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.
CARE SETTING
Although generally managed at the community level, inpatient stay may be required for periodic exacerbation of failure/development of complications.
RELATED CONCERNS
Myocardial infarction
Hypertension
Cardiac surgery
Dysrhythmias
Psychosocial aspects of care
Patient Assessment Database
ACTIVITY/REST
May report: Fatigue/exhaustion progressing throughout the day; exercise intolerance
Insomnia
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
CIRCULATION
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
EGO INTEGRITY
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
ELIMINATION
May report: Decreased voiding, dark urine
Night voiding (nocturia)
Diarrhea/constipation
FOOD/FLUID
May report: Loss of appetite/anorexia
Nausea/vomiting
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)
HYGIENE
May report: Fatigue/weakness, exhaustion during self-care activities
May exhibit: Appearance indicative of neglect of personal care
NEUROSENSORY
May report: Weakness, dizziness, fainting episodes
May exhibit: Lethargy, confusion, disorientation
Behavior changes, irritability
PAIN/DISCOMFORT
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
RESPIRATION
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
SAFETY
May exhibit: Changes in mentation/confusion
Loss of strength/muscle tone
Skin excoriations, rashes
SOCIAL INTERACTION
May report: Decreased participation in usual social activities
TEACHING/LEARNING
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.
DIAGNOSTIC STUDIES
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.
NURSING PRIORITIES
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.
DISCHARGE GOALS
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.
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.
CARE SETTING
Although generally managed at the community level, inpatient stay may be required for periodic exacerbation of failure/development of complications.
RELATED CONCERNS
Myocardial infarction
Hypertension
Cardiac surgery
Dysrhythmias
Psychosocial aspects of care
Patient Assessment Database
ACTIVITY/REST
May report: Fatigue/exhaustion progressing throughout the day; exercise intolerance
Insomnia
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
CIRCULATION
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
EGO INTEGRITY
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
ELIMINATION
May report: Decreased voiding, dark urine
Night voiding (nocturia)
Diarrhea/constipation
FOOD/FLUID
May report: Loss of appetite/anorexia
Nausea/vomiting
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)
HYGIENE
May report: Fatigue/weakness, exhaustion during self-care activities
May exhibit: Appearance indicative of neglect of personal care
NEUROSENSORY
May report: Weakness, dizziness, fainting episodes
May exhibit: Lethargy, confusion, disorientation
Behavior changes, irritability
PAIN/DISCOMFORT
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
RESPIRATION
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
SAFETY
May exhibit: Changes in mentation/confusion
Loss of strength/muscle tone
Skin excoriations, rashes
SOCIAL INTERACTION
May report: Decreased participation in usual social activities
TEACHING/LEARNING
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.
DIAGNOSTIC STUDIES
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.
NURSING PRIORITIES
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.
DISCHARGE GOALS
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.
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