Heart Failure:
Nursing Assessment and Care
Objectives
1. Understand the complexities of CHF and
the care needs of a patient with CHF.
2. Employ critical components of diseases
management into the care plan for frontline nursing care of the CHF patient
Overview of CHF: The Problem
One of most common causes of hospitalization, hospital
readmission, and death.
• Nearly 1.4 million hospitalizations (leading cause in >
64 y.o.)
• 27% readmitted
• Approximately 5.8 million Americans
Outcomes suboptimal
• 1 in 10 patients die within the first 30 days after
hospitalization
• 1 in 4 patients who survive are readmitted
Financial burden
$17 billion in total spending
Overview of CHF
…the inability or failure of the heart to provide
sufficient forward output to meet the the
perfusion and oxygenation requirements of the
tissues will maintaining normal filling pressures
Mechanisms:
• Systolic dysfunction: Impaired cardiac
contractile function
• Diastolic dysfunction: Abnormal cardiac
relaxation, stiffness or filling
Anatomy: two pump system
Functions: systole and diastole
Cardiac output (CO) and ejection fraction (EF)
CO = Stroke Volume X Heart Rate
Normal 5.5 l/min (males)
5.0 l/min (females)
EF = Stroke Volume / End Diastolic Volume X 100
Normal EF = 55-70%
Systolic HF
Abnormalities in systolic function
• Reduced left ventricular ejection
fraction (LVEF)
• Usually with progressive chamber
dilation and eccentric remodeling
• HF with reduced LVEF (HFrEF)
• EF < 50%
Diastolic HF
Abnormalities in diastolic function with
symptoms
• Normal LVEF
• Normal LVEDV
• Diastolic dysfunction
• Usually with concentric remodeling or
hypertrophy
• HF with preserved LVEF (HFpEF)
• EF > 50%
Overview of CHF…Simplified
Decrease in CO→
Increase in capillary pressure→
Symptoms
Causes of Heart Failure?
• Impairment of “filling it up or pumping it out”
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Hypertension
Cardiomyopathies
Coronary artery disease
Valvular disorders
Dysrhythmias
Diabetes
Other…..
Increased workload and end-diastolic volume enlarge
the left ventricle.
►Increased heart rate, pale and cool skin, tingling in the
extremities, decreased cardiac output, and arrhythmias.
Blood pools in the ventricle and atrium and eventually
backs up into the pulmonary veins and capillaries.
►Dyspnea on exertion, confusion, dizziness, orthostatic
hypotension, decreased peripheral pulses and pulse pressure,
cyanosis, and an S3 gallop.
Rising capillary pressure pushes sodium (Na) and water
(H2O) into the interstitial space, causing pulmonary edema.
►Coughing, subclavian retractions, crackles, tachypnea, elevated
pulmonary artery pressure, diminished pulmonary compliance, and
increased partial pressure of carbon dioxide.
Because the left ventricle can’t handle the increased
venous return, fluid pools in the pulmonary circulation,
worsening pulmonary edema.
►Decreased breath sounds, dullness on percussion, crackles, and
orthopnea.
The right ventricle may now become stressed because
it’s pumping against greater pulmonary vascular
resistance and left ventricular pressure.
►Worsening symptoms.
The stressed right ventricle enlarges with the formation
of stretched tissue.
►Increased heart rate, cool skin, cyanosis, decreased cardiac
output, dyspnea, and palpitations.
Blood pools in the right ventricle and right atrium. The
backed up blood causes pressure and congestion in the
vena cava and systemic circulation.
►Increased central venous pressure, jugular vein distention, and
hepatojugular reflux.
Backed up blood distends the visceral veins, especially the
hepatic vein. As the liver and spleen become engorged,
their function is impaired.
►Anorexia, nausea, abdominal pain, palpable liver and spleen,
weakness, and dyspnea secondary to abdominal distention.
Rising capillary pressure forces excess fluid from the
capillaries into the interstitial space.
►Edema, weight gain, and nocturia.
Classification: ACC/AHA
High risk of developing heart failure:
• Hypertension diabetes, CAD, and family history of
cardiomyopathy
Asymptomatic heart failure:
• Previous history of MI, left ventricular dysfunction, and
valvular heart disease
Symptomatic heart failure:
• Structural heart failure, dyspnea and fatigue, and impaired
exercise tolerance
Refractory end-stage heart failure:
• Marked symptoms at rest despite maximal medical therapy
Classification: NYHA
Class 1 (mild):
• No limitation of physical activity; physical activity doesn’t cause
tiredness, heart palpitations, or shortness of breath.
Class II (mild):
• Slight limitation of physical activity; the patient is comfortable at
rest, but ordinary activity causes tiredness, heart palpitations,
and/or shortness of breath.
Class III (moderate):
• Marked limitations of physical activity; the patient is comfortable
at rest, but less than ordinary physical activity causes tiredness,
heart palpitations, or shortness of breath.
