Hi, welcome back to Cardiovascular Nursing Essentials. This week we're going to talk about some non-pharmacological therapies, whereas last week we spent some time talking about medications and devices. So I'm Jenny Kennedy, VP of Care Transformation with Medaxium. These are my disclosures. Here are our objectives today. Again, I want to get us thinking a little bit beyond just medications and devices because there's a whole lot of lifestyle modifications and resources we can tap into. So I want to make sure that you understand what those resources are and how to identify them. Here are some readings for this week. And we're going to talk today about some different lifestyle management techniques. So we're going to talk about really how we do effective education, how things we can do to educate them on nutrition and physical activity, weight management, and stress management. We overlook a lot of times stress management and things like sleep. So I really want to make sure we're covering those in detail today so that you're more aware of those and you can link them to resources within your organization as tools for these patients. So some of these services are probably more familiar to you than others. So that would be cardiac rehab, maybe you have dietician services, do you have sleep centers, behavioral health services, social worker services, and palliative medicine or hospice. So let's talk first about education. And I want to go over some of your best practices because we never want to assume that everybody knows what they're talking about. And we never want to assume what that patient's learning style is. So one of the first things we have to do is assess how they best learn. So is that they want to hear from you? Is that they need to read something? Is it that they have to listen to it or watch it? Really ask them how they learn best and assess their style and preference. You want to make sure you're using credible, reliable sources. So you can access anything you want on the internet, but that does not necessarily mean that it's true. So often our patients go to Dr. Google or WebMD and we want to make sure that we're sending them to the right direction. So making sure that we're using credible sources with accurate information. It is best to standardize your materials so that everybody's getting the same message across your practice or your organization. And you want to make sure that the literacy and the language is appropriate for a broad range of patients with different education levels. And you want to not only engage your patients, you need to engage your fellow staff members so they know what they're educating on, they're messaging the same. And so when you're considering what tools or resources you have, these are things you want to consider. And health literacy is important because not everybody's on the same reading level. And obviously not everybody has the education or the background that health care providers do. So we're talking on a different level to a different audience. So it's important that we keep our language very clear and simple and that it's on a lower reading level. So really we think about a grade five reading level or your organization may have a standard, but you want to keep it lower so that it can reach that broad audience. When you're going over information with your patient, it can be helpful to circle or highlight certain areas that are pertinent to them. Oftentimes we give them handouts and printouts and it's very overwhelming and they may not look at it. But maybe while you're getting to know or maybe you know your patient and you think of a specific area or topic, point them to that direction as a starting point. That will help you personalize these materials so it will make a connection with them and make a difference as opposed to just being given a big pamphlet or booklet and it doesn't really have any context for them. We've talked in some of the modules about the teach back method and we want to make sure we're doing that so that what we're relaying is understood by that patient or their caregivers so that they understand the information. And if they don't understand it, just try again until they get it. And then we want to reinforce the information in follow-up visits, phone calls, messages, and office visits. So we want to try to make sure we're circling back and reinforcing education. It's not a one and done. So a statistic I find interesting is a normal person, it takes seven times of hearing something to retain that information. So if you have some lower blood flow or cognitive impairment, it's going to take more than seven times to hear something. So that's why it's so important that we reinforce this information. And then train your patients on how to access your portals, apps, or the internet to those reliable sources so they can kind of get the information on their own. These are a few reliable education sources that I want to guide you to so that you have information that's accurate and you can share with your teams, with your patients. The American College of Cardiology has a great tool called CardioSmart. I encourage you to look that up. If you have up-to-date, a lot of healthcare organizations have that embedded in their EHR. I encourage you to tap into that. That's regularly updated and a great source of information. And American Heart Association and the ACC have some great patient tools. So I encourage you to take a look at those and get familiar with their sites and