Patients with heart failure (HF) and their families are invited to attend a teaching session that's offered biweekly at Texas Health Harris Methodist Hospital in Fort Worth. If an inpatient is discharged before attending the class, he or she is encouraged to come to a class as an outpatient. This educational program was established to maximize information sharing between the nursing staff, patients with HF, and their families.1,2

Complex medical conditions combined with the stress of being in the hospital can overwhelm patients.1,3 As an easy way to educate patients with HF about managing their condition, we developed a mnemonic based on the acronym SWAM:

* S: sodium and smoking

* W: weigh daily

* A: develop an activity schedule

* M: know about and take medications1,4,5

This article describes our methods of introducing SWAM to patients with HF and the success we've had with the program.

Diving in

Each patient receives a packet of information before entering the teaching session. The packet contains printed HF symptom management information and a daily weight chart.3 The teaching sessions are led by a cardiovascular clinical education specialist, a cardiovascular nurse specialist, or an expert cardiovascular nursing staff member.

The teaching session starts with an overview of HF and an introduction to the SWAM acronym, which helps patients remember symptom management strategies. Each letter of the acronym is explained using a slide presentation, the letters SWAM are posted on the wall, and objects that reinforce the main points are used during teaching.

S stands for monitoring sodium intake and eliminating smoking . We use a saltshaker to reinforce this critical point. Patients are encouraged to throw their saltshakers in the trash and use alternative seasonings. Cans of soup and pictures of food nutrition labels are used to explain how to read the labels and determine the amount of sodium in food. Patients are instructed to follow the usual limit of 2,000 mg/day of sodium unless their primary care provider (PCP) has told them otherwise.3 We also explain how to read serving sizes for nutrition accuracy. A list given to patients divides food into "good" and "bad" categories so they can remember what to avoid.

Facts about how smoking affects the heart are presented to encourage smoking cessation.4 Additional smoking cessation programs are offered to patients who smoke.

W stands for monitoring weight daily . A bathroom scale is the object used to reinforce this critical point. We hand out and explain a daily weight-monitoring chart. The chart is included in the slide presentation so patients can recognize it in their informational packets. It's red, yellow, and green; green indicates that the patient's symptoms are being managed, yellow indicates that he or she should call the PCP for interventions, and red indicates that he or she needs to go to the ED. Patients are encouraged to weigh themselves (wearing the same amount of clothes) each day as soon as they get out of bed, before eating or drinking anything, and after urinating. They're instructed to immediately record their weight on the chart and compare it with the previous day's weight. Patients are instructed to call their PCPs when their weight increases 3 lb (1.36 kg) in 1 day or 5 lb (2.27 kg) in 1 week.4

Patients begin working with daily intake and output charts during their hospitalization so they can practice monitoring their fluid in-take and output before discharge.

A conversion chart is included in their packets so they can convert cup sizes to mL-a daily 2-L fluid restriction is recommended, unless otherwise directed by their PCP.4

A correlation between weight gain and fluid intake is made evident during the session. We also stress that salt has a great impact on fluid retention resulting in weight gain.

A stands for encouraging patients to be active . We use a pair of tennis shoes to illustrate this point. Patients are encouraged to start an activity program, with a set routine, so they can monitor their levels of exercise tolerance. We encourage patients to balance activity with rest periods. If shortness of breath, fatigue, or other symptoms of activity intolerance occur, they're instructed to call their PCP.4 For example, a patient who can usually walk around a swimming pool five times but can now walk around only three times because of shortness of breath needs to notify his or her PCP.

M stands for medication . A large medicine bottle and a pillbox are used to emphasize this point. We usually have a pharmacist available to answer patients' questions. We also suggest that patients purchase a pillbox for organizing medications and remembering dosages. Common medications such as diuretics are reviewed, and the importance of adhering to medication regimens is stressed. We emphasize that failure to follow treatment regimens is a common reason patients are readmitted for worsening HF.4 We also explain to patients why their electrolyte levels and renal function studies should be evaluated periodically during treatment.

Any questions?

At the end of each teaching session, patients answer simple, fill-in-the-blank questions to help reinforce what they've learned and encourage them to make commitments to lifestyle changes. They're asked about their weight gain parameters and strategies for remembering to take medications. They're also asked to identify three high-sodium foods they'll avoid.

Most patients and families are highly engaged during our SWAM presentation and are grateful that we've taken the time to help them understand life with HF. To date, over 300 patients and family members have attended the class; more than 200 of the attendees were patients. The current overall readmission rate is 13.5% for HF patients. We're thrilled knowing that we're helping patients with HF take control of their lives.

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