Heart Failure

Heart failure

Heart failure is a chronic, progressive cardiovascular disorder that causes fluid buildup in the heart from impaired myocardium contractility. It usually occurs from a damaged left ventricle, but it may also result from right ventricular damage. It's classified according to physical limitations.

Pathophysiology

Left-sided heart failure occurs when ineffective left ventricle contractile function results in decreased cardiac output. Blood backs up into the left atrium and lungs, causing pulmonary congestion. Right-sided heart failure occurs when ventricular injury impedes contractibility of the right ventricle's cardiac cells. Ineffective ventricular pumping leads to blood backup in the right atrium and, eventually, the peripheral circulation.

Complications

Acute

■ Pulmonary edema

■ Acute renal failure

■ Arrhythmias

Chronic

■ Activity intolerance

■ Renal impairment

■ Cardiac cachexia

■ Metabolic impairment

■ Thromboembolism

Assessment (only potential abnormalities listed)

Nursing history by Functional Health Pattern

Health perception and management

■ History of heart failure, hypertension, or cardiovascular disease

■ Noncompliance with prescribed diet, medications, or activity restrictions

■ Peripheral edema or fatigue (common)

Nutrition and metabolism

■ Anorexia (common)

■ Nausea or vomiting

■ Weight loss and cachexia

Elimination

■ Altered urinary patterns

■ Constipation

■ Nocturia

Activity and exercise

■ Inability to participate in exercise or leisure activities (common)

■ Difficulty participating in activities of daily living (ADLs)

Cognition and perception

■ Difficulty understanding problem and treatment protocols

■ Headaches, confusion, or memory impairment

Sleep and rest

■ Disturbed sleep patterns

■ Use of two or three pillows during sleep

■ Paroxysmal nocturnal dyspnea

Self‑perception and self‑concept

■ Body image disturbances

Sexuality and reproduction

■ Decreased libido and impotence or orgasmic dysfunction

Roles and relationships

■ Difficulty fulfilling role responsibilities

Coping and stress management

■ Anxiety

■ Depression, withdrawal

Physical Examination

General appearance and nutrition

■ Sitting up and leaning forward

■ Shortness of breath, inability to answer questions (during acute episode)

Mental status and behavior

■ Altered level of consciousness (based on degree of hypoxia)

■ Anxiety and restlessness

Integumentary

■ Dependent edema of lower extremities

■ Cyanosis

■ Clubbing of fingers (in chronic heart failure)

■ Jaundice (in those with long-term heart failure who develop cardiac cirrhosis)

Respiratory

■ Dyspnea

■ Crackles (usually bibasilar)

■ Cough (may produce frothy, blood-tinged sputum with episode of pulmonary edema)

■ Progressive bilateral diminishing of breath sounds

Cardiovascular

■ Tachycardia

■ S₃

■ S₄ with summation gallop (with tachycardia)

■ Atrial and ventricular arrhythmias

■ Jugular vein distention

■ Systolic murmur (in advanced heart failure)

■ Decreased peripheral pulses

■ Parasternal heave

■ Point of maximal impulse shifted to the left

Gastrointestinal

■ Abdominal distention

■ Vomiting

■ Tenderness over liver

■ Liver enlargement

Neurologic

■ Increased irritability

■ Impaired memory

■ Confusion (rare)

Musculoskeletal

■ Weakness and easy fatigability

■ Muscle wasting (rare)

Renal and urinary

■ Decreased urine output

Diagnostic studies

■ Serum electrolyte levels reveal electrolyte imbalances from fluid shifts, diuretic therapy, or response of organ systems to decreased oxygen and increased congestion.

■ Arterial blood gas (ABG) measurements indicate lowered partial pressure of arterial oxygen (Pao₂) related to pulmonary congestion; elevated partial pressure of arterial carbon dioxide (respiratory acidosis) may be from pulmonary edema or hypoventilation.

■ Blood urea nitrogen (BUN) and creatinine levels are elevated, reflecting decreased renal function.

