Prepared by:
BSN, Level IV
Sarah Jane A. Cristobal
Known as congestive heart failure (CHF),
occurs when your heart muscle doesn't pump
blood as well as it should. Conditions such as
narrowed arteries in your heart (coronary artery
disease) or high blood pressure gradually leave
your heart too weak or stiff to fill and pump
efficiently.
The heart's pumping power is weaker than
normal. With heart failure, blood moves
through the heart and body at a slower rate,
and pressure in the heart increases. As a
result, the heart cannot pump enough oxygen
and nutrients to meet the body's needs. The
chambers of the heart may respond by
stretching to hold more blood to pump through
the body or by becoming stiff and thickened.
This helps to keep the blood moving, but the
heart muscle walls may eventually weaken and
become unable to pump as efficiently. As a
result, the kidneys may respond by causing the
body to retain fluid (water) and salt. If fluid
builds up in the arms, legs, ankles, feet, lungs,
or other organs, the body becomes congested,
and congestive heart failure is the term used to
describe the condition.
In evaluating heart failure patients, the clinician
should ask about the following comorbidities
and/or risk factors:
Myopathy
Previous MI
Valvular heart disease, familial heart disease
Alcohol use
Hypertension
Diabetes
Dyslipidemia
Coronary/peripheral vascular disease
Sleep-disordered breathing
Collagen vascular disease, rheumatic fever
Pheochromocytoma
Thyroid disease
Substance abuse history
History of chemotherapy/radiation to the chest
The parts of the physical exam that are most
helpful in diagnosing heart failure are:
Measuring blood pressure and pulse rate.
Checking the veins in the neck for swelling or
evidence of high blood pressure in the veins
that return blood to the heart. Swelling or
bulging veins may indicate right-sided heart
failure or advanced left-sided heart failure.
Listening to breathing (lung sounds).
Listening to the heart for murmurs or extra
heart sounds.
Checking the abdomen for swelling caused by
fluid buildup and for enlargement or tenderness
over the liver.
Checking the legs and ankles for swelling
caused by fluid buildup (edema).
Measuring body weight.
Results
Usually, signs of some heart condition are
present, such as high blood pressure or a heart
murmur that means heart valve disease.
Results
If you have symptoms typical of heart failure,
the physical exam may be all that your doctor
needs to make the diagnosis. But you will have
additional tests to determine the specific cause
and type of heart failure so that you can
receive appropriate treatment.
Normal
Lung and heart sounds are normal, blood
pressure is normal, and you have no sign of
fluid buildup or swollen veins in the neck.
You may have further exams or tests to check
for other causes of symptoms.
High blood pressure (140/90 mm Hg or above)
or low blood pressure is present. Low blood
pressure could be a sign of late-stage heart
failure.
An irregular heart rate (cardiac arrhythmia)
A third heart sound (indicating abnormal
movement of blood through the heart) is heard.
Heart murmurs may or may not be present.
The impulse normally felt from the lower tip of
the heart (apex) is not felt in its normal position
on the chest wall, suggesting enlargement of
the heart.
Swollen neck veins or abnormal movement of
blood in the neck veins suggest that blood may
be backing up in the right ventricle.
Noises (pulmonary rales) such as bubbling or
crackling are heard, which may point to fluid
buildup in the lungs. Your doctor uses a
stethoscope to hear these noises while you
take deep breaths.
You have a swollen liver or have pain in the
right upper abdomen, loss of appetite, or
bloating. This suggests that blood may be
backing up into the body.
You have swelling in your legs, ankles, or feet
or in the lower back when you lie down, and it
is clearly not caused by another condition.
Fluid buildup first occurs during the day and
goes away overnight.
As heart failure becomes worse, fluid buildup
may not go away.
Some people with early symptoms of heart
failure have no physical findings.
A diagnosis of heart failure depends on the
whole picture of physical findings, symptoms,
and tests.
