Heart failure (HF), sometimes referred to as Congestive Heart Failure (CHF), occurs when the heart can’t supply blood effectively to the rest of the body. The left ventricle of the heart is larger and is responsible for most of the pumping action. In left-sided HF, the left ventricle either loses its contractility so it isn’t able to pump normally or the ventricle becomes stiff and so it cannot relax and fill with blood properly between each beat.
Left-sided HF often leads to right-sided heart failure. In right-sided HF, if the right ventricle can’t pump properly, blood backs up in the veins which leads to congestive heart failure (CHF).
An ejection fraction (EF) is a percentage that will measure how well the ventricles are pumping. An EF of 55-70% is normal. 40-54% is slightly below normal and may not produce symptoms. 35-39% is considered mild heart failure. An EF less than 35% is moderate to severe heart failure. These numbers help the provider determine treatment but are also helpful for the nurse to know and understand.
If the heart isn’t pumping blood effectively to the body, all organ systems will suffer. If the brain isn’t receiving oxygen-rich blood the patient may have confusion or dizziness. Shortness of breath and difficulty laying flat to sleep can result from pulmonary congestion from blood backing up in the lungs. If the kidneys aren’t receiving blood, they cannot filter properly leading to edema and decreased urine output.
Heart failure typically occurs as a result of something else (i.e. another condition/disease or possibly a medication) having already damaged the heart muscle. Conditions that could potentially damage the heart and lead to heart failure include: coronary artery disease, myocardial infarction, hypertension, heart valve disease, myocarditis, congenital heart defects, cardiac arrhythmias, or other long-term, chronic conditions that are poorly managed such as diabetes mellitus, HIV, hyperthyroidism, or hypothyroidism.
Signs and Symptoms
Patients with heart failure can display a variety of symptoms including:
- Dyspnea on exertion
- Edema in lower extremities
- Irregular heart beat
- Low exercise tolerance level
- Persistent cough
- Abdominal swelling
- Rapid weight gain
- Nausea, lack of appetite
- Decreased alertness
- Chest pain
If heart failure is left untreated it can cause additional complications for the patient including:
- Renal damage – because heart failure causes a reduction in blood flow it can result in a reduction in blood flow to the kidneys, the body’s filtering system. This can result in a buildup of toxins or medications within the body. If renal damage becomes severe enough the patient may require dialysis.
- Heart Valve Disease – the heart valves are designed to prevent blood from backflowing in the heart. When the heart is not functioning properly, the muscle becomes stiff, or pressures increase within the heart it can then cause dysfunction of the valves as well.
- Cardiac Arrhythmias – If the heart function is significantly reduced, it can increase the likelihood that a person may experience other cardiac dysrhythmias, some of which can be fatal.
- Liver Damage – The backup of fluid that can occur with heart failure can potentially put more pressure on the liver thereby causing liver dysfunction and damage.
Since heart failure is a chronic condition it will require lifetime treatment. First form of treatment is aimed at identifying any potential contributing factors and treating those (i.e. repairing a heart valve if possible). Many times, patients require multiple medications to management this condition. The table below lists the most common classes of medications used for the treatment and management of heart failure.
|Angiotensin-converting enzyme (ACE) inhibitors||ACE inhibitors relax the blood vessels which results in improved blood flow, lower blood pressures, and less strain on the cardiac muscle|
|Angiotensin II receptor blockers (ARBs)||ARBs relax the blood vessels which results in improved blood flow, lower blood pressures, and less strain on the cardiac muscle|
|Beta Blockers (BB)||BBs lower the heart rate and blood pressure which can improve heart function|
|Diuretics||Diuretics cause an increase in urination to remove excess fluid from the body|
|Aldosterone antagonists||These medications are potassium-sparing diuretics that help in the treatment of systolic heart failure|
|Inotropes||Typically given IV while hospitalized, these are designed to increase the effectiveness of the heart pumping and maintain blood pressures|
|Digoxin||Increases the strength of the heart’s contractions|
Stages of Heart Failure
There are various stages defined as classes of heart failure dependent on the symptoms the patient is experiencing. These stages along with the associated symptoms are listed below.
|Class I||No heart failure symptoms|
|Class II||Activities of daily living can be completed without difficulty; however, exertion causes shortness of breath and some fatigue|
|Class III||Difficulty in completing activities of daily living|
|Class IV||Shortness of breath occurs while resting|
Prevention is incredibly important and patients should receive proper education on how to prevent heart failure. Actions taken by the patient that can reduce the chances of developing heart failure include: quitting smoking, eating heart-healthy food items, staying active, keeping weight within the normal range for their body type, and treating and appropriately managing other health conditions (i.e. hypertension, diabetes, etc.).
The Nursing Process
Nurses play a pivotal role not only in treating patients with heart failure but educating them on lifestyle modifications to prevent disease progression or complications.
The nurse must understand the mechanism of the heart and the pathophysiology of HF in order to effectively treat patients, monitor for impending changes, and prevent worsening effects on other body systems.
