 Pulmonary congestion; cough,

HEART FAILURE fatigability; tachycardia with an S3 heart

sound, anxiety, restlessness;
 Dyspnea on exertion (DOE), orthopnea,
paroxysmal nocturnal dyspnea (PND)
HEART FAILURE (COR PULMONALE)  Cough may be dry and nonproductive
 Sometimes referred to as “Congestive Heart but is most often moist
Failure”  Bibasilar crackles advancing to crackles
 It is the inability of the heart to pump sufficient in all lung fields.
blood to meet the needs of the tissues for oxygen  Large quantities of frothy sputum,
and nutrients. which is sometimes pink (blood-tinged).
 Heart failure is a clinical syndrome
characterized by signs and symptoms of fluid FORWARD FAILURE
overload or inadequate tissue perfusion.  Tachycardia
 The underlying mechanisms of heart failure  Weak, thread pulse
involves impaired contractile properties of the  Anxiety
heart (systolic dysfunction) or filing of the heart  Oliguria and nocturia
(diastolic) that lead to a lower-than-normal  Altered digestion
cardiac output.  Ashen, pale, cool and clammy skin
 The low cardiac output can lead to
compensatory mechanisms that ]cause increased RIGHT-SIDED HEART FAILURE
workload on the heart and eventual resistance to  Congestion of the viscera and peripheral tissues
filling of the heart.  Edema of lower extremities (dependent edema),
 Heart failure is a lifelong diagnosis managed usually pitting edema, weight gain,
with lifestyle changes and medications to hepatomegaly
prevent acute congestive episodes.  Distended neck veins (jugular vein distention),
 Congestive heart failure is usually an acute ascites, anorexia and nausea
presentation of heart failure.  Nocturia and weakness
 Common underlying conditions include
coronary atherosclerosis (primary cause), ASSESSMENT AND DIAGNOSTIC METHODS
valvular disease, cardiomyopathy, and  Evaluation of clinical manifestations
inflammatory or degenerative muscle disease  Hemodynamic monitoring
and arterial hypertension.  Cardiac catheterization with radionuclide
 A number of systemic factors can contribute to ventriculography, or invasively, by
the development and severity of cardiac failure. ventriculogram
Increased metabolic rate (fever, thyrotoxicosis),  Echocardiogram (ejection fraction)
hypoxia, and anemia require an increased  Chest radiographs, ECG Exercise testing to
cardiac output to satisfy systemic oxygen detect coronary artery disease
demand.  Laboratory studies (blood urea nitrogen [BUN],
 Dysrhythmia decreases the efficiency of creatinine, thyroid stimulating hormone,
myocardial function. compete blood count [CBC], urinalysis)

CLINICAL MANIFESTATIONS MEDICAL MANAGEMENT

 Symptoms of inadequate tissue perfusion  Treatment goals are to eliminate or reduce
 Diminished cardiac output with accompanying etiologic factors, reduce the workload of the
dizziness, confusion, fatigue, exercise or heat heart, increase the force and efficiency of
intolerance, cool extremities, and oliguria myocardial contractions with pharmacologic
 Congestion of tissues agents, and eliminate the excessive
 Increased pulmonary venous pressure accumulation of body water.
(pulmonary edema) manifested by cough and  Smoking, alcohol and excess fluid intake are
shortness of breath. prohibited.
 Dysrhythmias may indicate heart failure or may  Medications and oxygen (including intubation)
be noted as a result of the treatment for heart are prescribed as indicated.
failure.  Nutritional therapy may include sodium
 Increased systemic venous pressure, as restriction (2 to 3 grams per day) and avoidance
evidenced by generalized peripheral edema and of excess fluid intake to prevent, control or
weight gain. eliminate edema.

