Fatigue Experience, Symptom Management Strategies, and Functional Status in Patients With
บัณฑิตวิทยาลัยมหาวิทยาลัยมหิดล พย.ม. (การพยาบาลผู้ใหญ่) / 1
FATIGUE EXPERIENCE, SYMPTOM MANAGEMENT STRATEGIES, AND FUNCTIONAL STATUS IN PATIENTS WITH CONGESTIVE HEART FAILURE
Lt. JG. AMORNRAT KRONKASEM5437267 NSAN/M
M.N.S.(ADULT NURSING)
THESIS ADVISORY COMMITTEE: DOUNGRUT WATTANAKITKRILEART, D.N.S., KANAUNGNIT PONGTHAVORNKAMOL, Ph.D.(NURSING),
ANEK KANOKSILP, M. D.
Extended Summary
Background and Significance of the Study
Congestive heart failure is an important health problem of the population, both at a national and at an international level. It is the first leading cause of deaths in the western world (World Health Organization, 2011). There are about 2,000,000 newly diagnosed cases of congestive heart failure around the world in each year. In the United States, the number of patients with congestive heart failure is 6,000,000, and about 500,000 patients are diagnosed with congestive heart failure annually (American Heart Association, 2011). It has been estimated that in 2030, the number of patients with congestive heart failure will rise to 9,000,000 in the United States of America (American Heart Association, 2011). As for Thailand, according to the statistics of the patients with congestive heart failure, there is no report on the numbers of morbidity and mortality caused by congestive heart failure in particular, but it has been documented that between 2006 and 2010, the mortality rates caused by heart diseases were equal to 54.5, 55.2, 56.0, 55.2, and 61.9 in 100,000 persons, respectively (Office of Policy and Strategy, B.E. 2553). In the United States of America, patients with congestive heart failure have to be hospitalized at least twice a year on average, and each patient has to take as many as six medicines on average. The medical expenses to treat patients with congestive heart failure ranges from 10 billion to 38 billion US dollars (American Heart Association, 2011). Therefore, congestive heart failure is considered a major problem that affects public health and economy of countries all over the world.
Congestive heart failure is a syndrome that results from abnormalities of the structure or pathology of the heart, causing the heart to work harder that usual (Hunt et al., 2005; American Heart Association, 2011). The stroke volume decreases, so there is not enough blood to nurture different tissues and organs in the body. Thus, the body has a responsive mechanism that stimulates functioning of the sympathetic nervous system, resulting in secretion of neurohormonal mediators to maintain the blood volume to suit the needs of the body. If such a responsive mechanism continues without any correction, leading to the size, shape, and functioning of the heart will change. (Borlaug & Paulus, 2010; Lindenfeld et al., 2010), makes patients with congestive heart failure encounter various symptoms (Nordgren & Soresen, 2003; Walke, Gallo, Tinetti, & Fried, 2004; Zambroski, Moser, Bhat, & Ziegler, 2005; Barnes et al., 2006) including physical symptoms such as fatigue, dyspnea, panting, congested chest, swelling, and loss of appetite (Hunt et al., 2005; The Heart Failure Society of America, 2006; Kemp, & Conte, 2012;Maclver, Dayer, & Harrison, 2012), as well as psychological symptoms and emotional symptoms such as depression and anxiety (Konstam, Moser, & Song, 2005). These sympotms reduce patients’ ability to carry out activities (Blinderman et al., 2008; Jurgens et al., 2009).
Functional status is considered one important component of quality of life. In fact, functional status plays a significant role in appraisal of patients at first diagnosis to determine appropriate treatment, monitoring of responses to treatment, prognosis of the disease, prediction of rates of survival, and prediction of exacerbation of the disease (Allard, Dionne, & Potvin, 1995; Wang, 2004). Nittaya Srisuk conducted a study to investigate quality of life in the health aspect of 140 patients with congestive heart failure in Bangkok Metropolis and found that congestive heart failure made it necessary for patients to rest or take a nap during the day, so they had difficulty working and doing activities with others.
