Authors

  1. Peer, Nancy PhD, RN, CNE

Abstract

Heart failure is a combination of the body's compensatory mechanisms kicking in to ensure ventricular filling and adequate cardiac output of oxygenated blood to the circulatory system. These compensatory mechanisms are triggered either by sudden or chronic changes to the heart as a result of myocardial infarction (MI), coronary artery disease, hypertension, high cholesterol, diabetes, infection, or kidney and respiratory disorders. Among the compensatory mechanisms are the release of epinephrine/norepinephrine (catecholamines) by the sympathetic nervous system, which supplements cardiac output through increased muscle contractility and blood vessel constriction. Also, the secretion of antidiuretic hormone by the pituitary gland and the hormone renin by the kidneys stimulates the reabsorption of sodium and water to increase blood flow.

Article Content

Cardiovascular disease ranks among the leading causes of death in the United States, according to the U.S. Department of Health and Human Services. As a result, objectives developed by Healthy People 2020 look to decrease mortality and improve quality of life for individuals with cardiovascular disease. The focus is put on modifiable risk factors that contribute to cardiovascular disease, such as obesity, physical inactivity, and poor diet.

  
Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Because heart failure can be self-limiting, get progressively worse, and cause residual organ damage, patient education about treatment is an important nursing goal. In an effort to identify the effects of heart failure on quality of life and aide nurses in providing care, a creative teaching exercise was developed in which the hosting of a dinner party for guests experiencing different levels of cardiovascular disease is used to outline the nursing process. This exercise will help you understand the important role of nutrition in cardiovascular disease and its implications for quality of life.

 

A quick refresher

Heart failure is a combination of the body's compensatory mechanisms kicking in to ensure ventricular filling and adequate cardiac output of oxygenated blood to the circulatory system. These compensatory mechanisms are triggered either by sudden or chronic changes to the heart as a result of myocardial infarction (MI), coronary artery disease, hypertension, high cholesterol, diabetes, infection, or kidney and respiratory disorders. Among the compensatory mechanisms are the release of epinephrine/norepinephrine (catecholamines) by the sympathetic nervous system, which supplements cardiac output through increased muscle contractility and blood vessel constriction. Also, the secretion of antidiuretic hormone by the pituitary gland and the hormone renin by the kidneys stimulates the reabsorption of sodium and water to increase blood flow.

 

However, these compensatory mechanisms can cause peripheral edema, pulmonary edema, and excess strain on the heart, which can lead to decreased respiratory function, poor organ perfusion, and heart damage due to ventricular remodeling (see Key symptoms of heart failure). Although commonly seen in older patients, heart failure can now be seen in other age groups as healthcare advances allow more individuals to live with acute or chronic heart problems.

 

Many changes can be incorporated into an individual's lifestyle to slow the progression of heart failure, as well as maintain a higher quality of life. Among the nutritional challenges of healthy aging are the incorporation of healthful eating patterns; adequate nutrient intake; and decreasing weight gain due to lower metabolism, physical inactivity, and poor dietary intake. A nutritional intake of nutrient-dense food (fruits and vegetables) and less reliance on processed foods containing high salt and fat content are cornerstones of a heart-healthy diet.

  
Figure. Key symptoms... - Click to enlarge in new windowFigure. Key symptoms of heart failure

By using the nursing process, you can play a vital role in decreasing the exacerbation of heart failure and assisting with positive lifestyle modifications that can promote a better quality of life for your patients.

 

Your guests

Erika F. Volume has recently been discharged from the hospital after experiencing breathing complications due to excess fluid volume. She was diagnosed with heart failure after blood tests revealed increases in B-type natriuretic peptide (BNP), a cardiac marker specifically secreted by heart cells used to determine cardiac causes of dyspnea. BNP is released from the ventricles when diastolic BP increases to assist the kidneys with excreting sodium as a compensatory mechanism to decrease fluid volume. Although once very active, she's slowed down considerably after experiencing angina secondary to chronic hypertension. She's been struggling with her low-salt diet and fluid intake restrictions, but sees positive differences in her daily weight and how her clothes fit. She's also dealing with the management of an increase in diuretic medication and her need for potassium supplements due to the potassium lost with diuretic use.

