Chronic Heart Failure
1. When assessing a pt with symptoms of heart failure, how does the nurse differentiate
between right and left sided failure?
Left-sided failure- “backward failure”
-dyspnea, cough, pulmonary crackles and lower than normal oxygen saturation levels. An extra
heart sound, S3, may be detected on auscultation.
-Dyspnea, or SOB may be precipitated by minimal to moderate activity, dyspnea may also occur
at rest.
-Orthopnea, difficulty in breathing when lying flat.
-Cough is usually dry and non productive- dry hacking cough. The cough may become moist.
Large quantities of frothy sputum, which is sometimes pink or blood tinged, may be produced.
This usually indicated severe pulmonary congestion (pulmonary edema).
-Adventitious breath sounds may be heard in various lobes of the lungs. Usually crackles that do
not clear with coughing are heard in the early phase of left ventricular failure. As it worsens,
crackles may be heard throughout the lung field.
- Blood flow to the kidneys decreases, causing decreased perfusion and reduced urine output
(oliguria).
- Sodium and fluid retention increases.
-dizziness, lightheadedness, confusion, restlessness, and anxiety are due to decreased 02,
-peripheral blood vessels constrict, so the skin appears pale or ashen and feels cool and clammy
Right-sided failure
-congestion of the peripheral tissues predominates.
-increase in venous pressure leads to jugular vein distention
-edema of the lower extremities, hepatomegaly, distended jugular veins, ascites (accumulation
of fluid in the peritoneal cavity), weakness, anorexia and nausea, and paradoxically, weight gain
due to fluid retention.
-edema usually affects the feet and ankles, worsening when patient stands or dangles legs.
Swelling decreasing when pt elevated legs.
-hepatomegaly and tenderness in right upper quadrant because of enlargement. This can also
increase pressure on the diaphragm, causing respiratory distress.
-anorexia and nausea or abdominal pain.
2. What are the compensatory mechanisms the overloaded heart resorts to when attempting to
maintain normal cardiac output?
Remember that CO= HR x Stroke Volume
Systolic HF (alteration in ventricular contraction) decreases amt. of blood ejected from ventricle
- causes SNS responses and neurohormonal responses that lead to increased workload and
further damage to heart
Decreased contractibility causes increased end-diastolic blood volume in ventricles therefore
increasing the size of the ventricle. Increased size leads to increased workload. This is also called
the “Vicious cycle of HF” (p. 797)
To compensate for increased workload: Ventricular hypertrophy to help with contractability –
but does not increase capillary supply (so can lead to myocardial ischemia)
Diastolic HF (alteration in ventricular filling) develops due to an increased workload on heart
To compensate: Increased number and size of myocardial cells WHICH
Cause resistance to ventricular filling WHICH
Increase ventricular filling pressures WHICH
Cause low CO (cardiac output) WHICH
Cause neurohormonal responses
3. What drug therapies are commonly used for a person who has an exacerbation of chronic
heart failure? How do these medications work?
- ACE inhibitors- major role in management of HF, may be the first medication prescribed for
mild failure. They have been found to relieve the S&S of HF and decrease mortality and
morbidity. ACE promotes vasodilatation and dieresis by decreasing after load and preload.
This helps to decrease the workload of the heart. ACE stimulates the kidneys to excrete
sodium and fluid, while keeping potassium. This reduces left ventricular filling pressure and
decreasing pulmonary congestion.
- Angiotensin II Receptor Blockers (ARBs)- usually prescribed when patients can’t tolerate
ACEs. ARBs block the effects of angiotension II at the angiotension II receptor. They lower
blood pressure and lower systemic vascular resistance.
- Beta-blockers- When used with an ACE, they have been found to reduce mortality and
morbidity. However, beta blockers may produce side effects such as exacerbation of HF,
which are most common in the initial few weeks of treatment. The most frequent side
effects are dizziness, hypotension, and bradycardia. To minimize effects, stagger beta
blockers and ACEs. Any type of beta blocker is contraindicated in patients with severe or
uncontrolled asthma because it can cause bronchiole constriction.
- Diuretics- increase rate of urine production and remove excess extracellular fluid from the
body. Three most common are:
 Thiazide- inhibit sodium and chloride reabsorption mainly in the early distal
tubules. They also increase potassium and bicarbonate excretion
 Loop- inhibit sodium and chloride reabsorption mainly in the ascending loop
of Henle.
 Potassium sparing- inhibits sodium reabsorbtion in the late distal tubule and
collecting duct.
- Digitalis- most commonly prescribed for is digoxin. The medication increases the force of
myocardial contraction and slows conduction through the AV node. It also enhances
-
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dieresis, which removes fluid and relieves edema. It is effective in decreasing the symptoms
of systolic HF and in increasing the patient’s ability to perform activities of daily living.
Calcium Channel Blocker- Contraindicated in pt. with systolic dysfunction although they
may be used in pt. with diastolic dysfunction. Cause vasodilation, reducing systemic vascular
resistance. Improve symptoms in pt’s with nonischemic cadiomyopathy
Other Medications- Anticoagulants, especially if the patient has a Hx of an embolic event or
atrial fibrillation. Antianginal medications. NSAIDs should be AVOIDED! As they increase
systematic vascular resistance and decrease renal perfusion, especially in the elderly. Use of
decongestants should be avoided
4. What are other therapeutic interventions would be anticipated for a person who has an
exacerbation of chronic heart failure?