Fatigue is a self-defense mechanism that prevents the body from too much energy expenditure and maintains body balances. Individuals will express lack of energy, to loss of energy (Piper, Lindsey, & Dodd, 1987). Pathological changes in patients with congestive heart failure at four weeks after the critical period, it is found that patients with congestive heart failure will suffer from fatigue (Friedman, 2003). A study conducted by Zambroski, Moser, Bhat, and Ziegler (2005) has shown that patients with congestive heart failure suffer from 15 symptoms on average, particularly fatigue, dyspnea, and difficulty sleeping. Fatigue can be expressed in different dimensions, both physical dimension and psychological dimension. It affects physical functioning of the patients (Tiesinga et al., 1996; Treandall, 2000) Symptom management strategies refer to different methods that are used by patients when they experience symptoms. The goal of symptom management strategies is to continuously prevent or prolong negative outcomes (Dodd et al., 2001). Ekman and Ehrenberg (2002) found that activities that can effectively reduce fatigue in female patients with congestive heart failure are sleeping or doing light leisure activities such as reading, watching television, etc. However, when it comes to male patients with congestive heart failure, it has been found that only sleeping works effectively. In addition, Falk et al. (2007) have found that doing fewer activities or doing activities more slowly and sleeping or taking a rest can relieve fatigue in patients with congestive heart failure.
Dodd et al. (2001) have proposed the symptom management model which consists of three interrelated concepts of symptom experiences, symptom management strategies, and symptom outcomes. Symptom experiences encompass three dimensions of perceived symptoms, symptom appraisal, and responses to symptoms. According to this concept, if individuals perceive that their body or behavior has changed from what it used to be, they will consider the severity of the symptom, its causes, frequency, and threat to their life and living so that they will come up with appropriate physical, psychological, social, and behavioral responses. Individuals are likely to seek strategies to manage their symptoms based on their own perception to relieve the symptoms and to maintain their own normal functioning.
A review of related literature conducted abroad has resulted in a number of studies conducted with patients with congestive heart failure. For instance, Zambroski et al. (2005) carried out a study with 53 patients with congestive heart failure whose heart capacity was categorized according to the Functional Classes II-IV of the New York Heart Association. It was found that the study sample encountered 15 symptoms of congestive heart failure on average. The most commonly found symptoms in the frequency dimension were difficulty sleeping, other pain such as chest pain, lack of energy, and shortness of breath, respectively. Such findings shed light on the overall picture of signs and symptoms of patients with congestive heart failure. There are also research studies on fatigue experience of patients with congestive heart failure. For example, Ekman and Ehrenberg (2002) investigated fatigue experience of 158 patients with congestive heart failure with Functional Classes III and IV. There were 92 male patients and 66 female patients. The study findings revealed that 47% of male patients and 49% of female patients explained their fatigue experience as a feeling of lack of energy that made them lose the energy to carry out their duties or perform activities, making them encounter difficulty in activities of daily living. Thus, it can be seen that the existing research literature has not extensively covered the topics of symptom management of fatigue and outcomes of symptom management strategies in patients with congestive heart failure.
As regards studies conducted in Thailand, Wasana Suwanrassamee (B.E. 2555) examined symptom experience, symptom management, and functional status in 88 patients with congestive heart failure whose heart capacity was categorized according to the Functional Classes II-III of the New York Heart Association. The study findings showed that the five leading symptom experiences of the study sample were shortness of breath, fatigue, difficulty sleeping, dyspnea when in supine position, and numbness or pain in the limbs, respectively. Most of the patients managed their symptoms by positioning, breathing control, and taking sleeping pills. However, such findings shed light only on overall symptom experiences and symptom management. Furthermore, functional status of the patients was also investigated using the Minnesota Living with Heart Failure (LWHF) questionnaire which divided functional status into three components of physical, emotional, and socioeconomic functional status. The study findings showed that overall functional status was at a good level (Mean = 3.69, SD = 0.77). However, it is worth noting that helped reveal only physical, emotional, and socioeconomic functional status of patients with congestive heart failure.
