When you think about congestive heart failure (CHF) in your patients, do you think that this is really a nursing case? Do you think there is anything you can offer this person? Do you really know what congestive heart failure is?
The definition of CHF is: a physiologic state in which the heart is unable to pump enough blood to meet the metabolic demands of the body at rest or during exercise. Since this is one of the most common -diagnoses that send people back to the hospital, it is important that we recognize the signs of someone going into congestive heart failure. It is also beneficial for us to help these patients learn to function optimally within their limitations.
The initial evaluation should take into account any cardiac history and any co-morbidity that may affect the functional level of the person. These may impact how goals are set and what we are actually able to do with the patient, especially if there are any musculoskeletal or neurological deficits. We also need to include the patient in the goal-setting process so that we are not forcing our ideas on him.
Since patients with CHF usually have co-morbidities, and the CHF is often "unseen," it is common that we overlook this diagnosis and focus on what is visible to us. This is most certainly a mistake; we need to look at CHF along with whatever else is going on for this patient. It is one more thing that we can help with in our treatment and improve the quality of life for the patient.
When you are treating a patient with CHF, it is important to take his blood pressure both before and after activity. This should be done in two planes, sitting and standing, to evaluate for orthostatic hypotension.
You should also take their heart rate and notice the rhythm. Is it regular? Does it skip a beat? Is it fast or slow? Respiratory rate should also be checked, along with any symptoms or signs of overexertion that you note or that the patient reports.
Another way to see how the person is doing is to rate their perceived exertion. An evidence-based assessment, such as the Borg Scale, helps determine the patient's response to activity. This is a very reliable tool, especially for patients with pacemakers or who take beta blockers, which inhibit a rise in heart rate as a response to exercise. Pulse oximetry can also be used if ordered by a physician and you have been trained to use the pulse oximetry machine.
Occupational therapy can teach energy conservation and work simplification. This will allow patients to perform ADL as independently as possible without getting too short of breath or fatigued. This includes grooming, bathing, dressing, toileting, meal preparation and any other IADL that patients may want to engage in or hobbies that they want to resume.
Another occupational therapy offering is endurance exercises, which should be graded in terms of repetitions, increased resistance and increased activity. Patients need to be encouraged to increase their activity level as they progress, moving from more sedentary activities like reading or watching television to more active ones like doing the dishes or laundry. If the patient is a little younger, he can be encouraged to perform activities that require a little more activity.
As part of the team, you can help monitor the CHF patient, help him progress and help keep him from returning to the hospital. It doesn't hurt to reinforce some of the teachings that the nurse is doing (without duplicating services). Ask some simple questions when you visit, such as whether the patient has weighed himself that day.
Keeping patients from returning to the hospital is very important, as each agency has been charged with reducing acute care hospitalizations. This will, in the future, have an impact on how your agency gets paid as we move towards a pay for performance (P4P) model. By helping to keep patients out of the hospital, we demonstrate to our agencies how important occupational therapy is in the care of all kinds of patients.
Phyllis L. Ehrlich, MS, OTR/L, CHES, has been an OT for more than 29 years and has been working in home health for more than 19 years. She currently works for Holy Redeemer HomeCare. She has specialized training in NDT and is a certified health education specialist. She has co-edited and is a contributing author to Home Health Practice: A Guide for the Occupational Therapist. Readers may contact her by e-mail at firstname.lastname@example.org.