There were 32 articles with contents consistent with this research purpose. In addition, one book in which nursing care based on evidence was shown was added, and 33 subjects [9] [13] - [42] were taken as target literature.

From the target literature, the background of discontinuation of treatment and symptomatic monitoring performed in the acute exacerbation phase of chronic heart failure in patients with impaired cognitive function became clear (Figure 1).

Table 1 shows the outline of the certified nurses who were the subjects of this study. A total of 22 people, including 7 certified chronic heart failure nurses and 15 nurses with dementia nursing care experience, were eligible. Age was 41.7 ± 7.8 years for chronic heart failure nurses and 42.7 ± 5.7 years for certified dementia nurses. Average years of experience as a nurse were 18.4 ± 8.6 for chronic heart failure nurses and 20.2 ± 5.7 years for certified dementia nurses. The years of experience of certified nurses were 3.3 ± 1.3 years for certified chronic heart failure nurses and 4.3 ± 1.6 years for certified dementia nurses. Sex in certified chronic heart failure nurses was 6 females and 1 male and for certified dementia nurses, it was 12 females and 3 males.

As a result of holding semi structured interviews using an interview guide prepared based on the background of the discontinuation of treatment and symptomatic monitoring in Figure 1, we obtained opinions/views on 8 situations namely, “cognitive function at hospitalization”, “characteristics at hospitalization”, “characteristics when receiving examinations, procedures or treatment”, “characteristics of course of treatment”, “characteristics related to difficulties in

grasping the symptoms of chronic heart failure and indices of deterioration”, “characteristics when using diuretics”, “characteristics concerning compliance with dietary restrictions” and “support required for discharge from hospital” and we divided the results into 8 situations and summarized them.

As shown from responses such as “It is difficult to identify dementia”, “It is difficult to create a nursing protocol based on the type and severity of dementia” and “It is difficult to determine dementia, type and severity”, there are cases in which the diagnosis of dementia is not made at the time of admission.

Responses such as “It is difficult to distinguish between BPSD and delirium”, “There are times when it is possible to distinguish between dementia and delirium and times when it is not possible” and “It is difficult to show characteristics

of delirium and onset of dementia” also show that it is clear that it is difficult to respond to the type and severity of dementia as it is not possible to distinguish between them. Therefore, at the time of admission, it is first necessary to screen patients with high risk of suspected dementia or delirium. There was also the opinion that “Nursing protocols cover the elderly”. We do not distinguish between delirium and dementia, we think that it is reasonable to think that elderly people aged 65 and older are generally considered to be in a state of declining cognitive function during the period of acute exacerbation of chronic heart failure. Certified chronic heart failure nurses presented the opinion that “Users of INOVAN injections are prone to delirium”. INOVAN is used with severe cardiac function issues, and it seems that mental symptoms such as delirium are likely to appear from hypoxic state at hospitalization. Predictive judgment of cognitive decline associated with cardiac function is also important, because treatment content also serves as a material for estimating the severity of cardiac function. The viewpoint of treatment for heart failure was specialized for certified chronic heart failure nurses.

Meanwhile, certified dementia nurses mentioned the indicators of assessment as objective evaluation of cognitive decline. The viewpoint of the assessment on the cognitive function using the tool was specialized in certified dementia nurses.

There was an opinion that there were many unscheduled hospitalizations due to emergency transport caused by management of the situation before hospitalization and poor subjective symptoms as shown in Table 4. Patients with decreased cognitive function may not receive sufficient support and may be suddenly hospitalized as opposed to hospitalization during a regular outpatient visit. There was also the opinion that “At hospitalization heart load is applied due to environmental change and symptoms of deterioration”. It is considered that there is maladaptation to the environment, that “Patients are relieved if families and familiar doctors are involved” and that providing a familiar environment prevents excessive heart load and leads to early recovery. Patients who did not have a noticeably lower level of consciousness at the time of admission corresponded to the opinion that “In patients without knowledge there is a desire to go home”. As seen from the opinion of “Subjective symptoms are less likely to occur comparable to other diseases”, it seems that patients are in a situation in which they do not recognize the necessity of hospitalization.

