2. Phenomenon: Fatigue in Congestive Heart Failure
• Fatigue is a common symptom of Congestive Heart Failure (Heart and Stroke
Foundation of Ontario, 2010).
Concept Descriptors
• Overwhelming, sustained sense of exhaustion
• Persistent tiredness
• Decreased capacity for physical and mental work
• Increased dependency
(North American Nursing Diagnosis Association, 2004; Trendall, 2000; Yang & Wu, 2005)
Fatigue Mental Work (Cognition) Decision Making
3. The Middle-RangeTheory of Unpleasant SymptomsLenz, Pugh, Milligan, Gift, & Suppe (1997)
Physiologic
Factors
(systems,
pathologic
problems,
energy
substrate)
• Congestive Heart
Failure
• Fatigue
• Shortness of Breath
• Edema
Psychologic
Factors
(mental,
reaction to
illness)
• Depression
• Anxiety
• Increased dependence
for personal support
• Lives in Community
Situational
Factors (life
style,
personal
experience)
• Recent Hospitalization
• Previous CHF
exacerbation
• Received CHF
management education
Performance
Functional Status: Role
Cognitive Functioning:
Problem Solving
Physical Performance:
Activity Level
4. Self-Care in Congestive Heart Failure
• Self-Care is comprised of self-care maintenance, self-care monitoring, and self-
care management (Riegel, Jaarsma, & Stromberg, 2012).
Self-Care Management Descriptors
• Recognition of alteration in health status, reflection, insight, decision making,
and deliberate actions to promote a healthy state(Harkness et al., 2014; Orem, 2001; Riegel et al.,
2012).
Recognition Reflect/Insight Decision Making Action
5. A Middle-RangeTheory of
Self-Care of Chronic Illness:
Congestive Heart Failure
Adapted from A Middle-Range Theory of Self-Care of Chronic Illness. Riegel,
Jaarsma, & Stromberg (2012)
•Medications as prescribed
•Attend regular medical
appointments
•Healthy diet
•Exercise
Self- Care
Maintenance
•Daily weights
•Monitor fluid intake
•Monitor sodium intake
•Monitor edema
•Monitor for changes in
symptoms (breathing)
Self-Care
Monitoring
•Recognition of change in
symptoms
•Evaluate change in symptom/
Decision making/Insight
•Action/ Help seeking
behaviors
Self-Care
Management
6. • Negative Outcomes:
Performance
•Physical: Activities of Daily
Living (ADL)
•Role: Instrumental Activities
of Daily Living (IADL)
•Cognitive: concentration,
problem solving
•Mood: depression, anxiety
•Cognitive Functioning -
•Recognition of change in
symptoms
•Evaluate change in
symptom/ Decision
making/Insight
•Action/ Help seeking
behaviors
•Role Performance (IADL) -
•Cognitive Functioning -
•Daily weights
•Monitor fluid intake
•Monitor sodium intake
•Monitor edema
•Monitor for changes in
symptoms (breathing)
•Adherence Decreased
•Role Performance (IADL) -
•Medications as prescribed
•Attend regular medical
appointments
•Healthy diet
• Physical Activity Level
(ADL) -
•Exercise
•Adherence Decreased Self-Care
Maintenance
Self-Care
Monitoring
Introduction
of
Unpleasant
Symptom
(fatigue)
Self-Care
Management
Self-Care Management in the Presence of Unpleasant Symptoms
Adapted from Middle-Range Theory of Self-Care of Chronic Illness and Middle-Range Theory of Unpleasant Symptoms. Riegel, Jaarsma, & Stromberg (2012); Lenz, Pugh, Milligan, Gift, & Suppe (1997)
Constance Schumacher
7. References
Harkness, K., Heckman, G. A., Akhtar-Danesh, N., Demers, C., Gunn, E., & McKelvie, R. S. (2014). Cognitive function and self-care
management in older patients with heart failure. European Journal of Cardiovascular Nursing, 13(3), 277-284.
Heart and Stroke Foundation of Ontario. (2010). End of Life Planning and Care for Heart Failure Patients. Retrieved from
www.heartandstroke.on.ca/.../END%20OF%20LIFE%20PLANNING%2...
Lenz, E., Pugh, L., Milligan, R., Gift, A., & Suppe, F. (1997).The middle-range theory of unpleasant symptoms: An update. Advances
in Nursing Science, 19(3), 14-27.
North American Nursing Diagnosis Association. (2004). Nursing diagnosis: Definitions and classification, 2003-2004. Philadelphia,
PA: NANDA.
Orem, D. (2001). Nursing concepts of practice (6th Ed.). St. Louis: Mosby.
Riegel, B., Jaarsma,T., & Stromberg, A. (2012). A middle-range theory of self-care of chronic illness. Advances in Nursing Science,
35(3), 194-204.
Trendall, J. (2000). Concept analysis: Chronic fatigue. Journal of Advanced Nursing, 32(5), 1126-1131.
Yang, C., &Wu, C. (2005).The situational fatigue scale: A different approach to measuring fatigue. Quality of Life Research, 14, 1357-
1362. doi: 10.1007/s11136-004-5680-0
Editor's Notes
Fatigue from three dimensions – Physiological, Psychological, and Situational
Impacting performance – Relational statements mirrored in the tasks of self-care stages.
Relational statements : Reflection/Insight related to relational statements in the theory of unpleasant symptoms (Cognition/ Problem Solving)
Self-care as a complex cyclic process of tasks.
Implications : Practice; The model breaks down the process of self-care when influenced by unpleasant symptoms, this helps to identify areas that are critical for successful management skills. If the cognitive component of recognition, decision making is not optimized the patient will not initiate the help seeking behaviors required to halt/minimize an impending exacerbation. Are recall and teach-back methods of evaluating health literacy accurate reflections of whether the patient has acquired insight and adopted the behavior skill of help seeking?
Do patients that experience fatigue require decision making support measures to decrease exacerbations (telemedicine, nurse monitoring).
Theory: Towards a theory of adherence in chronic illness.
