The use of a low sodium diet in the management protocol of congestive heart failure patients has remained a standard for many decades in the medical field. But recently, questions have been raised about the efficacy of this intervention. There are much research that supports the roles of sodium diet in CHF, but the method with which they can be successfully carried out remains to be learned. In this regard, the nursing theory of self efficacy holds much promise as it allows patients and guides them towards taking a more proactive control over their health. Therefore, research to understand the applicability of this particular condition and how it can be used to control blood pressures in congestive heart failure may be able to answer many questions pertaining to it.
Chronic diseases in the industrialized nations are perhaps the biggest economical burden on the health care sector. Currently approximately 125 million people are suffering from one or the other chronic medical condition, of which five million are suffering from congestive heart failure. The death toll due to these chronic conditions is 140,000 and the total cost amounts to $173 billion (Rundall et al, 2002).
Heart failure is a very common condition in elderly people, with 10 out of every 1000 patients suffering from it (Sheu, 2008). Its mortality rates as well as costs to the health care setup are very high, and are one of the most common reasons why patient may present for hospitalization (Sheu, 2008). These rates of readmission are 50% within 6 months only, and continue to increase in frequency as the age of the patient increases (Sheu, 2008). Lack of proper knowledge about the disease, ignorance of the medical symptoms and self medication all contribute to the worsening of the condition upon presentation (Sheu, 2008).
Congestive heart failure is defined as follows:
“Congestive heart failure is the inability of the heart to pump blood effectively thereby causing a negative effect on other body functions. The inability to pump blood causes accumulation of blood in organs such as lungs and legs, and other organs such as kidneys may be affected. The body becomes congested therefore the name” (Living with Advanced Congestive Heart Failure: A Guide for Family Caregivers, 2002).
The incidences and numbers of patients suffering from heart conditions are expected to increase. This is in turn a positive indication in the reduction of number of acute heart related deaths such as myocardial infarction. However, the replacement of acute with the chronic form of heart disease that is the congestive heart failure demonstrates still a rising number of people suffering from such conditions. The costs in many parts of the world that is committed to heart related problems is staggering, which cuts the budgets of many other health programs such as vaccinations and others (Stewart et al, 2002).
Thankfully there are now more efforts than before to address the issue of chronic medical conditions. Some of these techniques include the use of guidelines, disease management techniques, case management and patient education among few (Rundall et al, 2002).
The role of nurses in the prevention of recurrence of any health complications is an important development. Nurses are now an important part of various such preventive conditions such as use of patient care teams, supportive information systems and at home care etc. The role of multi-specialty practices with a range of public health personnel (Rundall et al, 2002).
Some of the causes of congestive heart failure are as follows
- Conditions or diseases that cause weakening or damaging of the heart muscles
- Coronary artery disease
- Residual damage of myocardial infarction
- Damage to heart due to infections
- Severe lung disease
- Problems with heart valves
- Chronic kidney disease
- Abnormal or irregular heartbeat (Living with Advanced Congestive Heart Failure: A Guide for Family Caregivers, 2002).
Family perspective analysis of congestive heart failure
CHF is of a concern to health care professionals for the increased number of complications that they create on the patient’s health. Study by Gure et al (2007) show that patients with CHF are more likely to be disabled compared to those without the condition. This rate of admission from CHF complications is as high as 69.5% compared to 43% without CHF in two years duration (Gure et al, 2007). They are more likely to be admitted to healthcare institutions and nursing homes and therefore claim more time from the nursing and health are staff. The nurses have to give more informal hours to patients with CHF as opposed to those without it. Therefore, it is easy to see the enormous burden that CHF condition has on the patients, their families and the long term health care systems (Gure et al, 2007).
Study carried out by Juenger et al in 2001 based on scoring on the New York Heart Association classification found that patients with higher scores on the NYHA had a higher decrease in the quality of life (Juenger et al, 2001). This kind of a decrease in the quality of life is comparable with other chronic conditions. Therefore, the issue holds importance and priority in addressing it immediately (Juenger et al, 2001).
