الفهرس 
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Abstract
One of the most common cardiovascular complications is heart failure, which is also known as congestive heart failure. These two terms are used interchangeably, as it becomes a significant global health issue due to its high prevalence, morbidity and mortality. Heart failure is considered a serious health care drawback not just for patients and their family, but additionally for society, because it considerably contributes to huge costs related to those patients’ care.
According to the American Heart Association‘s 2017, Heart Disease and Stroke Statistics update; the number of individuals diagnosed with CHF is increasing and estimated to be risen to 46 percent by 2030, leading to over addition of 8 million people with HF. In addition, 1-2% of the adult population worldwide suffers from HF but prevalence increases 10-fold in those over 75 years of age.
Congestive heart failure often causes changes in life style and leads to low quality of patients‘ life. Despite improvements in its therapy, rates of CHF hospitalization and readmission are high. Some readmissions have been ascribed to patients‘ lack of compliance, insufficient knowledge about diet, medication, and management of CHF symptoms.
The clinical cardiology nurse is one of the multidisciplinary care coordination teams for hospitalized CHF patients, who should apply the nursing process in designing the individualized discharge care plan; that conceptualize each patient’s needs either physical, psychological and spiritual. As well, these applied educational nursing interventions should be continued in outpatient settings after hospital discharge, in order to improve patients knowledge concerning CHF, promoting self-care emphasizing on weight control, salt and fluid restrictions, compliance with medication, exercise, and coaching on the symptoms that indicate the disease is worsening; which consequently improving their clinical outcomes and minimize their readmission.
The aim of this study was to determine the effect of implementing the discharge plan on health outcomes of the adult patients with congestive heart failure. Material and methods:- Material:
The research design utilized in this study was a quasi-experimental design.
The study was carried out at the inpatient Cardiology Department of the Alexandria Main University Hospital and its affiliated Outpatient Cardiac Clinic.
The subjects of this study were a purposive sample of 70 patients who were admitted to the above mentioned study settings and diagnosed with CHF. They were enrolled randomly into 2 equal groups, control group (I): were subjected to routine hospital care, and study group (II): were received the discharge plan of care, (35 patients in each).
Four tools were used to determine the effect of implementing the discharge plan on health outcomes of the adult patients with CHF. Tool I: Congestive Heart Failure Patients’ Nursing Assessment Sheet. This tool included five parts: part I: Patient‘s sociodemographic characteristics, part II: Patients’ health history, part III: Cardiovascular physical examination, part IV: prescribed medications, routine laboratory and diagnostic tests, and part V: Patient’s health problems / needs.
Tool II: Atlanta Heart Failure Knowledge Test (AHFKT-V2). This tool focused on five CHF knowledge domains namely; CHF pathophysiology, nutrition, behavior, medications, and symptoms assessment/management with a total of 30 questions in MCQ form. Tool III: Congestive Heart Failure Health Outcome Indicators. This tool consisted of three parts: part I: Respiratory status indicators, part II: Cardiac status indicators, and part III: Functional status indicators. Tool IV: Self-Care of Heart Failure Index (SCHFI V6.2 English). This tool included three self-care scales: the first scale (Self-care maintenance), the second scale (Self-care management), and the third scale (Self-care confidence).
