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Journal of Cardiovascular Nursing
Vol. 22, No. 5, pp 382Y389 x Copyright B 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins
Weight and Symptom Diary for
Self-monitoring in Heart Failure
Clinic Patients
Cathy A. Eastwood, BN, MN; Lucille Travis, PhD, RN, CNA, BC;
Tanya T. Morgenstern, MSN, MPH; Erin K. Donaho, RN, BSN
Background: For people with chronic heart failure, self-monitoring has been linked with improved body
awareness and better communication with health professionals. Cognitive theory and the concept of somatic
awareness help explain self-monitoring behaviors. This study compares the clinical and hospital outcomes of heart
failure patients who are using and not using a diary to record weight, vital signs and, symptoms and evaluates the
diary format. Methods: All patients enrolling in an outpatient heart failure clinic were given a Heart Health Diary.
Seventy patients used the diary and 54 did not. A review of these 124 patients (82 men and 42 women) was
completed 6 months after enrollment. Results: Diary nonusers were more likely to be younger women with a
lower ejection fraction and worse functional status. Those using a diary had 35% and 47% more contacts via
telephone and clinic, respectively. Both groups had significant functional and B-type natriuretic peptide
improvement. If hospitalized after enrollment in the heart failure clinic, average length of stay for all hospital
admissions for diary users decreased by 58% (P G .002) and average cost per case decreased by 56% (P G .011).
Length of stay and cost per case did not significantly change for those not using diaries. Conclusion: Diary users
showed evidence of improved clinical and hospital outcomes. Further investigation is needed to clarify the
characteristics of a diary user and the effect of diary use on self-management and outcomes.
KEY WORDS:
diary, heart failure, outcomes, self-monitoring, somatic awareness
I
ntensive outpatient clinical follow-up and education have been well documented to reduce hospitalizations for people with chronic heart failure
(HF).1Y4 In a review of posthospitalization nursing
interventions in the HF population, HF clinics that
included nursing interventions effectively reduced
admissions, emergency visits, and overall costs;
decreased mortality; and improved self-care and
Cathy A. Eastwood, BN, MN
Lecturer, School of Nursing, Memorial University, St. John’s,
Newfoundland and Labrador, Canada.
Lucille Travis, PhD, RN, CNA, BC
Associate Dean and Director, School of Nursing, College of Health
and Human Services, University of North Carolina at Charlotte,
Charlotte, NC.
Tanya T. Morgenstern, MSN, MPH
Family Nurse Practitioner, Private Practice, Otolaryngology and
Allergy, Mark S. Robertson, DO, Albany, Ore.
quality of life.5 Reduced hospitalizations have been
linked to the patient’s ability to effectively detect and
report worsening HF symptoms.6 Research on nursing interventions that enhance detecting and reporting of symptoms in HF patients is limited.
The outpatient Heart Failure Clinic and Program
(HFC) at St. Luke’s Episcopal Hospital/Texas Heart
Institute in Houston offers private-practice cardiologists the option of added multidisciplinary support
for HF patients when enrolled in the hospital-based
outpatient program. Cardiologists, nurse practitioners, and specialized nurses ensure that medications are optimized based on current practice
guidelines. Nursing interventions in the HFC include
a 90-minute HF education class, a weight and
symptom diary, regular telephone monitoring, and
frequent clinic visits provided by nursing personnel
between medical visits.
Erin K. Donaho, RN, BSN
Heart Failure Coordinator, Heart Failure Department, Heart & Lung
Transplant Treatment Center, Houston, Tex.
Purpose
The authors have no conflicts of interest to declare.
Weight monitoring and symptom monitoring have
become standard topics for outpatient HF education.
Practice guidelines suggest that the patient and
family be educated to demonstrate understanding
of the early signs of fluid retention by documenting
Corresponding author
Cathy A. Eastwood, BN, MN, School of Nursing, Memorial
University, Prince Philip Drive, PO Box 4200, St. John’s,
Newfoundland and Labrador, Canada A1C 5S7
(e-mail: [email protected]).