If physical findings and your medical history
strongly suggest heart failure, you most likely
will have a chest X-ray, an echocardiogram,
and electrocardiography to evaluate the heart
size, shape, and function and to evaluate the
lungs for signs of fluid buildup.
The most common tests are:
Medical history and physical examination
Electrocardiogram (ECG)
Blood tests
Chest x-ray
Echocardiogram
Additional tests may be able to find out more
about your heart failure or identify the cause.
These include:
Lung function tests
Exercise testing
Cardiac Magnetic Resonance Imaging (MRI)
Cardiac catheterization and angiography
Nuclear medicines techniques
Multi-slice Computer Tomography (MSCT)
The signs and symptoms of heart failure (HF)
are due in part to compensatory mechanisms
utilized by the body in an attempt to adjust for a
primary deficit in cardiac output. Neurohumoral
adaptations, such as activation of the renin-
angiotensin-aldosterone and sympathetic
nervous systems by the low-output state,
Can contribute to maintenance of perfusion of
vital organs in two ways:
Maintenance of systemic pressure by
vasoconstriction, resulting in redistribution of
blood flow to vital organs.
Restoration of cardiac output by increasing
myocardial contractility and heart rate and by
expansion of the extracellular fluid volume.
In HF, these adaptations tend to overwhelm the
vasodilatory and natriuretic effects of natriuretic
peptides, nitric oxide, prostaglandins, and
bradykinin [3-5]. Volume expansion is often
effective because the heart can respond to an
increase in venous return with an elevation in
end–diastolic volume that results in a rise in
stroke volume (via the Frank-Starling
mechanism).
1. Decreased cardiac output r/t altered heart rate
and rhythm AEB bradycardia
Assess for abnormal heart and lung sounds.
Monitor blood pressure and pulse.
Assess mental status and level of
consciousness.
Assess patient’s skin temperature and
peripheral pulses.
Monitor results of laboratory and diagnostic
tests.
Monitor oxygen saturation and ABGs.
Give oxygen as indicated by patient symptoms,
oxygen saturation and ABGs.
Implement strategies to treat fluid and
electrolyte imbalances.
Administer cardiac glycoside agents, as
ordered, for signs of left sided failure, and
monitor for toxicity.
Encourage periods of rest and assist with all
activities.
Assist the patient in assuming a high Fowler’s
position.
Teach patient the pathophysiology of disease,
medications
Reposition patient every 2 hours
Instruct patient to get adequate bed rest and sleep
Instruct the SO not to leave the client unattended
2. Excessive Fluid volume r/t decreased cardiac
output and sodium and water retention AEB
crackles on both lung field and edema on
extremities secondary to CHF and IHD
Establish rapport
Monitor and record VS
Assess patient’s general condition
Monitor I&O every 4 hours
Weigh patient daily and compare to previous
weights.
Auscultate breath sounds q 2hr and pm for the
presence of crackles and monitor for frothy
sputum production
Assess for presence of peripheral edema. Do
not elevate legs if the client is dyspneic.
Follow low-sodium diet and/or fluid restriction
Encourage or provide oral care q2
Obtain patient history to ascertain the probable
cause of the fluid disturbance.
Monitor for distended neck veins and ascites
Evaluate urine output in response to diuretic
therapy.
Assess the need for an indwelling urinary
catheter.
Institute/instruct patient regarding fluid
restrictions as appropriate.
3. Acute Pain
assess patient pain for intensity using a pain
rating scale, for location and for precipitating
factors.
Administer or assist with self-administration of
vasodilators, as ordered.
Assess the response to medications every 5
minutes
Provide comfort measures.
Establish a quiet environment.
Elevate head of bed.
Monitor vital signs, especially pulse and blood
pressure, every 5 minutes until pain subsides.
Teach patient relaxation techniques and how to
use them to reduce stress.
Teach the patient how to distinguish between
angina pain and signs and symptoms of
myocardial infarction.
