Abstract

Heart failure (HF), predominant in adults older than 65, is a chronic and progressive
syndrome frequently associated with the burden of distressing symptoms. HF symptom
management is directed at treating the underlying causes of acute decompensation,
which commonly relate to lack of medication adherence or dietary restriction. Therefore, for older adults capable of managing their health care needs, promotion of selfcare is essential for symptom management. Using the Model of Heart Failure Self-Care
as a guide, the purpose of this article is to discuss the relationship between self-care
and HF symptom management and to provide nursing strategies for assessment and
promotion of self-care in older adults with HF.

eart failure (HF), predominant in adults older than 65,

is a chronic and progressive
syndrome frequently associated with
the burden of chronic and distressing
symptoms (Masoudi, Havranek, &
Krumholz, 2002). HF is the result of
cardiovascular diseases such as myocardial infarction and hypertension,
which cause changes in the architecture
of the myocardium otherwise known

as ventricular remodeling. Symptoms

of HF such as dyspnea (breathlessness)
and fatigue result from an impaired
ability of the ventricle to eject blood
(systolic dysfunction) or fill with blood
(diastolic dysfunction). Fluid retention,
primarily associated with systolic dysfunction, can lead to pulmonary and
peripheral edema (Piano, 2008). Many
patients experience both systolic and
diastolic HF abnormalities.

Efforts to decrease symptom burden and hospital admissions include

maximizing medical therapies combined with multidisciplinary strategies
that acknowledge the interaction of
psychosocial and behavioral factors on
patient outcomes. Symptom management for HF patients is primarily directed at treating the underlying causes
of acute decompensation, which commonly relate to dietary indiscretion or
lack of adherence to medical therapy.
Therefore, for older adults who are
capable of managing their health care
needs, promotion of self-care is an
important strategy for symptom management. Daily monitoring of HF
symptoms, a component of self-care,
is pivotal, as symptoms predict hospitalization (Friedman, 1997; Jurgens,
2006; Parshall et al., 2001), morbidity
and mortality (Ekman et al., 2005),
and health-related quality of life (Heo,
Doering, Widener, & Moser, 2008).
We propose using the Model of Heart

Corrine Y. Jurgens, PhD, RN, ANP-BC, FAHA; Kathleen M. Shurpin, PhD, RN, ANP-C;
and Kellie A. Gumersell, MS, RN, ANP-C
24

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 2010 /iStockPhoto.com

Failure Self-Care developed by Riegel

(Riegel & Dickson, 2008) in guiding
plans of care for older adults managing their HF. The model incorporates
adherence behaviors, management of
symptoms when they occur, and the influence of self-care confidence on selfcare (See Riegel et al., 2009, for the complete model). The purpose of this article
is to discuss the relationship between
self-care and HF symptom management and to provide nursing strategies
for assessment and promotion of selfcare in older adults with HF.

Model of Heart Failure

Self-Care

Self-care is a naturalistic decisionmaking process patients use to choose

behaviors to maintain stability of
HF as well as respond to a change in
symptom severity. Naturalistic decision making is the process patients
use to make decisions in real-world

settings. The Model of Heart Failure

Self-Care (Riegel & Dickson, 2008)
has five stages. Stage 1 consists of
self-care maintenance activities that
are typically adherence behaviors.
Examples of self-care maintenance
activities include taking medications as prescribed, adhering to lowsodium diets, limiting fluid intake
for some, and monitoring symptoms
on a daily basis. Daily monitoring
of body weight and responding to
changes appropriately is an essential
self-care maintenance activity. Stages
2 through 5 comprise self-care management strategies. Self-care management encompasses decisions and
actions that occur in response to a
change in symptom status. Stage 2
involves recognizing worsening of
or a change in HF symptoms. Stage
3 is symptom evaluation, when the
patients determine whether their
symptoms relate to their HF or oth-

