Cardiovascular Critical Care SIGNS AND SYMPTOMS OF HEART FAILURE: ARE YOU ASKING THE RIGHT QUESTIONS? By Nancy Albert, PhD, CCNS, CCRN, NE-BC, Kathleen Trochelman, RN, MSN, Jianbo Li, PhD, and Songhua Lin, MS Background Patients may not verbalize common and atypical signs and symptoms of heart failure and may not understand their association with worsening disease and treatments. Objectives To examine prevalence of signs and symptoms relative to demographics, care setting, and functional class. Methods A convenience sample of 276 patients (164 ambula- tory, 112 hospitalized) with systolic heart failure completed a 1-page checklist of signs and symptoms experienced in the preceding 7 days (ambulatory) or in the 7 days before hospital- ization. Demographic and medical history data were collected. C E 1.0 Hour Results Mean age was 61.6 (SD, 14.8) years, 65% were male, 58% were white, and 45% had ischemic cardiomyopathy. Hospitalized patients reported more sudden weight gain, Notice to CE enrollees: weight loss, severe cough, low/orthostatic blood pressure, A closed-book, multiple-choice examination profound fatigue, decreased exercise, restlessness/confusion, following this article tests your under standing of irregular pulse, and palpitations (all P < .05). Patients in func- the following objectives: tional class IV reported more atypical signs and symptoms of 1. Recognize signs and atypical symptoms heart failure (severe cough, nausea/vomiting, diarrhea or loss that may be associated with worsening of appetite, and restlessness, confusion, or fainting, all P ≤.001). heart failure and functional class. Sudden weight gain increased from 5% in functional class I 2. Define key elements of a patient teaching to 37.5% in functional class IV (P < .001). Dyspnea occurred in plan related to heart failure and response all functional classes (98%-100%) and both settings (92%-100%). to treatment. Profound fatigue was associated with worsening functional 3. Define reliable indicators of functional class class (P < .001) and hospital setting (P = .001); paroxysmal noc- for heart failure patients. turnal dyspnea was associated with functional class IV (P = .02) and hospital setting (P <.001). To read this article and take the CE test online, Conclusion Profound fatigue is more reliable than dyspnea as visit www.ajcconline.org and click “CE Articles an indicator of functional class. Nurses must recognize atypi- in This Issue.” No CE test fee for AACN members. cal signs and symptoms of worsening functional class to deter- mine clinical status and facilitate patient care decisions. ©2009 American Association of Critical-Care Nurses (American Journal of Critical Care. 2010;19:443-453) doi: 10.4037/ajcc2009314 www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2010, Volume 19, No. 5 443 eart failure is a clinical syndrome characterized by a group of signs and symp- toms. The incidence of heart failure continues to increase, with 660000 new cases diagnosed annually in adults aged 45 and over. For men and women at age 40, the lifetime risk of heart failure developing is currently 1 in 5.1 Thus it is important for health care providers to better understand the signs and symp- Htoms of heart failure so that diagnosis is not missed at first presentation and worsening status is identified early and treated promptly. Additionally, common signs and symptoms of heart failure may be well known to health care providers who treat heart failure routinely, but atypical signs and symptoms associated with worsening status may not be recognized at presentation. Heart failure represents a substantial burden to patients and nurses recognize signs and symptoms of the health care system, with estimated direct and heart failure and understand the management of heart indirect costs in 2008 expected to approach $35 failure, interconnections between bodily changes, sen- billion,1 so it is important for health care providers sations, and behaviors may become more relevant. and patients to quantify common and atypical Patients may not verbalize signs or symptoms to signs and symptoms of heart failure in order to health care providers, either because providers do not optimize diagnostic testing and treat- ask or because patients believe or perceive the signs Recognizing signs ment decisions and facilitate appro- and symptoms to be unrelated to the heart. Alterna- priate monitoring of overall status. tively, patients who have not been educated in symp- and symptoms of Because signs and symptoms of tom monitoring or those who are fearful or uncertain heart failure are important determi- about taking actions when symptomatic may cope by worsening heart nants of worsening status, learning ignoring signs and symptoms, taking action only failure may affect