Nursing Diagnosis and Nursing Care Plan for Heart Disease Patients

Heart failure (HF) is a pervasive and intricate clinical syndrome arising from a multitude of functional or structural heart disorders. This condition impairs the heart’s ability to effectively fill with or eject blood, thereby compromising the circulatory system’s capacity to meet the body’s metabolic demands. Heart failure is not a disease in itself but rather a consequence of various underlying cardiac pathologies. A significant proportion of individuals with heart failure exhibit symptoms stemming from compromised left ventricular myocardial function, commonly manifesting as dyspnea, fatigue, reduced exercise tolerance, and fluid retention, clinically observed as pulmonary and peripheral edema.[1]

Heart failure resulting from left ventricular dysfunction is classified based on left ventricular ejection fraction (LVEF) into two primary categories: heart failure with reduced ejection fraction (HFrEF), defined as LVEF of 40% or less, and heart failure with preserved ejection fraction (HFpEF), characterized by LVEF greater than 40%.[2] Effective nursing care is paramount in managing heart failure, focusing on accurate nursing diagnoses and comprehensive nursing care plans to optimize patient outcomes. This article will delve into the essential nursing diagnoses and care planning strategies for patients with heart disease, specifically focusing on heart failure.

Common Nursing Diagnoses for Heart Failure Patients

Nursing diagnoses are crucial for guiding patient care and are based on the patient’s clinical presentation and needs. For heart failure patients, several key nursing diagnoses are frequently identified:

• Decreased Cardiac Output
• Activity Intolerance
• Excess Fluid Volume
• Risk for Impaired Skin Integrity
• Ineffective Tissue Perfusion
• Ineffective Breathing Pattern
• Impaired Gas Exchange
• Fatigue
• Anxiety

These diagnoses provide a framework for developing individualized nursing care plans aimed at addressing the specific challenges faced by heart failure patients.

Underlying Causes of Heart Failure

Heart failure can be triggered by a wide array of disorders affecting various components of the cardiovascular system, including the pericardium, myocardium, endocardium, cardiac valves, vasculature, or metabolic processes. The most prevalent causes of systolic dysfunction (HFrEF) include idiopathic dilated cardiomyopathy (DCM), coronary artery disease (ischemic heart disease), hypertension, and valvular heart disease. Diastolic dysfunction (HFpEF) shares similar etiological factors, with the addition of hypertrophic obstructive cardiomyopathy and restrictive cardiomyopathy as significant contributors.[1]

Risk Factors Predisposing to Heart Failure

Several risk factors elevate an individual’s susceptibility to developing heart failure. Identifying and managing these risk factors is crucial in both preventing and managing heart failure. Key risk factors include:

• Coronary artery disease (CAD)
• Myocardial infarction (MI)
• Hypertension
• Diabetes mellitus
• Obesity
• Smoking
• Alcohol use disorder
• Atrial fibrillation
• Thyroid diseases
• Congenital heart disease
• Aortic stenosis

Comprehensive Assessment of Heart Failure

A thorough assessment is fundamental to formulating appropriate nursing diagnoses and care plans. Symptoms of heart failure are broadly categorized into those arising from fluid overload and those resulting from reduced cardiac output. Fluid overload manifests as dyspnea, orthopnea, edema, hepatic congestion leading to pain, and abdominal distention from ascites. Reduced cardiac output symptoms include fatigue and weakness, particularly exacerbated by physical exertion.[1]

The presentation of heart failure can vary in acuity. Acute and subacute presentations (developing over days to weeks) are characterized by shortness of breath at rest or during exertion, orthopnea, paroxysmal nocturnal dyspnea, and right upper quadrant discomfort due to acute hepatic congestion associated with right heart failure. Palpitations, potentially accompanied by lightheadedness, may occur if atrial or ventricular tachyarrhythmias develop.