Journal of Gerontological Nursing Vol. 36, No. 11, 2010

er less-threatening illnesses. Stage

4 is self-treatment implementation
based on the symptoms experienced.
Examples of Stage 4 self-care management activities include taking
an extra diuretic medication in response to increasing weight, limiting fluid intake, or contacting ones
health care provider. Stage 5 involves
treatment evaluation in relation to
whether Stage 4 activities were effective. All stages of the self-care model
are affected by the patients degree
of self-care confidence. The self-care
management stages (2 through 5)
are particularly affected by self-care
confidence, especially recognizing
changes in symptoms.
Stage 2 of self-care, symptom recognition from the patient perspective, is one aspect of self-care that
is problematic, particularly when
responding to the initial changes in
symptom status. Early symptoms of

25

Percentage of patients reporting symptom

80
70
60
50
40
30
20
10
0

Dyspnea
on exertion

Fatigue

Cough

Edema

Increased
girth

Weight
gain

Median duration of symptoms = 7 days

Figure. Frequency of early symptoms of decompensated heart failure.

Data source. Jurgens (2006).

HF decompensation include dyspnea

on exertion (DOE), fatigue, weight
gain, and swelling. However, older
HF patients are known to delay responding to these early symptoms
until the increasing severity requires
hospitalization. Investigators report
a median duration of the early symptoms of decompensation to be 7 days
(Friedman, 1997; Jurgens, 2006; Jurgens, Hoke, Byrnes, & Riegel, 2009).
The Figure illustrates the percentage
of patients reporting typical early
symptoms of HF decompensation in
a study of 201 patients admitted for
HF symptom management (Jurgens,
2006). In this sample, patients tolerated these symptoms for a relatively
long time (median duration = 7 days)
before seeking care. Among ambulatory older HF patients, DOE is
common, with more than 95% of
patients experiencing this symptom
(Ahmed, 2005; Mueller et al., 2004).
Older adults typically discount the
early symptoms of impending decompensation (e.g., DOE, fatigue),
believing these symptoms relate to
normal aging (Leventhal & Prohaska,
1986; Miller, 2000; Patel, Shafazand,
Schaufelberger, & Ekman, 2007).
However, many factors contribute
to lack of concern about these symptoms among older adults with HF

26

(Horowitz, Rein, & Leventhal, 2004;

Jurgens, Hoke, et al., 2009).
Older adults ability to detect
changes in degrees of DOE and fatigue may be affected by sedentary
lifestyles that limit the experience or
perception of these symptoms. An
insidious increase in chronic symptoms may also make a change in severity difficult to detect, as for some
patients, breathlessness becomes a
part of everyday life (Edmonds et
al., 2005). Furthermore, HF symptoms (e.g., fatigue) are nonspecific
to the illness, and symptom profiles
vary from person to person, making
symptoms difficult to identify as HF
related. The same patient can perceive
the same symptom differently based
on the situation or activities of daily
living in which the patient engages.
Therefore, a family member may detect a change in symptoms or activity
tolerance before an older HF patient
is aware of the change (Jurgens, Hoke,
et al., 2009).
Advancing age and comorbid illness are other factors contributing to
variability of and response to symptoms. Specifically, age is a factor in
symptom presentation and perceived
severity. Adults 65 and older experience more symptoms but report less
distress than younger HF patients