their frequency relative to care set- when signs and symptoms are severe, or behaving in ting and clinical status (New York ways that ultimately exacerbate heart failure. a patient’s decision Heart Association [NYHA] functional Many behavioral theorists include signs and to seek treatment. class) provides insight about determi- symptoms as a precursor to coping or self-care nants of current heart failure–related behaviors. Behavioral models that directly or indi- health status that may affect decisions about the rectly link the signs and symptoms of a disease or need for hospitalization, readiness for discharge, and condition and behavior are the Common Sense frequency of monitoring. Model of Illness,3-5 the Health Promotion Model,6 Further, recognition of signs and symptoms of the Health Belief Model,7 the Self- worsening heart failure may affect a patient’s decision Regulation Model,8 and the Symptom Management to seek treatment, follow self-care recommendations, Model.9 For example, in the Common Sense Model and adhere to medications and other aspects of the of Illness, implicit sensations and symptoms of ill- treatment plan. In qualitative research, patients with ness are processed on both cognitive and emotional heart failure did not recognize common but not heart- levels to form a conscious level of danger and threat specific symptoms such as dyspnea and fatigue as that leads to goals for coping and coping actions. If important markers of worsening condition.2 When acknowledgment of signs and symptoms is a precur- sor to coping by adhering to self-care behaviors, health care professionals need to better understand About the Authors the scope of patients’ signs and symptoms so they Nancy Albert is director of nursing research and innova- can adequately assess patients’ status and provide tion in the Nursing Institute and a clinical nurse special- ist in the Kaufman Center for Heart Failure, Kathleen education and counseling. Trochelman is a nurse researcher in nursing research The primary aim of this study was to determine and innovation at the Nursing Institute, and Jianbo Li is patients’ perception of signs and symptoms of heart a statistician and Songhua Lin is a statistical program- mer, both in Quantitative Health Sciences, at Cleveland failure before an ambulatory visit or hospitalization. Clinic in Cleveland, Ohio. The secondary aims were to use a preprinted check- list of possible signs and symptoms of heart failure Corresponding author: Nancy Albert, PhD, CCNS, CCRN, NE-BC, FAHA, FCCM, Cleveland Clinic, 9500 Euclid Avenue, Mail to examine if symptoms differed relative to demo- code J3-4, Cleveland, OH 44195 (e-mail: [email protected]). graphics, NYHA functional class, and (for patients in NYHA functional class III or IV) care setting. 444 AJCCAMERICAN JOURNAL OF CRITICAL CARE, September 2010, Volume 19, No. 5 www.ajcconline.org Methods used in another study11 before this research. The label Setting and Sample NYHA functional class I is commonly thought of as This descriptive, cross-sectional study was con- asymptomatic heart failure; however, in this study it ducted at the Cleveland Clinic in Cleveland, Ohio, matched the original definition a large tertiary care medical center with both ambu- and reflected that symptoms did The checklist latory care and hospital services, including cardiac not prohibit or limit carrying out transplantation, for patients with heart failure. The ordinary physical activities of daily format prompted institutional review board approved the study pro- living. Patients could have reported patients to report tocol, and work was completed with the ethical symptoms on the checklist and standards set forth in the Helsinki Declaration of reported NYHA functional class I all signs and 1975. Study candidates were 276 adults: 164 sched- status if they believed ordinary uled for an ambulatory visit in the heart failure dis- physical activity did not cause symptoms they ease management program (a clinic led by an undue dyspnea, fatigue, palpita- were experiencing, advanced practice nurse) and 112 patients being tions, or chest pain. treated in the hospital for exacerbation of chronic The checklist format prompted rather than only heart failure. Convenience sampling was used to patients to report all signs and those they thought collect data for 11 months. Overall sample size was symptoms they were experiencing, not predetermined. The enrollment goal was to rather than reporting only those were related to achieve a minimum sample of 40 patients per NYHA that they thought were related to heart failure. functional class so that adequate assessment by heart failure. Wording of items was functional class could be completed. Inclusion crite- simplified to enhance patients’ understanding;