Chronic heart failure (present over months) may present with more pronounced fatigue, anorexia, abdominal distension, and peripheral edema, while dyspnea might be less prominent. Anorexia in chronic heart failure is multifactorial, resulting from poor perfusion of the splanchnic circulation, bowel edema, and nausea induced by hepatic congestion.[1]

Characteristic clinical findings in heart failure include:

• Pulsus alternans: An alternating strong and weak peripheral pulse with regular intervals, indicative of left ventricular systolic dysfunction.
• Displaced Apical Impulse: Laterally displaced apical impulse beyond the midclavicular line, suggesting left ventricular enlargement.
• S3 Gallop: A low-frequency, early diastolic sound, the most sensitive auscultatory indicator of ventricular dysfunction.
• Peripheral Edema: Accumulation of fluid in peripheral tissues, commonly in the lower extremities.
• Pulmonary Rales (Crackles): Adventitious lung sounds indicating fluid in the alveoli, a sign of pulmonary congestion.

The New York Heart Association (NYHA) Functional Classification provides a standardized method to categorize the severity of heart failure based on a patient’s symptoms and functional limitations:[3]

• Class I: Heart disease is present, but no limitation of physical activity. Ordinary physical activity does not cause undue fatigue, dyspnea, or palpitations.
• Class II: Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitations, or dyspnea.
• Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitations, or dyspnea.
• Class IV: Unable to carry on any physical activity without discomfort. Symptoms of heart failure are present even at rest.

Diagnostic Evaluation for Heart Failure

Several diagnostic tests are employed to evaluate heart failure and determine its underlying causes and severity:

• Electrocardiogram (ECG): Essential for detecting evidence of myocardial infarction (acute or prior), ischemia, and rhythm abnormalities like atrial fibrillation.
• Chest X-ray: Radiographic findings may include cardiomegaly (cardiac-to-thoracic ratio >50%), cephalization of pulmonary vessels, Kerley B-lines (indicating interstitial edema), and pleural effusions.

• Blood Tests:
  • Cardiac Troponin (T or I): To rule out acute myocardial infarction.
  • Complete Blood Count (CBC): To assess overall health and rule out anemia.
  • Serum Electrolytes: To evaluate for imbalances, particularly sodium and potassium, which are critical in heart failure management.
  • Blood Urea Nitrogen (BUN) and Creatinine: To assess renal function, often impaired in heart failure.
  • Liver Function Tests (LFTs): To evaluate for hepatic congestion and dysfunction.
  • Brain Natriuretic Peptide (BNP) or N-terminal pro-BNP (NT-proBNP): Elevated levels strongly support the diagnosis of heart failure and are valuable for prognosis and monitoring. BNP levels are often more diagnostically significant than other initial tests when combined with history and physical examination.
• Transthoracic Echocardiogram: A primary diagnostic tool to assess ventricular function, ejection fraction, valve function, and hemodynamics, crucial for classifying heart failure and guiding treatment.

Medical Management Strategies for Heart Failure

Pharmacological management of heart failure aims to alleviate symptoms, improve functional status, reduce hospitalization rates, and prolong survival. Medications commonly used include:

• Diuretics: To manage fluid overload and reduce symptoms of congestion.
• Beta-blockers: To reduce heart rate, improve left ventricular function, and decrease mortality in HFrEF.
• Angiotensin-Converting Enzyme Inhibitors (ACEIs) or Angiotensin Receptor Blockers (ARBs): To reduce afterload, improve symptoms, and decrease mortality in HFrEF.
• Angiotensin Receptor-Neprilysin Inhibitor (ARNI): Such as sacubitril/valsartan, superior to ACEIs in reducing mortality and hospitalization in HFrEF.
• Hydralazine and Isosorbide Dinitrate: Particularly beneficial in African Americans with persistent NYHA class III-IV HFrEF.
• Digoxin: To control heart rate in atrial fibrillation and improve symptoms in select patients.
• Aldosterone Antagonists (Mineralocorticoid Receptor Antagonists – MRAs): Such as spironolactone or eplerenone, to reduce aldosterone-mediated sodium and water retention and improve survival in HFrEF.