(Jurgens, Moser, et al., 2009). Furthermore, differentiating changes associated with HF from those of aging is
challenging. Systemic physiological
changes associated with aging and HF
blur patients perception and interpretation of symptoms (Ahmed, Allman, DeLong, Bodner, & Howard,
2002; Woo, Macey, Fonarow, Hamilton, & Harper, 2003). Comorbid
illness, common in older adults with
HF, further complicates determining
the source and meaning of symptoms
(Braunstein et al., 2003; Havranek et
al., 2002; Krumholz et al., 2000) (See
Table 1 for an abbreviated list of the
most common comorbid illnesses in
older HF patients, reported in a crosssectional sample of 122,630 Medicare
beneficiaries (Braunstein et al., 2003).
As a result, correctly labeling symptoms is problematic for patients, and
hospitalization for symptom management is common, with costs estimated
to be more than $39.2 billion for 2010
(American Heart Association, 2010).
Clearly, symptom recognition and
response are important components
of self-care for nurses to target when
educating HF patients.
The value of self-care was highlighted in a systematic review of randomized trials of multidisciplinary
strategies to improve outcomes for
HF patients. The authors concluded
that patients managed by a multidisciplinary team providing specialized
follow up were 24% less likely to be
readmitted at least once to the hospital
(McAlister, Stewart, Ferrua, & McMurray, 2004). However, the analysis
reported multidisciplinary strategies
that included enhanced self-care were
more effective. Those who had enhanced patient self-care activities were
34% less likely to be readmitted. Preventing hospitalization by enhancing
self-care is important, as hospitalization for HF is associated with poor
prognosis postdischarge. Readmission
within 6 months is common, and mortality is reported to be as high as 11.3%
at 30 days postdischarge (Fonarow,
Adams, Abraham, Yancy, & Boscardin, 2005; Kosiborod et al., 2006).

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Beyond timely symptom recognition to avoid hospitalization, the

importance of symptom management from the perspective of the patient is highlighted by evidence that
HF patients favor improvement of
symptoms over living longer (Stanek,
Oates, McGhan, Denofrio, & Loh,
2000). Symptoms of HF include both
physical and psychological components. Typical physical symptoms
include but are not limited to fatigue,
shortness of breath of varying degrees
of severity, weight gain, and lower extremity edema. Psychologically,
symptoms of depression are
common. One in five HF patients has clinically significant
depression, which increases
in prevalence as functional
status decreases (Rutledge,
Reis, Linke, Greenberg, &
Mills, 2006; Vaccarino, Kasl,
Abramson, & Krumholz, 2001).
Depression is also associated with
poorer outcomes such as worsening
of HF symptoms, lower quality of life,
and compromised physical and social
functioning (Rumsfeld et al., 2003).
Considering the interplay of physical and psychological symptoms with
self-care, comprehensive assessment of
older adults with HF dictates regular
assessment of physical and psychological status, as well as assessment of
self-care practices.
Psychosocial factors, health beliefs and behaviors, and cultural influences affect the management and
outcomes of older adults with HF.
Of particular significance is a diagnosis of depression. Prevalence of
depression among HF patients is
reported to range from 11% to 25%
for outpatients and 35% to 70%
for inpatients (Joynt, Whellan, &
OConnor, 2004). Higher prevalence
rates of depression were associated
with higher New York Heart Association (NYHA) functional class
(Rutledge et al., 2006), indicating a
decline in physical functioning. Use
of depression scales (e.g., Geriatric
Depression Scale) is helpful in assessing for depression in this population

(Yesavage et al., 1982). In settings

where administering the Geriatric
Depression Scale is not feasible, brief
screening can be done with two questions that are reported to identify up
to 95% of patients with major depression (Whooley, Avins, Miranda,
& Browner, 1997):
l During the past month, have
you often been bothered by feeling
down, depressed, or hopeless?

Psychosocial factors,
health beliefs
and behaviors,
and cultural
influences affect the
management and
outcomes of older
adults with heart
failure.

l During the past month, have

you often been bothered by little
interest or pleasure in doing things?
Vigilant attention to the recognition and treatment of depression in
HF patients is essential, as this diagnosis results in poorer HF outcomes
(Rutledge et al., 2006). Furthermore,
adequate management of depression
improves adherence to treatment regimens (e.g., self-care), which supports
symptom management (Luyster,
Hughes, & Gunstad, 2009; Thomas
et al., 2008).

