Martha Biddle

Critical care nursing practice regarding patient anxiety assessment and management

Anxiety is common in critically ill patients and can adversely affect recovery if not properly assessed and treated. The objectives of this study were to: (1) identify the clinical indicators that critical care nurses consider to be the defining attributes of anxiety in critically ill patients; and (2) delineate the interventions that critical care nurses use to alleviate anxiety in their patients. A total of 2500 nurses who worked in adult critical care areas were randomly selected from the membership of the American Association of Critical Care Nurses. Nurses selected were mailed a survey designed to determine what they considered to be the important attributes of anxiety in their patients and what interventions they commonly used to manage anxiety. The 593 nurses (31.6% response rate) who responded identified 70 individual anxiety indicators and 61 anxiety management strategies that were categorized into four and three major categories, respectively. The four major anxiety assessment categories were: (1) physical/physiological; (2) behavioral; (3) psychological/cognitive; and (4) social. The three major anxiety management strategies were: (1) care techniques; (2) improving knowledge and communication; and (3) support. Critical care nurses reported numerous and distinctive anxiety indicators and management strategies. Further research is needed to examine exactly how appropriate and effective these assessment indicators and management strategies are.

Medication adherence mediates the relationship between marital status and cardiac event-free survival in patients with heart failure

OBJECTIVE Prognosis is worse in unmarried patients compared with married patients with heart failure (HF). The reasons for differences in outcomes are unclear, but variations in medication adherence may play a role, because medication adherence is essential to achieving better outcomes. The study objective was to determine whether medication adherence mediated the relationship between marital status and cardiac event-free survival in patients with HF. METHODS Demographic, clinical, and psychosocial data were collected by questionnaires and medical record review for 136 patients with HF (aged 61 ± 11 years, 70% were male, 60% were in New York Heart Association class III/IV). Medication adherence was monitored objectively for 3 months using the Medication Event Monitoring System. Cardiac event-free survival data were obtained by patient/family interview, hospital database, and death certificate review. A series of regression and Cox survival analyses were performed to determine whether medication adherence mediated the relationship between marital status and event-free survival. RESULTS Cardiac event-free survival was worse in unmarried patients than in married patients. Unmarried patients were more likely to be nonadherent and 2 times more likely to experience an event than married patients (P = .017). Marital status was not a significant predictor of event-free survival after entering medication adherence in the model, demonstrating a mediation effect of adherence on the relationship of marital status to survival. CONCLUSION Medication adherence mediated the relationship between marital status and event-free survival. It is important to design interventions to increase medication adherence that take into account subgroups, such as unmarried patients, who are at higher risk for nonadherence.

Multivariate analysis of predictors of pre-hospital delay in acute coronary syndrome

BACKGROUND Few studies have had the opportunity to examine a broad range of predictors of pre-hospital delay from a multivariate perspective that includes not only sociodemographic and clinical features but also atypical symptoms, patient appraisal and behavior, across the acute coronary syndrome (ACS) spectrum. METHODS A total of 1894 hospitalized ACS patients were recruited predischarge after an ACS event. Patients completed a detailed questionnaire and clinical details were verified with their case notes. RESULTS The median pre-hospital delay times were, 4.06, 2.70, 4.51 and 5.50h, for all ACS, ST elevated myocardial infarction (STEMI), non-STEMI and unstable angina (UA) subgroups respectively. Multiple regression models examining 33 predictors of pre-hospital delay were significant (p<0.001), accounting for 32%, 42%, 34% and 29% of the variance for all ACS, STEMI, non-STEMI and UA subgroups respectively. The predictors that were singularly significantly associated with longer pre-hospital delay within all ACS were: taking medications, visiting family physician, and symptoms that were intermittent in nature. In the MI subgroups, not using an ambulance and gradual symptom onset, were also associated with longer delay. In STEMI patients non-attribution of symptoms to heart was also associated with longer pre-hospital delay. CONCLUSIONS Multivariable analyses found that although sociodemographic, clinical history or situational predictors contributed to the variance in pre-hospital delay, the main predictors of pre-hospital delay were behavioral and symptom presentation factors. These factors should therefore be incorporated into patient education and interventions, to further improve patient pre-hospital delay time.

Medication adherence, depressive symptoms, and cardiac event-free survival in patients with heart failure.

