|Year : 2021 | Volume
| Issue : 1 | Page : 36-40
Assessment of thirst intensity and thirst distress and the practices for its management among heart failure patients admitted to the cardiology unit
Karuna Thapa1, Smita Das1, Pragya Pathak1, Sandeep Singh2
1 Cardiological/CTVS Nursing, College of Nursing, AIIMS, New Delhi, India
2 Department of Cardiology, AIIMS, New Delhi, India
|Date of Submission||25-Jan-2021|
|Date of Decision||16-Mar-2021|
|Date of Acceptance||17-Mar-2021|
|Date of Web Publication||24-Apr-2021|
Masjid Moth, Hostel No. 15, AIIMS Campus, New Delhi
Source of Support: None, Conflict of Interest: None
Background: Thirst is reported as a troublesome symptom in patients with heart failure (HF), and very few studies have been done to assess thirst in these patients. Therefore, this study aims to assess thirst intensity, thirst distress, and practices of HF patients to manage thirst. Methods: A descriptive, cross-sectional study was conducted on 75 HF patients admitted to the cardiology department. Purposive sampling technique was used for collecting data from July 2019 to November 2019. Visual analog scale (0–100 mm) was used to assess thirst intensity, and 8-item thirst distress scale was used to assess thirst distress. The practices of the participants were assessed using a self-developed questionnaire. Results: The mean age of the participants was 44.83 ± 15.51 years and the majority (72%) was male. The majority of the participants (82.7%) had fluid restriction, and almost 97.3% of all of the participants were receiving diuretics. The median (interquartile range) thirst intensity was 33 (16–50) mm. About 66.7% of the participants had moderate-to-severe thirst distress. Both thirst intensity and thirst distress were associated with fluid restriction, New York Heart Association functional class, and serum urea level. The participants reported that they drink a small amount of water frequently, gargle with water, eat cucumber, drink buttermilk, lemon juice, and coconut water. Very few participants had made changes in their food habits and lifestyle. Conclusion: Two-thirds of the participants had moderate-to-severe thirst distress. Fluid restriction was associated with both thirst intensity and thirst distress. Thus, nurses are responsible to assess thirst among HF patients and help them to manage their thirst effectively.
Keywords: Heart failure, practice, thirst distress, thirst intensity
|How to cite this article:|
Thapa K, Das S, Pathak P, Singh S. Assessment of thirst intensity and thirst distress and the practices for its management among heart failure patients admitted to the cardiology unit. J Pract Cardiovasc Sci 2021;7:36-40
|How to cite this URL:|
Thapa K, Das S, Pathak P, Singh S. Assessment of thirst intensity and thirst distress and the practices for its management among heart failure patients admitted to the cardiology unit. J Pract Cardiovasc Sci [serial online] 2021 [cited 2021 Jun 22];7:36-40. Available from: https://www.j-pcs.org/text.asp?2021/7/1/36/314476
| Introduction|| |
Heart failure (HF) has become a major health problem in India with an estimated prevalence of about 1% (8–10 million) and the mortality of about 0.1–0.16 million people per year. The HF patients are kept on diuretics and fluid restriction for the management of congestive symptoms. Thirst was found to be associated with fluid restriction and diuretics in HF patients. It has been reported as troublesome which causes noncompliance with the pharmacological treatment and fluid restriction. The noncompliance with treatment increased the symptoms such as dyspnea, fatigue, edema resulting in frequent hospitalization, and poor quality of life.
It is vital to maintain compliance with treatments to prevent complications, and for this, it is necessary to understand the magnitude of thirst and the possible factors associated with it. It is also important to know how patients are managing their thirst.
Thus, the study aims to assess thirst intensity and thirst distress and the practices for its management among HF patients.
| Materials and Methods|| |
A descriptive cross-sectional study was conducted among 75 HF patients admitted to the cardiology unit (CT3 ward and CCU). Purposive sampling technique was used. Ethical clearance was obtained from the Institute Ethics Committee (Ref no. IECPG-134/February 28, 2019, RT-16/March 27, 2019), and written informed consent was taken from all the participants. Confidentiality and anonymity of the participants were maintained.
Patients diagnosed with HF at least for 1-month period, who were above 18 years, had left ventricular ejection fraction ≤45%, and able to read and understand Hindi or English and willing to participate were included in the study. HF patients having a disease associated with a possible risk of increased thirst such as diabetes type 1 and diabetes type 2 with insulin treatment, renal failure with dialysis, and pulmonary disease treated with oxygen and patient kept on NPO were excluded from the study.
The demographic characteristics of the participants were assessed by a self-developed performance which included age, gender, marital status, body mass index, and duration of HF. Clinical profile was also assessed by a self-developed performance, and participant's medical record file included symptoms present in the patient, number of symptoms, New York Heart Association (NYHA) functional class, left ventricular ejection fraction, blood investigations report, oral health, pharmacological and nonpharmacological treatment, the dose of diuretics, type of diuretics, and comorbidities.