Nursing Care Plans Related to Heart Failure
Decreased Cardiac Output Care Plan
A decline in stroke volume from a loss of cardiac contractility or muscle compliance results in reduced filling or ejection of the ventricles. This reduced output decreases blood flow to other organs.
Nursing Diagnosis: Decreased Cardiac Output
- Altered heart rate/rhythm
- Altered contractility
- Structural changes (aneurysm, rupture)
As evidenced by:
- Increased heart rate (palpitations)
- Shortness of breath
- Jugular vein distention; edema
- Central venous pressure changes
- Decreased peripheral pulses
- Decreased urine output
- Skin pallor, mottling, or cyanosis
- Patient will display hemodynamic stability with vital signs, cardiac output, and renal perfusion within normal limits
- Patient will participate in activities that reduce the workload of the heart
- Patient will report an absence of chest pain or shortness of breath
Decreased Cardiac Output Assessment
1. Assess vital signs, cardiac rhythm, and hemodynamic measurements.
HF patients benefit from continuous cardiac monitoring via telemetry. The nurse can then act quickly if a dysrhythmia is observed. Blood pressure, pulse rate, and oxygen saturation should also be assessed regularly for changes. Unstable patients may need hemodynamic monitoring to maintain adequate perfusion.
2. Monitor skin and pulses.
Poor cardiac output will result in decreased tissue perfusion. The nurse may observe skin mottling, pallor, or cyanosis. The skin may also feel cool or clammy. Along with these outward changes, peripheral pulses may be weak or irregular due to the lack of circulating blood volume.
3. Monitor mental status changes.
HF can have long-term mental effects on the brain leading to poor memory and impaired cognition. The nurse can monitor for subtle changes or a decline in baseline presentation such as acute confusion or altered alertness.
Decreased Cardiac Output Interventions
1. Apply oxygen.
Patients with low oxygen saturation may need supplemental oxygen due to the heart’s inability to pump oxygen-rich blood to the body. Patients with chronic HF may require oxygen therapy at home.
2. Administer medications.
Vasodilators open arteries and veins to allow for decreased vascular resistance, increasing cardiac output and reducing ventricular workload. Morphine and anti-anxiety medications help with relaxing and calming the patient which can reduce cardiac workload. Angiotensin receptor blockers (ARBs) lower blood pressure and make pumping blood easier for the heart.
3. Instruct on ways to reduce the workload of the heart.
Depending on the severity of the patient’s HF, they may need to modify daily activities. They may need assistance with ADLs, plenty of rest periods, and reduced exercise regimens.
4. Educate on risk factors and lifestyle modifications.
Patients who are not yet diagnosed with HF or only have mild HF should be educated on prevention. Educate patients on risk factors such as hypertension, diabetes, atherosclerosis, and myocardial infarction that increase the risk of developing heart failure. Modifiable risk factors like smoking, obesity, sedentary lifestyle, and diets high in fat also increase the risk.
Activity Intolerance Care Plan
Activity intolerance is a common manifestation and nursing diagnosis related to HF that can lead to worsening health conditions and physical deconditioning.
Nursing Diagnosis: Activity Intolerance
- Imbalance between oxygen supply and demand
- Sedentary lifestyle
As evidenced by:
- Vital sign changes in response to activity
- Chest pain on exertion
- Patient will perform activities within their limitations so as not to stress cardiac workload
- Patient will alternate between work and rest periods to complete ADLs
- Patient will demonstrate vital signs and heart rhythm within normal limits during activity
Activity Intolerance Assessment
1. Observe cardiopulmonary response to activity.
The nurse can monitor the patient’s heart rate, oxygen saturation, and cardiac rhythm during activity. A rise or drop in blood pressure, tachycardia, or EKG changes can signify overexertion and help plan appropriate interventions.
2. Assess the patient’s perspective.
Assess the patient’s understanding of their condition and their perceived activity limitations. The goal is to ensure the patient is not overexerting themselves but also feels motivated to make progress with their activity tolerance and maintain independence.
3. Assess the degree of debility.
Interventions can be tailored to the severity of the patient’s symptoms. Assess the level of fatigue, weakness, and dyspnea in relation to activity and length of exertion. The nurse may need to assist with ADLs or adjust the activities the patient can undertake for their safety.
Activity Intolerance Interventions
1. Provide a calm environment.
Dyspnea from HF can result in anxiety and restlessness. Provide the patient with a cool, dimly lit space free from clutter and stimulation. Assist the patient in taking slow, controlled breaths and provide emotional support so they feel in control.
2. Encourage participation.
Even a patient with chronic HF and severe activity intolerance can assist with care to some extent. Provide toiletries at the bedside so the patient can brush their teeth or comb their hair. Have the patient assist with turning themselves in bed. A patient who becomes immobile from a sedentary lifestyle is at an increased risk for other complications such as skin breakdown, deep vein thrombosis (DVT), and pneumonia.
