Eneida Rejane Rabelo

Comparison of self-care behaviors of heart failure patients in 15 countries worldwide

OBJECTIVE Clinicians worldwide seek to educate and support heart failure patients to engage in self-care. We aimed to describe self-care behaviors of patients from 15 countries across three continents. METHODS Data on self-care were pooled from 5964 heart failure patients from the United States, Europe, Australasia and South America. Data on self-care were collected with the Self-care of Heart Failure Index or the European Heart Failure Self-care Behavior Scale. RESULTS In all the samples, most patients reported taking their medications as prescribed but exercise and weight monitoring were low. In 14 of the 22 samples, more than 50% of the patients reported low exercise levels. In 16 samples, less than half of the patients weighed themselves regularly, with large differences among the countries. Self-care with regard to receiving an annual flu shot and following a low sodium diet varied most across the countries. CONCLUSION Self-care behaviors are sub-optimal in heart failure patients and need to be improved worldwide. PRACTICE IMPLICATIONS Interventions that focus on specific self-care behaviors may be more effective than general educational programs. Changes in some health care systems and national policies are needed to support patients with heart failure to increase their self-care behavior.

Aggressive Fluid and Sodium Restriction in Acute Decompensated Heart Failure: A Randomized Clinical Trial

IMPORTANCE The benefits of fluid and sodium restriction in patients hospitalized with acute decompensated heart failure (ADHF) are unclear. OBJECTIVE To compare the effects of a fluid-restricted (maximum fluid intake, 800 mL/d) and sodium-restricted (maximum dietary intake, 800 mg/d) diet (intervention group [IG]) vs a diet with no such restrictions (control group [CG]) on weight loss and clinical stability during a 3-day period in patients hospitalized with ADHF. DESIGN Randomized, parallel-group clinical trial with blinded outcome assessments. SETTING Emergency room, wards, and intensive care unit. PARTICIPANTS Adult inpatients with ADHF, systolic dysfunction, and a length of stay of 36 hours or less. INTERVENTION Fluid restriction (maximum fluid intake, 800 mL/d) and additional sodium restriction (maximum dietary intake, 800 mg/d) were carried out until the seventh hospital day or, in patients whose length of stay was less than 7 days, until discharge. The CG received a standard hospital diet, with liberal fluid and sodium intake. MAIN OUTCOMES AND MEASURES Weight loss and clinical stability at 3-day assessment, daily perception of thirst, and readmissions within 30 days. RESULTS Seventy-five patients were enrolled (IG, 38; CG, 37). Most were male; ischemic heart disease was the predominant cause of heart failure (17 patients [23%]), and the mean (SD) left ventricular ejection fraction was 26% (8.7%). The groups were homogeneous in terms of baseline characteristics. Weight loss was similar in both groups (between-group difference in variation of 0.25 kg [95% CI, -1.95 to 2.45]; P = .82) as well as change in clinical congestion score (between-group difference in variation of 0.59 points [95% CI, -2.21 to 1.03]; P = .47) at 3 days. Thirst was significantly worse in the IG (5.1 [2.9]) than the CG (3.44 [2.0]) at the end of the study period (between-group difference, 1.66 points; time × group interaction; P = .01). There were no significant between-group differences in the readmission rate at 30 days (IG, 11 patients [29%]; CG, 7 patients [19%]; P = .41). CONCLUSIONS AND RELEVANCE Aggressive fluid and sodium restriction has no effect on weight loss or clinical stability at 3 days and is associated with a significant increase in perceived thirst. We conclude that sodium and water restriction in patients admitted for ADHF are unnecessary. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01133236.