An extensive review of literature has shown that there are no previous studies conducted both in Thailand and abroad that directly investigated fatigue experience, management strategies, management outcomes, and relationship among fatigue experience, management strategies, and functional status of patients with congestive heart failure. Most of the studies were conducted with other groups of chronic patients such as cancer patients (Pichayada Kongsaktrakul, B.E. 2547), AIDS patients (Chotiwan Kongrod, B.E. 2549), renal disease patients on continuous hemodialysis (Duangrat Monthaisong, B.E. 2553), etc. Moreover, there is no study that was carried out to explore physical, psychological, social, and spiritual functional status of patients with congestive heart failure. Therefore, the researcher was interested in investigating fatigue experience, management strategies, and functional status of patients with congestive heart failure based on the symptom management model of Dodd et al. (2001), which was employed as the conceptual framework of the study to cover physical, psychological, social, and spiritual functional status of patients with congestive heart failure. It was anticipated that the study findings would yield baseline data for nurses and healthcare team members to develop a clinical nursing practice guideline to effectively manage fatigue of patients with congestive heart failure to reduce severity and frequency of fatigue, relieve their discomfort and disruption of daily living activities, and promote quality of life and functional status of the patients, thus enabling them to perform self-care practices and to live happily in society with others.
Research Objectives
1. To investigate fatigue experience including symptom perception, symptom appraisal, and symptoms responses; management strategies; and functional status of patients with congestive heart failure
2. To examine the relationships between fatigue experience and functional status of patients with congestive heart failure
3. To explore the relationships between management strategies and functional status of patients with congestive heart failure
Methodology
The present study was descriptive research. The study sample consisted of male and female patients diagnosed with congestive heart failure aged 18 years old or older who sought treatment at the Heart Failure Clinic and the Cardiac Clinic of the Central Chest Institute of Thailand, Nontaburi Province. The sample was recruited by means of convenience sampling based on the following inclusion criteria: they had been diagnosed with congestive heart failure for more than four weeks; they had a good level of consciousness; they had a normal perception of time, person, and place; and they were able to communicate in the Thai language. Data were collected between April and June, 2013. The sample size was calculated using the Power of Analysis Table, and the confidence level was set at 95%, alpha at 0.05, power of test at 0.80, and medium size effect at 0.03 (Wasana Suwanrassamee, B.E. 2555). The calculated sample size was 88.
Instrumentation
The instruments used in this study could be divided into four parts as follows:
Part I:Demographic characteristics questionnaire was designed to elicit data regarding demographic characteristics of the subjects including age, gender, religion, marital status, educational background, occupation, average monthly income, sufficiency of income, rights to medical reimbursement, chronic illnesses, duration of congestive heart failure, causes of congestive heart failure, regular medication intake, and heart capacity as determined using the categorization of the New York Heart Association.
Part II: Piper fatigue scale-12 was developed by Piper et al. (2012) and translated and back-translated by Piangjai Dalopakarn (B.E. 2545). The instrument consisted of 12 items, with the mean scores ranging from 0 to 10 points. Higher scores reflected more fatigue experience, and vice versa. In this study, Cronbach’s alpha coefficient of the instrument was equal to 0.96.
Part III:Management strategies and outcomes of management strategies questionnaire was adapted by the researcher from the instrument of Duangrat Monthaisong (B.E. 2553) to suit patients with congestive heart failure. There were 20 items in the questionnaire which could be divided into two parts—management strategies and outcomes of management strategies. As for the first part, the response of ‘yes’ meant the subjects used that particular method when they experienced fatigue, and the response of ‘no’ meant they did not use such a particular method when experiencing fatigue. With regard to outcomes of management strategies, the range of scores was 0 to 3 point, with hither scores reflecting more effectiveness of the strategies. In this study, Cronbach’s alpha coefficient of the instrument was equal to 0.82.
Part IV:Functional Performance Inventory Short Form (PFI-SF) was constructed by Leidy and Knebel (1999) and was translated and back-translated by Sarinrat Sriprasong (2008). The questionnaire contained 32 items, with higher total scores reflecting higher functional status. In this study, Cronbach’s alpha coefficient of the instrument was equal to 0.92.