 

Irving G. Exchange is home after experiencing a bout of pneumonia that left him physically weak and tired. Due to impaired gas exchange, he's using supplemental oxygen, which helped him regain his ability to perform activities of daily living. However, a history of cigarette smoking and numerous episodes of chronic bronchitis have caused him to have chronic respiratory problems. Although once physically active, he had to move into an assistive living environment where he can receive assistance with daily activities. He's now ready to resume his social activities and has a "fancy" for his neighbor, Doris, who doesn't seem to let anything cloud her positive, upbeat attitude.

 

Doris D. Knowledge has always prided herself on her social activities. She's almost always helping someone in her senior housing complex or planning/attending social functions. After previous cardiac surgery for complications of coronary artery disease, she was recently diagnosed with heart failure after experiencing shortness of breath and a 10 lb (4.5 kg) weight increase. Conveying to her healthcare provider that she lacks knowledge about her medication needs (a diuretic, a lipid-lowering drug, and an antiarrhythmic drug) and her nutritional modifications (low-saturated fat, low-carbohydrate, and low-salt diet), she knows that she's at increased risk for hospitalization or decreased socialization should she not comply with her healthcare provider's recommendations.

 

Angela A. Intolerance has been stuck at home with little energy or motivation to do anything outside of her house. Although once social, her chronic leg pain caused by diabetic neuropathy has caused her to rely on others for assistance with housekeeping and grocery shopping. She's also dealing with diabetic complications, medication adverse reactions, and a recent change in living accommodations, which have taken a toll on her emotionally. Once a great cook with a flair for hosting dinner parties, she now exhibits decreased interest in socialization, limiting her ability to develop the monthly senior newsletter.

 

David C. Output has slowed down quite a bit over the last month. Known for his "giant" view on life and interest in anything that will keep him physically active, he's been getting most of his activity from watching sports on TV. A recent MI scare and subsequent cardiac catheterization to unclog coronary arteries has left him quite nervous about his health. His healthcare provider has given him some new medication to increase his cardiac output, and he's hopeful that he can start resuming more activity, including dating Angela because he misses companionship after the death of his wife.

  
Figure. Dinner guest... - Click to enlarge in new windowFigure. Dinner guest nursing diagnoses

Using a creative social format, we'll stimulate conversation about heart failure, identify dietary needs, and provide education on nutritional choices that benefit patients with cardiovascular disease (see Dinner guest nursing diagnoses).

 

Menu planning

The overall goal of our simulated dinner party is to provide guests with a nutritional/educational focus to achieve heart failure management goals. These include decreased symptoms of heart failure, decreased symptoms of peripheral edema, increased energy to tolerate exercise, understanding the importance of nutrition and medication, and decreased heart failure complications.

 

Lifestyle modifications can seem daunting to those who've been sidelined by acute or chronic illness. Available resources such as cardiac rehabilitation after MI or coronary bypass surgery aren't commonly accessed by older adults; yet, approximately two-thirds of deaths from cardiovascular disease occur in those ages 75 and older, according to the American Heart Association. Although some modifiable factors can improve health, such as avoiding alcohol and tobacco consumption, adequate nutrition is essential for life. We must consider diet modifications as both individualized and achievable by the patient to ensure success.

 

For menu planning, key nutritional points are to keep the meal low in salt, easy to duplicate by guests, and with a variety of fruits and vegetables to ensure good sources of vitamins and nutrients (see DASH diet plan for cardiovascular disease). Keep food textures pleasing while also making it easy to digest because guests can tire quickly with excessive chewing. Minimize liquids and serve food with a variety of flavor that can be enhanced with low-potassium salt substitutes. Serve whole wheat rolls to ensure a good source of fiber intake and serve dairy and nuts to ensure protein intake. Nuts also provide a good source of fatty acids essential for cardiovascular health.

 

Considering these nutritional points, the menu will consist of a chopped salad with low-fat dressing, a butternut squash soup with grated fresh cheese, and whole wheat rolls (see The menu). For dessert, guests can enjoy low-fat vanilla yogurt topped with assorted cut-up fruit and crushed walnuts. This menu will accommodate stimulation of appetite and ease of digestion, which can be affected by breathing difficulties, medications, and recuperation from heart failure exacerbations. It also contains essential nutrients, such as potassium, which can be easily lost with diuretics or lack of nutrition.