382
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Self-monitoring in Heart Failure Clinic Patients 383
daily weights and monitoring symptom changes.7,8
These guidelines also suggest that, when possible,
individuals be taught to self-adjust diuretics in response to fluid retention.8 Although the HF literature2,5,6,9 suggests that patients record their weight
as an intervention, the use of a symptom diary in this
population has limited research. This article discusses the methods and results of a study comparing
the clinical and hospital outcomes of people with HF
who chose to document their weight, vital signs, and
symptoms in a daily diary with those of people with
HF who did not document. A secondary purpose of
the study was to evaluate the format of the Heart
Health Diary as a self-monitoring tool.
Theoretical Concepts
The complex work of self-monitoring is an important behavior for self- management required for
various chronic illnesses such as diabetes, hypertension, and HF. Coping strategies for chronic illness
include obtaining knowledge and skill for ongoing
self-care that involves developing Ban awareness
of body cues, interpreting physical changes accurately, and taking appropriate action either to alter
therapy or to seek help from health-care resources
to prevent a crisis.^10(p29) Becoming aware of body
cues and taking appropriate action are part of the
decision-making process that is described by cognitive theory.11 Riegel et al12 describe HF patients’
decision making regarding symptoms within the
cognitive theory stages as involving the patient recognizing that a body cue or symptom is related to
the illness, acting to address the symptom, and then
evaluating the effectiveness of the action taken to
relieve symptoms.
The concept of somatic awareness, defined as
sensitivity to physical sensations secondary to physiological change, may also play a role in symptom
reporting.13 Jurgens13 hypothesized that symptom
monitoring is impaired by poor somatic awareness.
Both HF somatic awareness and a sudden onset of
symptoms independently predicted delays in seeking care. Jurgens13 concluded that variability in the
type and severity of symptoms might be responsible
for patients’ difficulty developing a reliable cognitive
meaning upon which to make decisions about seeking care. Interventions focusing on developing somatic awareness and cognitive symptom experience
were suggested as potentially helpful to reduce delay
in seeking treatment.
Given somatic awareness and cognitive theory, a
diary is a tool that may focus attention on the body’s
physical patterns and changes. The conscious effort
of noting symptoms and writing them down may
improve the ability of patients to do the following:
know their body in relation to their chronic illness,
link symptoms with behaviors, report symptoms
early, and potentially prevent unnecessary hospitalizations. Self-monitoring by patients with chronic
conditions has been linked to improved body awareness, better communication with health professionals, and an improved sense of self-efficacy in
controlling HF.3,14
Literature Review
Health diaries described in the literature can be
broken down into 2 major types: ledger and journal formats. In the ledger format, occurrences such
as weights, blood pressure readings, healthcare
visits, and episodes of pain are recorded as they
occur. The advantages of ledger-type diaries are that
they usually contain few pages and they are written
in only when an event occurs. Conversely, journaltype diaries usually require daily entries, whether
or not an event has happened. With the journal format, the researcher is able to obtain more detailed
information and can more easily determine if data
are missing.15
Both in the chronic illness and cardiovascular
literature, symptom diaries are frequently used solely
to collect research data.16,17 These diaries are often
ledger style with Likert-scale check boxes. When
diaries are mentioned for data collection, it is not
clear to what degree the patients are encouraged to
actively evaluate and report symptoms for improved
self-management. Basilicato et al18 used a ledgertype diary to determine if it would assist cardiac patients in providing a more complete report of their
angina. They found that after using the diary,
patients were able to give a more concise report of
symptoms. The diary was advocated as a useful tool
for patient education and data collection about angina symptoms.
Most medical or nursing articles describing the
outcomes of outpatient HF programs mention that
they educate patients on weighing daily and monitoring symptoms.19Y21 A weight and symptom record
may have been encouraged, but most often, it is not
described. Several authors state that a diary is used
for weight and medication monitoring but include
it as one of many program interventions.22Y25 These
interventions included medication and diet education, a focus on medication adherence, and telephone contact with nurses.