Data collection
The study proposal was submitted to the Institutional Review Board on Research Involving Human Subjects, Nursing Committee, Mahidol University and the Central Chest Institute of Thailand. Once the study was approved, the researcher submitted the introductory letter to the director of The Central Chest Institute of Thailand to ask for permission to collect data. The researcher conducted data collection by herself after introducing herself to patients with congestive heart failure to ask for their cooperation in the study. The researcher explained research objectives, data collection procedures, and possible benefits and risks of the study. The researcher informed the patients that data collected from them would be kept strictly confidential, and the patients were assured that they had the rights to withdraw from the study at any time if they wished without any effects on the treatment they would receive from the hospital. If the patients agreed to participate in the study, they were asked to sign the informed consent form to indicate their willingness. Data were collected based on the consideration of protections of the rights of human subjects. Data collection procedures lasted approximately 40 to 45 minutes.
Data analysis
A computer program was used to analyze data. Data regarding demographic characteristics of the subjects, fatigue experience, management strategies and outcomes of management strategies, and functional status of patients with congestive heart failure were analyzed in terms of frequency, percentage, mean, and standard deviation. Moreover, Pearson’s Product-Moment Correlation Coefficient was employed to determine the relationship between fatigue experience and management strategies and functional status of patients with congestive heart failure.
Findings
1. The finding show that thesubjectsranged in age between 61 and 70 years old. (Max = 88, Min = 33, Mean = 67.64, SD = 13.98). More than half of the subjects, or 52.3%, were female, and almost all, or 96.6%, were Buddhist. In addition, 43.2% of the subjects were married, and 37.5% were divorced/widowed/separated. As regards educational background, 39.8% completed primary education, and 35.2% were unemployed, while 30.7% were wage earners. In terms of income, 30.7% of the subjects earned 5,001 to 10,000 baht per month on average, and most of them, or 88.6%, had sufficient income. Finally, more than half of the subjects, or 53.6%, had medical reimbursements from the government or public enterprise. The subjects had at least one co-morbidity in addition to congestive heart failure. The most commonly found co-morbidity was hypertension, accounting for 81.6%. More than two-thirds of the subjects, or 68.2%, had been diagnosed with congestive heart failure for one to five years. When considering the causes of congestive heart failure, half of the subjects, or 50%, had cardiovascular disease. All of the subjects received diuretics, and almost all of them, or 95.5%, had ACEIs. Finally, nearly two-thirds of the subjects, or 62.5%, were considered NYHA Functional class II.
2. The findings regarding fatigue experience of patients with congestive heart failure showed that the subjects had overall fatigue at a high level (Mean = 7.32, SD = 0.59). When considering each aspect of fatigue experience, it was found that the aspect of fatigue experience with the highest mean score was physical and psychological feelings of fatigue (Mean = 7.45, SD = 0.46). This was followed by perception of meaning of fatigue (Mean = 7.33, SD = 0.69). The aspect with the lowest mean score was behavior and severity of fatigue (Mean = 7.24, SD = 0.77).
3.As regards management strategies, it was found that the management strategy that was most frequently used by the subjects was sleeping, at 96.6%. This was followed by taking a short nap, at 90.9%, sitting and resting, at 88.6%, and doing light exercises, at 86.4%. The management strategies that were less frequently used by the subjects were acupuncture, at 1.7%, and taking vitamins or supplementary diets, at 4.4%.
The management strategy that was most effective to manage fatigue was sleeping, whose effectiveness was at a high level (Mean = 2.63, SD = 0.48). This was followed by taking a short nap (Mean = 2.36, SD = 0.48), sitting and resting (Mean = 2.34, SD = 0.60), and watching television (Mean = 1.51, SD = 0.72), whose effectiveness was at a moderate level. The management strategies that were least effective were acupuncture (Mean = 0.17, SD = 0.39) and taking herbal medicines (Mean = 0.43, SD = 0.56).
The sources of management strategies used by the subjects to manage their fatigue were self-learning or experience, at 68.6%. This was followed by family members, at 36.9%. The source of management strategies that was least commonly used by the patients with congestive heart failure was media such as television, radio, newspaper, and the Internet, at 2.6%.