■ Bilirubin, aspartate aminotransferase, and lactate dehydrogenase levels are elevated, indicating decreased liver function.

■ B-type natriuretic peptide level is elevated (level indicates the degree of heart failure).

■ Urinalysis reveals proteinuria and elevated urine specific gravity.

■ Chest X‑ray reveals an enlarged cardiac silhouette (common), distended pulmonary veins from redistribution of pulmonary blood flow, and interstitial and alveolar edema (common).

■ Echocardiography can identify valvular abnormalities, chamber enlargement, abnormal wall motion, hypertrophy, pericardial effusion, and mural thrombi.

■ Multigated blood pool imaging scan demonstrates decreased ejection fraction and abnormal wall motion.

Nursing care plan

Nursing diagnosis		Nursing priorities
Decreased cardiac output related to decreased contractility, altered heart rhythm, fluid volume overload, or increased afterload		■     Maintain optimum cardiac output.
Impaired gas exchange related to fluid accumulation in the lungs and at the alveolar level		■     Maintain optimal ventilation and oxygenation.
Excess fluid volume related to decreased myocardial contractility, decreased renal perfusion, and increased sodium and water retention		■     Optimize and monitor volume status and electrolyte balance.
Activity intolerance related to decreased cardiac output and impaired gas exchange		■     Increase activity level without exceeding cardiac energy reserves.
Imbalanced nutrition: Less than body requirements related to decreased appetite and dietary restrictions		■     Ensure adequate intake of nutrients needed for healing and increased energy requirements.
	Other potential nursing diagnoses: Ineffective therapeutic regimen management related to health beliefs, a negative relationship with caregivers, or the complexity of the regimen ■ Deficient knowledge (treatment regimen) related to lack of exposure to information

Decreased cardiac output related to decreased contractility, altered heart rhythm, fluid volume overload, or increased afterload

expected outcome

The patient will maintain optimal cardiac output as evidenced by stable vital signs, minimal or absent peripheral edema, normal peripheral pulses, warm, dry skin, and stable cardiac rhythm.

Suggested NOC Outcomes

Cardiac pump effectiveness; Circulation status; Tissue perfusion: Abdominal organs; Tissue perfusion: Peripheral; Vital signs

Nursing interventions

Intervention type	Intervention	Rationale
Independent	Monitor and document cardiovascular status: heart rate and rhythm, heart sounds, blood pressure, pulse pressure, and the presence or absence of peripheral pulses. Compare to the baseline assessment. Report abnormalities to the practitioner.	Monitoring cardiac status allows for rapid identification and treatment of decreased cardiac output.
Collaborative	Administer cardiac medications, as ordered, and document the patient's response. Observe for therapeutic and adverse effects.	Pharmacotherapeutic agents may relieve heart failure by altering preload, contractility, or afterload—major determinants of cardiac output. However, many of these agents have narrow therapeutic ranges or adverse effects that can worsen the underlying disease.
Independent	Observe for signs and symptoms of hypoxemia, such as confusion, restlessness, dyspnea, arrhythmias, tachycardia, and cyanosis. Ensure adequate oxygenation with proper positioning (semi‑Fowler's or upright) and supplemental oxygen, as ordered.	Prompt detection of hypoxemia allows timely intervention. The semi‑Fowler position prevents abdominal organs from pressing on the diaphragm and interfering with its movement. An upright position permits a severely dyspneic patient to use accessory muscles for breathing; it also redistributes blood to dependent areas, decreasing blood return to the heart and reducing preload in a patient with volume overload. A patient who has difficulty maintaining an arterial oxygen level above 60 mm Hg may benefit from supplemental oxygen.
Independent	Ensure adequate rest by monitoring the noise level, limiting visitors, grouping diagnostic tests, and spacing therapeutic interventions.	Rest reduces myocardial oxygen consumption.
Collaborative	Monitor fluid status: ■     Obtain accurate daily weight. ■     Maintain accurate intake and output record. ■     Assess lungs for crackles, decreased sounds, and a change from vesicular to bronchial breath sounds. ■     Assess for dependent edema and increasing dyspnea. ■     Assess for signs of dehydration.	Fluid volume may be increased from the heart's inability to maintain adequate flow and pressure through the kidneys: ■     Rapid weight gain (1 to 2 lb [0.5 to 1 kg] per day) indicates fluid retention and the need for increased diuresis. ■     Accurate intake and output records can warn of early fluid excess. ■     Crackles, decreased sounds, and bronchial breath sounds indicate fluid in the lungs and signal increasing left‑sided heart failure. ■     Dependent edema and dyspnea are signs of increasing right‑sided and left‑sided heart failure, respectively. ■     Fluid volume may be decreased from excessive diuresis.
Independent	Assess for increasing confusion.	When cardiac output is decreased, cerebral perfusion is diminished, producing confusion.
Independent	Decrease the patient's fear and anxiety by providing information and by eliciting concerns and responding to them.	Fear and anxiety activate the sympathetic nervous system and increase heart rate, myocardial contractility, and vasoconstriction. All these factors increase myocardial oxygen consumption.
	[Additional individualized interventions]