However, the growing role of family in the management of such patients is now being realized. Since they are in the most contact with the patients, they can be reliable information providers about developing complications. In this way they can reduce the chances of developing untoward conditions and complications (Living with Advanced Congestive Heart Failure: A Guide for Family Caregivers, 2002).
Certain regular and daily regimes can be easily managed by the family in their own home, and this can prevent unwanted visits to health service centers. By noting regular weight, routine medications, diet plan, emergency management and decision making regarding various situations, the family can help improve the chances of survival and minimization of complications manifold (Living with Advanced Congestive Heart Failure: A Guide for Family Caregivers, 2002).
Families can achieve this by keeping daily logs regarding breathing, medications, diet and activities and symptoms such as swelling. They can help decide when it is the time to call for medical help, knowing where to take the patient and who to call in emergency, and keeping track of information that is necessary for the doctors (Living with Advanced Congestive Heart Failure: A Guide for Family Caregivers, 2002).
Patients are identified as suffering from heart failure if they exhibit the following signs and symptoms
- Sudden weight gain
- Shortness of breath: dyspnea on exertion or at rest, orthopnea and paroxysmal nocturnal dyspnea
- Frequent hacking cough
- Peripheral edema
- Swelling of abdomen and loss of appetite
- Fatigue and weakness (Sheu, 2008)
General management of patients with CHF
Depending on the severity of the condition the CHF is divided into the following categories (Jessup et al, 2009).
Category A: Identifies patients having the risk factors of CHF. These include conditions such as coronary artery conditions, increased blood pressure, and diabetes. These patients on investigation do not show any abnormal cardiac activity and do not display impaired left ventricular function, hypertrophy or geometric chamber distortion (Jessup et al, 2009).
Category B: Patients who show abnormal cardiac activity, impaired left ventricular function, hypertrophy and geometric chamber distortions with no symptoms (Jessup et al, 2009).
Category C: Patients having current or past history of symptoms of heart failure with display of underlying structural pathologies (Jessup et al, 2009).
Category D: Truly refractive HF who will require specialized, advanced treatment strategies, such as mechanical circulatory support, procedures that facilitate fluid removal, continuous inotropic infusions or cardiac transplantation or other advanced surgical and end of life treatments (Jessup et al, 2009).
Patients are identified with one of the following features:
- They may complain of decreased exercise tolerance due to dyspnoea and fatigue etc. (Jessup et al, 2009)
- Complaint of fluid retention with swelling in the abdominal and foot region
- Either no symptoms or presenting with symptoms of other cardiac/non cardiac disorder or condition (Jessup et al, 2009).
It is here that the possible role of nurses in the management of care of patients can be understood. There is currently a large portion of nursing workforce handling cases of CHF and has been able to address many issues regarding quality care, timely maintenance and observation, guidance and counseling and helping deal in complicated conditions such as death or end of life support issues in CHF patients. They can help answer many questions that the family may pose towards them and can be an effective bridge in conveying information and wishes of the care takers and patients to the relevant care providers.
Already there are many examples of the effectiveness of nurse interventions and management strategies in overall reduction in the number of readmissions pertaining to chronic heart failure. Study carried out by Stewart et al in 2002 in the UK, examined the role of various nurse interventions in reducing the number of readmissions. The three models of care that were examined for the economic effectiveness of the nurse intervention included home based, clinic based or home and clinic based interventions respectively. The economic effect of the overall reduction in the number of readmissions was assessed. The results of the study were very promising, for the annual savings per 1000 patients were calculated to be £ 169,000. The researchers are hopeful that nursing interventions in all stages of care of the patient may help reduce the hospital admissions due to complications and in this way help in better prognosis overall (Steward et al, 2002).
However, the amount spent on the recruitment of additional nursing staff is not a small amount either. One particular study has shown that the “incremental cost effectiveness of recommended staffing versus median staffing was $321,000 per discounted quality adjusted life year gained” (Ganz, Simmons and Schnelle, 2005).