4. Ineffective tissue perfusion r/t decreased cardiac output
Assess patient pain for intensity using a pain rating scale, for location and for precipitating factors.
Administer or assist with self administration of vasodilators, as ordered.
Assess the response to medications every 5 minutes.
Give beta blockers as ordered.
Establish a quiet environment.
Elevate head of bed.
Monitor vital signs, especially pulse and blood
pressure, every 5 minutes until pain subsides.
Provide oxygen and monitor oxygen saturation
via pulse oximetry, as ordered.
Assess results of cardiac markers—creatinine
phosphokinase, CK- MB, total LDH, LDH-1,
LDH-2, troponin, and myoglobin ordered by
physician.
Assess cardiac and circulatory status.
Monitor cardiac rhythms on patient monitor and results of 12 lead ECG.
Teach patient relaxation techniques and how to use them to reduce stress.
Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial infarction.
Reposition the patient every 2 hours
Instruct patient on eating a small frequent feedings
5. Elevated body temperature RT increased
metabolic rate secondary to pneumonia
Assess vital signs, the temperature.
Monitor and record all sources of fluid loss
such as urine, vomiting and diarrhea.
Performed tepid sponge bath.
Maintain bed rest.
Remove excess clothing and covers.
Increase fluid intake.
Provide adequate nutrition, a high caloric diet.
Control environmental temperature.
Adjust cooling measures on the basis of
physical response.
Provide information regarding normal
temperature and control.
Explain all treatments.
Administer antipyretics as ordered.
Control excessive shivering with medications
such as Chlorpromazine and Diazepam if
necessary.
Provide ample fluids by mouth or intravenously
as ordered.
Provide oxygen therapy in extreme cases as
ordered.
6. Ineffective breathing pattern r/t fatigue and
decreased lung expansion and pulmonary
congestion secondary to CHF
establish rapport
inspect thorax for symmetry of respiratory
movement
observe breathing pattern for SOB, nasal
flaring, pursed-lip breathing or prolonged
expiratory phase and use of accessory
muscles
monitor VS
measure tidal volume and vital capacity
assess emotional response
position patient in optimal body alignment in
semi- fowler’s position for breathing
assist patient to use relaxation techniques
7. Activity intolerance r/t imbalance O2 supply and demand AEB limited ROM, generalized weakness and DOB
Establish Rapport
Monitor and record Vital Signs
Assess patient’s general condition
Adjust client’s daily activities and reduce intensity of level. Discontinue activities that cause undesired psychological changes
Instruct client in unfamiliar activities and in alternate ways of conserve energy
Encourage patient to have adequate bed rest and sleep
Provide the patient with a calm and quiet environment
Assist the client in ambulation
Note presence of factors that could contribute to fatigue
Ascertain client’s ability to stand and move about and degree of assistance needed or use of equipment
Give client information that provides evidence
of daily or weekly progress
Encourage the client to maintain a positive
attitude
Assist the client in a semi-fowlers position
Elevate the head of the bed
Assist the client in learning and demonstrating
appropriate safety measures
Instruct the SO not to leave the client
unattended
Provide client with a positive atmosphere
Instruct the SO to monitor response of patient
to an activity and recognize the signs and
symptoms
8. Ineffective airway clearance RT retained
secretions AEB presence of rales on both lung
fields.
Monitor and record vital signs.
Assess patient’s condition.
Monitor respirations and breath sounds, noting
rate and sounds.
Position head properly
Position appropriately and discourage use of
oil-based products around nose.
Auscultate breath sounds and assess air
movement.
Encourage deep breathing and coughing
exercises
Elevate head of bed and encourage frequent
position changes.
Keep back dry and loosen clothing
Observed for signs and symptoms of infection.
Instruct patient have adequate rest periods and
limit activities to level of activity intolerance.
Give expectorants and bronchodilators as
ordered.