their resources. So again, I want to reinforce the teach-back method because it's really important as it really kind of tests how well we're communicating and you can take it as an opportunity to improve your education style. And it's really appropriate for any patient regardless of their literacy level. It's just really how we communicate and what they understand. And we know not every patient comprehends the same. So our teaching may not be the same based on each individualized patient. It's really not a test of what their knowledge is, but it's really a test of how well we're explaining the concept. And again, that can improve over time. So nothing to be ashamed of or embarrassed about, but use it as a guiding tool for you to learn from as well. Don't wait to just drop a bunch of the information and wait till the very end to kind of check in with them. You want to do it during the duration of your conversation or your visit and keep checking in with them because the amount of information they may be able to receive may be a little or maybe more. So you're assessing to see what they can take. So don't wait till the very end of that visit to check in. And then the show me method. So sometimes they hear what you say, but then when they have to demonstrate it or do it, they may make mistakes. So if you have the opportunity, get them to show you how they're going to do something. So an example is I need you to take two pills today. So show me how many pills you're going to take and have them show you so you can correct them. It's easier to say you understand something than actually to show you. Using research. So handouts are a nice complement to teach back. They can write down information. They can circle and highlight things. You can point specific things out. Just make sure that those patients understand that when they're returning or teaching back to you that they're using their own words and not reading it off of the handout. And then use this as an example for other staff. When they see you modeling teach back, they're going to adapt it to. And this can be used for non-clinical team members who interact with patients. So maybe they're making appointments, scheduling. So teach your co-workers how to use this method and it'll be more effective all around. So for example, you can wrap up with a patient, say we've covered a lot today and I want to make sure I explain things clearly to you. So let's review what we discussed. Can you please describe the three things you agreed to do today to help lower your blood pressure? And that gives them an opportunity to respond and you can recorrect or re-educate as needed. And the reason is important not only for education, but we want to engage them. So we've got to use tools and one tool is motivational interviewing, which helps people find a motivation to make a change. So a lot of these modifications require change. People don't like to change and it's not your job to make them make the change. But if you can encourage and motivate them to do so, they can maybe be more engaged and willing to make those changes. So we do this through communication, empowerment, support, and reinforcement. So some of the things we've already talked about is finding out their preferred communication pattern. Are you speaking on their level? And are you listening? So communication is not just about talking, it's about listening and understanding what's important to them. So don't forget to listen. Take the time and pick up on any important cues as you're talking or meeting with these patients. Empower them. Encourage them to speak up when they don't know. Encourage them to not be afraid to ask questions. Let them have the space to ask questions and get the information. And again, you'll see across the board here, are we listening? Supporting them. Do they have the support at home? Are there areas that they do need support in that you can help either yourself or through referring to someone else? And then reinforcing. What are resources and tools that they can use to help support their own engagement? And then following this up during calls, messages, or office visits to make sure they're on track, or if they've gotten off or not been able to start, how can we get them started? And again, listening is the key. You've got to listen to those cues. You've got to see where they need assistance and reinforcement because they don't always know what to say. They don't even know how to communicate. They may not even know what they need. So I want to make sure that you're listening and really seeing opportunities to fill in gaps for these patients. So let's talk about some of these lifestyle modification activities. First and foremost, physical activity. According to our 2023 HAACC Guidelines for Chronic Coronary Disease, you know, always emphasize cardiovascular exercise, but we see that regular movement is very beneficial, even in small doses. So this is a great graphic and way to help educate your patients to find small ways to do movement during the day. So instead of sitting and letting the dog run in the backyard, you can take your dog for a walk. You can take the stairs versus the elevator, things of that nature. And what we've seen is about a 10% reduction in mortality and cardiovascular disease when people increase their daily step count by a thousand. So research shows that the non-cardio exercise and just regular movement during the day is very beneficial and that may help motivate some patients to see