  
Figure. DASH diet pl... - Click to enlarge in new windowFigure. DASH diet plan for cardiovascular disease

To assist guests, keep serving dishes that are portion controlled and lightweight to accommodate diet and physical restrictions. Also, don't have a water pitcher on the table; rather, prepour water into glasses to monitor fluid intake. To assist digestion and easy consumption by guests, serve chopped salad with dressing on the side and allow a suitable period of rest between the salad and soup entree to encourage socialization. Serve the soup warm, not hot, so guests won't run the risk of swallowing difficulties, and serve fruit on top of the vanilla yogurt for dessert. Arrange to pass around a small dish of chopped walnuts for guests to take at will.

 

Evaluation of healthy outcomes

Evaluating your dinner guests, you note that Erika was able to control her fluid intake and enjoyed socializing with her friends without constant interruptions to go to the bathroom. These key learning goals showed her the importance of managing fluid balance and medication effects, as well as the importance of eating a nutrient-rich diet to prevent heart failure complications.

 

Irving found that eating simple foods with nutritional value allowed him to enjoy eating out without experiencing any breathing difficulty. This insight decreased his anxiety about accepting social invitations and increased his confidence in living with heart failure.

 

Doris learned about Irving's dependence on continuous oxygen and in discussing his health, she found that taking better care of herself could delay the progression of heart failure. This included paying attention to portion control, as well as notifying her healthcare practitioner of any weight gain of over 3 lb (1.4 kg). Because weight is a major patient tool to gauge fluid volume changes due to heart failure, Doris now has the motivation to take better care of her health-another goal to assist with quality of life for heart failure patients.

 

Angela enjoyed the ability to meet and talk with her friends. Since she realized that she isn't alone in living with a chronic condition, she's planning a column in the monthly newsletter to educate others about cardiovascular disease. Angela's insight on the positive benefits of talking with others about chronic illness and its impact on quality of life led to the learning goal of sharing knowledge to benefit others.

 

David enjoyed talking with Angela and reminiscing about his travels with his late wife. He and Angela are making plans to start walking around the senior complex and signing up for the next senior center outing. David's enjoyment of companionship and planning physical activity led to his learning the value of physical activity and socialization to both his and Angela's well-being.

 

Understanding the primary symptoms of heart failure, such as fatigue, edema, shortness of breath, and activity intolerance, can assist you with cardiovascular education. As evidenced by our dinner guests, symptoms can be exacerbated by lack of dietary modifications, lack of knowledge, and lack of regular healthcare monitoring. Each hospitalization can set the heart failure patient up for dangerous complications with other body systems, such as Irving's need for continuous oxygen, David's decrease in physical activity, and Angela's decrease in independence.

  
Figure. The menu... - Click to enlarge in new windowFigure. The menu

Using the nursing process, assess your patient's needs to help plan for health enhancement, implement nursing interventions, and evaluate his or her achievement of healthcare goals. Educate your patient on appropriate lifestyle modifications, specialized diet requirements, and facilitating peer-to-peer learning. Implement interventions that address physical limitations, increase socialization, and allow for diet modifications that are easy to duplicate. With positive outcomes achieved, your patient is now ready to adjust his or her lifestyle to live a quality life with heart failure.

 

Way to clean up!

Because patient education is one of our primary nursing interventions to ensure positive health outcomes, making learning opportunities memorable for those restricted by chronic illness can lead to the adoption of positive patterns and lifestyle modifications. As in our simulated dinner party, you can holistically address nutritional needs, socialization opportunities, and knowledge deficits by utilizing a community approach. Critical reflection on patient assessment, appropriate planning goals, and creative nursing interventions helps reinforce the basics of living with cardiovascular disease and increase quality of life. A job well done!

 

REFERENCES

 

Ackley BJ, Ladwig GB. Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care. 10th ed. St. Louis, MO: Elsevier Mosby; 2014.

 

American Heart Association. Statistical fact sheet, 2016 update. http://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_483962.pdf.

 

Billings DM, Halstead JA. Teaching in Nursing: A Guide for Faculty. 4th ed. St. Louis, MO: Saunders-Elsevier; 2012.

 

Grodner M, Roth SL, Walkingshaw BC. Nutritional Foundations and Clinical Applications: A Nursing Approach. 5th ed. St. Louis, MO: Elsevier Mosby; 2012.

 

HealthyPeople.gov. 2020 topics and objectives. http://www.healthypeople.gov/2020/topics-objectives.

 

Herrman JW. Creative Teaching Strategies for the Nurse Educator. Philadelphia, PA: F.A. Davis Company; 2008.

 

Lewis SL, Dirksen SR, Heitkemper MM, Bucher L. Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 9th ed. St. Louis, MO: Elsevier Mosby; 2014.