NCP Heart Failure Chronic


Failure of the left and/or right chambers of the heart results in insufficient output to meet tissue needs and causes pulmonary and systemic vascular congestion. This disease condition is termed heart failure (HF). Despite diagnostic and therapeutic advances, HF continues to be associated with high morbidity and mortality. (Agency for Health Care Policy and Research [AHCPR] guidelines [6/94] promote the term heart failure [HF] in place of congestive heart failure [CHF] because many patients with heart failure do not manifest pulmonary or systemic congestion.) The New York Heart Association functional classification system for HF includes classes I to IV. Common causes of HF include ventricular dysfunction, cardiomyopathies, hypertension, coronary artery disease, valvular disease, and dysrhythmias.


Although generally managed at the community level, inpatient stay may be required for periodic exacerbation of failure/development of complications.


Myocardial infarction


Cardiac surgery


Psychosocial aspects of care

Patient Assessment Database


May report: Fatigue/exhaustion progressing throughout the day; exercise intolerance


Chest pain/pressure with activity

Dyspnea at rest or with exertion

May exhibit: Restlessness, mental status changes, e.g., anxiety and lethargy

Vital sign changes with activity


May report: History of hypertension, recent/acute multiple MIs, previous episodes of HF, valvular heart disease, cardiac surgery, endocarditis, systemic lupus erythematosus (SLE), anemia, septic shock

Swelling of feet, legs, abdomen, “belt too tight” (right-sided heart failure)

May exhibit: BP may be low (pump failure), normal (mild or chronic HF), or high (fluid overload/ increased SVR)

Pulse pressure may be narrow, reflecting reduced stroke volume

Tachycardia (may be left- or right-sided heart failure)

Dysrhythmias, e.g., atrial fibrillation, premature ventricular contractions/tachycardia, heart blocks

Apical pulse: PMI may be diffuse and displaced inferiorly to the left

Heart sounds: S3 (gallop) is diagnostic of congestive failure; S4 may occur; S1 and S2 may be softened

Systolic and diastolic murmurs may indicate the presence of valvular stenosis or insufficiency, both atrial and ventricular.

Pulses: Peripheral pulses diminished; central pulses may be bounding, e.g., visible jugular, carotid, abdominal pulsations; alteration in strength of beat may be noted

Color ashen, pale, dusky, or even cyanotic

Nailbeds pale or cyanotic, with slow capillary refill

Liver may be enlarged/palpable, positive hepatojugular reflex

Breath sounds: Crackles, rhonchi

Edema may be dependent, generalized, or pitting, especially in extremities; JVD may be present


May report: Anxiety, apprehension, fear

Stress related to illness/financial concerns (job/cost of medical care)

May exhibit: Various behavioral manifestations, e.g., anxiety, anger, fear, irritability


May report: Decreased voiding, dark urine

Night voiding (nocturia)



May report: Loss of appetite/anorexia


Significant weight gain (may not respond to diuretic use)

Lower extremity swelling

Tight clothing/shoes

Diet high in salt/processed foods, fat, sugar, and caffeine

Use of diuretics

May exhibit: Rapid/continuous weight gain

Abdominal distension (ascites); edema (general, dependent, pitting, brawny)

Abdominal tenderness (ascites, hepatic engorgement)


May report: Fatigue/weakness, exhaustion during self-care activities

May exhibit: Appearance indicative of neglect of personal care


May report: Weakness, dizziness, fainting episodes

May exhibit: Lethargy, confusion, disorientation

Behavior changes, irritability


May report: Chest pain, chronic or acute angina

Right upper abdominal pain (right-sided heart failure [RHF])

Generalized muscle aches/pains

May exhibit: Nervousness, restlessness

Narrowed focus (withdrawal)

Guarding behavior


May report: Dyspnea on exertion, sleeping sitting up or with several pillows

Cough with/without sputum production, dry/hacking—especially when recumbent

History of chronic lung disease

Use of respiratory aids, e.g., oxygen and/or medications

May exhibit: Tachypnea; shallow, labored breathing; use of accessory muscles, nasal flaring