that they don't have to have rigorous exercise. So we need to think of movement as medicine. So being sedentary is very, you know, it's very bad for our bodies and we know this and we need to practice this, but we've got to make sure that we're motivating our patients and getting them to understand the importance of it too. So we always want to consider safety first. So we want to make sure that the patient is cleared by a provider and we want to make sure that they know they're not training for a marathon. This is not something we're looking for hardcore exercise. We want them to start slow and increase it over time, setting small goals, even starting at five minutes, working up to 10 minutes. That's a great starting point. We want them to focus on those incremental gains or small wins because those make a difference. We do need them to be in tune with their body. So if they're having any angina, any lightheadedness or dizziness, unusual shortness of breath or racing or uneven heartbeat, that means they need to stop. So make sure that they're educated on when they need to stop exercise or physical activity and kind of give their body a rest. There's lots of suggested activities that people can do without gym, without having to be strenuous, things like walking around your neighborhood, a little park, or even the track of the mall. I've seen people walking through the mall sometimes, just getting that movement. Anything stationary like a bike, that may not seem rigorous, but it sure can be very good for your body. Swimming, tennis, those are all great ways to move and get activity. Light housework like sweeping, vacuuming, dusting, all of those are good ways to move the body. So just talking to your patients and getting to know them to see what some of their likes are. Maybe it's somebody who likes to be outside and work in their garden. That's a great way to get movement and get some physical activity into their day. Some patients may qualify for cardiac rehab, which is a medically supervised program. And these are really intended to target patients that have had a heart attack, heart failure, heart surgery, and get them back on track while being monitored. So it's a team effort. It requires doctors, nurses, exercise specialists, dieticians, a nutritionist. So they're really working from a team perspective to meet the needs of these patients. And they go in phases. So there's phase one, two, and three. And typically they go into 36 sessions over 12 weeks. It can vary based on their progress or their program. And again, they're really exercised while being monitored. So you have nurses and exercise specialists that are looking at heart rate, blood pressure, EKG, assessing symptoms, just taking in their color, all of that while they're exercising. And there's significant benefit to cardiac rehab because it can reduce the risk of further heart problems that can improve their quality of life, not just physically, but a lot of people get a lot of social enjoyment from it and they make new friends. It's a community kind of feeling. So it can be very beneficial in helping with feelings of loneliness. And then they can see weight loss and the benefits, the health benefits that come with those. Nutrition, which is a huge component to any healthy lifestyle. We know nutrition is the foundation of health. Even if you're exercising daily, you can't outrun a bad diet is common saying. And so we really want to make sure that patients make the right or have the information to make the best decisions for their diet. So the ACC and AHA primary prevention guidelines really target nutrition with fruits, vegetables, whole grains, legumes, or beans, nuts, and fish. So healthy fats, fibers, vitamins, all of those things. So we really want to find a way to message to patients that will cure them. And so sometimes when we start talking about these things, it gets very overwhelming and they can kind of shut down. So we want to try to help them understand how to make healthy patterns. How do they include fruits and vegetables within their diet? Maybe they're kind of a meat and potatoes person. Can they add a vegetable with their dinner? Things like that. Highly processed foods can worsen, not just a physical appearance, but also mental health. So we want to make sure that they're being cautious about how much processed food they're eating. We want to optimize their metabolic health. So that means balancing a healthy dietary pattern with a lifestyle to really try to reduce negative health impact. And proteins, looking at replacing animal-based protein with plant protein has actually showed to reduce mortality. So some patients have transitioned to an all plant protein diet, or maybe it's just incorporating some and not eating as much animal-based proteins. And one example is the Mediterranean diet is a good one that's been associated with improved cardiovascular outcomes compared to our typical Western dietary patterns. So information on that can be very helpful in leading these patients towards a healthier pattern of eating. Here are some just recommendations and it's really kind of about keeping it simple in terms of lower ingredients or chemicals in our food products. So eating more whole foods, which would be fruits and vegetables, those minimally processed foods, whole grains. So looking at brown rices, sweet potatoes, as opposed to pastas and simple carbs, minimizing added sugars, healthy proteins. So looking at lean fishes, chicken, low or non-fat