Heart failure is the leading cause of hospital admission in older people over 65. Readmissions within 30 days exceed 25%, with enormous costs for the healthcare system and patients’ quality of life. Structured, proactive home care can significantly reduce this phenomenon.
Daily monitoring: weight, breathlessness and oedema
Daily body-weight checks are the most sensitive parameter for early detection of fluid retention due to heart failure. A gain of 1-2 kg in 2-3 days requires immediate contact with the doctor. The home nurse teaches patients how to perform this monitoring and periodically assesses vital signs, dependent oedema and exercise tolerance.
Therapeutic education for patients with heart failure
Fluid restriction (if prescribed), a low-sodium diet, adherence to therapy (diuretics, ACE inhibitors, beta-blockers), adapted physical activity and recognition of warning signs are the pillars of heart failure self-management. A structured therapeutic education programme reduces readmissions by 30-40%.
Telemedicine and remote monitoring
Remote monitoring technologies — connected scales, pulse oximeters and remote ECG — allow continuous surveillance of patients with heart failure. The home nurse integrates these data into clinical assessment, ensuring truly proactive care.
📚 Scientific evidence
- McDonagh T.A. et al. (2021). 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J, 42(36):3599-726.
- Inglis S.C. et al. (2015). Structured telephone support or non-invasive telemonitoring for patients with heart failure. Cochrane Database Syst Rev.
- ANMCO-SIC (2022). Documento di consenso sulla gestione dello scompenso cardiaco. Roma.