Improved Oral Anticoagulation After a Dietary Vitamin K–Guided Strategy. A Randomized Controlled Trial

Background— Dietary vitamin K is thought to be an important factor that interferes with anticoagulation stability, but the clinical applicability of this interaction has not been evaluated adequately in prospective studies. Methods and Results— In a randomized controlled trial that enrolled outpatients with a recent international normalized ratio (INR) outside the therapeutic target, we compared 2 strategies to optimize long-term oral anticoagulation: (1) a conventional approach based on changes in anticoagulant prescription and (2) a dietary vitamin K–guided strategy based on simple modifications of the amount of vitamin K–rich foods ingested per week. The primary efficacy end point was the percentage of patients who achieved a prespecified INR target at 90 days after randomization. Study population (n=132) predominantly included men with mechanical heart prostheses (58%) or atrial fibrillation (35%). Over time, patients allocated to the vitamin K–guided strategy reached the prespecified INR more frequently so that after 90 days of follow-up, 74% were on target compared with 58% of patients managed conventionally (P=0.04). Patients allocated to the dietary vitamin K–guided strategy had the same magnitude and direction of INR variation as those observed with the conventional approach in the short term (15 days) for both underanticaogulated and overanticoagulated patients. Minor bleeding or use of parenteral vitamin K were also marginally less frequent in patients managed according to the dietary intervention (1 [1.5%] versus 7 [11%]; P=0.06). Conclusions— A vitamin K–guided management strategy to adjust long-term oral anticoagulation is feasible and safe and may result in an increased chance of reaching target levels of INR.

Nursing process: from literature to practice. What are we actually doing?

OBJETIVO: descrever os passos do processo de enfermagem descrito na literatura e investigar como este e realizado na rotina diaria de um hospital geral. METODOS: Estudo transversal retrospectivo (maio/junho 2005) realizado em Porto Alegre, RS. Foram revisados prontuarios de pacientes adultos admitidos em unidades cirurgicas, clinicas e unidade de terapia intensiva para identificar os passos do processo de enfermagem realizados durante as primeiras 48 horas da admissao. O instrumento de coleta de dados foi elaborado de acordo com a literatura. RESULTADOS: 302 prontuarios foram avaliados. Registros de enfermagem e exame fisico estavam descritos em mais de 90% dos prontuarios revisados. O diagnostico de enfermagem nao foi encontrado em nenhum dos prontuarios. Entre os passos realizados do processo, a prescricao foi a menos frequente. A evolucao dos pacientes foi registrada em mais de 95% dos prontuarios. CONCLUSAO: Todos os passos recomendados na literatura, exceto o diagnostico de enfermagem sao realizados na instituicao pesquisada.OBJECTIVES To describe the steps of the nursing process as prescribed in the literature and to investigate the process as actually applied in the daily routine of a general hospital. METHODS Cross-sectional retrospective study (May/June 2005), performed in a hospital in Porto Alegre, RS. Medical records of adult patients admitted to a surgical, clinical or intensive care unit were reviewed to identify the nursing process steps accomplished during the first 48 h after admission. The form for data collection was structured according to other reports. RESULTS 302 medical records were evaluated. Nursing records and physical examination were included in over 90% of them. Nursing diagnosis was not found in any of the records. Among the steps performed, prescription was the least frequent. Evolution of the case was described in over 95% of the records. CONCLUSIONS All nursing steps recommended in the literature, except for diagnosis, are performed in the research institution.Objectives: To describe the steps of the nursing process as prescribed in the literature and to investigate the process as actually applied in the daily routine of a general hospital. Methods: Cross-sectional retrospective study (May/June 2005), performed in a hospital in Porto Alegre, RS. Medical records of adult patients admitted to a surgical, clinical or intensive care unit were reviewed to identify the nursing process steps accomplished during the first 48h after admission. The form for data collection was structured according to other reports. Results: 302 medical records were evaluated. Nursing records and physical examination were included in over 90% of them. Nursing diagnosis was not found in any of the records. Among the steps performed, prescription was the least frequent. Evolution of the case was described in over 95% of the records. Conclusions: All nursing steps recommended in the literature, except for diagnosis, are performed in the research institution.

Factors that inhibit the use of nursing language.