dairy, things of that nature. Looking at using less salt, little or no added salt when you're cooking is ideal. Liquid non-tropical vegetable oils. So things like coconut, avocado, and olive oils as opposed to canola or vegetable. And then we prefer no alcohol, but obviously some patients do want to, we prefer that you limit that if possible. And this may sound stringent, but it doesn't mean that you are restricted. We want our patients to enjoy celebrations and dining out. And I want, if at all possible, to help them to prepare for those situations. Because just because they're going out doesn't mean they have to forgo everything else. And they can have a heart healthy diet while they're celebrating and eating out. Moderation is something we tend to tell people. Yes, you can have something in moderation, but some people maybe can't control or have the self-control, and then moderation can be relative or mean a different thing for each person. So setting them up for success may be helping them to understand how to prepare for going out by reading labels or looking at menus and nutrition items before they go to the restaurant or the celebration so they can look at sodium levels. Is there added sugar? What's the fat content? How many servings? So right now, I mean, you can go online and look at menus and find the nutrition facts. So I encourage people to do that, use the internet to look those up, and then looking for healthier choices, such as grilled, broiled, roasted options, as opposed to fried, breaded, things of that. And then also telling them not to add salt to cooking. A lot of the food is prepackaged, so they may not be able to be no salt, but they can absolutely decrease or take off or not add additional seasonings when they're preparing food, so people can ask for that. Sleep, we know we've seen, I'm sure everybody's seen how important sleep is. Everybody needs to get eight hours, and how do you do that? But if people aren't sleeping well, it does impact your entire body. A large amount of our population has undiagnosed sleep apnea. And the issue with that is that sleep apnea is found to increase the risk of cardiovascular disease. So it's important that we're assessing for this. So hypertension, stroke, CAD, and cardiac arrhythmias are more common in people with sleep disorders. Sleep apnea and atherosclerosis share some common physiological characteristics. So it's important to note because sleep apnea may be an important predictor of cardiovascular disease. There are two types. We have obstructive sleep apnea and central sleep apnea. So obstructive sleep apnea is the most common type, and we do see it present or manifest in non-cardiovascular ways. So patients may have increased daytime sleepiness, decreased quality of life. Their work performance can be impacted. They may have issues with memory and cognition. They may feel more depressed, and it may be linked to higher incidences of cancer. So obstructive sleep apnea increases the interthoracic pressure. And so it causes an intermittent hypoxia and hypercapnia. So it interrupts the sleep cycle. So patients aren't really getting a full restful sleep. So in the cardiovascular system, it's gonna increase our SNS or sympathetic response. It's also gonna cause inflammation and endothelial dysfunction. So we know that when our sympathetic nervous system is responding for prolonged periods of time, we know that wears on our body and can lead to other issues. On the metabolic side, it decreases insulin sensitivity. It increases leptin resistance, which can contribute to weight gain, increased lipolysis, and impaired lipoprotein clearance dysfunction. So you can see the havoc that obstructive sleep apnea can reap on a patient. So in terms of the cardiovascular system, consequences we may see, increased blood pressure, pulmonary hypertension, arrhythmias, heart remodeling, which leads to heart failure, diabetes, dyslipidemia, CID, stroke, and cardiovascular mortality. So we can see how important it is that we're tracking or screening for obstructive sleep apnea. And we do that typically with what's called the STOP-BANG questionnaire. And it's really intended to look at at-risk patients who are complaining of these symptoms that we just talked about, and we can get them to a sleep center and assess for sleep apnea. If you don't have a screening or not screening within your practice, I urge you to talk about maybe implementing this, because it's a great way, as you're seeing cardiovascular patients, we already know they're at risk, and we may be able to help or delay some of the progression of disease if we can correct or get them a CPAP or BiPAP for their sleep apnea. So again, we're looking at those at-risk patients that you're seeing in your clinic, those with heart disease, they're generally overweight or obese, and it is more common in men. So the STOP-BANG asks several questions, and it's gonna give you a score and allow you to kind of make that decision if they need to be referred for a sleep study. So things that they assess are, are you snoring? And it's generally snoring so loud that someone can hear it from another room. Are you tired more than normal? Has anybody observed you stop breathing in your sleep? What is your BMI? If it's greater than 35, that tends to be a risk factor. Are they over 50 years of age? Neck size greater than 16 inches? And are they male? So again, these are things that are putting patients at higher risk for having a sleep apnea. Smoking, we've