Suction secretions PRN
Administer oxygen therapy and other
medications as ordered
dietary sodium and fluid restriction
physical activity as appropriate
attention to weight gain
1. ACE INHIBITORS
Angiotensin-converting enzyme (ACE)
inhibitors are indicated for the treatment of all
patients with heart failure caused by systolic
dysfunction.
2. BETA BLOCKERS
Beta blockade is recommended in patients with
heart failure caused by systolic dysfunction,
except in those who are dyspneic at rest with
signs of congestion or hemodynamic instability,
or in those who cannot tolerate beta blockers.
3. ALDOSTERONE ANTAGONISTS
Aldosterone antagonism is indicated in patients
with symptomatic heart failure who have rest
dyspnea or a history of rest dyspnea within the
past six months (ARR = 11 percent over two
years; number needed to treat [NNT] = 9).
4. DIRECT-ACTING VASODILATORS
Direct-acting vasodilators were among the first
medications shown to improve survival in
patients with heart failure.
5. DIURETICS
Diuretics are used, and often required, to
manage acute and chronic volume overload.
Because diuretics may produce potassium and
magnesium wasting, monitoring of these
electrolytes is important.
6. ARBS
Evidence supports the use of ARBs as a
substitute agent in patients with heart failure
who cannot tolerate ACE inhibitors19; the
combination of isosorbide dinitrate and
hydralazine is also effective in this population.
7. DIGOXIN
The collection of drugs that have a beneficial
impact on mortality in heart failure is
expanding, and because polypharmacy can
become a barrier to compliance, the role that
digoxin will ultimately play in heart failure is
unclear. Usual dosage range for digoxin is
0.125 to 0.250 mg daily
Drugs to avoid in heart failure
Pro-anti-arrhythmics with potentially negative
inotropic effects, eg flecainide.
Calcium-channel blockers - eg verapamil,
diltiazem (only amlodipine is advisable).
Tricyclic antidepressants.
Drugs to avoid in heart failure
Lithium.
NSAIDs and cyclo-oxygenase-2 (COX-2)
inhibitors.[10]
Corticosteroids.
Drugs prolonging QT interval and potentially
precipitating ventricular arrhythmias - eg
erythromycin, terfenadine.
Electrophysiologic intervention:
cardiac resynchronization therapy (CRT),
pacemakers, and
implantable cardioverter-defibrillators (ICDs);
revascularization procedures
coronary artery bypass grafting (CABG) and
percutaneous coronary intervention (PCI)
valve replacement or repair;
and ventricular restoration.
When progressive end-stage heart failure
occurs despite maximal medical therapy, when
the prognosis is poor, and when there is no
viable therapeutic alternative, the criterion
standard for therapy has been heart
transplantation.
However, mechanical circulatory devices such
as ventricular assist devices (VADs) and total
artificial hearts (TAHs) can bridge the patient to
transplantation; in addition, VADs are
increasingly being used as permanent therapy
Preoperative Care
Measure and document the patient’s baseline
vital signs.
Monitor baseline laboratory values for
abnormalities (eg, serum potassium).
Perform a thorough head-to-toe nursing
assessment, which focuses on
adventitious lung sounds,
jugular venous distention,
Preoperative Care
peripheral edema, and
urinary output.
Measure the patient’s baseline weight.
Ensure adequate IV access.
Preoperative Care
Institute preoperative warming techniques.
Obtain and review the patient’s medication list
and record the last dose taken.
Apply thromboembolic stocking and sequential
compression devices, if applicable, for deep
vein thrombosis prophylaxis.
Intraoperative Care
Monitor the patient’s vital signs closely for changes from baseline values.
Ensure patency and accessibility of IV lines.
Monitor the patient closely for signs of fluidoverload, such as
respiratory crackles on auscultation,
jugular venous distension,
shortness of breath, or
increased respirations.
Intraoperative Care
Assess positioning of the patient and consider
using the lawn chair position during induction, if
possible.
Institute thermoregulatory techniques (eg, use
of a temperature-regulating blanket during
surgery).