Self-Care Maintenance:
Symptom Monitoring and
Treatment Adherence

Symptom Monitoring
Stage 1 of self-care involves selfcare maintenance activities of daily
symptom monitoring and treatment
adherence. The basics of symptom
monitoring include recording daily

Journal of Gerontological Nursing Vol. 36, No. 11, 2010

weights, checking for swelling, and

evaluating symptoms after activity. An
increase of 2 to 3 pounds in a day or
4 to 5 pounds in a week is indicative
of fluid retention and may be associated with swelling (edema), increasing
fatigue, and activity intolerance. Some
patients are unsure of the meaning of
changes in their symptoms or weight
and fail to act (Horowitz et al., 2004).
Monitoring and discussing the
meaning of daily weights and
other HF symptoms in older
adults hospitalized with decompensated HF is an opportunity for nurses to promote understanding of the
relationship between weight,
volume overload, and self-care.
Interestingly, patients hospitalized
for decompensated HF are known to
deny having swelling, which is subsequently found during physical examination (Friedman, 1997). Asking
patients if their shoes feel tighter than
usual or if their clothes feel tighter
around their waist may be more effective in eliciting an accurate history
of swelling (Glotzer, 2008). Patients
should also check for the presence of
swelling at the end of the day. To do so,
nurses can teach patients to press over
a bony prominence such as the tibia. A
depression that is slow to refill or resume its original shape indicates fluid
retention.
Patients can accommodate an increase in the severity of HF symptoms by decreasing activity levels.
Therefore, quantifying functional
capacity associated with activity is
essential for symptom monitoring.
Absence of symptoms at rest is inadequate for determining symptom
status. Functional capacity can be
determined by asking patients about
their present maximal asymptomatic activity level compared with recent and distant time points (Table
2). Function includes the ability to
carry out such activities as bathing,
dressing, eating, toileting, and walking. Tools to quantify functional
status include the NYHA classification system (Criteria Committee

27

Table 1

Common Comorbid
Illnesses in Heart
Failure Patients
Alzheimers disease/dementia
Asthma
Cerebrovascular disease
Chronic obstructive pulmonary
disease/bronchiectasis
Chronic renal failure/renal
insufficiency
Depression/affective disorders/
anxiety
Diabetes mellitus
Hypercholesterolemia
Hypertension
Intravertebral injury, spondylosis, or other chronic back
disorders
Ocular disorders (e.g.,
retinopathy, macular disease,
cataract, glaucoma)
Osteoarthritis
Osteoporosis
Peripheral and visceral
atherosclerosis
Prostatic hyperplasia
Thyroid disorders
Source. Braunstein et al. (2003).

of the NYHA, 1994) or the Specific

Activity Scale (Goldman, Hashimoto, Cook, & Loscalzo, 1981). The
NYHA classification uses symptom
impact to classify patients as Class I
(having no symptoms) to Class IV
(indicating symptoms at rest). The
Specific Activity Scale uses common
daily activities such as the ability to
climb stairs to measure functional
performance measured in metabolic units. A change in function
may be an early indicator of volume
overload in older adults. For older
adults, changes in weight, activity
tolerance, behavior, and cognition;
somnolence; anorexia; and irritability are the more common indications of HF, particularly after age 80
(Rich, 2006).

28

Treatment Adherence
Treatment adherence to prevent
decompensation of HF status is the
other essential component of selfcare maintenance. Treatment adherence includes following the advice of
health care providers, taking medications as prescribed, restricting dietary
sodium, restricting alcohol, initiating
or maintaining smoking cessation,
and engaging in preventive behaviors
(e.g., yearly influenza vaccine) (Riegel et al., 2009). Although all of the
self-care maintenance behaviors are
important, this article will focus on
factors and strategies related to medication adherence and dietary sodium
restriction.
Medication therapy for HF relates
to the clinical severity of the syndrome. The goal of this therapy focuses on improving patient function
and symptoms, as well as the reversal
of ventricular remodeling. Diuretic
agents, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin
receptor blockers, and beta-adrenergic blockers are the primary drug classifications used in the management of
HF. Other drug classes may be added
when symptoms are severe and persistent. Medication therapy is outlined
by the American College of Cardiology and American Heart Associations Guidelines for the Diagnosis
and Management of Heart Failure in
Adults (Hunt et al., 2009).
Diuretic medications are used in
the treatment of HF to achieve euvolemia (fluid balance) and to prevent
edema. Diuretic selection can be difficult with patients with severe HF,
and these patients must be closely
observed for serum electrolyte abnormalities. ACEIs may be prescribed
at all stages of HF. ACEIs slow the
remodeling process of the abnormal
ventricle and thus can prevent the development of HF in patients with left
ventricular dysfunction without HF
as well as improve exercise performance. ACEIs also reduce mortality
and hospital readmissions for patients
with HF. For those patients who experience severe persistent cough sec-

ondary to ACEI use, angiotensin receptor blockers are equally effective.

