Introduction
Congestive heart failure patients have decreased physical endurance and emotional concerns resulting from significant changes in their quality of life. Congestive heart failure patients’ perception of quality of life depends on individual health status and limitations in caring for themselves. Programs with a focus on patient education and disease management can improve quality of life and decrease hospital readmission rates for congestive heart failure patients (Chelho, Ramos, Prata, Bettercourt, Ferreira & Cerqueira-Gomes, 2005).

Congestive heart failure is a chronic disease that progressively decreases patients’ abilities of self-care due to significant weakness that is experienced as a result of compromised cardiac and respiratory systems. This disease is present in 10% of elderly over the age of 70. Congestive heart failure patients’ readmission rate to hospitals due to poor disease management is an ongoing problem. The cost of congestive heart failure admissions to the hospital ranges from 8 to 15 billion dollars a year (Quaglletti, Atwood, Ackerman, & Froelicher, 2000).

Current patient care models focus on the physical, social, emotional, and educational needs of patients. Congestive heart failure patients may have physical, social, emotional and/or education needs depending on the severity and stage of their disease process, knowledge of the disease, and current social support systems. It is imperative to evaluate and analyze various patient care models, and to choose one that best meets the particular patient’s needs because care plans are the essential framework through which nurses work to provide the care a patient needs (Anderson & McFarlane, 2004).

Lydia Hall’s Care, Cure, and Core Model (Figure A) refers to patients as having three needs of care: the physical, the medical, and the social needs. Nurses can easily provide the Care, Core and Cure model of nursing to meet the needs of patients with chronic disease (Touhy & Birnbach, 2001).

Nurses using Lydia Hall’s model, assist with education, medical management, and provide physical, emotional, or social support for congestive heart failure patients. The medical management and education offered by nurses increases patients’ knowledge and ability to manage their disease and prevent exacerbations and reduce hospital readmissions (Quaglietti et al., 2000).

Development of the nurse and patient relationship is critical in problem solving and providing care and education to promote effective health management for the congestive heart failure patient. Open communication and trust is necessary to facilitate care, provide education, and arrange discharge planning (Touhy & Birnbach, 2001).

Framework
Lydia Hall’s model for nursing provides a framework to encourage open communication between patients and nurses. The model has three interrelated circles that represent medical and clinical management nurses give to patients.

The care circle is the intimate care nurses provide to patients to assist in bathing, dressing and assistance with daily activities. The disease management and treatment of the patient is addressed in the cure circle of the framework. The core circle symbolizes the emotional and social structure of the patient. The model is not static, but rather the patient can be in an individual circle or the circles can overlap depending on the needs of the patient during management of their disease. Patients who have their care, cure, and core needs met have improved self-esteem and awareness of the importance of disease management and improved quality of life. The care, cure, core model provides an opportunity for Patients to develop trust and communicate their fears and concerns in relation to disease management (Touhy & Birnbach, 2001).

Care Model
The care model (Figure B) dominates when Nurses provide hands on care to congestive heart failure patients. Hands on care for patients produces an environment of comfort and trust and promotes open communication between nurses and patients. Open communication encourages expressions of thoughts and fears and decreases anxiety. Patients develop feelings of security and verbalize concerns of disease management, emotional, and/or social issues in relation to the lifestyle changes they are experiencing secondary to congestive heart failure (Touhy & Birnbach, 2001).

Patient education and discharge planning begins in the care model. During this phase, nurses have the primary role of answering questions and address concerns in relation to disease process, disease management. Congestive heart failure patients’ needs are addressed as nurses and patients develop both interpersonal and professional working relationships (Touhy & Birnbach, 2001).

Cure Model
The cure model (Figure C) dominates when nurses perform physical assessments and care management plans for congestive heart failure patients. During this phase, nurses assess patients’ ability to perform activities of daily living based on physical changes that occur during walking, talking or bathing (Touhy & Birnbach, 2001). Nurses monitor patients fatigue level, respiratory status, blood pressure and oxygen saturation to determine patients’ tolerance level and need for supplemental oxygen. Lung sounds are osculated for diminished breath sounds or crackles for signs of fluid congestion. Congestive heart failure patients’ pulse strength, edema, and temperature are assessed to monitor circulation status secondary to decrease cardiac output and potential of pooling of fluid in the lower extremities (LeMone & Burke, 2004).

Education to congestive heart failure patients is essential to increase their understanding of their disease process and to improve medication compliance. It is important that nurses review medications and stress the importance of compliance to medication schedules. Improved compliance can improve the quality of life for the congestive heart failure patient and result in decreased hospital readmissions (Coelho et al., 2005).

Diet compliance also improves the status of congestive heart failure patients. Patients who understand their ordered diet understand the importance of compliance to prevent weight gain due to fluid overload. Patients who recognize the symptoms that accompany their disease understand when to notify the physician of weight gain, increased shortness of breath, fatigue, or dizziness (LeMone & Burke, 2004).

Core Model
The core model (Figure D) of the framework dominates when nurses and patients are able to discuss emotional concerns and distress to physical and mental changes due to patients’ disease process. Patients address emotional concerns and distress due to their perceived ability or inability to manage their disease, living alone, and general fear of their disease process. These emotions and concerns effect compliance to the medical plan and quality of life (Touhy & Birnbach, 2001).
An essential role of nurses in the healthcare plan is to assist with management of congestive heart failure patients by providing medical, physical, and social care. The framework of Lydia Hall is used in the following care plan to assist in meeting the personal, medical, and social needs of congestive heart failure patients (Touhy & Birnbach, 2001).

