By Beatrice Leavel Nelson

 Congestive Heart Failure (CHF) “affects 5 million people in the United States” (Crowder, 2006, p.27)  CHF is expected to double in prevalence by the year 2030 (Horowitz et al. 2004)  Hammer and Ellion (2005) state that CHF patients “represent the highest readmission rate of all diagnostic groups” (p.231)  Esposito et al.(2009) estimated the cost for 2008 for CHF to be $34.8 billion dollars (p.437)

 Annema, Luttic and Jaarsma (2009) estimated that in CHF patients that 23-31% of readmissions were perceived as preventable  According to Lowery, Massaro, and Yancy (2004) readmission rates are high for CHF patients at “2%, 20%, and 50% within 2 days, 1 month and 6 months respectively.” (p.5)

 Patients with CHF are frequently readmitted to the acute care facility (Hamner and Ellison, 2005)  Patients with CHF need education on medications, a low sodium diet, daily weights, and monitoring for changes.  A person with CHF needs to be able to recognize a change, decide on an appropriate intervention then evaluate the effectiveness of that intervention (Riegel, et al, 2009)

Through identification of early symptoms in patients with CHF, patients can seek treatment for an exacerbation of CHF before they require hospitalization. Teaching patients early symptom management will hopefully decrease decompensation and improve overall well-being in the CHF patient population.

 The theory of unpleasant symptoms (TOUS) is a middle range theory based on the idea that common experiences are found among people experiencing different symptoms in different populations in varied experiences (McEwen and Wills, 2007)  Lenz and Pugh (2003) describe symptoms as “the perceived indicators of change in normal functioning as experienced by patients.” (p.74)

 The theory has three major components (McEwen and Wills (2007m p.258) - The symptom the individual is experiencing - Influencing factors that produce or affect the symptom experience - The consequences of the symptom experience

 TOUS uses the terms of duration, intensity, distress and quality to describe unpleasant symptoms  TOUS uses factors that are physiological, psychological or situational  TOUS notes that symptoms can occur singularly, but more often they occur in combination  The authors of TOUS note one purpose of TOUS is help nurses remove or relive unpleasant symptoms

 Driscoll, Davidson, Clark, Huang and Aho (2009) stated that patients must be supported in their conditions to reduce hospitalizations and improve symptoms.  Driscoll et all (2009) state that CHF patients often experience shortness of breath, decrease exercise tolerance, and lethargy. These are symptoms that CHF patients can be taught to monitor.

 Jurgens et al. (2009) recommends the identification of symptom clusters to identify exacerbations or worsening of the disease  Jurgens et al (2009) used the TOUS to demonstrate that when multiple symptoms were present that often it was difficult for patients to differentiate the quality of each individual symptom. Thus they recommended the identification of clusters of symptoms.

CHF is a common reason for hospital readmission. The TOUS describe the interplay often seen when multiple symptoms are occurring at the same time. By identification of symptoms early, perhaps interventions can be provided to decrease symptoms. By decreasing symptoms in the home, acute care admissions should also decrease.

 Annema, C., Littik, M.-L., & Jaarsma, T. (2009). Reasons for readmission in heart failure: Perspectives of patients, caregivers, cardiologist, and heart failure nurses. Heart & Lung 38 (5),  Crowder, B. F. (2006). Improved symptom mangement through enrollment in an outpatient congestive heart failure clinic. MEDSURG Nursing, 15 (1),  Dickson, V. V., & Riegel, B. (2009). Are we teaching what patients need to know? Building skills in heart failure self care. Heart & Lung, 38 (3),  Driscoll, A., Davidson, P., Clark, R., Huang, N., & Aho, Z. (2009). Tailoring consumer resources to enhance self-care in chronic heart failure. Australian Critical Care,  Esposito, D., Bagchi, A. D., Verdier, J. M., Bencio, D. S., & Kim, M. S. (2009). Medicaid beneficiaries with congestive heart failure: Association of medication adherence with healthcare use and costs. American Journal of Managed Care, 15 (7),  Hallerbach, M., Francoeur, A., Pomerantz, S. C., Morris, D. L., Eiger, G., Cohn, J., et al. (2008). Patterns and predictors of early hospital readmission in patients with congestive heart failure. American Journal of Medical Quality,  Hamner, J. B., & Ellison, K. J. (2005). Predictors of hospital readmission after discharge in patients with congestive heart failure. Heart & Lung, 34 (4),

 Holzapfel, N., Zugck, C., Muller-Tasch, T., Lowe, B., Wild, B., Schellberg, D., et al. (2007). Routine screening for depression and quality of life in outpatients with congestive heart failure. Psychosomatics, 48 (2),  Horowitz, C. R., Rein, S. B., & Leventhal, H. (2004). A story of maladies, misconceptions and mishaps: Effective managment of heart failure. Social Science & Medicine, 58,  Jurgens, C. Y., Moser, D. K., Armola, R., Carlson, B., Sethares, K., & Reigel, B. (2009). Symptom clusters of heart failure. Research in Nursing and Health,  Lenz, E. R., & Pugh, L. C. (2003). The Theory of Unpleasant Symptoms. In M. J. Smith, & P. R. Lehr, Middle Range Theory for Nursing (pp ). New York: Springer Publishing Company.  Lowery, S. L., Massaro, R., & Yancy, C. W. (2004). Advances in the management of acute and chronic decompensated heart failure. Lippincott's Case Management,  McEwen, M., & Wills, E. M. (2007). Theoretical basis for nursing (2nd Edition ed.). Philadelphia: Lippincott Williams & Wilkins.  Riegel, B., Moser, D. K., Anker, S. D., Appel, L. J., Dunbar, S. B., Grady, K. L., et al. (2009, September 22). Promoting self-care in persons with heart failure a scientific statement from the American heart association. Circulation:Journal of the American heart association,