The nurse management regarding congestive heart failure cases is to improve self care and maintenance among the patients themselves, so that they are more informed about their condition, and are able to decide when they need intervention and medical assistance before having any complications. Of the many therapies that are now advocated, the non pharmacological means of obtaining control is very popular. The patients are instructed to control their lifestyle habits and consumption of food and create balance in their life style. This in the long run is one of the most effective, cheap and rewarding practices in preventing complications. The nursing staff in this regard is a very important contributor and has been supporter of such programs (Sheu, 2008).
Among these non pharmacological interventions, a very common method advocated includes reducing the amount of dietary sodium salt intake in the patient. This method however, like so many others, is primarily reliant on the adherence of the patient (Sheu, 2008).
The middle range nursing theory of self efficacy
The Middle Range Nursing Theory of Self Efficacy is not an original theory but has been rather derived from the works of Bandura’s social cognitive theory (Resnik, 1998). Barbara Resnik, the theorist, was able to find a positive correlation with behavioral interventions such as power of self efficacy enhancement and psycho-behavioral interventions with positive health outcomes in the older age groups (Resnick, 1998). The outline essentially remains the same from the original theory of Bandura, however, Resnik emphasized that these interventions are very simple and of everyday pattern and can be easily practiced by the nursing staff. Resnik believed that by proper encouragement in various forms, the patients take more interest in their health and are able to generate the required health responses as desired by the medical team (Resnik, 1998). This theory has now become an integral part of the nursing training.
This theory can be applied in many ways. The main aim is to increase the awareness of the patient so that he or she starts taking more interest and lead in addressing his condition. Many physicians accept and advocate the importance of informative posters and materials, which are written in simple language, and allow the patient to learn more. This method is considerably cheaper than other modes of educational learning, and is more likely to remain in the minds of the patient. The availability of this material in the waiting room allows patients to concentrate exclusively on the material while in the waiting. The patients can then verify or clear any concepts that they feel confused about with the physician, thereby increasing their retention of the information provided. Finally, the use of colors and animation helps to attract attention and create more interest in all age groups (Sheu, 2008).
Description of specific portions of the theory
Patients with advanced age are usually lacking many forms of positive stimuli in life that may increase their morbidity. It is not surprising that chronic conditions may help increase rates of depression among the patients. Hospital environments are usually too depressing to create any improvement. Therefore, the theory suggests that by introducing positive stimuli related to person’s health by the health professionals, the patient will begin to make more effort to improve his condition. With positive and recurrent positive reinforcement through various verbal, visual and tactile stimuli, the rates of congestive heart failure complications due to non compliance and non adherence may be reduced significantly (Resnik, 1998).
There are two specific portions of the theory which can be very helpful in managing patients with the condition of heart failure and promote a more proactive role (Benight and Bendura, 2004). The enactive attainment portions help the patients in addressing their fears of a situation and ways to improve coping and recovering from various forms of stress. The patient is motivated to improve his or her condition by actively taking control of his or her situation and various methods can be employed to bolster this confidence and maintain it (Benight and Bendura, 2004).
Enactive attainment in clinical researches has so far given results in areas such as phobias, in quitting smoking habits, in exercising behaviors and performance of functional activities and in achieving weight loss. By increasing the self efficacy expectations, the person is likely to overcome all forms of behavioral problems he or she is facing. This in the case of CHF patients is applicable to two aspects of general life functioning (Peterson and Bredow, 2008). Firstly, the patient follows the doctor’s advice on the type of food intake and nutritional maintenance that is important for his or her health. In the case of our study, the aim will be to motivate patients to decrease salt intake and frequency from their diets in order to reduce their blood pressures. The second aspect where this particular portion of theory can be applied is ensuring adherence and compliance to the drug regime given to the patient. By giving the patients the confidence that they can improve their health and outcomes, the rates of BP shoot ups in congestive heart failure patients can be reduced significantly (Peterson and Bredow, 2008).