Only 1 article focused specifically on outcomes
that may be related to diary use. Wright et al26 found
that 76 of 197 patients used the diary that was
encouraged to everyone in their HF intervention
group. Those who used the diary were on more
medication; were more likely to attend education
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384 Journal of Cardiovascular Nursing x September/October 2007
sessions, HF clinic, or primary care visits; and had
lower symptom and mortality rates.
checkbook, so that it could fit in a purse or pocket
for ease of transport to clinic visits.
Objectives
Methods
Based on the body of research about health diary use
in monitoring patients, we developed a combination
ledger- and journal-format diary. The hypotheses for
this study were the following: (1) Diary users would
have improved communication with providers, as
evidenced by more contact by telephone and clinic
visits during the first 6 months in HFC; and (2) Diary
users would have improved clinical and hospital outcomes comparing pre- and post-HFC enrollment.
The Heart Health Diary was developed with an
expert panel of nurses and cardiologists from
cardiology, cardiac rehabilitation, and the outpatient
HFC. The type of diary in this study is a combination of ledger and journal format, with columns for
data and space for personal comments. Using the
Agency for Health Care Policy Research guidelines
for HF,27 the expert team identified the salient vital
signs and symptoms for the patient to note and
record. The diary contained instructions, 6 pages for
noting current medications, and space for 6 months
of daily information (Figure 1). Weight, blood
pressure, pulse, fatigue, trouble breathing, cough,
swelling/bloating, and chest pain were the essential
columns. Blood sugar was included because many
people with cardiovascular disease also have diabetes and could keep 1 record, not 2. The incision/
wound column was added for postoperative cardiovascular patients or those in postprocedure (heart
catheterization) to document any problems. The size
chosen for the diary was 3 8 inches, the size of a
This study was a retrospective descriptive design. A
review of 124 patient records between January 2001
and August 2002 was completed, collecting data on
the 6 months after patients were enrolled in the
HFC. All clinical data were collected and saved in
CHF Manager, a commercial computer database. At
all times during the study, patient information and
privacy were protected by limiting access to charts
and the database only to departmental personnel. All
patients signed a hospital-wide consent to treatment
form before enrollment in the program. Institutional
review was not required at the time for this retrospective study.
Frequency of patient telephone contacts and clinic
visits with clinic staff was counted. At each visit, a
nurse and a physician examined the patients and determined the New York Heart Association (NYHA)
functional class as a subjective measure of HF severity (Table 1).28 Left ventricular ejection fraction
(LVEF), a measure of the amount of blood pumped
from the left ventricle with each beat, was measured by echocardiogram as a part of routine care.
Left ventricular ejection fraction is measured as the
percentage of blood ejected from the left ventricle
with each contraction, with 60% being normal and
less than 40% considered dysfunctional. B-type natriuretic peptide (B-NP) blood levels were measured
at each patient clinic visit using the Biosite Point
of Care Assay. The B-NP level correlates with left
ventricular end diastolic pressure.29 Hospitalization
FIGURE 1. Heart Health DiaryB.
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Self-monitoring in Heart Failure Clinic Patients 385
TABLE 1
New York Heart Association
Functional Class28
Class I
Class II
Class III
Class IV
No limitations of activities;
no symptoms with ordinary activities
Slight or mild limitation of activity;
comfortable with rest or mild exertion
Marked limitation of activity;
comfortable only at rest
Any physical activity brings on discomfort,
and symptoms occur at rest
data were captured using the hospital’s financial accounting system, including the number of admissions,
length of stay (LOS), and cost per case 6 months before and after enrollment in the HFC.
The Heart Health Diary was given to all patients
upon enrollment in the HFC. Diary users are defined
as those who regularly recorded their weight and
symptoms. Diary nonusers chose not to keep a record. Any form of symptom record was counted as a
diary because a few patients preferred to track their
information on a computer, calendar, or other small
booklet. All documentation behavior was encouraged and commended. Patients received instruction
for use of the diary from the HFC nurses during their
initial clinic visit and education session. The importance of recording in the Heart Health Diary was
reinforced during subsequent visits and during telephone contacts with the patient. Patients were encouraged to document in the diary and bring it with
them to each clinic visit. Patients were also asked to
refer to the diary during telephone contacts with the
nurses to discuss exact information.
