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versão impressa ISSN 0080-6234
Rev. esc. enferm. USP vol.47 no.2 São Paulo abr. 2013
Nursing diagnoses and interventions for patients with congestive heart failure using the ICNP®*
Diagnósticos e intervenciones de enfermería para pacientes portadores de insuficiencia cardíaca congestiva utilizando la CIPE®
Angela Amorim de AraújoI; Maria Miriam Lima da NóbregaII; Telma Ribeiro GarciaIII
IRegistered Nurse. MSc. in Nursing
from the Postgraduate Program in Nursing of the Federal University of Paraíba.
Doctoral student in Biomedical Gerontology of the Pontifícia Universidade
Católica of Rio Grande do Sul Professor of the Technical School of Health of
the Federal University of Paraíba. João Pessoa, PB, Brazil. firstname.lastname@example.org
IIRegistered Nurse. PhD in Nursing. Professor of the Department of Public Health and Psychiatric Nursing of the Center of Health Sciences of the Federal University of Paraíba. Director of the ICNP® Research and Development Center of the Postgraduate Program in Nursing of the Federal University of Paraíba. CNPq researcher. João Pessoa, PB, Brazil. email@example.com
IIIRegistered Nurse. PhD in Nursing. Professor of the Department of Public Health and Psychiatric Nursing of the Center of Health Sciences of the Federal University of Paraíba. Director of the ICNP® Research and Development Center of the Postgraduate Program in Nursing of the Federal University of Paraíba. João Pessoa, PB, Brazil. firstname.lastname@example.org
The aim of this descriptive exploratory study was to construct nursing diagnosis and intervention statements for patients with Congestive Heart Failure. To accomplish this aim, 53 terms were identified in the focus axis of the International Classification for Nursing Practice (ICNP®), which guided the construction of these statements using the guidelines of the International Council of Nurses and ISO 18. 104. A total of 92 nursing diagnosis statements were constructed, which resulted in 66 statements after standardization. The standardized statements were separated according to the following pathophysiological models: 13 related to tachycardia, 20 related to dyspnea, 19 related to edema, and 14 related to congestion. A total of 234 interventions were constructed for these statements using the terms from the 7-Axis Model of the ICNP®, the literature in the area and the clinical experience of the authors. The nursing diagnosis and intervention statements designed are expected to facilitate the evaluation of CHF patients and assist in the construction of a terminological subset for the ICNP®.
Descriptors: Heart failure; Nursing diagnosis; Nursing care; Classification
Estudio exploratorio, descriptivo, objetivando construir declaraciones de diagnósticos e intervenciones de enfermería para pacientes portadores de insuficiencia cardíaca congestiva. Al efecto, fueron identificados en la CIPE® 53 término del eje foco, que orientaron la construcción de las declaraciones utilizando las directivas del Consejo Nacional de Enfermeros y la ISO 18.104. Se construyeron 92 declaraciones de diagnósticos de enfermería que, luego de normalizados, resultaron 66 y fueron separados acorde al modelo fisiopatológico, distribuyéndoselos así: 13 de taquicardia, 20 de disnea, 19 de edema y 14 de congestión. Para esas declaraciones se construyeron 234 intervenciones, tomando en consideración los términos del Modelo de los Siete Ejes de la CIPE®, literatura del área y la experiencia clínica de las autoras. Se espera que las declaraciones de diagnóstico e intervenciones de enfermería elaboradas puedan colaborar en la evaluación de individuos portadores de ICC y en la construcción de un subconjunto terminológico de la CIPE®.
Descriptores: Insuficiencia cardíaca; Diagnóstico de enfermería; Atención de enfermería; Clasificación
Congestive heart failure (CHF) is considered a global public health problem, and in the last three decades, it has increased in both its incidence and prevalence. There is no single cause of CHF, but there are factors that increase the probability of its occurrence, such as cardiovascular risk factors. The main types of cardiovascular risk factors are arterial hypertension, dyslipidemia (high cholesterol), smoking, diabetes mellitus, a sedentary lifestyle, obesity, heredity and stress(1-2).
By 2020 in Brazil, CHF is estimated to affect approximately 6.4 million people, with a mortality of approximately 1%. Healthy eating habits are deteriorating and the incidence of sedentary lifestyles, smoking and stress are increasing, causing an increased incidence of potential causes of heart dysfunction such as artery disease, diabetes mellitus and arterial hypertension in the population(2).