Congestive Heart Failure Plan of Care

Care:

Problem 1: Potential for inability to care for self related to weakness and decreased mobility

Intervention

1. Asses patient’s ability to bathe and dress self
2. Assist with activities of daily living as
   needed for personal care
3. Teach importance of rest when bathing and
   dressing

Goal

1. Patient will have increased strength to
   bathe and dress self
2. Patient will have assistance as needed for
   personal care
3. Patient will verbalize and demonstrate the
   importance of rest when bathing and dressing

---

Problem 2: Potential for decreased social interaction secondary to fear, anxiety, and trust

Intervention

1. Identify cause(s) of stress/anxiety
2. Provide comfort and support
3. Encourage open communication
4. Identify strengths

Goal

1. Patient will verbalize stress and
   anxiety issues and have decrease fear
2. Patient will feel comfort and support
   during care
3. Patient will communicate openly
4. Patient will verbalize strengths in
   ability to care for self

Cure:

Problem #1:  Activity intolerance secondary to decrease cardiac output and weakness

Intervention

1. Assess vital signs
2. Monitor respiratory status
3. Encourage rest periods during activity
4. Assess need for oxygen and stress importance of compliance of oxygen use

Goal

1. Pulse, blood pressure and respiratory
   rate with be within patient’s limit
2. Respiratory effort, oxygen saturation
   with be within patient’s normal limit
3. Patient rest during activity and verbalizes importance of rest

Problem #2:  Fluid volume excess secondary to decreased circulatory status/cardiac output

Intervention

1. Teach patient to monitor daily weight, pulse, edema and respiratory effort
2. Teach patient medication protocol and
   importance of medication compliance
3. Teach importance of diet compliance
4. Teach importance of notifying the
   physician of status change

Goal

1. Patient will verbalize the importance of monitoring weight, pulse, edema, and respiratory effort
2. Patient will verbalize medication schedule and importance of compliance
3. Patient will verbalize importance of diet
   compliance
4. Patient will verbalize the importance of
   notifying the physician

Core:

Problem #1: Ineffective coping secondary to disease process

Intervention

1. Assess patient’s image of body/health changes
2. Identify patient’s strengths in caring for self
3. Assess patients ability to care for self

Goal

1. Patient will understand and begin to accept changes related to disease process
2. Patient will verbalize strengths and weakness
3. Patient will have care needed to promote
   optimal health

Problem #2:  Potential for non-compliance secondary to knowledge deficit and low self esteem

Intervention

1. Assess patient’s knowledge of disease process, treatment and medication schedule
2. Assess patients feelings of ability to care for self
3. Promote patient’s strengths and self esteem

Goal

1. Patient will understand disease process, treatment and medication schedule
2. Patient will verbalize feeling of ability to care for self and assist in discharge planning of disease process
3. Patient will increased self esteem in ability to care for self and disease management
   (RN Central, 2005)

Discharge Planning
Discharge planning during the core phase provides patients with essential emotional support and serves to decrease anxiety and fear (Touhy & Brinbach, 2001). Social isolation and the fear of dying affect the survival of cardiac patients. Patients may not have access to quality care or support needed to manage their disease. During this phase, nurses can provide emotional support and assistance by arranging home health care that best suits the needs of patients when they are discharged to home (Asadi-Lari, Parkham, & Gray, 2003).

Conclusion
Nurses work with the medical team to assist in evaluating congestive heart failure patients’ understanding of symptoms of their disease, compliance to diet and medication regimens, and the importance of informed follow up with their physician or nurses. Nurses can promote trust and facilitate open communication with patients when providing hands on care (Touhy & Brinbach, 2001).

Licensed Practical Nurses have an important role in management of congestive heart failure patients’ assessment and education. Lydia Hall’s Framework of Care, Cure, and Core provide a model for nurses to follow when evaluating congestive heart failure patients’ physical, medical, and social needs (Figure E). The individualized care offered by nurses promotes improved quality of life and decreased hospital readmissions for congestive heart failure patients (Touhy & Birnbach, 2001).

References
Asadi-Lari, M., Packham, C., & Gray, D. (2003). Unmet Health
needs in Patients with Coronary Heart Disease:
Implications and Potential for Improvement in Caring
Services. Health Quality of Life Outcomes, 1(26), 1-8.
Retrieved January 10, 06, from http:www.pubmedcentral.gov
Web Site: http://www.hqlo.com/concent/1/1/26

Coelho, R., Ramos, S., Prata, J., Bettercourt, P., Ferreira, A., & Cerqueira-Gomes, M. (2005). Heart Failure and Health related Quality of Life. Clinical Practice and Epidemiology in Mental Health, 1(19), 1-13. Retrieved January 16, 2006, from http://www.pubmedcentral.gov

LeMone, P., & Burke, K. (2004). Heart Failure. In P. LeMone & K. Burke (Eds.), Medical Surgical Nursing: Critical Thinking in Client Care (3rd ed., pp. 870-888). Upper Saddle River: Prentice Hall, Inc.

Paris, M. (2002, February 5). National Quality Management Program. Retrieved July 30, 2005, from http://www.jcaho.org/pms/core+measures.htm

Quaglietti, S., Atwood, E., Ackerman, L., & Froelicher, V. (2000). Management of The Patient with Congestive Heart Failure using Outpatient, Home, and Palliative Care. Progress in Cardiovascular Diseases, 43, 259-274.Retrieved

RN Central. (2005). RN Central. Retrieved January 10, 06, from www.rncentral.com/careplans/main.html

Touhy, T. A., & Birnbach, N. (2001). Lydia Hall, The Care, Core, Cure Model. In M. E. Parker (Ed.), Nursing theories and nursing practice (pp.135-137). Philadelphia: F.A. Davis Company.