Sample
This study includes a nonrandomized sample, with
the study group being the diary users. One hundred
forty-four charts were reviewed. Twenty charts without data on diary use were excluded; 124 records
containing data on diary use were included in the
study. The sample consists of consecutive patients
who were referred to the program for hospitalization in the past year, were classified as NYHA
functional class II to IV, had evidence of difficulty
TABLE 2
adhering to the recommended medications or 2-g
sodium diet, or wait too long to report symptoms.
The population ranges in age from 20 to 93 years;
is almost equally male and female; and is 40%
white, 40% African American, 10% Hispanic, and
10% of other races.
Data Analysis
Data were analyzed using SPSS version 11.5 to calculate descriptive statistics and comparisons between
groups. Paired t test, univariate analysis of variance,
and repeated measures analysis of variance were
used to explore the hypothesis of this study. The level
of significance was set at P e .05.
Results
The sample consisted of 82 men (50 used the diary)
and 42 women (20 used the diary) (Table 2). The mean
age of the diary users was 65.0 years (T11.9 years),
and the mean age of the diary nonusers was 56.7
years (T15.4 years). Baseline ejection fraction was
5% higher in the diary users. Upon enrollment in the
program, there was no significant difference in the
mean NYHA functional class between diary users
(mean T SD, 3.1 T 0.69) and diary nonusers (2.9 T
0.77). B-type natriuretic peptide level also had no significant difference between groups.
Patient Contact
As an indicator of active decision making, we reviewed the frequency of telephone calls to the clinic
nurses and clinic visits by the subjects over a 6-month
period. We compared both variables by diary users
and nonusers. The mean number of contacts during
the 6 months of the study is shown in Table 3. Diary
users had 35% more telephone contacts and 47%
more clinic visits than diary nonusers did.
Clinical Outcomes
A comparison of baseline to 6 months after HFC
enrollment indicated that ejection fraction improved
Characteristics of the Sample (N = 124): Diary Users Versus Diary Nonusers
Subset, no. (%)
Age, mean T SD, y
Sex, no. (%), M/F
Mean baseline LVEF, mean T SD, %
Mean baseline NYHA, mean T SD
Mean baseline B-NP, mean T SD
Diary Users
Diary Nonusers
P
70 (56)
65 T 11.9
50/20 (71/29)
26.9 T 11.9
3.1 T 0.69
459 T 392
54 (44)
56.7 T 15.4
32/22 (59/41)
21 T 7.0
2.9 T 0.77
430 T 395
G.004
G.074
.769
LVEF indicates left ventricular ejection fraction; NYHA, New York Heart Association; B-NP, B-type natriuretic peptide.
Copyright @ Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
386 Journal of Cardiovascular Nursing x September/October 2007
(Figure 3). There was no difference between groups in
frequency, LOS, or cost with HF admission. However,
the total costs for admissions for reasons other than
HF decreased significantly for diary users and increased for nonusers (Figure 4).
TABLE 3
Clinical Contacts Over 6 Months
Compared Between Diary Users and Diary
Nonusers
Variable
Telephone contacts
Total
Range
Mean T SD
Clinic visits
Total
Range
Mean T SD
Diary
Users
(n = 70)
Diary
Nonusers
(n = 54)
525
0Y25
7.5 T 5.24
265
0Y31
4.9 T 5.14
617
3Y25
8.9 T 4.57
273
1Y20
5.1 T 3.37
P
Discussion
G.007
G.001
more for the diary users (n = 50): 27.0% (T11.2%)
to 29.3% (T14.2%), a change of 23% (P G .038).
There was no change in the ejection fraction measures of diary nonusers (n = 25): 22.4% (T7.6%) to
22.5 (T7.2%).
Change in the NYHA functional class of patients
over 6 months is provided in Table 4. Functional
class improved significantly for both diary users and
nonusers.
B-type natriuretic peptide was measured as an
indicator of HF severity because high levels of B-NP
indicate the greater stretch within the left ventricle.29
For both diary users and nonusers, the B-NP level
improved significantly (Table 4).