-provide general counseling and education about sodium restriction, monitor daily weights and
other signs of fluid retention, encourage regular exercise, and recommending avoidance of
excessive fluid intake, alcohol, and smoking.
-Mechanical devices (ventricular devices and counterpulsation) may provide respite for the
heart in acute failure.
-Supplemental oxygen-by mask or cannula relieve hypoxia and dyspnea and improve oxygencarbon dioxide exchange. For hypoxemia, partial breather masks with a flow rate of 8-10L/min
can be used to deliver oxygen concentrations of 40%-70%. A non-breathing mask can achieve
even higher oxygen concentrations.
-If supplemental oxygen does not raise the arterial oxygen tension (PaO2) above 60mm Hg, the
client may need intubation and ventilator management. Intubation also provides a route for
removing secretions from the bronchi.
-If severe bronchospasm or bronchoconstriction occurs, bronchodilators are given.
****the heart rhythm is monitored because some bronchodilators may lead to dysrhythmias
-Position the client in a high Fowlers position or chair to reduce pulmonary venous congestion
and to relieve dyspnea. The legs remain in a dependent position as much as possible. Even if legs
are edematous they should not be elevated. Elevating legs increases venous return rapidly.
-Reduce fluid retention. Controlling sodium and water retention improves cardiac performance.
Sodium restriction should be in place. Potassium supplements and adequate dietary potassium
are important.
-Reduce stress and risk of injury. This means reducing physical and emotional stress. Rest is also
important.
5. What are the nursing responsibilities related to the administration of digoxin? What are the
signs and symptoms of digitalis toxicity?
Digoxin: increases the force of myocardial contraction; slows cardiac conduction through the AV
node and therefore slows the ventricular rate in instances of supraventricular dysrhythmias;
increases cardiac output by enhancing the force of ventricular contraction; promotes dieresis by
increasing cardiac output.
Therapeutic level is usually 0.5 to 2.0 ng/ml
-Take vitals before administering drug
-Before administration it is standard to assess apical heart rate for 1 MINUTE and make sure
heart rate is above 60 beats per min. Note rate, rhythm, and quality.
- Withhold medication and notify physician if apical pulse falls below ordered parameters
- dray blood samples for determining plasma digoxin levels at least 6 hours after daily dose and
preferably just prior to next scheduled dose.
-Monitor doe drug toxicity.
Digoxin Toxicity
- fatigue, depression, malaise, anorexia, nausea, and vomiting (early effects of digitalis toxicity).
-change in hear rhythm: new onset of regular rhythm or new onset of irregular rhythm.
-ECG changes indicating SA or AV block; new onset of irregular rhythm indicating ventricular
dysrthythmias; and atrial tachycardia with block, junction tachycardia, and ventricular
tachycardia.
6. Outline and prioritize a long term care plan for someone with an exacerbation of chronic heart
failure.
Goals for the patient with chronic congestive heart failure include: decreased peripheral edema,
decreased shortness of breath, increased exercise tolerance, decreased drug regimen, and no
complications related to CHF.
-promoting activity tolerance- prolonged bed rest should be avoided because of effects such as,
pressure ulcers, phlebothrombosis, and pulmonary embolism. A total of 30 minutes of physical
activity 3-5 times a week should be encouraged. Alternate periods of activity and rest. Increase
activities, such as walking, gradually, as long as they don’t cause fatigue or shortness of breath.
-managing fluid volume- oral diuretics should be taken in the early morning so it does not
interfere with nighttime rest. Teach patient about low-sodium diet by reading food labels, and
avoiding high sodium foods such as canned, processed, and convenience foods.
Teach patient about different positions and how to assume those positions to shift fluid away
from the heart. Increase number of pillows, head of bed elevated, or pt. may sit in a chair. Lower
arms are supported by pillows to eliminate fatigue caused by constant pull of their weight on
the shoulder muscles.
Frequent change in position to avoid pressure, and the use of compression stockings, and leg
exercises can help to prevent skin injury.
-controlling anxiety- HF patients have difficulty maintaining adequate oxygenation, they are
likely to be restless and anxious and fell overwhelmed by breathlessness. Symptoms intensify at
night. O2 may be administered during an event to decrease the work of breathing and increase
comfort.
-relaxation techniques to help relax patient.
-inform that lack of sleep can effect anxiety
-drug therapy- Take each drug as prescribed. Make a daily chart to ensure drugs have been
taken. Take pulse daily before taking medication and know the parameters your health care
provider wants your heart rate. Learn how to take your own BP at specific pre-determined
times and know the parameters that are acceptable for you as provided by your doctor. Know
the signs and symptoms of orthostatic hypotension and know how to prevent them. Know the
signs and symptoms of internal bleeding such as: bleeding gums, increased bruises, blood in the
urine or stool, and what to do if on anticoagulants. Know how often to have blood monitored if
on warfarin (usually weekly once at an acceptable level) and know where you INR should be (23)
Orthopnea, difficult in breathing when lying flat. Patients usually don’t like to lie flat. They may want
or need pillows to prop themselves up in bed, or they may sit in a chair and even sleep sitting up.