CHF can be classified in several ways according to its clinical conditions, either acute or chronic, and cause hemodynamic or functional alterations. Depending on whether the CHF is acute or chronic, complications may occur in the right, left or both cardiac chambers. Complications on the left side are characterized by the signs and symptoms of pulmonary congestion, which refers to the failure of the left ventricular to fill and empty properly and leads to increased pressure in the ventricle and congestion in the pulmonary vascular system. Complications on the right side are related to the inability of the right ventricle to pump properly, the most common cause of right-sided heart failure (RHF), and generally present as symptoms of systemic congestion, which are: peripheral edema, hepatic congestion and jugular turgescence. Recognizing the heart chamber(s) affected is essential for the differential diagnosis(3).
Generally, CHF does not progress slowly; instead, it abruptly increases in severity, evolving into acute decompensation. However, when precipitant conditions are controlled and the treatment is intensified, patients can remain stable for months or up to years. The treatment of patients with CHF has short and long term objectives. The short-term aim is to improve the hemodynamics and relieve symptoms; in the long term, the aim is to improve the quality of life and prolong the survival of the patient by slowing, halting or reversing the progression of ventricular dysfunction(4).
Considering these aspects, this disease has become increasingly frequent over the years, and the preventive and care aspects should be reviewed by the health team. The number of new patients with heart failure has grown despite advances in treatment. What are the possible explanations for the increased incidence? Some of the possible causes are the survival conditions of the population, increasing industrialization and urbanization in the developing countries(5).
Nursing action in recent decades has emphasized supporting and treating this disease because non-pharmacological treatment has been shown to be increasingly important, thus justifying the development of clinics and support programs for heart failure patients(6). Systematic care by nurses practicing evidence-based teaching and research reduces the negative impact of cardiovascular complications on patient outcomes(1, 6).
To implement nursing care in a systematic way, the nursing process and the classification systems of the nursing practice elements should be used. Among these systems, the International Classification for Nursing Practice (ICNP®) allows the construction of nursing diagnosis, interventions and outcomes statements, and its use promotes the registration and quality of the care in the practice, especially when targeted at specific areas of nursing care represented by terminology subsets of the ICNP®. The terminology subsets are understood as subsets of nursing diagnosis, intervention and outcome statements for a particular selected area or specialty of nursing care with specific purposes. Notably, these subsets do not replace the clinical judgment or the decision-making process of the nurse, which will always be essential for providing individualized care to the clients and their families; however, they do act as an available reference to the nurse(7).
In 2007, the International Council of Nurses (ICN) presented a methodology for the development of ICNP® Catalogues that contained ten steps: to identify the intended clientele and the health priority; to document the significance for nursing; to contact the ICN to determine if other groups were already working with the health priority of interest in the Catalogue; to identify potential collaborations; to use the 7-Axis Model of the ICNP® to compose the nursing outcome and intervention statements; to identify additional statements by reviewing the literature and relevant evidence; to develop support content to test or validate the statements of the Catalogue in two clinical studies; to append, delete or revise the statements of the Catalogue, as needed; to work with the International Council of Nurses for the preparation of the final copy of the Catalogue; and to assist in the dissemination of the Catalogue(8).
Another process to develop terminology subsets was announced in 2010. The developmental process contained six steps related to the main areas of the ICNP® Terminology Lifecycle: identification of clients; collection of terms and concepts relevant to the health priority; mapping of identified concepts to the ICNP®; structuring of new concepts; completion of the catalogue and dissemination of the catalogue. Nurses are requested to use this methodology or develop other methods to facilitate the development of ICNP® terminology subsets(9).
With respect to the previously mentioned processes, the aim of this study was to construct nursing diagnosis and intervention statements for patients with CHF in the functional category III of the New York Heart Association (NYHA) scale based on the ICNP® terms with the aim of developing an ICNP® terminology subset for CHF.
This study is included in the research project, Terminology subsets of the ICNP® for areas of clinical specialties and primary health care, which is being developed by the ICNP® Center of the Federal University of Paraíba Postgraduate Nursing Program. This project was submitted to the Research Ethics Committee of the Lauro Wanderley University Hospital of the Federal University of Paraíba before commencement and was in accordance with the aspects mentioned in Resolution No. 196/96, which regulates research involving human subjects(10), and authorized under protocol No. 141/08.