Beta-adrenergic blockers also improve
symptoms in patients with HF. Three
beta-adrenergic blockerscarvedilol
(Coreg), metoprolol (Dutoprol),
and bisoprolol (Zebeta)have been
reported to improve survival in patients with HF (Hunt et al., 2009).
The number of medications typically prescribed for HF as well as associated comorbid illnesses complicates
medication adherence for older adults.
A study of discharge medications for
older HF patients reported an average of 7.5 medications prescribed, totaling 11.1 doses per day at a cost of
$3,823 per year (Masoudi et al., 2005).
Complexity of medication regimens,
inadequate or confusing instructions,
beliefs regarding use of medication,
and concerns about side effects also
are factors affecting adherence (Moser,
Doering, & Chung, 2005).
Interventions to improve medication adherence include assessing
current self-maintenance practices,
simplifying current prescriptions
(i.e., once daily versus multiple dosing), assessing and addressing patient
education needs, and developing an
acceptable method for reliably taking
medications as prescribed (Morrow
et al., 2004; Morrow, Weiner, Steinley, Young, & Murray, 2007; Riegel &
Moser, 2008; Winland-Brown & Valiante, 2000). For older adults, medication instructions are more effective
if presented in the following order
(Morrow & Leirer, 1999):
1. Identify the medicine.
2. Identify how to take the medicine.
3. Identify possible outcomes.
Older patients also prefer instructions in a larger font, bulleted lists of
information versus paragraph formats,
and use of pictures to support written
information (Morrow et al., 2007).
Drug delivery options to improve
adherence include developing a medication schedule, prefilling weekly pill
boxes, and using automatic dispensers
with voice-activated messages (Morrow et al., 2004; Morrow et al., 2007;

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Winland-Brown & Valiante, 2000).

Other factors to consider when promoting adherence include assistance
with planning for medication side effects, such as adjusting the timing of
diuretic medications for travel and
sleep. Asking patients to bring the
original containers of current medications will facilitate accuracy and assist
identification of any duplication of
medications, as might occur with prescriptions using generic labels versus a
brand name. Support from health care
providers and family is associated with
better medication adherence; therefore, including family in education is
suggested (Wu et al., 2008).
Restriction of sodium intake is difficult for many HF patients (Chin &
Goldman, 1997; Michalsen, Konig, &
Thimme, 1998; Ni et al., 1999). Lack
of knowledge about choosing lowsodium foods, age-related changes in
smell and taste, and unwillingness to
change dietary habits are some of the
factors contributing to lack of adherence to sodium restriction (Bentley,
De Jong, Moser, & Peden, 2005).
Strategies for managing medications
and sodium restriction encompass assessing barriers to adherence (e.g., lack
of knowledge) and facilitating strategies to improve self-care maintenance.
Many HF patients are unsure of how
to limit sodium beyond that added in
cooking or at the table (Lennie et al.,
2008). Even those who report limiting
sodium are often unaware of the sodium content of processed and canned
foods (Dunbar et al., 2005; Lennie et
al., 2008). The guidelines for sodium
restriction vary according to the
source and range from 2 to 4 grams
per day (Heart Failure Society of
America, 2006; Hunt, American College of Cardiology, & American Heart
Association Task Force on Practice
Guidelines, 2005; Riegel et al., 2009).
In reviewing differences in various
published guidelines, a recommendation for limiting sodium to 2.3 grams
per day is suggested in the scientific
statement on self-care published by
the American Heart Association (Riegel et al., 2009).