talked about the dangers of smoking for years, and now we don't have to worry just about smoking, but also vaping. So vaping may even be more prevalent. And often it's hard for patients to quit. So we've gotta find a way to help guide them. And so I wanted to go over just a few little points that may help patients develop their own plan for stopping. So helping them to choose a quit day. So they pick a date within the next seven days, or maybe it's two weeks, whatever is in their mind, and determine that day they're gonna stop using any kind of tobacco products, whether they're smoking, chewing tobacco, or vaping. They need to choose their method. Is it gonna be, I'm gonna quit cold turkey? Is it gonna be a gradual decrease? And then they're gonna make a plan for their quit day. So they're gonna be prepared by having healthy snacks, maybe sugar-free mints, having gum available. They're gonna find ways to fill their time so that they can be distracted when they're tempted to smoke. Maybe they go work out at the gym. Maybe they go for a walk, go to a movie. Maybe they have a cup of coffee instead. Trying a new hobby, getting something to engage their hands and keep them busy so that they're not tempted to go back to smoking. And then they can quit tobacco on their quit day. It's not that easy, obviously. It may take a couple chances. There are some resources. There's a quit line, 1-800-QUIT-NOW, which is a national quit line that will help support patients from quitting. But this is really important for our population to understand the dangers of smoking and vaping. Next, I wanna talk a little bit about social determinants of health. And these are things that are really important and a topic of discussion. So social determinants of health are really those non-medical factors that really influence health outcomes. So it can be the community where people live, where they grow up, where they work. It can be a wider set of forces like food insecurities, things of that nature that really impact their daily life and their ability to make healthy choices. So data shows that areas, environments with lower incomes and higher poverty are linked to higher risk of cardiovascular disease, diabetes, and other health concerns because of an inavailability of healthy food options and healthy environments. So these are all forces that may be economic, political, may have things to do with social norms, can even include racism, unfortunately, that impact our patients. So this is something we wanna consider, especially as we're looking at population health within our cardiology world and how we can make a change and make health equitable for all patients, regardless of their socioeconomic status. Anxiety and depression are something that we often also overlook in our cardiovascular patients. Generally, we're focused on the event that's happening. So when you're seeing patients on the outpatient side, perhaps following maybe a patient's had a open heart surgery or they had an acute MI, they are more vulnerable to be anxious and depressed. We need to do a better job at bringing that to the forefront so patients feel comfortable talking about it and we can connect them with the resources. So it's much easier to understand the physical needs of someone who's recovering from a cardiovascular event, but we have to make sure we're addressing those mental and emotional needs. So the psychological distress that comes with CBD is really linked to the risk of future cardiovascular events. So depression, anxiety, and post-traumatic stress disorder are very common. They can be regular. So they can be physiological effects like increased heart rate and blood pressure, reduced blood flow to the heart, and increased cortisol levels, again, increasing the risk for more cardiac events. So over time, those build up and it can lead to metabolic and cardiac disease. So we wanna make sure we're screening. Listen for those cues. There are anxiety and depression screenings. I encourage you to make use of those if you can or have not already. And also don't forget about the family members because they're impacted just as much as those patients and they may need some support as well. So while you're doing your interviewing and assessing all the things, I wanna make sure you're listening for those cues. One of the questionnaires is the PHQ-9. That's a great resource if you are looking to implement something in your program. Cardiac rehab is just a really great, as we said, social arena, and they can make friends and peer groups as it's more of a peer-to-peer support. And maybe they can share stories of what they've gone through. And maybe they're meeting somebody who's been through a cardiac event and they worked through depression and anxiety and can help them. A more formal support group, such as Mended Hearts is a wonderful way. Again, as healthcare providers, we don't always know how they're feeling if we haven't experienced it. So connecting them to a group of peers or connecting family to other family members can be really therapeutic in helping them move past some of these really intimidating points in their life. And then also tap into your internal organization resources. Is there a behavioral health program that they can get counseling? Maybe they need some additional therapy. So I encourage you to be on the lookout for those. And then palliative care is a hot topic as well. And it's really an approach to improve the patient's quality of life. So often it gets