This is a descriptive exploratory study(11) developed in two stages: the collection of terms and concepts relevant to nursing care for patients with CHF in functional category III and the construction of nursing diagnosis and intervention statements from the identified terms. In the first stage, the concepts that were relevant to the nursing practice with patients with CHF contained on the focus axis were identified, which could guide the construction of nursing diagnosis and intervention statements. The pathophysiological model of CHF was used to facilitate this process, which classifies its main signs and symptoms according to the clinical data relevant to the disease: edema, tachycardia, dyspnea and congestion. Initially, the authors read the terms in the ICNP® focus axis repetitively to identify the terms relevant to the nursing practice with patients with CHF, taking into consideration experience in the area of cardiology and the use of the ICNP®. Subsequently, lists of the terms identified were unified after removing repetitions to generate a list of 53 words.
When the nursing diagnosis and intervention statements were constructed, the 53 terms identified and the guidelines presented by the International Council of Nurses(7) for the construction of these statements were considered. The guidelines were developed with consideration of the ISO 18. 104 standard: Integration of a reference terminology model for nursing(12). For the construction of the nursing diagnosis statements, one term from the Focus axis (area of care that is relevant to nursing) and one term from the Judgment axis (clinical opinion or determination related to the focus of the practice) were obligatorily included, along with additional terms as needed from the Focus, Judgment, Client, Location and Time axes. For the construction of nursing intervention statements, one term from the Action axis and one Target axis term, any term of the other axes except the Judgment axis, were obligatorily included, along with additional terms as needed from the Focus, Client, Location, Means, Action and Time axes(7,13). Following the construction of the nursing diagnosis and intervention statements for CHF, they were classified according to the relevant clinical data, i.e., edema, tachycardia, dyspnea and congestion, and presented in alphabetical order.
A total of 53 terms on the Focus axis were identified as relevant to the care of a patient with CHF; the terms were related to the main signs and symptoms relevant to the disease: edema, tachycardia, dyspnea and congestion, shown in Chart 1.
Using these terms and the guidelines of the International Council of Nurses, 92 nursing diagnosis statements were constructed, normalized, edited for repetitions, and classified by the main signs and symptoms most frequent in CHF patients. This process resulted in 66 statements, with 13 related to tachycardia, 20 related to dyspnea, 19 related to edema and 14 related to congestion.
A total of 234 nursing interventions were constructed from the 66 diagnosis statements, taking into consideration the terms contained in the 7-Axis Model of the ICNP® Version 1.0, that followed the guidelines of the International Council of Nurses, the literature of the area and the clinical experience of the authors. Given space limitations, examples of diagnoses will be presented with their respective interventions according to the four signs and symptoms of CHF.
Heart failure is a challenging disease for healthcare teams due to the multiple etiologies and high incidence. One of the major team objectives is to achieve and maintain clinical stability of patients in lieu of very complex treatments, which require more investments in physical and human resources to improve the quality of life, reduce the length of hospitalization and increase patient survival(11-12).
Training the nursing staff to educate and influence patients to be conscientious of their quality of life is one of the goals and is an important activity to establish better outcomes. Nurse intervention becomes significant because it can provide clear and objective information regarding the health status and prognosis of the client, educate the patient on the disease process, which encourages self-care, and customize treatment regimens to the lifestyle of the patient(14).
One of the main proposals of this study was to organize the care of clients suffering from CHF according to the main signs and symptoms related to CHF. Symptoms of tachycardia are present when a heart is abruptly seriously injured, which occurs as a compensatory mechanism such as in acute myocardial infarction, and subsequently, its pumping capacity is immediately decreased. As a result, there are two essential effects: reduced cardiac output and increased systemic venous pressure. When individuals with low cardiac reserves remain at rest, they maintain themselves in the initial HF condition. However, tachycardia and its effects can be recognized during heart failure by requesting the patient to climb stairs or take a walk. The increased load on the heart rapidly consumes the small amount of reserve available. With the acute effect, an excessive increase in the cardiac rate is observed where nervous reflexes react excessively in an attempt to overcome the inadequate cardiac output(15). This can increase the cardiac rate to > 140 bpm, cause discomfort and lead nursing professionals to develop actions that will reduce the burden of exertion for the patient, even if minimally, as they perform their hygiene habits(16).