BACKGROUND Medication nonadherence and depressive symptoms predict hospitalization and death in patients with heart failure (HF). Depressed patients have lower medication adherence than nondepressed patients. However, the predictive power of the combination of medication adherence and depressive symptoms for hospitalization and death has not been investigated in patients with HF. OBJECTIVE The aim of this study was to explore the combined influence of medication adherence and depressive symptoms for prediction of cardiac event-free survival in patients with HF. METHODS AND RESULTS We monitored medication adherence in 216 HF patients who completed the Patient Health Questionnaire-9 (PHQ-9) at baseline. Medication adherence was measured objectively with the use of the Medication Event Monitoring System (MEMS). Patients were followed for up to 3.5 years to collect data on cardiac events. Survival analyses were used to compare cardiac event-free survival among groups. The risk of experiencing a cardiac event for patients with medication nonadherence and depressive symptoms was 5 times higher than those who were medication adherent without depressive symptoms. The risk of experiencing a cardiac event for patients with only 1 risk factor was 1.2-1.3 times that of those with neither risk factor. CONCLUSIONS Medication nonadherence and depressive symptoms had a negative synergistic effect on cardiac event-free survival in patients with HF.

Cardiac rehabilitation after myocardial infarction: What influences patients’ intentions to attend?

Background: Cardiac rehabilitation (CR) programmes have increased their availability and expanded their eligibility criteria. This study sought to identify current predictors and reasons influencing myocardial infarction patients’ pre-discharge intentions to attend CR. Methods: Patients in this longitudinal, prospective, five site study completed questionnaires that surveyed their intentions to attend, attendance and main reasons for non-attendance at CR. Results: 84% of the 1172 patients indicated that they intended to attend CR. Multivariate analyses revealed that age, employment and earlier history of myocardial infarction were significant predictors of intention to attend CR, yet contributed to only a small proportion of the variance. The main reasons given for not intending to attend CR were lack of interest and perception that the programme would not be beneficial. Other obstacles included work, transport or time. A total of 708 (60%) patients responded at 12 months, and of these, 44% who did not intend to attend CR had attended. Conclusion: Patient sociodemographic and clinical profile, although significant, are not major predictors of intention to attend CR. Lack of interest and misconceptions regarding CR are cited as key barriers. Some of these seem to have been addressed post discharge as a good proportion of patients who had not intended to attend CR did change their minds and attended. Motivation of patients to participate in CR, including the identification of barriers and the provision of comprehensive information about the purpose and varied formats of CR programmes, could be used to help further address barriers to attendance.

Symptom Variability, Not Severity, Predicts Rehospitalization and Mortality in Patients with Heart Failure

Background: Inability of heart failure (HF) patients to recognize worsening symptoms that herald an exacerbation is a common reason for HF readmissions. Aims: To examine the relationship between patterns of HF symptom variability, and HF event-free survival. Methods: Patients with HF (N = 71) rated HF symptoms daily for 30 days. Symptoms were rated on a 10 point scale anchored at the extreme ends by “worst symptom could be” and “best symptom could be”. Patients were followed for an average of 1 year to track HF and cardiac rehospitalizations and all-cause mortality. Results: Cox regression comparing event-free survival between patients who had highly variable symptom ratings across the 30-days and those whose symptoms were less variable revealed worse event-free survival in patients with more variable symptoms of shortness of breath or edema. Symptom variability predicted event-free survival independently of severity of symptoms, ejection fraction, comorbidities, age and gender. Symptom severity did not predict rehospitalization or mortality. Conclusion: Regardless of symptom severity, patients whose symptoms fluctuated in an improving and worsening pattern were at substantially greater risk for poorer event-free survival. These patients may become accustomed to this pattern such that they expect symptoms to improve and thus do not seek treatment with worsening symptoms.