Table 2

Questions for Assessing Functional Capacity

Are you able to walk a city block or two?
Can you climb a set of stairs without stopping?
How many pillows do you use to sleep at night?
Are you ever short of breath at rest?
If patients are relatively sedentary, ask the following type of questions:
Can you shower and get dressed without stopping because of being short of breath?
Can you make a bed without becoming short of breath?

Similar to promoting medication

adherence, including family members
and other caregivers is important in
educational strategies directed at sodium restriction (Chung et al., 2009;
Dunbar et al., 2005). Strategies for
promoting sodium restriction include
using the labels on food containers to
help patients identify low-, medium-,
and high-sodium foods. An emphasis
on discussing sodium per serving of
prepared food is important, as some
erroneously believe a container equals
one serving. In addition to removing
the salt shaker from the table and eliminating salt when cooking, choosing
the low-sodium version of prepared
foods is to be encouraged. As sodium
indiscretion is a frequent precipitant of
decompensated HF, discussing appropriate food choices, additional consultation with a dietician, and accessing
published resources prior to discharge
may be helpful (e.g., the Heart Failure
Society of Americas How To Follow a
Low-Sodium Diet brochure, available
free from http://www.hfsa.org/pdf/
module2.pdf).

Self-Care Management:
Symptom Recognition,
Evaluation, and Treatment

Self-care management begins with

recognizing a change in symptom
status (Stage 2). Following symptom
recognition, depending on the meaning of the change (HF related or not),
treatment and evaluation of the effectiveness of the treatment occurs
(Stage 3 through Stage 5) (Riegel &

Journal of Gerontological Nursing Vol. 36, No. 11, 2010

Dickson, 2008). Given the difficulty

with accurate symptom assessment,
assisting older adults in identifying
their own unique signs and symptoms of HF may provide a context
for correctly labeling symptoms. To
do this, HF symptom assessment
includes exploring the full range of
potential signs and symptoms versus limiting assessment to dyspnea,
fatigue, and swelling (Table 3). Patients with HF are reported to experience multiple symptoms, with the
mean number of symptoms ranging
from 7 to 15 per person (Bekelman
et al., 2007; Nordgren & Sorensen,
2003; Zambroski, Moser, Bhat, &
Ziegler, 2005). Dyspnea and fatigue
are particularly important targets for
self-care, as these symptoms predict
an increased risk of hospitalization
and death (Ekman et al., 2005). The
goal is the creation of individualized
self-care algorithms with specific
guidelines for self-care management
(Hunt et al., 2009). Symptom profiles vary among HF patients; therefore, teaching patients to monitor
their particular symptoms in clusters
versus viewing them as discrete entities (e.g., weight gain) may benefit in
interpreting their meaning (Jurgens,
Moser, et al., 2009).
Symptom clusters, defined as
three or more symptoms that are
concurrent and related to one another
(Dodd, Miaskowski, & Lee, 2004),
were explored in 687 patients hospitalized with HF (Jurgens, Moser, et
al., 2009). The factor analysis identi-

29

Table 3

Signs and Symptoms of

Heart Failure
Anorexia
Anxiety
Change in mental status
Confusion
Cough
Depression
Difficulty sleeping
Dyspnea
Dyspnea on exertion
Fatigue
Lower extremity edema
Nausea
Orthopnea
Paroxysmal nocturnal dyspnea
Somnolence
Weight gain
Wheezing

fied three clusters that reflected: (a)

acute volume overload (dyspnea, fatigue/low energy, sleep difficulty);
(b) an emotional cluster (depression,
worry, difficulty concentrating/memory); and (c) chronic volume overload
(swelling, increased need to rest, and
dyspnea on exertion). Symptoms of
volume overload in older adults can
be subtle in the early phase of failure
due in part to systemic physiological changes associated with aging and
other comorbidities and health problems. Symptoms occurring together
such as increased weight, fatigue, and
swelling relate to volume overload.
Knowledge of how symptoms cluster may make it easier for patients
to compare differences in symptoms
from day to day, particularly in relation to activity tolerance.
Symptom diaries may be useful
for HF patients to see changes in
symptom burden, although studies
report a variable effect on self-care and
outcomes (Eastwood, Travis, Morgenstern, & Donaho, 2007; Webel, Frazier,
Moser, & Lennie, 2007; White, Howie-