The constructed nursing diagnosis and intervention statements related to tachycardia are associated with an elevated heartbeat as the present and important factor establishing its clinical diagnosis. The evaluation is performed through a primary clinical examination that can support evaluations in which major changes can be found, such as arrhythmia (the formation and/or conduction of the cardiac impulse); the location of these alterations in certain anatomical regions of the heart determine the clinical presentation of arrhythmia(17). Tachycardia can also generate anxiety or an uncomfortable feeling of distress or fear, followed by an autonomic response (18). Cardiac pain (resulting from myocardial ischemia without infarction) is believed to stimulate the release of acidic substances, such as lactic acid, or other products, such as histamine, kinins or cellular proteolytic enzymes. Elevated concentrations of these substances stimulate the nerve endings in heart muscle, and pain impulses are conducted to the central nervous system(16, 19).
The lack of knowledge about the factors that trigger tachycardia and may induce arrhythmias could be associated with cognitive deficits. That possible association indicates a point to be worked on due to the risk of this patient undergoing exertion and triggering a worsening of their clinical condition possibly evolving into cardiogenic shock, a clinical syndrome characterized by inadequate tissue perfusion caused by severe cardiac dysfunction(20). This syndrome includes decreased cardiac output in the presence of adequate intravascular volume with consequent tissue hypoxia. Systemic arterial hypertension is considered essential for the diagnosis of heart failure and associated with the clinical signs of poor tissue perfusion, such as cold extremities, peripheral cyanosis, altered state of consciousness and presence of oliguria(19, 21).
The episodes of dyspnea, a very common sign of heart failure, are originated from pulmonary venocapillary hypertension and are usually activated when the patient performs physical exertion greater than their capacity. Scales are used to measure the severity of the heart failure in patients, which use the tolerance of the patient to exertion as the reference. This evaluation, from the functional class with less dysfunction to its most severe form, is important. An example is the New York Heart Association scale; this scale was developed for those who have dyspnea at rest originating from heart failure that intensifies in the decubitus by increased hydrostatic pressure in the pulmonary region, improving in the sitting or standing position(22).
The dyspnea symptom is abnormal, and when it occurs at rest or when triggered by moderate exertion, it can be related to cardiovascular complications. Shortness of breath or dyspnea is a sign of heart failure. The etiology of dyspnea is diverse, including lung, heart and chest wall diseases and anxiety. The presentation of dyspnea, such as respiratory discomfort, one of the most characteristic symptoms of CHF, is usually associated with pulmonary venocapillary congestion that sometimes occurs with difficulty breathing at night when the person is lying down due to the displacement of liquid into the interior of the lungs. Individuals with CHF may need to sleep in a sitting position to prevent pulmonary venocapillary congestion (21).
The constructed nursing diagnosis and intervention statements related to dyspnea identified different definitions such as dyspnea at rest, which relates to the position of the patient, dyspnea when lying down and improving with the sitting position (orthopnea)(16) or functional dyspnea, a state in which the characteristics are associated with physical activity, such as exercising and walking. As the diagnostic event for CHF, dyspnea leads to dysfunctions of mechanical (ventilation-perfusion) and functional origins (gas exchange and respiratory acidosis), which have an impact on the quality of life of the patient defined by walking, hygiene activities and even sleep, in phases III and IV of the NYHA scale(21).
The development of edema in patients with heart failure is associated with the regulation of intravascular volume. The presence of edema confounds the control of arterial pressure because changes in arterial pressure are rapidly reflected as variations in the intravascular volume. During heart failure after a muscle injury, the heart is unable to maintain an adequate cardiac output, the effective volume decreases, mean arterial pressure, therefore, drops slightly and the kidneys start to rapidly retain water and sodium, as if the body was experiencing real hypovolemia. All of these interrelated events that occur during heart failure contribute to nervous and humoral stimuli that cause an elevated arterial pressure in the right atrium, reflecting the inability of the heart to provide for the kidneys; fluid and salt retention in the kidneys causes a continual accumulation in the interstitial space that may evolve into congestion(1-2). Edema occurs with disease progression because the circulatory demand causes a deterioration of cardiac function and other corrective mechanisms involved in the retention of salt (sodium) by the kidneys. To maintain a constant concentration of sodium in the blood, the body retains water concomitantly. One of the main consequences of fluid retention is that the increased blood volume promotes myocardial distension; distended muscle contracts with more force, which is one of the main mechanisms used by the heart to improve its performance in incidences of heart failure. However, as the heart failure progresses, the excess liquid escapes from the circulation and accumulates in different body sites, producing swelling (edema)(1,16).