Communicate the patient’s status to his or her
family members, when possible.
Postoperative Care
Monitor the patient’s vital signs closely for
changes from baseline values.
Maintain the patient’s airway.
Monitor telemetry for changes in heart rhythm.
Monitor the patient closely for signs of pain
and provide adequate pain relief.
Elevate the head of the bed according to the
patient’s comfort level.
Postoperative Care
Continue to monitor closely for signs of fluid
overload.
Continue thermoregulatory techniques (eg,
use a temperature-regulating blanket, put on
patient’s socks).
Monitor for signs of deep vein thrombosis,
such as swelling in one or both legs or warmth,
redness, tenderness or discolored skin in the
affected leg.
Postoperative Care
Monitor for signs of pulmonary embolism, such
as
sharp, stabbing chest pain or
sudden shortness of breath.
Communicate the patient’s status to his or her
family members.
Cultural Competency: Considering the Diversity
of Patients
Adherence to Low Risk Lifestyle Reduces Risk
of Cardiac Events
Talking about lifestyle change with patients can
be very frustrating for both parties.
Facilitating Lifestyle and Behavior Change
DISCUSSION POINTS:
So, what do we know about facilitating lifestyle and behavior change?
Advice from a medical provider is important and sought after by most patients.
For some, it is enough to motivate change, usually around 5% of people.
Make the most of your professional opinion and advice, be clear, caring, and compelling.
Asking Permission/Patient Autonomy: Sample Questions
“I know you came in today for your Pap, and I’m really concerned about your blood pressure. Would it be alright if we talked about that also?”
“I realize that you are in the driver’s seat here with your diabetes. I want to let you know that I am very concerned about _______. I believe that the new medication will help if that is something you are willing to try.”
Talking About Change
• If a person talks about her desire, reason,
ability, and need to change, she is more likely
to change. If she is given the chance to say
out loud what she intends to do, she is more
likely to do it.
Ask directly for a response.
o What concerns do you have about _____?
o What do you think will work best for you?
Why?
o Where would you like to start?
o Is this what you are going to do?
Recognition of escalating symptoms and
concrete plan for response to particular
symptoms.
The patient/caregiver(s) should be able to
identify specific
signs and symptoms of heart failure, and
explain actions to take when symptoms occur.
Actions may include a -excessible diuretic
regimen or -urined restriction for volume
overload.
Example of signs and symptom include:
• Shortness of breath (dyspnea)
• Persistent coughing or wheezing
• Buildup of excess -uid in body tissues (edema)
• Tiredness, fatigue, decrease in exercise and
activity
• Lack of appetite, nausea
• Increased heart rate
Activity/exercise recommendations. In order to
reduce chances of readmissions, and to
improve ambulatory status, it is important for
the patient to follow specific exercise
recommendations provided by the patient
educator.
Indications, use, and need for adherence with
each medication prescribed at discharge.
Patients require guidance on how to institute
an individualized system for medication
adherence.
Importance of daily weight monitoring. Sudden
weight gain or weight loss can be a sign of
heart failure or worsening of condition.
Modify risks for heart failure progression. Below
are some of the modifiable risk factors to
discuss, as needed, prior to patient discharge:
• Smoking cessation: If the patient is a smoker,
then the educator should provide counseling on
the importance of smoking cessation.
Maintain specific body weight that promotes a
“normal” body mass index
Specific diet recommendations: individualized
low-sodium diet; recommendation for alcohol
intake.
Sodium Restriction: Patient/caregiver(s) should
be able to understand and comply with sodium
restriction
Alcohol: Patients/Caregiver(s) should be able
to understand the limits for alcohol
consumption or need for abstinence if history of
alcoholic cardiomyopathy.
Follow-up Appointments: Patients/Caregiver(s)
should understand the rationale of the follow-
up appointment in improving the patient’s
quality of life and reducing readmission even if
the patient feels fine.
Thank you…
I Love You Po!!