LEFT-SIDED HEART FAILURE SURGICAL MANAGEMENT

Most often precedes right-sided heart failure.  Coronary bypass surgery
 PTCA
 Other innovative therapies as indicated (e.g.
BACKWARD FAILURE mechanical assist devices, transplantation)
 COLLABORATIVE PROBLEMS/POTENTIAL
PHARMACOLOGIC THERAPY COMPLICATIONS
 Alone or in combination: vasodilator therapy  Cardiogenic shock
(angiotensin-converting enzyme [ACE]  Thromboembolism
inhibitors), select beta-blockers, calcium channel  Pericardial effusion and pericardial tamponade
blockers, diuretic therapy, and cardiac  Dysrhythmias
glycosides.
 Dobutamine, milrinone, anticoagulants, beta- PLANNING AND GOALS
blockers, as indicated. MAJOR GOALS INCLUDE:
 Possibly antihypertensives or antianginal  Promotion of activity while maintaining
medications and anticoagulants. vital signs within identified range
 Reduced fatigue
NURSING MANAGEMENT: THE PATIENT WITH  Relief of fluid overload symptoms
HEART FAILURE  Decreased anxiety or increased ability to
manage anxiety
ASSESSMENT  Knowledge of self-care program
Nursing assessment of the patient with heart failure is  Ability to make decisions and influence
directed toward evaluating the therapeutic effectiveness outcomes.
of medical and nursing interventions and observing for
signs and symptoms of pulmonary and systemic fluid NURSING INTERVENTIONS
overload. All untoward signs are recorded and reported. PROMOTING ACTIVITY TOLERANCE
 Note report of sleep disturbance due to shortness  Monitor patient’s response to activities.
of breath, and the number of pillows used for Instruct patient to avoid prolonged bed
sleep. rest; patient should rest if symptoms are
 Note activities reported to cause shortness of severe but otherwise should assume
breath. regular activity.
 Respiratory: auscultate lungs at frequent  Encourage patient to perform an activity
intervals to determine presence or absence of more slowly than usual, for a shorter
wheezes or crackles. Note rate and depth of duration, or with assistance initially.
respirations.  Identify barriers that could limit
 Cardiac: auscultate for S3 heart sound, which patient’s ability to perform an activity,
may mean pump is beginning to fail; signs of and discuss methods of pacing an
fluid overload (orthopnea, PND, DOE). activity (e.g. chop or peel vegetables
 Assess sensorium and level of consciousness. while sitting at the kitchen table rather
 Periphery: assess dependent parts of body for than standing at the kitchen counter).
perfusion and edema, and liver for hepatojugular  Take vital signs, especially pulse,
reflux, and jugular vein distention. before, during, and within the
 Measure intake and output, weigh patient daily. predetermined range; heart rate should
return to baseline within 3 minutes. If
DIAGNOSIS patient tolerates the activity, develop
NURSING DIAGNOSIS short-term and long-term goals to
 Activity Intolerance (or risk for) related increase gradually the intensity,
to imbalance between oxygen supply duration, or frequency of activity.
and demand secondary to decreased  Refer to a cardiac rehabilitation program
cardiac output. as needed, especially for patients with a
 Fatigue secondary to heart failure. recent myocardial infarction, recent
 Excess fluid volume related to excess open heart surgery, or increased anxiety.
fluid or sodium intake or retention
secondary to heart failure and its REDUCING FATIGUE
medical therapy  Collaborate with patient to develop a
schedule that promotes pacing and
 Anxiety related to breathlessness and prioritization of activities. Encourage
restlessness secondary to inadequate patient to alternate activities with
oxygenation. periods of rest and avoid having two
 Powerlessness related to inability to significant energy-consuming activities
perform role responsibilities secondary occur on the same day or in immediate
to chronic illness and hospitalization. succession.
 Noncompliance related to lack of  Help patient develop a positive outlook
knowledge. focused on patient’s strengths, abilities,
 Deficient knowledge of self-care and interests.
program related to nonacceptance of  Encourage family to stagger visits to
necessary lifestyle changes. allow for rest between visits or calls;
identify a spokesperson to relay
 messages from and to other friends and provoking situations (relaxation
family members. techniques)
 Identify patient’s peak and low periods  Assist in identifying factors that
of energy, and plan energy-consuming contribute to anxiety (lack of sleep, lack
activities accordingly. of information, misinformation, or poor
 Explain that small, frequent meals tend nutritional status).
to decrease the amount of energy needed  Provide accurate information.
for digestion while providing adequate
nutrition. NURSING ALERT!!!
Cerebral hypoxia with superimposed carbon dioxide
MANAGING FLUID VOLUME retention, if present in cardiac failure, may cause patient
 Administer diuretics early in the to react to sedative-hypnotic medications with caution
