*4.5.2 Management of physical activity*

Lifestyle exercises [walking, using stairs when possible, parking at a distance from shops, light gardening, and dancing] and structured activities and exercise can be useful as a priority for patients with heart failure. However, especially in patients with advanced heart failure, supervised exercise is recommended to increase exercise tolerance and improve quality of life [30]. One of the aims of self-care behaviours is for patients with advanced stage heart failure to come to a condition in which gradual mobilisation or stretching/relaxing movements of small muscle groups can be made and daily living activities can be performed.

### *4.5.3 Drug management*

Different pharmacological combinations are used in the treatment of advanced heart failure. The aim in self-care management is to provide drug compliance of the patient. Within drug compliance, the patient is expected to adhere to the principles of rational drug use. These principles are that drugs are taken at the prescribed time and dose, that the patient has information about the drugs, and that vital signs and

drug-related symptoms are recorded and healthcare professionals are informed. In recent years, many interventions have been developed to increase the drug compliance of cardiovascular disease patients, including technical interventions such as drug reminder applications, educational interventions, and interventions to increase motivation.

#### *4.5.4 Oedema control, water and salt restrictions*

The control of fluid intake is the primary nutritional recommendation. Daily fluid intake should be at the level of 1500–2000 ml, and daily weight follow-up should be made in respect of rapid weight increases. Salt restriction is a lifestyle change that should not be neglected in heart failure patients. In the American Heart Society guidelines, salt consumption of <3gr/day is recommended for symptomatic grade C and D patients [43]. The education of patients and their carers in respect of water and sodium restrictions and their follow-up are extremely important. Sodium-restricted diets can reduce total calorie and/or macro- and micronutrient intake and can therefore worsen the nutritional status [44].

#### *4.5.5 Diet*

Daily energy intake should be 25–30 Kcal/kg/day, and the amount of protein intake should be 1.5–2 gr/kg/day. Cholesterol in the diet should be restricted to be <200 mg per day; more foods containing unsaturated fat should be given, and fatty dairy products and foods high in saturated fats should be avoided [43].

The frequent use of diuretics leads to a decrease in potassium, sodium, and magnesium levels, and an increase in uric acid, blood glucose, and lipids. Those taking diuretics that lose potassium can be recommended to consume more foods with a high potassium content such as prunes, bananas, apricots, soya, oranges, broccoli, melon, tomatoes, spinach, and potatoes. Recommended herbal products include daily 1–2 cloves of garlic, 200–300 mg hawthorn extract, 1500 mg calcium, and 500 mg magnesium supplements. Thiamin, selenium, magnesium, zinc, calcium, and vitamin D deficiencies are frequently seen in patients with heart failure. It has been shown that with the addition of micronutrients such as iron, copper, selenium, riboflavin, folate, and vitamins A, B1, B6, B12, C, D, and E to the treatment of these patients, exercise tolerance has increased and symptoms have decreased [42]. When oral nutrition remains insufficient, enteral nutrition can be applied with foods high in protein concentration. This can be changed to parenteral feeding when the gastrointestinal system is significantly affected [45].

#### *4.5.6 Sleep management*

In cases with heart failure and obstructive sleep apnoea [OSA], positive pressure mask treatment [CPAP] can be considered. There is some evidence that OSA symptoms, cardiac function, biomarkers of cardiovascular disease, and quality of life can improve with CPAP treatment in patients with heart failure, but there is little evidence of an improvement in mortality [36].

As there can be a higher mortality rate in patients with predominantly central sleep apnoea and low ejection fraction, they should be applied with adaptive servo-ventilation.

## *4.5.7 Symptom management*

It is important to convert to behaviour the teaching given by healthcare professionals of advanced heart failure symptoms and observe progression, symptom identification, support for listening to the body, and/or interpretation of heart failure symptoms. Follow-up of patient behaviours must be performed by healthcare professionals. Follow-up should be made with a symptom diary kept by the patient, heart failure decompensation, and criteria for hospitalisation and mortality [39].