Cough: Dry/hacking/nonproductive or may be gurgling with/without sputum production

Sputum may be blood-tinged, pink/frothy (pulmonary edema)

Breath sounds may be diminished, with bibasilar crackles and wheezes

Mentation may be diminished; lethargy, restlessness present

Color: Pallor or cyanosis


May exhibit: Changes in mentation/confusion

Loss of strength/muscle tone

Skin excoriations, rashes


May report: Decreased participation in usual social activities


May report: Use/misuse of cardiac medications, e.g., beta-blockers, calcium channel blockers

Recent/recurrent hospitalizations

Evidence of failure to improve

Discharge plan

DRG projected mean length of inpatient stay: 5.5 days

Assistance with shopping, transportation, self-care needs, homemaker/maintenance tasks

Alteration in medication use/therapy

Changes in physical layout of home

Refer to section at end of plan for postdischarge considerations.


ECG: Ventricular or atrial hypertrophy, axis deviation, ischemia, and damage patterns may be present. Dysrhythmias, e.g., tachycardia, atrial fibrillation, conduction delays, especially left bundle branch block, frequent premature ventricular contractions (PVCs) may be present. Persistent ST-T segment abnormalities and decreased QRS amplitude may be present.

Chest x-ray: May show enlarged cardiac shadow, reflecting chamber dilation/hypertrophy, or changes in blood vessels, reflecting increased pulmonary pressure. Abnormal contour, e.g., bulging of left cardiac border, may suggest ventricular aneurysm.

Sonograms (echocardiogram, Doppler and transesophageal echocardiogram): May reveal enlarged chamber dimensions, alterations in valvular function/structure, the degrees of ventricular dilation and dysfunction.

Heart scan (multigated acquisition [MUGA]): Measures cardiac volume during both systole and diastole, measures ejection fraction, and estimates wall motion.

Exercise or pharmacological stress myocardial perfusion (e.g., Persantine or Thallium scan): Determines presence of myocardial ischemia and wall motion abnormalities.

Positron emission tomography (PET) scan: Sensitive test for evaluation of myocardial ischemia/detecting viable myocardium.

Cardiac catheterization: Abnormal pressures are indicative and help differentiate right- versus left-sided heart failure, as well as valve stenosis or insufficiency. Also assesses patency of coronary arteries. Contrast injected into the ventricles reveals abnormal size and ejection fraction/altered contractility. Transvenous endomyocardial biopsy may be useful in some patients to determine the underlying disorder, such as myocarditis or amylodosis.

Liver enzymes: Elevated in liver congestion/failure.

Digoxin and other cardiac drug levels: Determine therapeutic range and correlate with patient response.

Bleeding and clotting times: Determine therapeutic range; identify those at risk for excessive clot formation.

Electrolytes: May be altered because of fluid shifts/decreased renal function, diuretic therapy.

Pulse oximetry: Oxygen saturation may be low, especially when acute HF is imposed on chronic obstructive pulmonary disease (COPD) or chronic HF.

Arterial blood gases (ABGs): Left ventricular failure is characterized by mild respiratory alkalosis (early) or hypoxemia with an increased PCO2 (late).

BUN/creatinine: Elevated BUN suggests decreased renal perfusion. Elevation of both BUN and creatinine is indicative of renal failure.

Serum albumin/transferrin: May be decreased as a result of reduced protein intake or reduced protein synthesis in congested liver.

Complete blood count (CBC): May reveal anemia, polycythemia, or dilutional changes indicating water retention.

Levels of white blood cells (WBCs) may be elevated, reflecting recent/acute MI, pericarditis, or other inflammatory or infectious states.

ESR: May be elevated, indicating acute inflammatory reaction.

Thyroid studies: Increased thyroid activity suggests thyroid hyperactivity as precipitator of HF.


1. Improve myocardial contractility/systemic perfusion.
2. Reduce fluid volume overload.
3. Prevent complications.
4. Provide information about disease/prognosis, therapy needs, and prevention of recurrences.


1. Cardiac output adequate for individual needs.
2. Complications prevented/resolved.
3. Optimum level of activity/functioning attained.
4. Disease process/prognosis and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.