Heart-to-heart lessons

By Michaela Gibson Morris/NEMS Daily Journal

Penny Keaton thought a hernia was pushing on her heart and leaving her short of breath.
The 56-year-old Okolona woman was diagnosed with congestive heart failure and ended up at North Mississippi Medical Center when she became severely short of breath during outpatient diagnostic tests.
“She gave everybody a good scare,” said Jan Starling, NMMC Home Health nurse, who is Mississippi’s first registered nurse certified in heart failure care.
“It scared me, too,” Keaton added.
The condition is serious, but not necessarily as ominous as it might sound; the blood flow out of the heart slows, and blood returning to the heart backs up in the veins. This can cause swelling, especially in the legs and ankles. Fluid also can collect in the lungs, making it hard to breathe, especially when someone is lying down.
Heart failure is a very common condition; about 5.7 million people in the United States have heart failure, according to the National Heart, Lung and Blood Institute.
“It’s a chronic disease that varies from person to person,” said Dr. Lee Greer, a geriatric specialist who also serves as chief quality officer for North Mississippi Health Services. “If it’s well controlled, they can have a very good quality of life for many years.”
Keaton and others have new tools to help them achieve that control. In June, NMMC began offering Congestive Heart Failure Self-Care College, where patients with the condition sit down with a dietitian, pharmacist and nurse and work through the key elements they need to manage the condition.
“You don’t learn how to ride a bike with a book,” said Greer, who helped develop the program. “You shouldn’t learn how to manage congestive heart failure by reading a pamphlet.”
Managing HEART FAILURE
Doctors can adjust medications, but the real work in controlling heart failure is done by the individual, Greer said.
“They really are in control of their health care needs,” he said.
Managing heart failure requires a concerted effort on three fronts – managing medication, diet adjustments and closely monitoring weight.
Many heart failure medicines need to be taken very precisely, Greer said. They need to be taken in the right dose at the right time. If a person misses a fluid pill for a day or two, they may have fluid build up in their lungs, which can land them back in the hospital.
Additionally, most people with heart failure have other chronic conditions to manage.
“They were on 4 to 5 medications already,” before diagnosed with congestive heart failure, Greer said. “It can get very complex.”
The right nutrition is also extremely important for controlling heart failure. Almost every person diagnosed with congestive heart failure is on a reduced sodium diet – to help reduce blood pressure and fluid retention.
Tracking sodium can be tricky, said Registered Nurse Kim Mayhall, NMMC congestive heart failure case manager.
“They’ll say, ‘I don’t add any salt at the table,’” Mayhall said, and they’ll put chicken noodle soup, ham and canned meat on their typical menu. “A lot of things you don’t realize are packed full of sodium.”
In some cases, doctors may also recommend fluid-restricted diet, which also can be difficult to track. People just don’t think about ice, gelatin, popsicles and ice cream as fluids.
“If it wiggles, jiggles or melts, you have to count it,” Starling said.
The scale provides the best early warning sign about how well patients are managing their congestive heart failure. Weight gain usually indicates a fluid build up; a weight gain of two pounds overnight or three to five pounds in a week should be reported, Starling said.
“If you intervene early, you can keep fluid from getting into the lungs,” Greer said.
Self-care college
Traditionally, patients have gotten these guidelines on discharge from the hospital. But just telling folks isn’t enough. Nationally about 24 percent of heart failure patients end up back in the hospital within 30 days, Greer said. That’s expensive for hospitals, Medicare and insurers, and miserable for patients.
At the NMMC self-care college, patients go through simulations where they weigh themselves, make sure they understand their medications, what they do and how they should be taken and how they will manage their diet.
Weighing yourself may seem simple; however, it’s not always easy. In some cases, the person may not be able to read the scales. In other cases, they may be so weak from the heart failure, they can’t balance on traditional scales.
Reading food labels can take practice. Managing medications, especially for multiple conditions, can be a challenge. The focus is on getting patients the resources they need before they go home, Mayhall said. The follow-up doesn’t end with the self-care college session. The patients get weekly calls from Nurse Link to check up on their progress for the first month they are home.
The NMMC program has already seen dividends. In 2009-2010 fiscal year average, NMMC averaged 19 percent 30-day readmission rate for heart failure patients.
Of the 105 people who had gone through Self-Care College from June to mid-October, only 15 percent have been readmitted, Mayhall said.
If the program continues to do well, NMMC may consider applying the concept to other conditions in and out of the hospital, Greer said.
It’s already been successful for Penny Keaton. She has taken what she learned and applied it to her life. She’s reading labels and tracking her weight. So far, she’s lost five pounds. But the best thing is that it’s not keeping her up at night. Before she was diagnosed, she would wake up several times a night, gasping for breath.
“I can sleep” now, Keaton said. “I’m not waking up for anything.”
michaela.morris@journalinc.com

Heart Failure Basics
Congestive heart failure is a serious, but manageable condition.

The weakened heart doesn’t move blood efficiently through the body, and fluid begins
to back up, especially in the feet, legs and
lungs.

Most common risk factors:
• Coronary artery disease
• Prior heart attack
• Chronic high blood pressure
• Diabetes
• Also: Abnormal heart valves, heart muscle
disease, congenital heart defects, severe
lung disease, sleep apnea
Less common risk factors:
• Severe anemia
• Overactive thyroid gland
• Abnormal heart rhythms

Symptoms:
• Shortness of breath
• Persistent wheezing or coughing
• Swelling in feet, legs, ankles or abdomen
• Persistent fatigue; difficulty with everyday
activities such as shopping, climbing
stairs, carrying groceries or walking.
• Lack of appetite or nausea
• Confusion and impaired thinking
• Increased heart rate
These symptoms should be evaluated by a
physician.