Nursing diagnosis: Knowledge deficit [Learning Need] regarding condition, treatment regimen, self-care, and discharge needs related to lack of understanding, misconceptions about interrelatedness of cardiac function, disease, and failure.
Possibly evidenced by
Questions
Statements of concern, misconceptions
Recurrent, preventable episodes of HF
Desired Outcomes/Evaluation Criteria—Client Will
Knowledge: Cardiac Disease Management
Identify relationship of ongoing therapies (treatment program) to reduction of recurrent episodes and prevention of complications.
List signs and symptoms that require immediate intervention.
Identify own stress and risk factors and some techniques for handling them.
Initiate necessary lifestyle and behavioral changes.
Nursing care plan intervention with rationale:
1. Discuss normal heart function. Include information regarding client’s variance from normal function. Explain difference between heart attack and HF.
Rationale: Knowledge of disease process and expectations can facilitate client’s participation in management of HF, including prescribed treatment regimen (Tenenbaum, 2003).
2. Reinforce treatment rationale. Include SO and family members in teaching as appropriate, especially for complicated regimens such as management of technology, for example,
implantable cardioverter-defibrillator (ICD) or LVAD, dobutamine infusion home therapy when client does not respond to customary combination therapy or cannot be weaned.
Rationale: Client may believe it is acceptable to alter postdischarge regimen when feeling well and symptom-free or when feeling below par, which can increase the risk of exacerbation of symptoms. Understanding of regimen, medications, technology, and restrictions may augment cooperation with control of symptoms. Home IV therapy requires a significant commitment by caregivers to operate and troubleshoot infusion pump, change dressing for peripherally inserted central catheter (PICC) line, and monitor I&O and signs and symptoms of HF.
3. Encourage developing a regular home exercise program and provide guidelines for sexual activity.
Rationale: Promotes maintenance of muscle tone and organ function for overall sense of well-being. Changing sexual habits, for example, sex in morning when well rested, client on top,
inclusion of other physical expressions of affection, may be difficult, but provides opportunity for continuing satisfying sexual relationship.
4. Discuss importance of being as active as possible without becoming exhausted and need for rest between activities.
Rationale: Excessive physical activity or overexertion can further weaken the heart, exacerbating failure, and necessitates adjustment of exercise program.
5. Discuss importance of sodium limitation. Provide list of sodium content of common foods that are to be avoided or limited. Encourage reading of labels on food and drug packages.
Rationale: Dietary intake of sodium of more than 3 g/day can offset effect of diuretic. Most common source of sodium is table salt and obviously salty foods, although canned soups and vegetables, luncheon meats, and dairy products also may contain high levels of sodium.
6. Refer to dietitian for counseling specific to individual needs and dietary customs.
Rationale: Identifies dietary needs, especially in presence of obesity (major risk factor for developing HF), diabetes, or presence of nausea and vomiting and resulting wasting syndrome (cardiac cachexia). Eating six small meals and using liquid dietary supplements and vitamin supplements can limit inappropriate weight loss.
7. Review medications, purpose, and side effects. Provide both oral and written instructions.
Rationale: Understanding therapeutic needs and importance of prompt reporting of side effects can prevent occurrence of drugrelated complications. Anxiety may block comprehension of input or details, and client and SO may refer to written material at later date to refresh memory.
8. Recommend taking diuretic early in morning.
Rationale: Provides adequate time for drug effect before bedtime to prevent or limit interruption of sleep.
9. Instruct and receive return demonstration of ability to take and record daily pulse and BP and when to notify healthcare provider, for example, parameters above or below preset rate and changes in rhythm or regularity.
Rationale: Promotes self-monitoring of condition and drug effect. Early detection of changes allows for timely intervention and may prevent complications, such as digoxin toxicity.
10. Explain and discuss client’s role in control of risk factors, such as smoking and alcohol abuse, and precipitating or aggravating factors, such as high-salt diet, inactivity or overexertion, and exposure to extremes in temperature.
Rationale: Adds to body of knowledge and permits client to make informed decisions regarding control of condition and prevention of recurrence or complications. Smoking potentiates vasoconstriction; sodium intake promotes water retention and edema formation. Improper balance between activity and rest and exposure to temperature extremes may result in exhaustion, increased myocardial workload, and increased risk of respiratory infections. Alcohol can depress cardiac contractility. Limitation of alcohol use to social occasions or maximum of one drink per day may be tolerated unless cardiomyopathy is alcohol induced, which requires complete abstinence.
11. Review signs and symptoms that require immediate medical attention, such as rapid and significant weight gain, edema, shortness of breath, increased fatigue, cough, hemoptysis,
and fever.
Rationale:Self-monitoring increases client responsibility in health maintenance and aids in prevention of complications such as pulmonary edema, pneumonia. Weight gain of more than 3 lb in 1 week requires medical evaluation or adjustment of diuretic therapy. Note: Client should weigh self daily in morning without clothing, after voiding, and before eating.
12. Provide opportunities for client and SO to ask questions, discuss concerns, and make necessary lifestyle changes.
Rationale: Chronicity and recurrent, debilitating nature of HF often exhausts coping abilities and supportive capacity of both client and SO, leading to depression.
13. Address caregiver’s concerns and needs. Refer for support, assistance, and resources, as indicated.
Rationale: Caregiver burden can exhaust SO’s coping capabilities and health, especially when client has advanced HF, has a ventricular assist device, or is awaiting heart transplantation.
14. Discuss general health risks, such as infection, and recommend avoidance of crowds and individuals with respiratory infections and obtaining yearly influenza immunization and
one-time pneumonia immunization.
Rationale: This population is at increased risk for infection because of circulatory compromise.
15. Stress importance of reporting signs and symptoms of digoxin toxicity: development of gastrointestinal and visual disturbances, changes in pulse rate and rhythm, and worsening
of HF.
Rationale: Early recognition of developing complications and involvement of healthcare provider may prevent toxicity and hospitalization.
16. Identify community resources or support groups and visiting home health nurse, as indicated.
Rationale: May need additional assistance with self-monitoring and home management, especially when HF is progressive.
17 Discuss importance of advance directives and of communicating plan and wishes to family and primary care providers.
Rationale: Up to 50% of all deaths from HF are sudden, with many occurring at home, possibly without significant worsening of symptoms. If client chooses to refuse life-support measures, an alternative contact person (rather than 911) needs to be designated, should cardiac arrest occur.
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