The second portion of the theory, the physiological feedback as reinforcement is also a very important physical method to improve health outcomes. While the former is more related to the mental readjustment of the mind towards better performance, the physiological feedback allows patient to see the physical outcomes of the various interventions he or she undertakes and there by improve and motivate the patient further (Peterson and Bredow, 2008). Coping with stress giving factors, the physical accomplishments of the patients and the health functioning all contribute to the physiological feedback. In the case of our study, the reduction in the levels of blood pressure readings and the improvement in the symptoms of CHF will be gauged as physiological cues that can help improve health outcomes of the patients. Any improvement seen in the charts will motivate the patients further and ensure further effort and participation of the patients in their own health (Peterson and Bredow, 2008).
Applying theory to research proposal
The steps taken for management of CHF are divided into three broad categories. First is the avoidance of harmful habits. Second is by enhancing the feeling of well being in the patient. And finally, promotion of favorable changes in neuroautonomic function, muscular status and peripheral circulation through physical training (Solar and Miralda, 1994).
If seen from the perspective of the efficacy theory, it is very easy to see how significant this theory can be for the patients with CHF. The first category of avoiding harmful habits mostly consists of lifestyle modifications. In this regard, the reduction in the intake of sodium is an essential prerequisite for successful management of CHF symptoms. The second set of management requires an intensive effort on part of patient and the family to address the psychological need of well being and support in the patient. This self efficacy will allow the patient to feel more confident about his or her self and how he can manage the condition. Both these conditions are in line with the theory of self efficacy. And therefore, the theory retains a very high potential in the future management of the patients with CHF (Solar and Miralda, 1994).
Since congestive heart failure patients have very high rates and risk of readmission into the hospitals, they should be the first target population in the preventive strategy. Proper monitoring can help reduce much hassle regarding medical hospital admissions and intervention, therefore, introducing patients to repeated evaluations and their beneficial effects can ensure good results. Resnik’s theory is very important in understanding perhaps the basic management protocol of patients with chronic conditions. Patients who come in for congestive heart failure complications are mostly in their elder ages, and may not be able to manage their medicines by themselves. The nursing staff through regular monitoring in the primary care centers or even outside of these spaces can help ensure patient compliance is retained. The study aims to understand the possible role of positive cognitive interventions and their outcomes in the form of good patient compliance and adherence to medical regime. The medical regime in such cases includes both pharmacological as well as non pharmacological interventions, as proposed by the physician.
In this particular study, the effects and outcomes of the theory will be tested by decreasing the salt consumption of the patients who suffer from CHF. This non pharmacological intervention has been claimed as a good option in the overall treatment of CHF conditions.
These two aspects of the self efficacy theory can be applied as a behavioral and cognitive modification of the patients with CHF. In this regard the decreased consumption of sodium in diet and its effects will be the first of the attempts to increase self efficacy of the patients. The results of the blood pressure changes can then be applied as the physiological component and motivation to increase the enactive effort of the patient in CHF management.
It is essential to understand the various issues that surround current research about reduction of salt consumption in CHF patients. Decrease in dietary sodium almost became a mainstay in the treatment strategies as early as in 1960s (Solar and Miralda, 1994). The dosages at the time were fixed and followed for a long time at 0.5 grams per day. Later on, this dose increased to 2 to 3 grams of sodium as the role of diuretics and its use in therapy gained popularity. There are however, recent researches that show that many health care systems of the world now do not advocate this method (Soler and Miralda, 1994).
So what caused this change? The answer may lie in the manner that research was carried out regarding role of salt consumption in CHF. Studies in this regard were limited only to the neuroendocrine and metabolic dimensions of the disease and failed to focus on other clinical effects. The activation of the rennin angiotensina and the sympathetic activity is another reason why clinicians shied away from this approach. However, what these studies failed to realize was that sodium retention can increase considerably in the body among advanced cases of CHF and may lead to other clinical complications. Therefore, the need is to carry out more researches on what role dietary sodium can play in improving the condition of CHF (Soler and Miralda, 1994).