Class IV (severe):
• Severe limitations of physical activity; the patient is unable to carry
out any physical activity without discomfort. Symptoms are
present at rest, and any physical activity increases that discomfort.
Diagnosis
• History and physical examination
• Symptoms
• Tests
• EKG, Chest X-ray
• Labs
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CBC
Electrolytes
Glucose
BUN and Creatinine
B-type natriuretic peptide (BNP)
• Echocardiogram
Prognosis
• If decompensated and hospitalization
required:
• Significant mortality risk of more than 20%
at one year
• NYHA stage IV have mortality rate of up to
50% at one year
Treatment
• Lifestyle modification
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Smoking cessation
Limited alcohol consumption
Low sodium diet
Fluid restrictions
Daily weight / symptom monitoring
Medication compliance
Treatment
• Medications
• Beta-blockers
• Angiotensin-converting enzyme inhibitors
(ACEI)
• Angiotensin II receptor blocker (ARB)
• Diuretic (1 liter of urine output = 1 Kg weight
lost)
Treatment
• Procedures
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Cardioversion
Ablation
Cardiac resynchronization therapy (CRT)
Implantable cardioverter defibrillator (ICD)
Transplant
Caring for the HF Patient
• Assess
• Teach/Coach Self Management
• Advocate
Self Management for HF
•Assess ability to self
manage
• Self Care of Heart Failure Index
• European Heart Failure Selfcare Behavior Scale
Self Management for HF
• Assess ability to self manage
• Self Care of Heart Failure Index
• European Heart Failure Self-care
Behavior Scale
• Medication management
• Daily monitoring for signs/symptoms
• Adherence to a low sodium diet
• Routine exercise
Self Management: Meds
Obtaining initial and refill prescriptions
Incorporating meds into daily routine
Adhering to the daily medication schedule
Understanding and implementing
prescription changes
• Recognizing common side effects of
medications
• Managing changes of routine (travel, illness)
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Patient Medication Instruction
• Take each medication each day at the times
indicated by using a system (list, pill box, etc)
• Do not allow prescriptions to expire of bottels
to become empty before refilling
• Use same pharmacy each time
• Bring all medications to each doctor’s visit
• Contact their doctor immediately if they feel
they are having side effects from medications
(rather than stopping them without telling
anyone).
Medication Management Skills
• Know which pill is their diuretic
• Know how to change the dose of the
diuretic according to the HF action plan
• Be able to carry out any additional
changes that should accompany
diuretic dosage changes
• i.e. need for earlier refills, addition of
potassium supplementation
Daily Monitoring of Signs/Symptoms
Daily Weights
• Use scale with large enough print to be readily
visible
• Use a scale that is big enough for the patient to
stand on easily
• Use a scale that is easy to “zero,” such as a
digital scale
• Weigh themselves at the same time every morning
• After urinating but before eating or drinking
• Before getting dressed or in the same amount of
clothing each day
Heart Failure Signs
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Edema/swelling
Ankle/leg edema
Palpitations
Abdominal edema
Irregular pulse
Sudden weight gain
Change in urine
output compared to
normal
• Weight loss
• Low blood pressure or
orthostatic blood
pressure
• Heart rate <60/min or
>120/min
• Cool, pale or mottled
skin
Heart Failure Symptoms
Shortness of breath
Exercise intolerance
Orthopnea
Profound fatigue with
exertion or
generalized weakness
• Dizziness/lightheadedness
• Nausea/vomiting:
diarrhea or loss of
appetite
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• Paroxysmal nocturnal
dyspnea
• Restlessness,
confusion or fainting
• Right-sided
abdominal fullness,
discomfort or
tenderness
• Severe cough
• Chest pain
• Wheezing
Daily Monitoring of Signs/Symptoms
• Record the results in a log book or other
permanent record (calendar)
• May be telemonitored
• Compare results to previous day and to previous
week
• Know their target weight
• 2 to 5 lb. weight gain in one week, diet/medications
changes should be made
• >5 lb. weight gain in one week requires immediate
call to physician/nurse
Daily Monitoring of Signs/Symptoms
Daily Checks for Edema
• Examine their legs each day for swelling
or an increase in existing swelling
• Describe how far up the leg the swelling
reaches (ankle, shin, knee) or measure
ankle circumference
• Worsening edema requires diet/medication
changes
Daily Monitoring of Signs/Symptoms
Daily Check of Symptom Severity
• Monitor exercise tolerance
• Using a scale ranging from no shortness of breath, SOB after
moderate exertion, SOB after mild exertion, SOB at rest
• Monitor their breathing at night
• Using a scale ranging from no SOB lying flat, needing two or
more pillows, sleeping upright or awakening with sudden SOB
• Watch for dizziness or lightheadedness
• Using a scale ranging from not dizzy, dizzy, dizzy for a while
after standing, near syncope/syncope or fall
• Less severe needs diet/medication modification
• Severe symptoms needs immediate call to physician/nurse