Visual analog scale was used to assess the thirst intensity of the participants. It is a 100 mm scale in which 0 mm means no thirst and 100 mm means worst possible thirst. It has been used in other studies to measure the thirst intensity.
Eight-item thirst distress scale for HF (Cronbach's alpha 0.74) was used to measure the thirst distress. The researcher took permission from Nana Waldreus et al., RN, Lecturer, Karolinska Institute, Sweden, who developed the original 8-item Thirst Distress Scale for HF patients. The forward and backward translation of the tool was done to develop the final tool as per the guidelines provided by the author of the tool. It consisted of 8 items rated from 1 (strongly disagree) to 5 (strongly agree) and the total score ranges from 8 to 40. The score is categorized as no thirst distress (score 8), mild thirst distress (score 9–16), moderate thirst distress (score 17–24), high thirst distress (score 25–32), and severe thirst distress (score 33–40).
A self-developed semi-structured questionnaire was used to assess the practices adopted by participants to manage their thirst through an interview. It consisted of 8 questions related to practices for thirst management.
Data were collected from the participants from July 2019 to November 2019. The HF patients were approached in CT3 ward and CCU, and those meeting the inclusion criteria were enrolled for the study. The data were collected at the bedside of the participants in the morning before breakfast to nullify the effects of food and fluid on thirst intensity. The demographic and clinical profile was collected. The visual analog scale was provided to measure thirst intensity. Participants were instructed to mark their thirst intensity from 0 (no thirst) to 100 (worst possible thirst). Then, the distance between zero and the mark was measured using a scale and was noted. Then, the participants were asked to tick according to their agreement and disagreement with the statement in an 8-item thirst distress scale to assess the thirst distress of a period of 1 month. At last, the participants were interviewed with a self-developed semistructured questionnaire to assess their practices for managing thirst. The overall procedure took 20–25 min to complete.
The analysis of the data was done using descriptive and inferential statistics on STATA 15.0 version (StataCorp LLC, College Station, Texas, USA). Descriptive statistics, i.e., mean, standard deviation, median, interquartile range (IRQ), frequency, and percentage, were used for demographic and clinical variables. Inferential statistics, i.e., Fisher's exact test, one-way ANOVA test, Mann–Whitney U-test, Kruskal–Wallis test, and Spearman's rank correlation were used to find the association of thirst intensity and thirst distress with selected variables.
Spearman's rank correlation was used to find the correlation between continuous variables when at least one variable does not follow the normal distribution. Mann–Whitney U-test and Kruskal–Wallis test are nonparametric tests used to find the relationship of continuous variables without normal distribution with the categorical variable. Fisher's exact test is used for categorical variables. One-way ANOVA is a parametric test used to find the relationship between a normally distributed continuous variable and a categorical variable.
| Results|| |
A total of 108 HF patients were screened. Of them, 33 were excluded and 75 were enrolled in the study. The demographic and clinical profile of the participants is given in [Table 1]. The mean age of the participants was 44.83 ± 15.51 years and was predominantly male. The median (IQR) duration of HF was 24 months (7–60).
The most common symptoms reported by the participants were fatigue (89.3%) followed by dyspnea (85.3%), cough (44%), palpitations (24%), and ankle edema (21.3%). The other less frequently reported symptoms were facial puffiness (9.3%), syncope (8%), jugular vein distension (6.7%), ascites (5.3%), hepatomegaly (5.3%), chest pain (5.3%), orthopnea (4%), and paroxysmal nocturnal dyspnea (2.7%). The mean number of symptoms was 3.09 ± 1.26. The median (IQR) serum urea level was 39 (28–52) mg/dl. The median (IQR) dose of diuretics per day was 40 (35–70) mg. The comorbidities present in participants are shown in [Figure 1].
|Figure 1: Bar diagram showing comorbidities present in participants (n = 42).|
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Thirst intensity and distress
The median (IQR) thirst intensity of the participants was found to be 33 (16–50) mm. The thirst distress score ranged from 8 to 39 with a mean of 20.53 ± 7.66. The percentage distribution of thirst distress is depicted in [Figure 2].
|Figure 2: Pie chart showing the percentage distribution of thirst distress in participants (n = 75).|
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Factors affecting thirst intensity and thirst distress
The correlation and association of thirst intensity with selected variables are shown in [Table 2] and [Table 3], respectively. Thirst intensity has significant mild negative (r = −0.36) correlation with left ventricular ejection fraction at P = 0.002. Thirst intensity has a moderately positive (r = 0.41) correlation with serum urea level at P = 0.001. Thirst intensity is significantly associated with NYHA functional class and fluid restriction at P = 0.037 and 0.002, respectively. The Bonferroni correction was performed after the Kruskal–Wallis test and found a significant difference between NYHA functional Class I and III at P = 0.035.