Methods for collection of data for research
The research was carried out in two phases. Phase I involved the location of the articles and primary sources of relevant information regarding the reduction of intake of salt among the CHF patients as a non pharmacological measurement. It included collection of information regarding various types of heart failures and congestive heart failure and how it is diagnosed. The research also looked for causes of heart failure and how it presents itself in the clinical setting. The many ways of identification and the appropriate intervention techniques were included. However, the primary area of concern was the non pharmacological interventions in the management of CHF and their effectiveness. In this regard, our research is primarily concerned with the decrease in the use of salt and it effects on the patient, therefore this remained the main object of research.
This information was stored and attempts were made to find only those articles that were written within 5 years of the present research. This helps in creating the current understanding of the issue and helping base the most advanced knowledge into the possible theory solutions. However, many of the articles are of much older time frame and have been included due to their exceptional study methods, detail and conciseness and preciseness of information.
The phase II of the research involved reading and removing unnecessary documents not relevant to the study. In this regard, the use of pharmacological intervention was intentionally excluded as the research was aimed at identifying salt consumption as a non pharmacological intervention. The articles were then checked for their legitimacy by the journal or archive where it was published. In some cases, cross or repeated citations were used to assess the authenticity of the research. Those articles that were not relevant to the role of reduced salt intake in CHF patients and role of nurses in this regard were not taken.
These articles were reviewed, checked for authenticity and were finally included in the paper.
The following is the hypothesis for this research
“Adhering to a low sodium diet improves BP control in heart failure patients”.
The hypothesis for this study includes the following
- Decreased salt intake among the patients with CHF may improve outcomes in the overall health and fitness of the patients
- The role of nurses can be instrumental in introducing the concept of non pharmacological intervention
- With the help of theories, nurses can help improve compliance among patients and improve outcomes with decreased salt intake. In this regard, the use of self efficacy theory will be utilized. The two components of this theory will include the enactive portion of the theory and the physiological feedback mechanism respectively.
Research variables their conceptual definition
Research variables can be defined as those factors included in a study that can either be manipulated or measured (Research Variables, 2008). These are broadly divided into dependant and independent variables (Research Variables, 2008).
In this study, the research variables will be as follows:
Independent variable is-Low sodium diet.
An independent variable is one that is placed as the basis or any experiment. This particular variable has been isolated by the researcher (Research Variables, 2008). The study aims to look at the low sodium diet as an effective tool in improving blood pressure conditions of congestive heart failure patients.
Dependent variable is- uncontrolled BP
The dependant variable is one that is dependant on the independent variable, hence the name. The dependant variable will show changes with the changes in the independent variable, but will not affect the independent variable (Research Variables, 2008). The reduced salt intake will affect the blood pressure readings on the patient or not will depend on the type of dosage etc. taken for the independent variable. Any changes in the blood pressure will depend on the changes in the salt intake concentrations.
Operational definition: – Blood pressure machine
The machine used for measuring blood pressure is the sphygmomanometer. “It is designed to monitor blood pressure by measuring the force of the blood in the heart where the pressure is the greatest. This occurs during the contraction of the ventricles, when the blood is pumped from the heart to the rest of the body or systolic pressure. The minimal force is also measured this occurs during the period when the heart is relaxed between beats and pressure is lowest or diastolic pressure” (Sphygmomanometer, 2008).
“A sphygmomanometer is used to establish a baseline at a healthcare encounter and on admission to a hospital. Checking blood pressure is also performed to monitor the effectiveness of medication and other methods to control hypertension and as a diagnostic aid to detect various diseases and abnormalities” (Sphygmomanometer, 2008).
According to American Heart Association a low sodium diet is defined as follows:
“Reduction in the amount of sodium intake in the diet to help control high blood pressure” (Blood Pressure, Low Sodium Diet, 2008)
“It is recommended to eat less than 2300 mg of salt per day. People such as African Americans, middle aged and older age groups and patients with high blood pressure should reduce intake to 1500 mg per day” (Blood Pressure, Low Sodium Diet, 2008).
These are those unwanted or “undesirable” variables that “influence the relationship between the variables that an experimenter is examining. They can influence the outcome of an experiment, though they are not the variables of interest” (Extraneous and Confounding Variables and Systematic Vs. Non-Systematic Error, 1998).