PURPOSE The purpose of this study was to identify the impact of institutional, professional, and personal factors on nurses and on their efforts to make nursing diagnoses. METHODS A cross-sectional study was conducted in which all participants completed a questionnaire established to measure each individual group of factors. A score (0-100) was established to measure each group of factors. RESULTS Twenty-one nurses responded that their busy shifts, the number of patients per nurse, and their involvement with administrative tasks were the three parameters most frequently identified as interfering with implementing nursing diagnosis. CONCLUSION The recognition of these factors and improved institutional support may facilitate the implementation of nursing diagnoses. PRACTICE IMPLICATIONS Electronic records may contribute to the implementation of the nursing process, particularly if the identified signs and symptoms are documented and then linked to nursing diagnoses and interventions.

What to teach to patients with heart failure and why: the role of nurses in heart failure clinics

O principal objetivo do tratamento da insuficiencia cardiaca (IC) consiste em alcancar e manter a estabilidade clinica dos pacientes. Varios estudos demonstram que programas multidisciplinares para educacao sistematica sobre a doenca sao estrategias positivas para estes pacientes. Enfermeiros engajados em clinicas de IC desempenham papel fundamental no processo de educacao e acompanhamento dos pacientes. Os objetivos deste processo sao ensinar, reforcar, melhorar e avaliar constantemente as habilidades dos pacientes para o autocuidado, que incluem a monitorizacao do peso, a restricao de sodio e de liquidos, a realizacao de atividade fisica, o uso regular das medicacoes, a monitorizacao de sinais e de sintomas de piora da doenca e o contato precoce com a equipe assistencial. Desta forma, a educacao para o entendimento da IC, e o desenvolvimento de habilidades para o autocuidado, sao considerados chaves para melhorar a adesao, evitar crises de descompensacao e consequentemente manter a estabilidade clinica dos pacientes. Neste artigo nos revisamos detalhadamente os aspectos envolvidos no processo de educacao dispensados aos pacientes por enfermeiros no contexto das clinicas de IC.

Educação e monitorização por telefone de pacientes com insuficiência cardíaca: ensaio clínico randomizado

FUNDAMENTO: Diferentes abordagens de enfermagem no manejo de pacientes com insuficiencia cardiaca (IC) tem demonstrado beneficios na reducao da morbidade e mortalidade. Entretanto, a combinacao de educacao intra-hospitalar com contato telefonico apos a alta hospitalar tem sido pouco explorada. OBJETIVO: Comparar dois grupos de intervencao de enfermagem entre pacientes hospitalizados devido a IC descompensada: o grupo intervencao (GI) recebeu intervencao educativa de enfermagem durante a hospitalizacao, seguida de monitorizacao por telefone apos a alta hospitalar e o grupo controle (GC) recebeu apenas a intervencao hospitalar. Os desfechos foram conhecimento da IC e autocuidado, numero de visitas a emergencia, re-hospitalizacoes e morte em um periodo de tres meses. METODOS: Ensaio clinico randomizado. Pacientes adultos com IC e fracao de ejecao do ventriculo esquerdo (FEVE) < 45% que podiam ser contatados por telefone apos a alta foram estudados. O conhecimento da IC foi avaliado por meio de um questionario padronizado que tambem incluia questoes referentes ao conhecimento do autocuidado, o qual foi respondido durante o periodo de hospitalizacao e tres meses depois. Para os pacientes do grupo GI, os contatos foram realizados por meio de telefonemas e as entrevistas finais foram conduzidas em ambos os grupos ao final do estudo. RESULTADOS: Quarenta e oito pacientes foram alocados no GI e 63 no grupo GC. A idade media (63 ± 13 anos) e FEVE (aproximadamente 29%) eram similares nos dois grupos. Os escores para conhecimento da IC e autocuidado foram similares na avaliacao basal. Tres meses depois, ambos os grupos demonstraram melhora significativa dos escores de conhecimento da IC e autocuidado (P < 0,001). Outros desfechos foram similares. CONCLUSAO: A intervencao educativa de enfermagem intra-hospitalar beneficiou todos os pacientes com IC em relacao ao conhecimento da doenca e autocuidado, independente do contato telefonico apos a alta hospitalar.BACKGROUND Nursing approaches to manage patients with heart failure (HF) showed benefits in reducing the morbidity and mortality. However, combining intra-hospital education with telephone contact after hospital discharge has been little explored. OBJECTIVE To compare two nursing intervention groups among patients hospitalized due to decompensated HF: the intervention group (IG) received educational nursing intervention during hospitalization followed by telephone monitoring after discharge and the control group (CG) received in-hospital intervention only. Outcomes were levels of HF and self-care knowledge, the frequency of visits to the emergency room, rehospitalizations and deaths in a three-month period. METHODS Randomized clinical trial. We studied adult HF patients with left ventricle ejection fraction (LVEF) < 45% who could be contacted by telephone after discharge. HF awareness was evaluated through a standardized questionnaire that also included questions regarding self-care knowledge, which was answered during the hospitalization period and three months later. For patients in the IG group contacts were made using phone calls and final interviews were conducted in both groups at end of the study. RESULTS Forty-eight patients were assigned to the IG and 63 to the CG. Mean age (63 ± 13 years) and L (around 29%) were similar in the two groups. Scores for HF and self-care knowledge were similar at baseline. Three months later, both groups showed significantly improved HF awareness and self-care knowledge scores (P < 0.001). Other outcomes were similar. CONCLUSION An in-hospital educational nursing intervention benefitted all HF patients in understanding their disease, regardless of telephone contact after discharge.