Suggested NIC Interventions

Anxiety reduction; Cardiac care; Cardiac care: Acute; Hemodynamic regulation; Medication administration; Oxygen therapy; Respiratory monitoring; Shock management: Cardiac; Vital signs monitoring

Impaired gas exchange related to fluid accumulation in the lungs and at the alveolar level

Expected Outcome

The patient will exhibit improved gas exchange as evidenced by improved ABG values, decreased dyspnea, decreased lung congestion, and no cyanosis.

Suggested NOC Outcomes

Respiratory status: Gas exchange; Vital signs

Nursing interventions

Intervention type	Intervention	Rationale
Independent	Assess respiratory status (rate, rhythm, and depth) every 2 to 4 hours and report abnormal findings: ■     Assess breath sounds. ■     Assess for absence or presence of cyanosis.	Respiratory rate, rhythm, and depth of respirations indicate severity of shortness of breath and respiratory distress: ■     Abnormal lung sounds can indicate presence of fluid buildup in the lungs. ■     Presence of cyanosis is a late indicator of hypoxia.
Collaborative	Administer oxygen as ordered.	This will help to improve oxygenation.
Collaborative	Monitor ABGs and pulse oximetry every 2 to 4 hours and report changes.	Abnormal Pao2 and arterial oxygen saturation indicate severity of hypoxia.
Collaborative	Administer diuretics as ordered.	Diuretics help promote fluid loss.
	[Additional individualized interventions

Suggested NIC Interventions

Acid-base management: Respiratory acidosis; Acid-base management: Respiratory alkalosis; Oxygen therapy; Respiratory monitoring; Vital signs monitoring

Excess fluid volume related to decreased myocardial contractility, decreased renal perfusion, and increased sodium and water retention

Expected outcome

The patient will obtain approximate balance between intake and output.

Suggested NOC Outcomes

Fluid balance

Nursing interventions

Intervention type	Intervention	Rationale
Independent	Monitor fluid balance (hourly fluid intake and output and 24‑hour fluid balance). Weigh the patient daily.	Intake and output monitoring provides an objective method of tracking fluid gains or losses, while 24‑hour summaries indicate net fluid balance. Daily weight measurements can reflect fluid gain or loss.
Collaborative	Administer I.V. solutions, as ordered. Avoid saline solutions.	The type and amount of I.V. fluid ordered depends on the patient's current condition and the cause of heart failure. Saline solutions can cause water retention.
Collaborative	Implement fluid restriction if ordered: ■     Explain the rationale to the patient and his family. ■     Establish a fluid intake schedule and teach the patient how to record oral fluids and use microdrip tubing or an infusion pump to control I.V. intake.	Fluid restriction helps limit excessive preload: ■     The patient and his family are more likely to comply with fluid restriction if they understand the reasons behind it. ■     Regular fluid intake, consistent measurements, and use of microdrip tubing or infusion devices help ensure maintenance of fluid restrictions.
	[Additional individualized interventions]

Suggested NIC Interventions

Fluid management; Fluid monitoring; Hemodynamic regulation

Expected outcome

The patient will exhibit electrolyte levels within expected parameters.

