Ch. 35 Nursing Management: Heart Failure

Heart failure (HF)
is an abnormal clinical syndrome involving impaired cardiac pumping and/or filling.
HF is characterized by
ventricular dysfunction, reduced exercise tolerance, diminished quality of life, and shortened life expectancy.
Risk factors (HF)
include coronary artery disease (CAD) and advancing age. Hypertension, diabetes, cigarette smoking, obesity, and high serum cholesterol also contribute to the development of HF.
HF Classification
Heart failure is classified as systolic or diastolic failure.
Systolic failure
results from an inability of the heart to pump blood effectively.
Diastolic failure
is an impaired ability of the ventricles to relax and fill during diastole.
Clinical Manifestations
HF can have an abrupt onset as with acute myocardial infarction or it can be an insidious process resulting from slow, progressive changes.
Compensatory mechanisms
are activated to maintain adequate cardiac output (CO). Several counter regulatory processes are activated, including the production of hormones from the heart muscle to promote vasodilation.
Cardiac compensation
occurs when compensatory mechanisms succeed in maintaining an adequate CO that is needed for tissue perfusion.
Cardiac decompensation
occurs when these mechanisms can no longer maintain adequate CO and inadequate tissue perfusion results.
chronic HF
Over time, ventricular remodeling, dilation, and hypertrophy develop
most common form of HF
left-sided failure from left ventricular dysfunction. Blood backs up into the left atrium and into the pulmonary veins, causing pulmonary congestion and edema.
Acute decompensated heart failure (ADHF) typically manifests as pulmonary edema, an acute, life-threatening situation.
Clinical manifestations of chronic HF
depend on the patient’s age and the underlying type and extent of heart disease. Common symptoms include fatigue, cough, dyspnea, tachycardia, edema, and limitations of usual activities of daily living (ADLs).
complications of HF
Pleural effusion, atrial fibrillation, thrombus formation, renal insufficiency, and hepatomegaly
Diagnostic Studies
To determine the underlying etiology of HF, a thorough history, physical examination, chest x-ray, electrocardiogram (ECG), laboratory data (e.g., cardiac enzymes, b-type natriuretic peptide [BNP], serum chemistries, liver function studies, thyroid function studies, complete blood count), hemodynamic assessment, echocardiogram, stress testing and cardiac catheterization may be done.
Collaborative Care: Acute Decompensated Heart Failure
The goals of therapy for ADHF are to improve patient symptoms, reverse ventricular remodeling, improve quality of life, and decrease mortality and morbidity.
Treatment strategies (ADHF)
(1)Decreasing intravascular volume with the use of diuretics or ultrafiltration,(2)Decreasing venous return (preload) to reduce the amount of volume returned to the left ventricle (LV) during diastole.(3)Decreasing afterload (the resistance against which the LV must pump) to improve CO and decrease pulmonary congestion.
Gas exchange
is improved by the administration of intravenous (IV) morphine sulfate and supplemental oxygen.
Inotropic therapy
and hemodynamic monitoring may be needed in patients who do not respond to conventional pharmacotherapy.
Reduction of anxiety
is an important nursing function, since anxiety may increase the sympathetic nervous system (SNS) response and further increase myocardial workload.
Collaborative Care: Chronic Heart Failure
The main goal in the treatment of chronic HF is to treat the underlying cause and contributing factors, maximize CO, provide treatment to alleviate symptoms, improve ventricular function, improve quality of life, preserve target organ function, and improve mortality and morbidity.
Administration of oxygen
improves saturation and assists greatly in meeting tissue oxygen needs and helps relieve dyspnea and fatigue.
Physical and emotional rest
allows the patient to conserve energy and decreases the need for additional oxygen. The degree of rest recommended depends on the severity of HF.
Nonpharmacologic therapies
including cardiac resynchronization therapy, biventricular pacing, intraaortic balloon pump, and ventricular assist devices, are an integral part of the management of HF patients.
are used in HF to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload.
Vasodilator drugs
have been shown to improve survival in HF by increasing venous capacity, improving EF through improved ventricular contraction, slowing the process of ventricular dysfunction, and decreasing heart size.
Angiotensin-converting enzyme (ACE) inhibitors
are the primary drug of choice in chronic HF patients with systolic dysfunction.
Angiotensin II receptor blockers
may be used in patients who are ACE inhibitor intolerant.
B-Adrenergic blockers
in combination with ACE inhibitors and diuretics have improved survival of patients with HF.
Digitalis glycosides
remain the mainstay in the treatment of HF; however, they have not been shown to prolong life.
Diet education and weight management are critical to the patient’s control of chronic HF.
is often treated by dietary restriction of sodium.
Fluid restrictions
are not commonly prescribed for the patient with mild to moderate HF. In moderate to severe HF, fluid restrictions are usually implemented.
Weight gain
Patients should weigh themselves daily. If a patient experiences a weight gain of 3 lb over 2 days or 3 to 5 lb over a week, the primary care provider should be called.
The overall goals for the patient with HF include a decrease in symptoms, an increase in exercise tolerance, compliance with the medical regimen, and no complications related to HF.
HF Treatment
control of underlying heart disease is key to preventing episodes of ADHF.
Nursing care of the patient with ADHF
revolves around the nursing diagnoses of decreased CO, impaired gas exchange, excess fluid volume, and activity intolerance.
Ambulatory and Home Care
Effective home health nursing can prevent or limit hospitalizations of the HF patient.
Preventive care
should focus on slowing the progression of the disease. Teaching must include information on medications, diet, and exercise regimens.
nursing responsibilities in the care of a patient with HF
(1) teaching the patient about the physiologic changes that have occurred, (2) assisting the patient to adapt to both the physiologic and psychologic changes, and (3) integrating the patient and the patient’s family or support system in the overall care plan.
Many patients with HF are at high risk for anxiety and depression.
Patient Teaching
Patients should be taught to evaluate the action of the prescribed drugs and to recognize the manifestations of drug toxicity.
Collaborative Care HF
The physical therapist, occupational therapist, or you should instruct the patient in energy-conserving and energy-efficient behaviors after an evaluation of daily activities has been done.
Goals for patients with end-stage HF include reducing the number of exacerbations that require hospitalization and maintaining comfort.
the transfer of a heart from one person to another, is used to treat a variety of terminal or end-stage heart conditions.
Once a patient meets the criteria for cardiac transplantation, a complete physical examination and diagnostic work-up is completed. Once accepted as a transplant candidate, the patient is placed on a transplant list.
Stable patients wait at home and receive ongoing medical care.
Unstable patients may require hospitalization for more intensive therapy, including the use of assistive devices that serve as a bridge to transplantation.
Key complications after transplantation
include acute rejection, risk for sudden cardiac death, infection, and cardiac transplant vasculopathy. Life-time immunosuppression plus corticosteroids are necessary.Endomyocardial biopsies are typically used to detect rejection.
Nursing management throughout the posttransplant period
focuses on promoting patient adaptation to the transplant process, monitoring cardiac function, managing lifestyle changes, and providing ongoing teaching of the patient and family.