30

Esquivel, & Caldwell, 2010; Wright et

al., 2003). Wright et al. (2003) reported
that diary users were more likely to
attend educational sessions and HF
clinic appointments. Diary users also
had lower symptom rates, shorter hospital stays when admitted, and lower
mortality rates at 1 year. Forty-six percent of non-diary users died within 12
months versus 11% of patients who
did use a diary. Other investigators
reported differences in contact with
health care providers. Diary users had
more contact with health care providers in one study (Eastwood et al., 2007)
but mostly failed to report weight gain
in another (White et al., 2010). Emphasizing action (self-care management) in
response to symptoms is important: In
one study of older adults hospitalized
with decompensated HF, 80% waited
for their symptoms to go away (Jurgens, Hoke, et al., 2009).
Self-care algorithms when symptoms worsen may mean a flexible diuretic plan for some or timely contact
with a health care provider for others
who are uncomfortable with taking
extra medication. Therefore, helping
patients plan for when and how to
access care in the face of worsening
symptoms is imperative. Investigators who tested interventions to improve transitions of care (e.g., hospital
to home), describe this planning for
accessing care as the 911 plan (McCauley, Bixby, & Naylor, 2006). Appropriate planning for treatment will
vary depending on symptom severity.
Dyspnea is one of the most frequent symptoms triggering hospital
admission for symptom management
(Friedman, 1997; Jurgens, 2006; Parshall, 1999). The severity of dyspnea
varies from that only occurring with
activity to experiencing dyspnea at
rest. More severe degrees of dyspnea
may include an inability to speak in
full sentences. Other types of dyspnea include orthopnea, an inability
to breathe while lying flat, or paroxysmal nocturnal dyspnea, which is
acute dyspnea that wakes patients 2 to
4 hours after going to sleep. Teaching
patients to report new or worsening

orthopnea is important since it is the

most sensitive and specific symptom
of elevated filling pressures (Grady
et al., 2000). Older adults with HF
are less likely to report orthopnea or
DOE (Ahmed, Allman, Aronow, &
DeLong, 2004), so reviewing other
symptoms such as dyspnea at rest,
paroxysmal nocturnal dyspnea, fatigue, and lower extremity edema
may increase the prediction of HF.
Patients with maximized HF
medications and adequate self-care
may continue to experience dyspnea. Pacing activity will moderate
the occurrence of dyspnea in some
patients. For those with dyspnea at
rest, sitting up and leaning forward
improves use of the diaphragm to
breathe and decreases accessory
muscle use for acutely dyspneic patients. Positioning patients for sleep
on their right side versus their left
side may avert adverse changes in
filling pressures and cardiac output
(Leung, Bowman, Parker, Newton,
& Bradley, 2003). Cognitive-behavioral strategies such as progressive
muscle relaxation and distraction
improved breathlessness in cancer
patients (Bredin et al., 1999) and may
be useful for HF patients.
Fatigue is common, and management of fatigue is aimed at identifying and treating any underlying cause
such as anemia, sleep disturbance,
dehydration, endocrine abnormalities, electrolyte abnormalities, side
effects of medications (e.g., betaadrenergic blockers), and depression
(Adler, Goldfinger, Kalman, Park, &
Meier, 2009; Goodlin et al., 2004).
Differentiating fatigue associated
with anxiety and depression from
other causes is important in selecting
strategies for care.
Exercise may be a self-care option
for some patients to manage fatigue.
The HF-ACTION trial examined
the efficacy and safety of exercise in
2,331 medically stable outpatients
with HF (OConnor et al., 2009).
Exercise was reported as safe in addition to being associated with modest reductions in hospitalization and

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mortality for patients with HF. A

small pilot study of a program of exercise typical of cardiac rehabilitation
programs was reported to decrease
fatigue (Pozehl, Duncan, & Hertzog,
2008). Investigators have used a variety of exercise modalities such as
walking, cycling, weight training,
and dancing. The American Heart
Association recommends exercise
(individually tailored) for HF patients who are clinically stable, even
for those with severe left ventricular
dysfunction (Hunt et al., 2005). Referral for exercise safety evaluation is
therefore appropriate.