Education and telephone monitoring by nurses of patients with heart failure: randomized clinical trial

FUNDAMENTO: Diferentes abordagens de enfermagem no manejo de pacientes com insuficiencia cardiaca (IC) tem demonstrado beneficios na reducao da morbidade e mortalidade. Entretanto, a combinacao de educacao intra-hospitalar com contato telefonico apos a alta hospitalar tem sido pouco explorada. OBJETIVO: Comparar dois grupos de intervencao de enfermagem entre pacientes hospitalizados devido a IC descompensada: o grupo intervencao (GI) recebeu intervencao educativa de enfermagem durante a hospitalizacao, seguida de monitorizacao por telefone apos a alta hospitalar e o grupo controle (GC) recebeu apenas a intervencao hospitalar. Os desfechos foram conhecimento da IC e autocuidado, numero de visitas a emergencia, re-hospitalizacoes e morte em um periodo de tres meses. METODOS: Ensaio clinico randomizado. Pacientes adultos com IC e fracao de ejecao do ventriculo esquerdo (FEVE) < 45% que podiam ser contatados por telefone apos a alta foram estudados. O conhecimento da IC foi avaliado por meio de um questionario padronizado que tambem incluia questoes referentes ao conhecimento do autocuidado, o qual foi respondido durante o periodo de hospitalizacao e tres meses depois. Para os pacientes do grupo GI, os contatos foram realizados por meio de telefonemas e as entrevistas finais foram conduzidas em ambos os grupos ao final do estudo. RESULTADOS: Quarenta e oito pacientes foram alocados no GI e 63 no grupo GC. A idade media (63 ± 13 anos) e FEVE (aproximadamente 29%) eram similares nos dois grupos. Os escores para conhecimento da IC e autocuidado foram similares na avaliacao basal. Tres meses depois, ambos os grupos demonstraram melhora significativa dos escores de conhecimento da IC e autocuidado (P < 0,001). Outros desfechos foram similares. CONCLUSAO: A intervencao educativa de enfermagem intra-hospitalar beneficiou todos os pacientes com IC em relacao ao conhecimento da doenca e autocuidado, independente do contato telefonico apos a alta hospitalar.BACKGROUND Nursing approaches to manage patients with heart failure (HF) showed benefits in reducing the morbidity and mortality. However, combining intra-hospital education with telephone contact after hospital discharge has been little explored. OBJECTIVE To compare two nursing intervention groups among patients hospitalized due to decompensated HF: the intervention group (IG) received educational nursing intervention during hospitalization followed by telephone monitoring after discharge and the control group (CG) received in-hospital intervention only. Outcomes were levels of HF and self-care knowledge, the frequency of visits to the emergency room, rehospitalizations and deaths in a three-month period. METHODS Randomized clinical trial. We studied adult HF patients with left ventricle ejection fraction (LVEF) < 45% who could be contacted by telephone after discharge. HF awareness was evaluated through a standardized questionnaire that also included questions regarding self-care knowledge, which was answered during the hospitalization period and three months later. For patients in the IG group contacts were made using phone calls and final interviews were conducted in both groups at end of the study. RESULTS Forty-eight patients were assigned to the IG and 63 to the CG. Mean age (63 ± 13 years) and L (around 29%) were similar in the two groups. Scores for HF and self-care knowledge were similar at baseline. Three months later, both groups showed significantly improved HF awareness and self-care knowledge scores (P < 0.001). Other outcomes were similar. CONCLUSION An in-hospital educational nursing intervention benefitted all HF patients in understanding their disease, regardless of telephone contact after discharge.