Combination therapy with these agents is often employed to optimize outcomes and reduce hospitalizations in heart failure patients.[3] Beta-blockers, ACEIs/ARNIs, and MRAs have demonstrated improved patient survival.[3] Diuretics are primarily used for symptomatic relief. ARNIs should not be administered within 36 hours of an ACE inhibitor dose due to the risk of angioedema.[3]

In specific populations, such as African Americans with persistent NYHA class III to IV HF and LVEF less than 40%, hydralazine plus oral nitrate is indicated when optimal medical therapy (including beta-blockers, ACEIs/ARBs, MRAs if indicated, and diuretics) is insufficient.[3]

Device therapy plays a critical role in managing certain aspects of heart failure:

• Implantable Cardioverter-Defibrillator (ICD): Used for primary or secondary prevention of sudden cardiac death in patients at risk of life-threatening arrhythmias.
• Cardiac Resynchronization Therapy (CRT): Biventricular pacing to improve symptoms and survival in patients with reduced LVEF, prolonged QRS duration, and in sinus rhythm, by coordinating ventricular contractions. Often combined with an ICD (CRT-D).
• Ventricular Assist Devices (VADs): Mechanical pumps to support ventricular function, used as a bridge to transplant or as destination therapy in advanced heart failure.
• Cardiac Transplantation: Reserved for patients with severe heart failure refractory to all other therapies.

Nursing Management and Nursing Care Plan Development

The cornerstone of nursing care for heart failure patients is the development and implementation of individualized nursing care plans. These plans are driven by the identified nursing diagnoses and focus on achieving specific patient outcomes. Key components of a nursing care plan for heart failure include:[4]

1. Addressing Fluid Overload:

• Nursing Diagnosis: Excess Fluid Volume related to decreased cardiac output and neurohormonal activation, as evidenced by peripheral edema, pulmonary congestion, and weight gain.
• Nursing Interventions:
  • Fluid Restriction: Implement and monitor prescribed fluid restrictions (typically 1.5-2 liters per day). Educate the patient and family on the importance of fluid restriction and strategies to manage thirst.
  • Sodium Restriction: Educate patients on a low-sodium diet (typically 2-3 grams per day). Provide dietary counseling and resources.
  • Diuretic Administration: Administer diuretics as prescribed, monitor diuretic effectiveness (urine output, weight, edema), and assess for electrolyte imbalances (potassium, sodium).
  • Daily Weight Monitoring: Instruct patients on daily weight monitoring at the same time each day and to report significant weight gain (e.g., 2-3 pounds in one day or 5 pounds in one week).
  • Positioning: Elevate the head of the bed to promote orthopnea relief and reduce pulmonary congestion.
  • Monitor Intake and Output: Accurately record fluid intake and output to assess fluid balance.

2. Managing Decreased Cardiac Output:

• Nursing Diagnosis: Decreased Cardiac Output related to altered contractility and structural changes in the heart, as evidenced by fatigue, weakness, and decreased peripheral pulses.
• Nursing Interventions:
  • Medication Management: Administer cardiac medications as prescribed (ACEIs, ARBs, ARNIs, beta-blockers, digoxin, etc.), monitor for therapeutic effects and side effects. Educate patients on medication purpose, dosage, and administration.
  • Rest and Activity Balance: Promote rest periods to reduce cardiac workload. Gradually increase activity as tolerated, monitoring patient response (heart rate, blood pressure, dyspnea, fatigue).
  • Oxygen Therapy: Administer supplemental oxygen as needed to maintain adequate oxygen saturation.
  • Hemodynamic Monitoring: Monitor vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation) frequently. In acute settings, more invasive hemodynamic monitoring may be required.
  • Assess Peripheral Perfusion: Regularly assess peripheral pulses, skin color and temperature, and capillary refill to evaluate tissue perfusion.