morning so that diuresis does not disturb because hepatic congestion may result in a decreased
nighttime rest. ability of the liver to metabolize the medication within a
 Monitor fluid status closely: auscultate normal time frame to prevent toxicity. Avoid use of
lungs, compare daily body weights, restraints in case of confusion and anxiety reactions. The
monitor intake and output. patient who insists on getting out of bed at night can be
 Teach patient to adhere to a low-sodium seated comfortably in an armchair.
diet by reading food labels and avoiding
commercially prepared convenience MINIMIZING POWERLESSNESS
foods.  Assess for factors contributing to a perception of
 Assist patient to adhere to any fluid powerlessness and intervene accordingly.
restriction by planning the fluid  Listen actively to patient often; encourage
distribution throughout the day while patient to express concerns and questions.
maintaining dietary preferences.  If indicated, review hospital policies and
 Monitor intravenous fluids closely; standards that tend to promote powerlessness,
contact physician or pharmacist about and advocate for their elimination or change
the possibility of double-concentrating  Provide patient with decision-making
any medications. opportunities with increasing frequency and
 Assess for skin breakdown, and initiate significance; provide encouragement and praise
preventive measures (frequent changes while identifying patient’s progress; assist
in position, positioning to avoid patient to differentiate between factors that can
pressure, elastic pressure stockings, and be controlled and those that cannot.
leg exercises).
 Position patient, or teach patient how to MONITORING AND MANAGING POTENTIAL
assume a position, to shift fluid away COMPLICATIONS
from the heart (increase number of  Monitor for hypokalemia caused by diuresis
pillows, elevate head of bed, place bed (potassium depletion). Signs are weak pulse,
legs on 20- to 30-cm [8- to 10-inch] faint heart sounds, hypotension, muscle
blocks), or patient may prefer to sit in a flabbiness, diminished deep tendon reflexes, and
comfortable armchair to sleep. generalized weakness.
 Assess electrolyte levels periodically to alert
NURSING ALERT!!! W health team members to hypokalemia,
hen teaching the patient about a low-sodium hypomagnesemia, and hyponatremia.
diet, specify the quantity of sodium in milligrams (there  To reduce the risk for hypokalemia, advise
are 393 mg of sodium in 1,000 mg of salt). patient to increase dietary intake of potassium.
Dried apricots, bananas, beets, figs, grapefruits
CONTROLLING ANXIETY (fresh and juice), orange or tomato juice,
 Decrease anxiety so that patient’s peaches and prunes (dried plums), potatoes,
cardiac work is also decreased. raisins, spinach squash and watermelon are good
 Administer oxygen during the acute sources of potassium.
stage to diminish the work of breathing
and to increase comfort.
 When patient exhibits anxiety, promote
physical comfort and psychological PROMOTING HOME AND COMMUNITY-BASED
support; a family member’s presence CARE
provides reassurance. TEACHING PATIENTS SELF-CARE
 Speak in a low, calm, and confident  Provide patient education, and involve
manner; state specific, brief descriptions patient in implementing the therapeutic
for an activity when necessary. regimen to promote understanding and
 When patient is comfortable, teach ways compliance.
to control anxiety and avoid anxiety-  Support patient and family, and
encourage them to ask questions so that
 information can be clarified and
understanding enhanced.
 Adapt teaching plan according to
cultural factors.
 Teach patients and family how the
progression of the disease is influenced
by compliance with the treatment plan.
 Convey that monitoring symptoms and
daily weights, restricting sodium intake,
avoiding excess fluids, preventing
infection, avoiding noxious agents such
as alcohol and tobacco, and participating
in regular exercise all aid in preventing
the exacerbation of cardiac failure.

CONTINUING CARE
 Reinforce and clarify information about diet and
fluid restrictions, monitor symptoms and daily
body weight, and reinforce follow-up healthcare
expectations.
 Provide assistance in scheduling and keeping
appointments.
 Encourage patient to increase self-care and
responsibility for accomplishing the daily
requirements of the therapeutic regimen.
 Refer patient for home care if indicated (elderly
patients or patients who have long-standing
heart disease and whose physical stamina is
compromised). The home care nurse assesses
the physical environment of the home and the
patient’s support system and suggests
adaptations in the home to meet patient’s
anxiety limitations.

EVALUATION
EVALUATING PATIENT OUTCOMES
 Demonstrates tolerance for increased
activity
 Experiences less fatigue and dyspnea
 Maintains fluid balance
 Experiences less anxiety
 Adheres to self-care regimen
 Makes decisions regarding care and
treatment
 Avoids complication