Suggested NOC outcome

Electrolyte & acid/base balance

nursing interventions

Intervention type	Intervention	Rationale
Independent	Monitor BUN and creatinine level and report increasing values.	BUN and creatinine levels reflect decreased renal perfusion from worsening heart failure. The BUN level rises disproportionately; the BUN‑creatinine level ratio can increase from the normal of 10:1 to as high as 40:1.
Independent	Monitor sodium and potassium levels. Report abnormal values and signs of imbalances.	Identification of abnormal values prompts rapid treatment to correct electrolyte levels.
Collaborative	Administer electrolyte supplements as ordered and indicated. Recheck levels after treatment.	Administration of electrolyte preparations can correct an imbalance and prevent complications.
	[Additional individualized interventions]

Suggested NIC interventions

Electrolyte management; Electrolyte monitoring

Activity intolerance related to decreased cardiac output and impaired gas exchange

expected outcome

The patient will demonstrate an improved level of activity and carry out ADLs to the fullest extent possible.

Suggested NOC Outcomes

Activity tolerance; Endurance; Energy conservation; Self-care: Activities of daily living (ADL); Self-care: Instrumental activities of daily living (IADL)

Nursing interventions

Intervention type	Intervention	Rationale
Independent	Determine cardiac stability by evaluating blood pressure, heart rhythm and rate, and indicators of oxygenation, such as level of consciousness and skin color.	Activity increases myocardial contractility, heart rate, blood pressure, and myocardial oxygen consumption and can compromise cardiac output.
Collaborative	When the patient is stable, institute a graduated activity program according to facility protocol. Evaluate the patient's tolerance of new activities.	Gradual increase in activity will promote circulation and endurance and reduce the risk of immobility. A too‑rapid activity increase can exacerbate heart failure. Activity goals that exceed the patient's capabilities may cause a psychological setback.
Independent	Alternate activity with rest periods.	Regular rest prevents depletion of cardiac reserves.
Collaborative	Administer anticoagulants as ordered. Monitor appropriate coagulation studies and report results that exceed set limits.	Anticoagulants prevent clot formation that may cause deep vein thrombosis.
	[Additional individualized interventions]

Suggested NIC Interventions

Activity therapy; Energy management; Exercise promotion: Strength training; Nutrition management; Self-care assistance

Imbalanced nutrition: Less than body requirements related to decreased appetite and dietary restrictions

expected outcome

The patient will meet daily calorie requirements.

Suggested NOC Outcomes

Appetite; Nutritional status; Nutritional status: Food & fluid intake; Nutritional status: Nutrient intake; Weight control

Nursing interventions

Intervention type	Intervention	Rationale
Independent	Keep a daily record to monitor calorie intake. Consult the dietitian to identify the patient's calorie needs.	Evaluating what a patient eats daily can help formulate an appropriate dietary plan
Independent	Assess the patient's food preferences and cultural influences on diet.	The patient may be more compliant if food preferences are considered whenever possible. Cultural influences should be incorporated into the dietary plan whenever possible.
	[Additional individualized interventions]

Suggested NIC Interventions

Diet staging; Fluid monitoring; Nutrition management; Nutritional monitoring

Teaching checklist

■ Disease process and treatment plan

■ Signs and symptoms of fluid overload

■ Risk factor reduction

■ Medications (use, dosage and administration, schedule, and possible adverse effects)

■ Dietary modifications

■ Activity restrictions

■ Follow-up care

■ Medical follow-up and instructions

■ Community agencies and support groups

■ Common emotional changes