Dietary vitamin K intake and anticoagulation in elderly patients.

Purpose of reviewVitamin K is an essential co-factor for the synthesis of several coagulation factors. Oral anticoagulants competitively inhibit enzymes that participate in vitamin K metabolism. The purpose of this review is to evaluate the potential interaction of dietary vitamin K and coagulation stability, particularly in the elderly patient. Recent findingsRecent prospective evidences suggest that dietary vitamin K plays an essential role in anticoagulation stability. Vitamin K intake of more than 250 μg/day was shown to decrease warfarin sensitivity in anticoagulated patients consuming regular diets. In a randomized crossover study, brief periods of changes on vitamin K intake also had significant effects on coagulation parameters. Patients that were allocated to an 80% decrease of intake increased International Normalized Ratio (INR) by almost 30% 7 days after the intervention. Similarly, it was estimated by dietary records that for each increase in 100 μg of vitamin K intake, the INR would be reduced by 0.2. A recent study also demonstrated that over-the-counter multivitamin supplements contain enough vitamin K1 to significantly alter coagulation parameters. SummaryContemporary data strengthen the concept that the interaction between dietary vitamin K and coumarin derivatives is clinically relevant and plays a major role in INR fluctuations in chronic anticoagulated patients.

Manejo não-farmacológico de pacientes hospitalizados com insuficiência cardíaca em hospital universitário

OBJETIVO: Descrever o manejo nao-farmacologico de pacientes internados com insuficiencia cardiaca (IC) em um hospital universitario. METODOS: Estudo de coorte longitudinal de pacientes com IC diagnosticados pelo escore de Boston. Durante as 72 horas iniciais de internacao, enfermeiras da clinica de IC realizaram entrevistas padronizadas e revisoes de prontuarios. RESULTADOS: Foram avaliadas 283 internacoes de 239 pacientes (idade = 64 ± 15 anos), aproximadamente 50% sexo masculino e 37% de etiologia isquemica. O padrao de prescricao dos diferentes cuidados nao-farmacologicos foi restricao de sal em 97%, controle de diurese em 85%, balanco hidrico em 75%, controle de peso em 61% e restricao hidrica em apenas 25% das internacoes. Embora os cuidados referidos estivessem nas prescricoes, frequentemente nao eram realizados pela equipe responsavel (p < 0,01 para todas as comparacoes). O uso irregular dos farmacos prescritos na semana anterior a hospitalizacao ocorreu em 22% e 21% dos pacientes sem e com re-internacoes, respectivamente (p = 1,00). Os pacientes com reinternacoes (n = 38) apresentaram disfuncao sistolica grave, mais hospitalizacoes previas e tempo prolongado de sintomas de IC, quando comparados aos nao-reinternados, alem de terem conhecimento mais adequado de aspectos relacionados com autocuidado (todos valores de p < 0,05). Na analise multivariada, apenas tempo de doenca sintomatica permaneceu como preditor independente de reinternacoes. CONCLUSAO: Nossos dados indicam que mesmo em hospital universitario ha importantes lacunas relativas a prescricao e realizacao de medidas nao-farmacologicas de autocuidado na IC. Demonstramos que pacientes que reinternam aparentam bom conhecimento da doenca; esse achado, entretanto, esta relacionado de forma importante com a gravidade e o tempo de evolucao da IC.