Hospital Outcomes
A comparison of all admissions 6 months before and
after HFC program enrollment demonstrated no significant difference between the diary users and nonusers in the number of hospitalizations. The mean
LOS when admitted for any reason decreased for
both diary users and nonusers; however, the decrease
in LOS was statistically significant for the diary
users: from 9.8 (T9.5) to 4.1 (T6.3) days (Figure 2).
Average cost per case decreased significantly for diary
users only, whereas it increased for diary nonusers
TABLE 4
Variable
LVEF, %
Baseline
6 Months
NYHA
Baseline
6 Months
B-NP
Baseline
6 Months
Sample
The diary nonuser was more likely to be a younger woman with a slightly lower ejection fraction and
functional status (Table 2). Further demographic data
are needed to better predict who would use the diary.
Patient Contact
Diary users had more telephone calls to staff and
clinic visits. Diary users may help define a subpopulation of patients who are more likely to be adherent
to a health regimen or more actively participate in
self-management.26
Diary nonusers may require more focused intervention. Possibly, more frequently scheduled clinic
visits and telephone contacts are needed for improved
outcomes. Analysis of the telephone call purpose and
subsequent interventions would further describe the
symptom-reporting behavior of both groups.
The diary nonuser group may indicate a group
that might benefit the most from electronic monitoring devices when considering cost and benefit. These
devices transmit weight and symptom data to the
providers who intervene with patients who indicate
worsening symptoms. Patients can be provided with
daily reminders of appropriate health behaviors and
feedback on their progress when more active patient
involvement is not attainable.30
Clinical Outcomes
Improvement in LVEF for diary users only is
marginally useful, given the low sensitivity of the
Changes in Clinical Outcomes Over 6 Months
Diary Users
P
Diary Nonusers
P
27 T 1.2 (50)
29.3 T 14.2
G.038
22.4 T 7.6 (25)
22.5 T 7.2
ns
3.1 T 0.69 (69)
2.6 T 0.80 (69)
G.001
2.9 T 0.77 (50)
2.4 T 0.80 (50)
G.001
459 T 392 (42)
351 T 359 (42)
G.011
433 T 397 (24)
271 T 277 (24)
G.004
LVEF indicates left ventricular ejection fraction; NYHA, New York Heart Association classification (1-4); B-NP, B-type natriuretic peptide (pg/mL).
Values are given in mean T SD. Numbers inside parentheses are the number of participants.
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Self-monitoring in Heart Failure Clinic Patients 387
FIGURE 2. Mean length of stay.
test and the inconsistent correlation with functional
status. NYHA functional class and B-NP levels
improved significantly for both groups, indicating
clinical improvement for all enrolled in the program.
NYHA class is subjective but is widely accepted as
a cardiovascular symptom severity measure. Data
were not collected on medications prescribed; therefore, it is difficult to separate other factors contributing to the improvements other than the general
program effect. Similarly, comorbidities were
tracked, but given the limited sample size regression
analysis, it was not possible to identify if other
disease conditions (ie, hypertension) contributed to
the results.
Hospital Outcomes
Reduction in hospital days and related costs for
diary users potentially indicates improved physical
health and/or less acute care needs when admitted.
Decreased LOS and cost when admitted for other
than HF for the diary group, which increased for
the diary nonuser group, may indicate better selfmanagement for all comorbidities for the diary users,
not just HF. It is not clear if the diary user group
might have had reduced hospital stays even without
a diary. The characteristics of a diary user need further study including more sensitive measures of self-
management, such as the Self-Management of
Heart Failure Instrument12 and the Heart Failure
Somatic Awareness Scale,13 to determine how different people act on symptoms and the greatest effect
on outcomes.
In sum, use of the diary was a potential contributing factor toward clinical improvement. A tool that
promotes participation in self-monitoring and early
reporting of health changes can strengthen a program effect.