Extraneous variables in this research are as follows
- Acuity of illness
Ways to control extraneous variables
Two measures can be taken to control these variables. Either the influential variable is made similar for all subjects, or balanced out in a group
Proper instilling of nursing practices can help improve patient compliance suffering from CHF into taking up more non pharmacological measures to improve health of the patients. In this regard, the reduction of salt intake among these patients by nursing staff education and encouragement can lead to better results.
- the sample selected will include
- Sampling Strategy
- exclusion criteria
- inclusion criteria
The research design chosen for this particular study is the quasi experimental design called the non equivalent control group design. This design shares the same features of an experimental design. Also known as the queasy experiments, they are marked by the lack of random assignment technique that is so commonly employed in various other experimental designs. Many claim that such an experiment may have inferior internal validity; however, they are easily implemented and have been used with success in experimental investigations (Living with Advanced Congestive Heart Failure: A Guide for Family Caregivers, 2002).
Within the quasi experimental design are many categories that are applied to clinical experiments as deemed fit? These include the non equivalent groups design, the regression continuity design and others such as the Proxy Pretest, the Double Pretest, the Non Equivalent Dependant Variables, Pattern Matching and the Regression Point Displacement Designs respectively (Living with Advanced Congestive Heart Failure: A Guide for Family Caregivers, 2002).
The first one of these the nonequivalent groups design is a commonly used one in various social researches. Again it follows the same principle of pre and post test randomized experiment, but without implementing the randomization method. The groups share similar features, and can be termed as treatment groups, control groups and various others as the experiment dictates. The term non equivalent itself points that there was no randomization involved in the study design.
- Data Collection method and data analysis plan
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- Blood Pressure, Low Sodium Diet, 2008.
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- Tanya Ruff Gure, Mohammad U. Kabeto, Caroline S. Blaum and Kenneth M. Langa, 2007. Degree of Disability and Patterns of Caregiving Among Older Americans with Congestive Heart Failure. J Gen Intern Med 23(1): 70-6.
- Mariell Jessup, William T Abraham, Donald E. Casey, Arthus M. Feldman, Gary S. Francis et al, 2009. Focused Update: ACCF?AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults. A Report of the American College of Cardiology Foundatoin/ American Heart Association Task Force on Practice Guidelines. Circulation 2009;119:xxx-xxx
- Living with Advanced Congestive Heart Failure: A Guide for Family Caregivers, 2002. The Washington Home Center for Palliative Care Studies. A division of RAND Corporation, 2002.
- Sandra J. Peterson and Timothy S. Bredow, 2008. Middle Range Theories. Edition II Illustrated. Published by Lippincott Williams and Wilkins, 2008.
- Thomas G Rundall, Stephen M Shortell, Margaret C Wang, Lawrence Cassalino, Thomas Bodenheimer, Robin R Gillies, Julie A Schmittdiel, Nancy Oswald and James C Robinson, 2005. As Good As It Gets? Chronic Care Management in Nine Leading US Physician Organizations.BMJ 2002; 325:958-61.
- Research Variables, 2008.
- J Juenger, D Schellberg, S Kraemer, A Haunstetter, C Zugck, W Herzog and M Haass, 2002. Health Related Quality of Life in Patients with Congestive Heart Failure: Comparison With Other Chronic Diseases and Relation to Functional Variables. Heart 2002; 87:235-241.
- Wei-Jen Shea, 2008. Signs and Symptoms of Heart Failure: An Educational Poster. Masters Project Submitted to the Faculty of College of Nursing for Master of Science Degree in the University of Arizona.
- J. Soler-Soler and G Permanyar Miralda, 1994. How do Changes in Lifestyle Complement Medical Treatment in Heart Failure? Br Heart F (Supplement) 1994; 72: 87-91.
- Sphygmomanometer, 2008.
- S. Stewart, L. Blue, A. Walker, C. Morrison and J. J. V. McMurray, 2002. An Economic Analysis of Specialist Heart Failure Nurse Management in the U.K.: Can We Afford Not to Implement It?European Heart Journal 2002:23:1369-1378.