activities throughout the day with adequate rest periods in between. This is especially important in hot weather and during large family gatherings, which can be stressful times for the elderly patient with a failing heart.
Also instruct elderly patients to protect themselves against excessive heat and cold when they exercise. Older people can overheat quickly because their sweat glands don’t function efficiently and their peripheral blood vessels don’t dilate fully to dissipate body heat. They’re also vulnerable to hypothermia because their blood vessels don’t constrict efficiently in response to cold. Either condition puts an added strain on the heart.
We eased Mrs. Savier into her exercise program by startling her on simple warm-up activities, then gradually increasing the time she spent walking. We encouraged her to join the YWCA or a local spa after discharge. Some local schools also have special exercise programs for senior citizens.
The challenge of a balanced diet
Patients with congestive heart failure usually require a low-sodium diet to reduce water retention. This restriction adds one more obstacle to the already difficult task of maintaining adequate nutrition. Since the sense of taste decreases with advancing age, restricting salt intake only makes matters worse. To compensate for the absence of salt, encourage patients to season their food with lemon peel or an herb and spice mixture.
Financial problems force some elderly people to forgo fresh fruits, vegetables, and meat in favor of canned and processed foods–all high in sodium. Such was the case with Mrs. Saver. Since she couldn’t avoid canned foods altogether, we urged her to buy items marked low sodium or no salt added.
We also warned her not to use laxatives or antacids without first checking the sodium content. Some contain large amounts of sodium.
Changes in the elderly patient’s gut can interfere with absorption of essential nutrients. CHF compounds digestive problems by decreasing circulation to the stomach and small intestine. This causes food to move slowly through the GI tract and produces a feeling of fullness or distention. To compensate, encourage small, frequent meals of high-protein, high-calorie foods that supply adequate bulk.
In addition to their other benefits, exercise and good diet help build resistance to infection, a danger to which CHF patients are particularly susceptible. Warn your CHF patients to avoid anyone with an upper respiratory infection. To bolster their resistance, encourage them to get a flu shot.
Special precautions for giving drugs
Patients like Mrs. Saver often take medications such as digitalis and diuretics to treat their heart condition. Aging alters the way the body absorbs, uses, and excretes these drugs. For example, gastrointestinal changes–including decreased acid production, prolonged stomach-emptying, and decreased intestinal motility–can cause variations in the absorption rate. To prevent adverse effects and ensure that the patient is getting therapeutic doses, you’ll need to check blood levels and monitor how well CHF symptoms are being controlled.
The aging process exacerbates decreased renal blood flow caused by CHF. This means you’ll have to pay extra attention when your patient’s taking any drug excreted primarily by the kidneys. Again, therapeutic levels for such drugs should be determined by monitoring serum drug levels.
Hepatic blood flow also decreases in congestive heart failure. This can lead to abnormally high blood levels of drugs that are detoxified by the liver, such as propranolol (Inderal) and theophylline. Watch for side effects and signs of toxicity even at low doses of these drugs.
Another problem you may encounter in elderly patients with CHF is the tendency to medicate themselves with OTC drugs or with prescription drugs shared with friends. We told Mrs. Saver of the dangers of this practice, stressing in particular the risks of OTC expectorants. These drugs can worsen heart failure by increasing the heart’s workload. We also reminded Mrs. Saver that a dry, non-productive cought occurring at night and clearing during the day is a symptom of the fluid overload of CHF, not a cold.
Fortunately, Mrs. Saver followed our advice. She also stuck to her exercise regimen and diet after she was discharged. As a result, she’s now doing well at home.
While not all elderly CHF patients are able to live with their disease as successfully as Mrs. Saver, chances are that thorough assessment and patient teaching will at least help them to do better.