Diary Format
The combination of a ledger and journal format
was useful for patients to see patterns and identify
related behaviors. The symptoms recorded are included in the list of 12 symptoms measured by
Jurgens.13 Daily recordings were most useful when
they included a minimum of daily weight, whether
it changed or not. Most people recorded daily
blood pressure readings. This was encouraged at
varied times of the day to capture any fluctuations
in blood pressure. The next most frequently recorded data were comments, including brief statements on changes in health, activity, or medications.
The symptom columns were often either filled out
completely or not at all. The symptom columns serve
as a reminder to the patient to reflect on his or
FIGURE 3. Mean cost per case.
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388 Journal of Cardiovascular Nursing x September/October 2007
FIGURE 4. Total admissions cost per case for other than heart failure.
her symptoms each day and, although often left
blank, are believed to remain valuable. The incision/
wound column is not frequently used for the outpatient HF population and could be excluded. The
diary size and format were reported to be portable
and functional.
Given that adherence to one’s medication regimen
is essential for maintaining and improving clinical
stability, it is strongly encouraged that all patients
come to the clinic with either their medication
bottles or a list of medications. Many chose to write
their medications on separate pages rather than
use the diary pages. This may be because of the frequency of medication changes, making a new page
clearer to follow. When a current list of medications
and diary data are recorded, it is evident that the
person is committed to self-monitoring and communicating health data.
Limitations and Recommendations
This study was limited by being a retrospective
rather than a prospective design. The retrospective
review of diary users versus nonusers helps identify those individuals more likely to document and
report concerns.
The nonrandomized sample of this study limits the generalizability of the results to other
populations. If the diary was randomly assigned,
some patients may still have not used it, potentially skewing study data. However, a nonrandom
design provides information about the diary user
and nonuser that might otherwise be lost in a
randomized study. The self-selection bias also reduces the ability to determine the strength of the
effect of the diary on outcomes compared with the
other program interventions. A study design powered for regression analysis might clarify which
variable within the program has the greatest effect
on outcomes.
Also, it was not clear whether it was the patient
or a significant other who recorded in the diary.
Consequently, recorded information may vary de-
pending on the recorder’s perspective. As well,
truthfulness was assumed and verified by comparing
reported symptoms with physical assessment and
interview findings. For consistency, we accepted the
data as recorded. The study lacked information on
each patient’s cognitive and education level, which
might further describe the groups.
For future study, a prospective approach is
recommended, with data collected to identify the
diary recorder and identify the diary user versus
nonuser at baseline. Specifically, information on
cognitive status, educational level, marital status,
race, and socioeconomic background might help
identify individuals or groups who might use a diary.
Psychological profile and depression measures might
also clarify factors influencing diary use. Additional
assessment with specialized questionnaires for selfmanagement12 and somatic awareness13 could provide the team with an indication of self-monitoring
skill that might need individualized intervention.
Health-related quality of life might be a useful
outcome to measure.
Commending patients when they report symptom
changes in a timely manner reinforces their somatic
awareness and their positive cognitive decision
making for their health. For others, nurses need to
highlight the worsening symptoms and clearly
describe the appropriate response to model decision
making. For example, BWhen your abdomen feels
this tight or your weight is up this much, you are
retaining fluid and you need to call me.^
Lastly, the potential patient- and system-related
barriers to adherence to diary use need further exploration. Literacy, social support, beliefs, cognition,
motivation, and accessibility to and response from
the HFC staff may affect diary use, self-monitoring,
and patient outcomes.
Conclusion
In conclusion, diary users showed some evidence of
improved clinical and hospital outcomes. Diary users
maintained closer contact with the health team with
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Self-monitoring in Heart Failure Clinic Patients 389
more frequent telephone calls and clinic visits.
Further investigation is needed to clarify the characteristics of HF patients who do and do not practice
routine self-monitoring and to determine the effect
of diary use on somatic awareness, health decision
making, and communication with health providers
and outcomes. Understanding differences in self-care
practices will help nurses refine monitoring methods
and educational approaches for HF patients.
Acknowledgments
We thank Hope Nora, PhD, for data analysis; Nancy
Cole for data collection; and Greg Poulin, MSN, for
support for patients in their use of the diary.
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