3. Improving Activity Tolerance:

• Nursing Diagnosis: Activity Intolerance related to decreased cardiac output and fatigue, as evidenced by reports of fatigue and dyspnea with exertion.
• Nursing Interventions:
  • Gradual Exercise Program: Develop a graded exercise program in collaboration with physical therapy, starting with short periods of activity and gradually increasing duration and intensity as tolerated.
  • Energy Conservation Techniques: Teach patients energy conservation techniques, such as planning rest periods, pacing activities, and using assistive devices.
  • Monitor Response to Activity: Assess patient’s response to activity, monitoring for signs of overexertion (excessive dyspnea, fatigue, chest pain, dizziness).
  • Promote Independence: Encourage patient participation in self-care activities within their tolerance level.

4. Preventing Impaired Skin Integrity:

• Nursing Diagnosis: Risk for Impaired Skin Integrity related to edema, poor tissue perfusion, and immobility.
• Nursing Interventions:
  • Regular Skin Assessment: Assess skin regularly, especially in edematous areas and pressure points, for signs of breakdown.
  • Pressure Relief: Implement pressure relief measures, such as frequent repositioning, pressure-reducing mattresses, and cushions.
  • Skin Care: Keep skin clean and dry. Use mild soaps and moisturizers.
  • Edema Management: Manage edema through diuretics, elevation, and support stockings as appropriate.

5. Enhancing Breathing Pattern and Gas Exchange:

• Nursing Diagnosis: Ineffective Breathing Pattern and Impaired Gas Exchange related to pulmonary congestion and fluid accumulation, as evidenced by dyspnea, orthopnea, and abnormal breath sounds.
• Nursing Interventions:
  • Respiratory Assessment: Monitor respiratory rate, depth, and effort. Auscultate breath sounds for rales or wheezes.
  • Oxygen Therapy: Administer oxygen as prescribed.
  • Positioning: Elevate the head of the bed to high Fowler’s position to improve lung expansion.
  • Deep Breathing and Coughing Exercises: Encourage deep breathing and coughing exercises to promote lung expansion and clear secretions.
  • Monitor Oxygen Saturation: Continuously or intermittently monitor oxygen saturation (SpO2).

6. Managing Fatigue:

• Nursing Diagnosis: Fatigue related to decreased cardiac output, disease process, and medication side effects, as evidenced by reports of overwhelming lack of energy and inability to maintain usual routines.
• Nursing Interventions:
  • Identify Contributing Factors: Assess for factors contributing to fatigue (anemia, sleep disturbances, medications).
  • Energy Conservation: Teach energy conservation techniques.
  • Rest and Sleep Promotion: Promote adequate rest and sleep. Establish a regular sleep schedule.
  • Nutritional Support: Ensure adequate nutritional intake to support energy levels.
  • Psychological Support: Address psychological factors contributing to fatigue, such as depression and anxiety.

7. Reducing Anxiety:

• Nursing Diagnosis: Anxiety related to dyspnea, disease prognosis, and changes in lifestyle, as evidenced by restlessness, worry, and expressed concerns about condition.
• Nursing Interventions:
  • Therapeutic Communication: Provide a calm and supportive environment. Listen actively to patient concerns and fears.
  • Patient Education: Provide clear and accurate information about heart failure, treatment, and prognosis. Reduce uncertainty through education.
  • Relaxation Techniques: Teach relaxation techniques such as deep breathing, guided imagery, and progressive muscle relaxation.
  • Spiritual and Emotional Support: Offer spiritual and emotional support. Connect patients with chaplains or counselors as needed.
  • Medication for Anxiety: Administer anti-anxiety medications as prescribed, if appropriate.

When to Seek Prompt Medical Assistance

Patients should be educated on when to seek immediate medical attention. Prompt assessment by the medical team is indicated in the following situations:

• Worsening shortness of breath or dyspnea, especially at rest.
• Increased or new swelling in ankles, legs, abdomen, or face.
• Persistent cough or wheezing.
• Unexplained weight gain (2-3 pounds in a day or 5 pounds in a week).
• Dizziness or lightheadedness, especially with activity.
• Chest pain or discomfort.
• Rapid or irregular heartbeat.
• Decreased urine output.
• Confusion or difficulty concentrating.