A monitoring and guidance program for patients with CHF significantly decreased complication signals such as edema, defined as the accumulation of fluid in the interstitial space as a consequence of the altered homeostasis of sodium and water. The edema may be generalized or localized. Edema evaluation can be performed by the verification of weight gain, through pitting or the Godet sign(2, 22). In the alteration records, edema is also associated with the state in which body fluids are composed of water (solvent) and dissolved substances, and these levels need to be within an acceptable range for the smooth operation of the body. The body uses mechanisms to control the balance. The kidneys must function properly because of their ability to alter the amount of acid or base excreted, but generally, this process takes several days. The heart also needs to pump competently to supply blood to the kidneys and other organs responsible for releasing hormones and for the function of the autonomous central nervous system, as a defense against sudden alterations in the body. In turn, when the condition worsens, the patient presents with ascites, the state in which there is excess fluid in the peritoneal cavity (the membrane lining the abdomen) between the organs of the cavity. The pathogenesis of ascites formation, also a change in the water balance in the body, may be caused by several factors and involves the kidneys, heart, liver, adrenal and pituitary glands and nervous system(16). The factors related to this retention, such as movement in bed and the presence of dry skin, directly affect the quality of life of the patient, care and self-care, which are factors that can significantly contribute to complications such as peripheral vascular disorders, edema, a marker of chronicity, or possibly to treatment not suited to the needs of the patient.
A frequent cause of death in heart failure is pulmonary congestion, occurring mainly in patients experiencing heart failure for prolonged periods of time. When pulmonary congestion occurs in a person without a new cardiac injury, it is usually triggered by a temporary overload of the heart, such as in an episode of heavy exercise, an emotional experience or a serious common cold. Congestion is believed to result from a weakened peripheral circulation venous return, due to the limited capacity of the left heart that results in the retention of blood in the lungs. In view of this occurrence, capillary pressure increases and a small amount of liquid begins to transude into the lung tissue and alveoli(4, 16, 22). In the congestion process, the harmful effects of excessive fluid retention in the severe stages of heart failure appear, in contrast to the beneficial effects of moderate fluid retention. The physiological consequences of this are extremely severe; they include excessive stretching of the heart, which further weakens the heart and causes liquid filtration into the lungs, pulmonary edema and consequently deoxygenation of the blood. A small amount of liquid begins to transude to the alveoli and lung tissues when pulmonary capillary pressure increases. This can occur with heavy exercise and emotional experience, which can happen violently because the heart muscle injury is already present(19, 21). Irregular clinical findings can be identified at this specific stage of pulmonary congestion, such as a cough, the sudden and explosive release of air from the lungs, or a productive cough, in which mucus is expelled. The mucus can drain the down the nasal passages to the throat and lungs and induction the cough reflex(15). When the progress of the pulmonary congestion is monitored, hypoxia may exist due to lung congestion, and gas exchange cannot be performed in a satisfactory manner, which may be sometimes caused by excess fluid volume and by physical exertion beyond the functional capacity. The cardiac patient is then restricted in their ability to perform tasks in their daily routines, such as difficulty bathing, dressing, grooming, transferring and performing activities related to hygiene.
The overall purpose of the nursing diagnosis and intervention statements constructed in the study was to cover all the previously mentioned aspects of the four main signs and symptoms of CHF. It should be noted that these statements need to be subjected to a content validation process by nurses of the area that is followed by clinical validation, where they will be tested with outpatient or hospitalized CHF patients.
The aims achieved in this work were to develop nursing diagnosis and intervention statements based on the ICNP® for CHF patients. It is noteworthy that when these statements are validated they will be used to structure a terminological subset of the ICNP® for CHF patients; this subset aims to support systematic documentation in nursing practice, to facilitate the construction of electronic medical records and to make the ICNP® a useful instrument that can be integrated into the practice of nursing care onsite.
The ICNP® is a proven instrument that can facilitate the promotion, organization and quality of care, which contribute to professional autonomy and self-confidence, provide visibility to the nursing practice and reward the profession in specific areas such as cardiology, which require the professionals to develop committed activities for care. The heart failure outpatient clinics represent one of the possible applications of this work in the field of nursing; these are sectors that require monitoring, evaluation, teaching and research to support the well-being of patients with this clinical disorder, and the actions of the nurse can significantly improve the quality of life of patients and reduce the cost of readmissions.
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Received: 09/09/2011 * Extracted from the Master's dissertation "ICNP® Catalogues
for Congestive Cardiac Failure", Postgraduate Program in Nursing of the Federal
University of Paraíba, 2009.
* Extracted from the Master's dissertation "ICNP® Catalogues for Congestive Cardiac Failure", Postgraduate Program in Nursing of the Federal University of Paraíba, 2009.