Cardiac Failure

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.

Risk factors

In evaluating heart failure patients, the clinician should ask about the following

comorbidities and/or risk factors[5] :

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

Physical exam

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.

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.

Abnormal findings that suggest heart failure

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.

Diagnosis

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 catheterisation and angiography

Nuclear medicines techniques

Multi-slice Computer Tomography (MSCT)

Pathophysiologic mechanism

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).

Nursing Dx & interventions:

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. Hyperthermia 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

monitor VS

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

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

Nonpharmacologic therapies include:

dietary sodium and fluid restriction

physical activity as appropriate

attention to weight gain

Pharma Tx:

ACE INHIBITORS

Angiotensin-converting enzyme (ACE) inhibitors are indicated for the treatment of all patients

with heart failure caused by systolic dysfunction.

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.

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).

DIRECT-ACTING VASODILATORS

Direct-acting vasodilators were among the first medications shown to improve survival in

patients with heart failure.

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.

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.

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.

Lithium.

NSAIDs and cyclo-oxygenase-2 (COX-2) inhibitors.[10]

Corticosteroids.

Drugs prolonging QT interval and potentially precipitating ventricular arrhythmias - eg

erythromycin, terfenadine.

Invasive therapies for heart failure include electrophysiologic intervention such as cardiac

resynchronization therapy (CRT), pacemakers, and implantable cardioverter-defibrillators

(ICDs); revascularization procedures such as 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

Peri-operative Nsg. Interv.

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,

peripheral edema, and

urinary output.

Measure the patient’s baseline weight.

Ensure adequate IV access.

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 fluid overload, such as

respiratory crackles on auscultation,

jugular venous distension,

shortness of breath, or

increased respirations.

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.

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.

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.

Bioethics

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.”

• “You are the only one who can decide what, if anything, you want to do; and as your

provider, ______ is the number one thing you could do to improve your health.

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?

Discharge planning

Recognition of escalating symptoms and concrete plan for response to particular symptoms.

The patient/caregiver(s) should be able to identify specic

signs and symptoms of heart failure, and explain actions

to take when symptoms occur. Actions may include a -exible

diuretic regimen or -uid 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 specic exercise

recommendations provided by the patient educator.

Instructions should include how to carry out the activity/

exercise, how long to carry out the activity/exercise, expected

physiological changes with exercise (moderate increase in

heart rate, breathing effort and diaphoresis), type and length

of time completing warm-up exercises and type and length

of time completing cool-down exercises.

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. Nonadherence with heart failure

medications can rapidly and profoundly adversely affect the

clinical status of patients. During the patient education period,

it is important for the educator to reiterate medication name,

dosing schedule, basic reason for specic medications,

expected side effects, and what to do if a dose is missed.

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 modiable 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. A smoking cessation intervention may

include smoking cessation counseling (eg, verbal advice

to quit, referral to smoking cessation program or counselor)

and/or pharmacological therapy).

• 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.