The opinions of “Heart failure becomes worse from the environmental change and excretion cannot be done properly” and “Age-related change in sensory organs affects adaptation to hospital environment” show that it is difficult to adapt to changes in the environment due to sudden hospitalization. As a result, as shown in the opinion of “Delirium is easy to see and prediction is important”, patients are in a high-risk state of delirium. For that reason, nurses are involved in building relationships of trust with patients and facilitating relaxation. As shown in the opinions of “Building trust is important”, “Relief-related involvement is necessary in care” and “The nurse needs explanation and contact to relieve the patient”, heart load resulting from anxiety can be prevented.

As shown in the opinion of “Patients with mild dementia may remember nurses at hospitalization”, as patients with a mild decline in cognitive function have mild core dementia symptoms, ingenuity such as the opinion of “Patients are calmed if their own living environment before hospitalization is incorporated” that enables the environment before hospitalization to continue as far as possible is important. From the opinions of “Families affect patient motivation for treatment” and “It feels more real if a doctor is involved”, we can see that assistance to cooperate with family and doctors and adapt quickly to sudden changes in the environment are required.

Patients with decreased cognitive function are in a hypoxic state in the acute exacerbation phase of chronic heart failure and as shown in the opinion of “It is difficult to have blood drawn at the confusion stage after treatment starts”, it seems that from the level of ordinary cognitive function, ability to understand was further deteriorated. Therefore, there is a need to “Explain in a way that patients can understand and be convinced” and “If the patient cannot understand the examination, sit next to the patient and explain what is happening”.

Invasive examinations such as cardiac catheter examinations are sometimes carried out due to underlying diseases connected to heart failure. For that reason, opinions such as “Drugs are used for resting during large invasive examinations”, “It is inevitable to take sedation with drugs at the time of examinations in consideration of safety” and “Cardiac catheterization obtains family cooperation, but is discontinued if drug use is ineffective” showed that safety was ensured using sedation. As shown in the opinion that “From the administrative side after cardiac catheterization, the radial artery was used to avoid the femoral artery”, even after examination, safety management is also required in order to prevent complications based on the characteristics of patients with decreased cognitive function who cannot maintain rest.

Although there is no denial of opinions such as “Blood sampling is often done” with respect less invasive examinations, as shown in the opinion of “The patients dislike echography gel”, examinations themselves are unlikely to cause pain even the patient doesn’t like the feeling of cold.

As shown in the opinion of “Changes in body temperature are observed after the start of the examination”, the risk of rising blood pressure also increases, so it is also necessary to keep patients warm so as not to cause excessive heart load.

As a response at the time of examination/treatment and at the time of hospitalization, doctors plan to take prompt treatment for early recovery and plan to start the treatment at an early stage and, as shown in the opinions of “The patients feel bad when treated in large numbers” and “Before choosing physical restraints, it is important to give a sense of security”, dementia patients who have deteriorated cognitive function will have anxiety and distrust. There were opinions such as “If relationships are built and patients are surrounded by familiar faces, medical staff will not be rejected”, “If the patient cannot understand the examination, sit next to the patient and explain what is happening” and “Doctors and nurses should always follow up the examination”. Nurses strive to build a relationship of trust between themselves and the patient, accompanying them during examinations/treatment and explain everything. Also, as explained in the opinion of “Patient related anxiety that the prospects are not good”, nurses explain in order to relieve anxiety at the prospect of a long treatment period which in turn leads to a reduction in the risk of excessive cardiac load.

As shown in the opinion of “Because of excretion needs, the patient becomes hyperactive and disturbed and rest cannot be maintained”, there was the characteristic that treatment could be easily interrupted in the acute exacerbation period of chronic heart failure because patients pulled at intravenous drips and indwelling bladder catheters or because patients were unable to articulate what was wrong with them. According to the opinions that “When inserting an intravenous drip, select a method that causes the least pain possible, devise a puncture site, the position of the route and fixation method”, “Minimize the insertion period of the indwelling bladder catheter, expand ALD by setting the excretion style according to the condition after removing the catheter” and “if the patient cannot maintain rest, incorporate activities according to the resting degree”, it is necessary to advance nursing assistance to alleviate distress and discomfort, and to prevent excessive heart load resulting from disturbance and excitement.

In addition, if BPSD or delirium is not improved even with nursing aid, it is also necessary to consider the use of drugs at an appropriate time as shown in such as “Understand the duration of action of antipsychotics and sleeping pills and use it effectively” and “Even if patients take antipsychotics after the onset of delirium or agitation, the effects are weak”.

