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!!