Continuous Monitoring of Heart Failure Patients

Ongoing monitoring is critical for managing heart failure effectively. Patients require frequent monitoring of:

• Vital Signs: Including heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation.
• Heart Rhythm: Telemetry monitoring may be necessary, especially during acute exacerbations or changes in condition.
• Symptoms: Regularly assess for changes in symptoms such as dyspnea, edema, fatigue, and chest pain.
• Daily Weight: Essential for detecting fluid retention.
• Electrolytes and Renal Function: Periodic blood tests to monitor electrolytes (potassium, sodium) and renal function, especially when diuretic therapy is used.

Interprofessional Coordination of Care

Optimal management of heart failure requires a collaborative, interprofessional team approach. The team typically includes:

• Primary care physician
• Cardiologist
• Emergency department physician
• Radiologist
• Cardiac nurses
• Internist
• Cardiac surgeons
• Pharmacist
• Dietitian
• Physical therapist
• Social worker

Effective communication and coordination among team members are essential to ensure comprehensive and patient-centered care. Nurses play a pivotal role in coordinating care, educating patients, and ensuring adherence to treatment plans.

Health Education and Promotion for Heart Failure Patients

Patient education is a cornerstone of heart failure management. Nursing care plans must incorporate comprehensive patient education to improve clinical outcomes and reduce hospital readmissions. Key areas of patient education include:

• Self-Monitoring of Symptoms: Teach patients how to recognize and monitor symptoms of worsening heart failure and when to seek medical attention.
• Medication Compliance: Emphasize the importance of taking medications as prescribed, understanding medication names, dosages, purposes, and potential side effects. Provide medication organizers and reminder systems if needed.
• Daily Weight Monitoring: Educate on the technique and importance of daily weight monitoring.
• Dietary Sodium Restriction: Provide detailed dietary education on sodium restriction (2-3 grams/day), including reading food labels and identifying high-sodium foods.
• Fluid Restriction: Educate on prescribed fluid restrictions (1.5-2 liters/day) and strategies for managing thirst.
• Activity and Exercise Recommendations: Provide guidelines for safe and appropriate physical activity. Encourage regular, moderate exercise as tolerated.
• Smoking Cessation: Strongly advise and support smoking cessation.
• Alcohol Limitation: Advise on limiting or abstaining from alcohol consumption, depending on individual circumstances.
• Management of Comorbidities: Educate on managing co-existing conditions like diabetes, hypertension, and sleep apnea.
• Vaccinations: Recommend annual influenza and pneumococcal vaccinations.

Discharge Planning for Heart Failure Patients

Effective discharge planning is crucial to ensure a smooth transition from hospital to home and prevent readmissions. Discharge planning should include:

• Medication Reconciliation and Education: Review all medications, ensure patient understanding of medications, and provide written medication lists and instructions.
• Dietary and Fluid Management: Reinforce dietary sodium and fluid restrictions. Provide written dietary guidelines and recipes.
• Activity Guidelines: Review activity recommendations and limitations.
• Follow-up Appointments: Schedule follow-up appointments with cardiology and primary care providers.
• Emergency Action Plan: Provide a written action plan for managing worsening symptoms and when to seek emergency care.
• Community Resources: Connect patients with community resources, such as home health services, support groups, and cardiac rehabilitation programs.
• Nurse-Driven Education: Nurse-led education at discharge has been shown to significantly improve therapy compliance and patient outcomes in heart failure.[6]

Conclusion

Developing and implementing comprehensive nursing diagnoses and nursing care plans are essential for the effective management of heart disease patients, particularly those with heart failure. By focusing on key nursing diagnoses such as fluid overload, decreased cardiac output, and activity intolerance, nurses can provide targeted interventions to alleviate symptoms, improve functional status, and enhance the quality of life for individuals living with heart failure. Patient education, interprofessional collaboration, and diligent monitoring are integral components of successful nursing care in this complex and prevalent condition.

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