|Table 2: Correlation between thirst intensity and the selected variables (n=75)|
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|Table 3: Association between thirst intensity and the selected variables (n=75)|
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The association of thirst distress with selected variables is given in [Table 4]. Thirst distress is significantly associated with serum urea level, NYHA functional class, and fluid restriction at P = 0.021, 0.044, and 0.047, respectively.
|Table 4: Association between thirst distress and the selected variables (n=75)|
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Practices of participants for managing thirst
All the participants made attempts to manage their thirst. The practices adopted by participants to manage their thirst are represented in [Table 5]. The majority (97.3%) reported that the measures taken by them were effective in alleviating their thirst. Among the participants, 44% immediately take action whenever they felt thirsty. More than half of the participants (64.5%) had adherence to their recommended fluid restriction. About 36% of the participants drank water as per their wish whenever they felt thirsty. The majority of the participants (61.3%) measure the amount of fluid before drinking. Only 22.7% of the participants had made changes in their food habits. Among them, ten participants started eating less salt and ten started eating less spicy, four avoided refined flour, three avoided fried items, three started eating dry curry, three avoided other fluids such as juice, tea, milk to take more amount of water, and one started taking less sugar. Barely, 13.3% had made changes in their lifestyle among which six avoided working under the sun and four involved less in physical activity.
Thirst intensity and thirst distress had a strong positive (r = 0.743) correlation which was statistically significant at P = 0.001. There was a significant association between thirst distress and adherence to recommended fluid restriction at P = 0.024.
| Discussion|| |
Assessment and management of thirst among HF patients seem to have received very little attention. Ignoring this distressing symptom could severely affect the quality of life of the patient with HF. Therefore, imparting knowledge regarding the importance of assessing thirst distress and intensity among these patients can help health-care professionals to search for ways that could be followed by HF patients to reduce this worrisome symptom.
To the best of researcher's knowledge, no such study has been conducted among the Indian population. The novelty of the study will contribute to the existing body of knowledge regarding the effective care of HF patients.
The finding showed that the median (IQR) thirst intensity was 33 (16–50) mm which was congruent with the finding of Waldréus et al., in which the median thirst intensity was 39 (14–59) mm but was in contrast with the finding of Waldréus et al., in which median thirst intensity was 14 (6–36). This divergence may be because in the present study, the assessment was done among admitted HF patients and they were under the direct supervision of the health-care providers for fluid intake as per prescription. Intense monitoring and strict fluid restriction for the admitted patients may have increased the thirst intensity among these patients. About 23 (66.67%) of the participants had moderate-to-severe thirst distress which is similar to the finding of Waldréus.
The study finding reported that thirst intensity was significantly associated with NYHA functional class and fluid restriction. Similar findings were reported by previous studies.,, The serum urea level, NYHA functional class, and fluid restriction were also significantly associated with thirst distress. This finding is in concordance with a previous study in which fluid restriction was associated with thirst. Patients having a higher NYHA functional class will have more symptoms, and diuretics will be prescribed for relieving these symptoms. Diuretics cause water loss and hence lead to dehydration. Strict fluid restrictions on the other hand worsened the situation by significantly affecting thirst distress.
There is a dearth of evidence-based interventions to manage thirst distress, but in the present study, all most all participants have reported attempting various ways to manage their thirst. All of the participants drank a small amount of water frequently to relieve their thirst. Such measure to manage thirst was also advised by the HF patients in the previous study. The other measures used by the participants to manage their thirst were gargling with water, eating cucumber, drinking coconut water, buttermilk, and lemon juice which were similar to the finding of previous studies.,
Only 22.7% of the participants had made changes in their food habits. A participant started taking less sugar, a similar finding was reported by a previous systematic review.
The use of standardized 8-item thirst distress scale for HF helped in the unbiased collection of data increasing the strength of the study. Since the participants were asked to mark their thirst distress of one period, recall bias could affect the reporting of thirst distress. The serum osmolality also has some effect on thirst intensity and distress, but this study could not assess the association of serum osmolality with thirst intensity and thirst distress. The findings of the present study yield information regarding how severe are the thirst among HF patients and how they are coping with the thirst. In the future, the interventional studies can be conducted to explore various measures to manage thirst and help HF patients to adhere to the prescribed treatment regimen.
| Conclusion|| |
The study found that most of the participants had moderate-to-severe thirst distress. Only some participants knew about other measures to relieve their thirst than to drink water, and only a few participants had made changes in their food habits and lifestyle. This reflects that health personnel has to consider thirst as an important problem in HF patients and take responsibility to assess and manage thirst in their patients in daily practice.
Ethical clearance was obtained from the Institute Ethics Committee.
We are grateful to sister in charge and nursing officers who provided support by making the availability of laboratory reports for data collection. Manuscript has not been presented as part at meeting, the organization, or any other place.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]