With regard to how to understand the symptoms of deterioration of heart failure, both types of certified nurses used “Decrease in level of consciousness, deterioration of respiratory state, cyanosis, decrease in percutaneous oxygen saturation (SpO₂), not being able to lie supine, edema, weight gain, decrease in urine volume, decreased appetite, malaise, decreased left ventricular ejection fraction (EF) are all a measure of symptoms”, “Brain natriuretic peptide (BNP), echocardiography (left ventricular ejection fraction), chest X-ray (CTR) inspection results as deterioration index” and “Breathing difficulty and arrhythmia will be a measure of symptoms” to measure deteriorating symptoms. It is difficult for patients with impaired cognitive function to detect symptoms of heart failure deterioration [11] [13] and it is important to find out about worsening symptoms at an early stage using objective indicators.

There were opinions such as “It feels uncomfortable and unpleasant and a response is necessary”, “The patient feels strange about the indwelling catheter” and “There were people who removed the indwelling bladder catheter from the connector and walked around holding it”. This suggests that patients who intend to make excretory complaints or toilet excretion behaviors despite the placing of a catheter due to discomfort of the indwelling bladder catheter are subject to excessive heart load and may delay recovery. “Measure urine volume while using Catecholamine” and “Continue to measure urine volume when using a pump” show that, while using drugs with diuretic action, excessive heart load is applied by repeated urine volume and repeated toilet operation. In addition, in order to evaluate the therapeutic effect, indwelling catheter for the bladder is necessary. However, when repeating off-bed activities due to discomfort, since excessive heart load is applied, it is necessary to provide assistance after removing the indwelling bladder catheter and minimizing such as in “Measure urine volume with a diaper” and “Measure urine volume with diapers and portable toilets”.

There was the opinion that there were “Different management methods depending on the time of onset of dementia”. It became clear that management ability differs depending on whether the onset of heart failure is before or after the onset of dementia. It is difficult to feel dry mouth due to introduction of Tolvaptan, etc. in situations in which “Strict liquid restrictions are decreasing”. In addition to this, in patients whose cognitive function has declined shown in “Most patients do not want to drink” and it is difficult to take actions to consume water spontaneously. It is necessary to note that dehydration leads to deterioration of heart failure rather than excessive intake as in “Dehydration leads to renal failure”. On the other hand, there were the opinions that “It is difficult to comply with liquid restrictions in recovery” and “Although feelings of thirst are not easily manifested, sometimes patients go to drink voluntarily”. In the recovery process, it was difficult to respond to excessive intake of liquid in patients with low self-reliant cognitive function. When preparing nursing protocols, in order to suppress the excessive intake of water during the recovery period of patients whose cognitive function with low autonomy has declined, a countermeasure method based on the contents of assistance such as “Share information on water intake” should be considered.

As for meal and salt intake management, as shown in opinions such as “When dietary restrictions continue, patients feel uneasy and angry” and “Patients exceed salt restrictions and are re-hospitalized”, in the process of recovery from the acute exacerbation phase of chronic heart failure and home care, excessive intake of meals was a problem in patients with low self-reliant cognitive function. It is necessary to suppress excessive heart load from BPSD such as anger and stealing behavior by decreasing the period of restriction. Although there is excess dietary intake, the opinions of “Temporarily relax salt reduction if there is loss of appetite” and “Have meals brought in if there is loss of appetite” show that the symptoms of deterioration of heart failure and progression of dementia are associated with anorexia which is also a problem.

There were opinions such as “It is possible to continue medicine or weight management from before the onset of dementia as long as it is made into a habit”. “The most important thing is taking medication and continuing to take it”, “Medication management and weight monitoring are important after discharge from the hospital” and “Make sure to take medication by innovating numbers and times of doses” and continuation of medication was regarded as important in home care management. On the other hand, there was the opinion of “Pay attention to how baths are taken so that heart failure does not get worse”.

While preventing exacerbation, as well as implementing lifestyle habits such as “Patients will be hospitalized if they do not change their lifestyles and deteriorate” and “Make early visits possible if there is fluctuation in body weight and blood pressure measurements” continued monitoring of deteriorating symptoms was conducted, and guidance was given to seek early visits without waiting for regular checkups if deterioration was observed. When preparing the nursing protocol, as a nursing aid in the recovery process, management for taking medication was the best, even if the patients cannot change their lifestyle habits and early detection of deterioration of heart failure so that they can deal with it early is important.