confused with hospice and we wanna make sure we're not giving that message. The goals of palliative care or palliative medicine are really about meeting the goals of their patient long-term as a disease progressives. So you really wanna incorporate it at the beginning of an illness diagnosis. So if we're talking about heart failure, it is hard conversation to start, but we really wanna align our treatment goals with the patient's goals. And continue that conversation during their trajectory. And then after a patient death, we wanna continue to support the family. So palliative is really appropriate at any stage of a serious disease or where it may be unclear what their diagnosis may be. So we're really targeting those chronic diseases. And the difference is really with hospice is that hospice is really more the end of life. So it's really palliative efforts in the last year of a patient's life. And it can be provided in a number of settings. So there are options. If you have palliative care departments within your group and you've not connected with them, I would urge you to connect with them. They are great resources. They can speak very well to their services in a non-intimidating way. So I would encourage you to connect with them. And perhaps there's opportunities to educate your practice or your organization. That does bring me to advanced directives. I just wanna bring this up again. It's a very difficult conversation to have. And so often it gets overlooked by our clinicians, but it is important that we have these. These are legal documents that designate what one's wishes are for end of life. And it means that whoever's designated to make those decisions, we follow their wishes as their healthcare team. We don't wanna leave the end of life decisions up for grabs. We wanna make sure we understand what that patient wants and what their desires are. So having these hard conversations, engaging family members and providing them with tools and resources to align these documents is gonna be critical. We wanna do it in advance of a critical event and not at the time where decisions have to be made. And that discussion has not happened. So hospice, again, just circling back quickly is a little bit different than palliative care. It's more the end stage of palliative, if you will. And the goal here with hospice is symptom treatment and making them comfortable. It is generally restricted to those with terminal illness and their prognosis is about six months or less. Again, there's variations depending on payers and things of that nature, but this is general. It does take place wherever that patient considers home, whether that's in a facility or at their own home. And there are various levels. So there are different ways to address patients' needs. And I know that it can be a little bit tricky, but again, I encourage you to speak with your internal departments on what their services look like. So we can understand, because we've just gone through a lot of information, how this can be very intimidating for a patient. So I wanted to provide a way to kind of wrap it up and maybe get you thinking about how you can help your patients action plan or set a goal. And we wanna be realistic in how we're guiding them and how they can be achieving a goal. So they're not gonna change everything at once. So we're gonna help them find what their priority is. So we wanna ask them permission to talk about what their goals are. And if they're able and willing to talk about it, we wanna help them find their motivation, help them select the goal that's important for them. And so in this example, you can see we go through a worksheet and this is a great tool to give a patient to help them kind of identify what they wanna work on. So in this example, a patient is working with diabetes and we're gonna increase their insulin dose from 20 to 25 units, and they're gonna make an appointment with their eye doctor. So those are things they talked about during the appointment, their actions. So next we wanna talk to them about what their goal is. And this patient chose a goal of lose 10 pounds with exercise and diet changes. So breaking it down into, okay, how are you gonna meet that goal? So one specific step is increasing activity with regular walking. What they're gonna do, they're gonna walk. How much? 30 to 40 minutes a day. During weekday lunch breaks, on the weekends, Saturday and Sunday mornings. And how often? Four times a week. And then giving them a confidence of how sure they are they can do it. Giving them something tangible is really, really helpful. Making it simple is very, very helpful. So I would encourage you to kind of look at a form or something similar to help your patients work through this and then again, like we talked about earlier, you wanna follow through and support them in meeting their goals. If they're having barriers or challenges, what are those? Help them get through those barriers and continue to assess their confidence and encourage them to be motivated. You are a support for this person and the family member. You are impactful to them. You have a significant amount of influence. So I hope you can take that with you as you realize you're educating these patients and changing their lives. Thank you for your time today. If you have any questions, please email academy at medaxium.com. Thanks for joining.

non-pharmacological therapies

lifestyle modifications

patient education

health literacy

nutrition

physical activity

sleep