[Congestive Heart Failure] When the ol' pump ain't what it used to be

This is a repost of my response on Reddit about how someone was going deal with a new sodium and fluid restricted diet after being hospitalized for heart failure. They loved milkshakes and had met with a dietician who really did not have a good therapeutic connection.

Trigger Warning - Below I'm going to talk about what I saw taking care of heart failure patients on a hospital cardiac unit. Someone who has had a heart failure episode may become anxious when I describe the early parts of their admission.

 

This discussion barely scratches the surface of the complexity of this condition. Most people are not admitted every week or two - but the advice I learned to reduce admissions for these patients helped to curate the discussion and education I provided to patients in the clinic and helped them have much more control over their own health and disease.

 ---------------

Day 1: I have had patients who were admitted about every 10-14 days like clock work. The ER gave them diuretics, the ER would take off 1-2 liters of fluid. By the time they get to my unit, they were still afraid from being short of breath and it being hard to breathe and this was the new and improved version. There is a look in a scared person's eye that doesn't leave you. I know that look from across the room.

Day 2: Less panic, still feeling very drained. We continue to remove fluid.

Day 3-4: Start to perk up, feeling a bit better. Better enough to be irritated with us, and complain about being hungry and don't like the food we're bringing because not enough salt/fluids. Sometimes they ask family to bring food - like fried chicken.

I cannot believe my anecdotes came about because I had so many patients who would come in and say how we didn't take care of their heart failure, but by day 3-4 they were having family bring fried chicken. #ffs #nurselife #we'veseensomeshit

Now let me get to the advice I found worked the best to stop repeat admissions:

Of all the dietary restrictions, salt+fluid can be one of the hardest.

Accept this is a difficult thing. I don't love people who treat it like it is easy like dieting and losing weight. *just* change your diet and the things you eat multiple times a day, every day for the rest of your life. Yeah bud, *just* is a 4-letter word. It is okay to have grief over this.

This person discussed a having dietitian who did not connect well with them: 

If you feel like you and the dietician aren't connecting, consider finding one who has empathy. I have seen great dieticians (they are part of your healthy team and they find ways to help you feel satisfied while having to change something you've been doing your whole life) and ones who just tell a grown adult patient what to do. I have no use for someone telling adults what to do like they are children.

Intake is all choices. You can absolutely eat all the fried chicken and drink all the ice cold milk shakes (or whatever items you love). Be prepared to spend an increasing amount of time in the ED and in the hospital as that taxes a heart that has had an injury.

Basically, the heart is a pump that is with you your whole life. That pump got hurt somehow. Maybe a heart attack or some other type of an injury but at the end of the day, the ol' pump ain't what it used to be. It can't pump like it used to. Your body has tried for a long time to help it - but it just can't do all it used to do. 

What happens when you try to use the pump the same way and it can't do it? These are the chains of events that bring some people to the hospital with a worsening of their heart failure enough to be admitted.

If you are committed to liquid, consider eating foods with less fluid - since the liquids add up you can trade off. Now if less liquid-y foods are dried (e.g. beef jerky) - mind the sodium.

I don't know how you are managing your HF, but daily weight is the gold standard.

Wake up, eliminate any stuff from your body and weigh in the "same clothes" (e.g. naked = same clothes) every day. Write the weight down. If you gain more than 3 pounds in a day or 5 pounds in a week, it is time to call the doctor as that is the best indicator of water weight.

What are the other upsides to daily weights?

Just for a bit of context - our patient often didn't get admitted with a 3 pound weight gain. They were frequently admitted with a 20-30 pound weight gain and often didn't detect it until they were short of breath (height and weight can change these numbers). Watching these numbers lets you know in short order what is going to cause more fluid retention. Daily weights give you insight about your intake from the day before and if it affected you, you can make adjustments.

This is great info for the doctor too. Your doctor can have a much more informed discussion with you over time when you can bring that one bit of data for daily weights to your PCP or Cardiologist.

I don't know your situation, but if you are a Veteran, they actually have a heart failure line where Veterans can call. The line has clinicians who can advise on medication adjustments if needed on the fly. I personally believe it should be an industry standard. The concept is simple, they can manage you at home to reduce admissions. Less cost for them and more convenience and quality of life for you.