Low-sodium diet self-management intervention in heart failure: pilot study results:

Background: Self-care management of a low-sodium diet is a critical component of comprehensive heart failure (HF) treatment. Aims: The primary purpose of this study was to examine the effectiveness of an educational intervention on reducing the dietary sodium intake of patients with HF. Secondary purposes were to examine the effects of the intervention on attitudes, subjective norm, and perceived behavioural control towards following a low-sodium diet. Methods: This was a randomized clinical trial of an educational intervention based on The Theory of Planned Behavior. Patients were randomized to either a usual care (n=25) or intervention group (n=27) with data collection at baseline, 6 weeks, and 6 months. The intervention group received low-sodium diet instructions and the usual care group received no dietary instructions. Nutrition Data Systems-Research software was used to identify the sodium content of foods on food diaries. Attitudes, subjective norm, and perceived behavioural control were measured using the Dietary Sodium Restriction Questionnaire. Results: Analysis of covariance (between-subjects effects) revealed that dietary sodium intake did not differ between usual care and intervention groups at 6 weeks; however, dietary sodium intake was lower in the intervention group (F=7.3, df=1,29, p=0.01) at 6 months. Attitudes subscale scores were higher in the intervention group at 6 weeks (F=7.6, df=1, 38, p<0.01). Conclusion: Carefully designed educational programmes have the potential to produce desired patient outcomes such as low-sodium diet adherence in patients with heart failure.

The Association of Co-morbid Symptoms of Depression and Anxiety With All-Cause Mortality and Cardiac Rehospitalization in Patients With Heart Failure

BACKGROUND Patients with heart failure (HF) experience multiple psychologic symptoms. Depression and anxiety are independently associated with survival. Whether co-morbid symptoms of anxiety and depression are associated with outcomes in patients with HF is unknown. OBJECTIVE To determine whether co-morbid symptoms of depression and anxiety are associated with all-cause mortality or rehospitalization for cardiac causes in patients with HF. METHOD A total of 1260 patients with HF participated in this study. Cox regression analysis was used to determine whether co-morbid symptoms of depression and anxiety independently predicted all-cause mortality and cardiac rehospitalization. Anxiety and depression were treated first as continuous-level variables, then as categorical variables using standard published cut points. Patients were then divided into 4 groups based on the presence of anxiety and depression symptoms. RESULTS When entered as a continuous variable, the interaction between anxiety and depression (hazard ratio = 1.02; 95% CI: 1.01-1.03; p = 0.002) was a significant predictor of all-cause mortality in patients with HF. When entered as a categorical variable, co-morbid symptoms of depression and anxiety (vs no symptoms or symptoms of anxiety or depression alone) independently predicted all-cause mortality (hazard ratio = 2.59; 95% CI: 1.49-4.49; p = 0.001). None of the psychologic variables was a predictor of cardiac rehospitalization in patients with HF whether using the continuous or categorical level of measurement. CONCLUSION To improve mortality outcomes in patients with HF, attention must be paid by health care providers to the assessment and management of co-morbid symptoms of depression and anxiety.

Theory-based low-sodium diet education for heart failure patients.

Theory-based teaching strategies for promoting adherence to a low-sodium diet among patients with heart failure are presented in this article. The strategies, which are based on the theory of planned behavior, address patient attitude, subjective norm, and perceived control as patients learn how to follow a low-sodium diet. Home health clinicians can select a variety of the instructional techniques presented to meet individual patient learning needs.

The Association Between Regular Symptom Monitoring and Self-care Management in Patients With Heart Failure

Background:Symptom monitoring is considered the first step toward self-care management (actions to manage altered symptom status) to avert worsening heart failure (HF). However, empirical evidence demonstrating that symptom monitoring leads to adequate self-care management is lacking. We examined the relationship of adherence to regular symptom monitoring with adequate self-care management in HF patients. Methods and Results:A total of 311 HF patients (60 years, 35% women) were divided into 3 groups by adherence to 2 symptom monitoring behaviors (monitoring daily weights and lower extremity edema). Patients who were adherent to both symptom monitoring behaviors formed the adherent group (15.1%). Those adherent to either of the symptom monitoring behaviors formed the partially adherent group (28.9%). Those adherent to neither of the symptom monitoring behaviors formed the nonadherent group (56.0%). The adjusted odds of performing adequate self-care management were increased by 225% (95% confidence interval, 1.13–4.48) and 344% (95% confidence interval, 1.55–7.62) for the partially adherent and adherent symptom monitoring groups, respectively, compared with the nonadherent group. Conclusion:Adequacy of self-care management was predicted by adherence to symptom monitoring behaviors. This finding suggests that regular symptom monitoring facilitates performance of adequate self-care management, which may contribute to a decrease in preventable hospitalizations in HF.