Methods:
Adult patients who fulfilled study subjects’ inclusion criteria were assigned sequentially and equally into two groups (35 patients each). The researcher interviewed each patient of the control and study group individually after his/her admission at Cardiology Department. Initial assessment of all patients of the control and study group was carried out using tools I and II to collect the baseline data about the CHF patient’s health status, problems/ needs, knowledge and self-care practices. Based on the assessment phase the individualized discharge care plan was developed by the researcher for each patient in the study group according to their health problems, needs and knowledge. Planning for the discharge plan included the following steps: prioritizing patient’s problems/needs, formulating nursing diagnosis based on (NANDA-I), setting the goals for each nursing diagnosis, arranging specific nursing interventions for each nursing diagnosis, and preparing educational booklet that containing information regarding: definition and causes of CHF, weight monitoring, monitoring the decompensation signs and symptoms that encompass new-onset of heart failure, compliance with medication, diet recommendations, physical activity and rest, sexual activity, and vaccination. Implementation of the discharge plan was started with the initial assessment that has been performed individually for each hospitalized patient in the study group considered as the first session. Specific nursing interventions related to the formulated nursing diagnosis for each patient of the study group were applied in the second session, as well the developed booklet was used for providing the health education regarding: definition and causes of CHF, weight monitoring, monitoring decompensation signs. The nursing interventions that corresponding to the relevant nursing diagnosis for each patient in the study group was implemented in the third session, accompanied by using booklet for health education concerning: compliance with medication, diet recommendations, physical activity and rest, sexual activity, and vaccination. The booklet instruction was reinforced with each hospitalized, study group patient by following his/her understanding of information through dialogue and questions in the fourth session.The time, which spent in each session was about one hour depending on the degree of tolerance and response of each patient. First nursing evaluation and reassessment of the control and the study group patients was done using tool III, 24 hours before hospital discharge. While, second and third evaluation was performed at the outpatient cardiac clinic for the control and study group patients after one and three months post hospital discharge respectively using tools II, IV. Comparisons were done between the two groups to determine the effect of implementing the discharge plan on health outcomes of the adult CHF patients.
The main results of the study were:
The highest percentage of patients in the control and study groups representing (51.4%, 68.6%) respectively were between 50 ≤ 60 years old.
More than half of patients in the control and study groups (60.0%, 54.3%) respectively were female.
The majority of the studied patients in the control and study groups (82.8%, 71.5%) respectively were married.
More than one third of patients in the control and study groups (48.6%, 34.3%) and (37.1%, 40.0%) respectively had primary education and manual work.
It was noted that (37.1%) of the control group patients’ were diagnosed with the disease from 4 ≤ 5 years. While, the same percentage of the study group (37.1%) had the disease since 3 ≤ 4 years.
More than half of patients in the control and study groups (60.0%, 54.3%) respectively, were previously admitted to the hospital due to CHF presentations.
The majority of patients in the control group (85.7%) and more than half (62.9%) of the study group patients’ were maintaining follow up appointment when they feel signs and symptoms of congestive heart failure.
All control and study group patients’ were complaining of dyspnea, reduced exercise tolerance, fatigue, and lower limb edema.While, more than two thirds of the control and study groups (65.7%, 71.4%) and (65.7%, 70.6%) respectively were complaining of orthopnea, and paroxysmal nocturnal dyspnea.
It was noted that all patients of the both studied groups were represented with nursing diagnosis regarding; reduced cardiac output, excess fluid volume, activity intolerance and knowledge deficit.
There was no statistically significant difference between the two studied groups during the studied periods in relation to overall mean scores of CHF patients’ health status indicators 24 hours before hospital discharge where p= 0.139.
A statistically highly significant difference was found between the studied groups during the studied periods in relation to all CHF knowledge domains of self-care where P= < 0.001*.
A statistically highly significant difference was noted between the studied groups during the studied periods in relation to overall CHF knowledge mean scores where P= < 0.001*.
A statistically highly significant difference was noticed between the study group patients during the studied periods in relation to overall mean scores of CHF three self care scales where P= < 0.001*. While no statistical significant difference between the control group patients was noted.
Conclusion:
Implementing the developed discharge plan has significantly improved the overall knowledge of adult CHF patients‘, as well as their self-care practices regarding self-care maintenance, self-care management and self-care confidence within the studied periods compared with CHF patients‘ managed with routine hospital care. Thus the study group patients who receive the discharge plan exhibit healthy outcomes than those who do not receive it. Recommendations:
- The developed educational booklet has to be available and distributed on CHF patients at cardiology departments and outpatient cardiac clinics; in order to enhance the commitment of those patients to the recommended lifestyle modifications, for better health outcomes and prevention of hospital readmission.
- Family members should be involved with their patients’ in the CHF educational program in order to ensure patients’ adherence to self-care practices; and in turn improve their health outcomes.
- Further researches need to be performed to assess: The effect of in service training program on nurses‘ knowledge and performance related to the care and education of CHF patients. The barriers that are hindering the nurses from applying the discharge plan for hospitalized CHF patients.