Self Management: Diet
• Adherence to low sodium (2 gram) diet
• No clinical trials demonstrating benefit
• Patients hospitalized with acute
exacerbation of HF found that excess
dietary sodium to be a precipitating event
in 1/5 of patients
• Sodium restriction can reduce BP and
enhance the response to antihypertensive
drugs
Patient Diet Instruction
• Understand the relationship between sodium
intake and edema
• Know that salt and “sodium” are the same
• Demonstrate ability to read a nutrition label
• Demonstrate ability to calculate total sodium
intake in a day
• Recognize “hidden” sources of salt intake
Dietary Management Skills
• Select low-salt foods and avoid high-salt
foods, including processed meats, hot
cereals, condiments
• Reduce salt added during home cooking
• Ask for reduced-salt meals at restaurants
and avoid known sources of salt
• Rinse canned goods before cooking and/or
eating
• Avoid instant foods and salty snacks
Self Management: Exercise
• Screen for absence of significant
ischemia or arrhythmias using exercise
testing prior to training
• Generally safe for NYHA class II and
• Cardiac rehabilitation program
Self Management: Smoking Cessation
• Current smoking independent predictor of
mortality in patients with HF
Self Management: Limited Alcohol
• < 2 standard drinks per day or < 1 standard
drink per day in women
Barriers to Self Care
• Inability to afford medications
• Generics
• Medication Assistance Programs
• Good Rx
• Therapy-related factors
• Common adverse effects / benefits
• Minimize pill quantity
• Side effects (impotence, depression, incontinence)
• Low health literacy
• Screen patients at risk
• Document learning preferences
• Integrate strategies to facility health understanding
Barriers to Self Care
• Multimorbidity
• Multiple clinicians
• Confusing or conflicting recommendations
• Aspiring in patient with CAD, Hx GI bleeding, and HF
• Depression and anxiety
• Highly prevalent in HF patients
• Effects cognition, social support, motivation and engagement
• Higher rates of medication nonadherence, hospitalization and
mortality
• Healthcare team/system factors
• Clinicians unable to provide self-care education, monitoring
and reinforcement
• Ancillary resources unavailable
• Rare reimbursement for counseling, follow-up and
monitoring
Promoting Effective Self Care
•Knowledge
•Skills
•Behavior change/patient
engagement
Promoting Knowledge
• Utilize teach-back techniques to
assure patient understands the
materials
• Ask specific questions to ensure the
patient understands the materials
• Limit teaching point to no more than 3
or 4 per session
• Repeat, reinforce and review teaching
points at regular intervals
Promoting Skill Development
• Experimental teaching
• have pt. read Rx label and take out correct
amount of medications, calculate the
amount of salt in a food product, etc.
• Role playing
• have pt. practice telling provider about
worsening symptoms
• Group sessions
• allows patients to learn from the experience
of other, similarly situated patients
Behavior Change/Pt Engagement
• Use motivational interviewing techniques
• Question patients explicitly about their beliefs in disease
etiology and efficacy of treatment
• Engage patients in developing a plan, and in filling out a
notebook or monitoring materials
• Use brainstorming with patients to help them incorporate
self-management into their lives: build on patient’s own
experience and routines
• Help patients identify one or two concrete actions they can
do for each self-care
• Have patients describe their self-management practices and
offer feedback to improve them, rather than suggesting or
imposing self-management practices
Heart Failure Action Plan
• Developed between patient /family and
provider
• Essential Discussion
• Completed Early in Course
• “Hope for the best and prepare for the worst”
Heart Failure Action Plan
• Identification of an approach to care
• Hospital vs home care or hospice for example
• Identification of goals
• Continued interventions to maximize function or length of
life versus simplifying treatment and focusing on
managing symptoms
• A plan to manage current interventions to achieve
goals, including each medication and device
• Assistance for family and care givers in delivering
care
• Resources for spiritual and emotional support for
patient and family
Heart Failure Action Plan
• Developed between patient and provider
• Divided into zones:
• Green – STABLE state
• Maintain plan as is
• Yellow – WORSENING status
• Additional diuretic intake
• Renewed vigilance to diet and medication compliance
• Orange – ACUTE EXACERBATION
• Immediate call to provider
• Rapid evaluation
• Red – CARDIAC EMERGENCY
• Call 911
Heart Failure Disease Management
• Multidisciplinary disease management
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Physician
Nurse
Pharmacist
Case Manager
Exercise Specialist
Dietitian
Social Worker
Spiritual Care
Palliative Care
Family
End of Life Considerations
• Symptom management
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Treatment of HF
Fatigue
Dyspnea
Pain
Anorexia and cachexia
• Emotional, spiritual, psychological and
social support
• ICD deactivation
• Hospice care
Summary
All patients deserve to know…
it is a terminal disease.