Implications for Nursing

Transitions of care such as discharge from hospital to home is a

vulnerable time for older adults with
HF. Multiple chronic and comorbid
conditions, debilitating symptoms,
complex management protocols, and
inadequate self-management skills
contribute to problems associated
with such transitions (Happ, Naylor,
& Roe-Prior, 1997). Research examining this transition has focused on
multidisciplinary and advanced practice nurse (APN) strategies for the
management of HF to decrease the
risk of rehospitalization and improve
overall outcomes. These studies have
provided evidence that multidisciplinary HF management programs
and APN-coordinated health care
teams prevent complications and improve outcomes as well as reduce the
cost of care (McCauley et al., 2006;
Naylor et al., 1994). Ultimately, any
community-dwelling older adult will
need to engage in self-care.
The role of nursing in the trajectory of HF symptom management
extends from identification of symptoms as they relate to functional
status and comorbid illness through
to treatment and education of the
patient and caregivers. Promotion
of self-care is an important strategy
for symptom management, as adherence to prescribed treatment (pharmacological and behavioral) is key
to averting acute decompensation of

keypoints

Jurgens, C.Y., Shurpin, K.M., & Gumersell, K.A. (2010). Challenges and Strategies for
Heart Failure Symptom Management in Older Adults. Journal of Gerontological Nursing,
36(11), 24-33.

Assessment and promotion of self-care is an important strategy

for heart failure (HF) symptom management and the prevention
of hospitalization.

2
3
4

A sedentary lifestyle and comorbid illness complicate the assessment and meaning of HF symptoms in older adults.
Assessing symptom burden with activity versus at rest as activity
tolerance is one indicator of symptom impact.
Older HF patients and their families need specific education on
when and how to access support from health care providers for a
change in symptoms.

HF. In particular, HF patients need to

know when and how to access support from health care providers for
assistance with symptoms, as all too
frequently patients wait for symptoms to improve (Jurgens, Hoke,
et al., 2009). Nursing management
of older adults with HF therefore
consists of assessing symptoms and
assisting both patients and caregivers in understanding the meaning of
individual symptom clusters and the
process for responding to changes in
symptom burden.

Conclusion

Self-care is an essential component

of HF disease management. Promoting self-care includes regularly assessing self-care behaviors, involving
family and other sources of support
in plans of care, and explaining the
importance of ongoing management.
Assessing self-care practices will
help providers identify individual
educational needs to target for review. Clinically stable or asymptomatic HF patients may view HF as an
acute rather than a chronic illness,
which may impede consistent selfcare practices. HF as a chronic and
progressive illness is challenging for
patients and their families. Promoting self-care in addition to medical
therapy will help older adults with

Journal of Gerontological Nursing Vol. 36, No. 11, 2010

HF improve their quality of life by

managing HF symptoms.
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About the Authors

Dr. Jurgens is Associate Dean for

Nursing Research and Clinical Associate
Professor, Dr. Shurpin is Professor, Stony
Brook University, School of Nursing, and
Ms. Gumersell is Clinical Nurse Specialist,
Stony Brook University Medical Center,
Stony Brook, New York.
The authors disclose that they have no
significant financial interests in any product
or class of products discussed directly or indirectly in this activity, including research
support.
Address correspondence to Corrine
Y. Jurgens, PhD, RN, ANP-BC, FAHA,
Associate Dean for Nursing Research and
Clinical Associate Professor, Stony Brook
University, School of Nursing, HSC L2,
Stony Brook, NY 11794-8240; e-mail:
Corrine.jurgens@stonybrook.edu.
Received: March 6, 2010
Accepted: June 16, 2010
Posted: October 22, 2010
doi:10.3928/00989134-20100930-06

33

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