3. Teach methods to conserve energy.
Group tasks together, sit when possible when performing ADLs, plan rest periods, promote restful sleep, do not rush activities, and avoid activities in hot or cold temperatures.
4. Recommend cardiac rehabilitation.
This is a medically supervised outpatient program that teaches a patient with a cardiac history how to reduce their risk of heart problems through exercise, heart-healthy diets, stress reduction, and management of chronic conditions. This is a team-based approach working with providers, nurses who specialize in cardiac care, PT and OT, and dieticians.
Excess Fluid Volume Care Plan
Heart failure results in poor perfusion of the kidneys. If the kidneys cannot excrete sodium, water retention will occur and accumulate in tissues leading to fluid overload.
Nursing Diagnosis: Excess Fluid Volume
- Fluid intake or sodium intake
- Reduced glomerular filtration rate
- Increased secretion of antidiuretic hormone
As evidenced by:
- Shortness of breath
- Weight gain
- Edema in extremities
- Jugular vein distention
- Adventitious breath sounds (crackles, rales)
- High blood pressure
- Pulmonary congestion
- S3 heart sound
- Patient will demonstrate stable fluid volume through balanced intake and output, normal baseline weight, and no peripheral edema
- Patient will verbalize signs and symptoms of fluid overload and when to seek help
- Patient will verbalize dietary recommendations and fluid restrictions to maintain
Excess Fluid Volume Assessment
1. Assess for peripheral edema, anasarca, and JVD.
Signs of fluid retention include edema in the lower legs and feet which is often pitting or generalized edema to the entire body known as anasarca. The most reliable sign indicating fluid overload is jugular vein distention (JVD).
2. Monitor breath and heart sounds.
Patients with congestive heart failure (CHF) will present with shortness of breath and may have a cough with blood-tinged sputum due to pulmonary congestion. Upon assessment, the nurse will likely hear “wet” breath sounds (crackles). An S3 gallop signifies significant heart failure.
3. Monitor urine output and strict I&Os.
Strict documentation of intake and output is required to monitor hydration and prevent worsening fluid overload. The nurse should record intake from oral and IV sources, maintain adherence to fluid restrictions, and assess urine output and characteristics. This is especially important if the patient is on diuretic therapy.
Excess Fluid Volume Interventions
1. Maintain upright position.
Semi-Fowlers or Fowler’s positioning will help the patient breathe easier and maintain comfort. They may require extra pillows or need to sleep in a reclining chair at home.
2. Administer diuretics.
Diuretics are often prescribed as they rid the body of excess fluid which will decrease edema and dyspnea. Diuretics can be given by mouth or IV and must be monitored closely as they increase urination, decrease blood pressure, and decrease potassium.
3. Instruct on sodium and fluid restrictions.
Diet education may include decreasing sodium and restricting fluids and will be directed by a provider. Patients should not use table salt or add salt to foods and should be aware of sodium contents in frozen or canned food. If a fluid restriction is ordered, the patient can track this by using a large pitcher that is their daily amount of fluid and drinking from it throughout the day. Ensure the patient understands their restriction includes all sources of fluid: soups, jello, and ice cream.
4. Teach how to monitor for fluid volume overload.
Educate patients at discharge on signs of fluid retention. They should weigh themselves daily, using the same scale and at the same time each day. If a weight gain of 2 lbs in 24 hours or 5 lbs in a week is observed, they should call their doctor. Observed swelling to ankles or feet as well as an increase in dyspnea also requires assessment.
Impaired Gas Exchange Care Plan
Inadequate blood flow results in decreased oxygenation and perfusion to tissues and organs. Heart failure itself is a related factor, but complications such as excess fluid can further impair gas exchange.
Nursing Diagnosis: Impaired Gas Exchange
- Ventilation perfusion imbalance related to altered blood flow
- Changes to the alveolar-capillary membrane
- Pulmonary congestion due to fluid retention
As evidenced by:
- Changes in mental status
- Abnormal ABGs
- Changes in respiratory rate, depth, or rhythm
- Patient will maintain ventilation and perfusion as evidenced by ABGs within normal limits
- Patient will display improvement in ventilation by oxygen saturation above 95%
- Patient will participate in ambulation and ADLs as allowed by respiratory ability
Impaired Gas Exchange Assessment
1. Auscultate breath sounds.
The patient may experience crackles, wheezes, or diminished breath sounds related to excess fluid in the lungs. Monitor closely for acute respiratory changes.
2. Monitor pulse oximetry.
Abnormal oxygen saturation levels are a sign of hypoxemia, a lack of oxygen in the blood. This requires oxygen therapy and the underlying cause should be investigated and treated.
3. Monitor arterial blood gases (ABGs).
ABGs measure the amount of oxygen and carbon dioxide in the blood. Abnormal or worsening ABGs indicate that the lungs are not ventilating or removing CO2 adequately.
Impaired Gas Exchange Interventions
1. Educate on coughing and deep breathing exercises.
Clearing the airway and expanding the lungs will assist in promoting oxygenation.
2. Change positions frequently.
Movement also assists with the drainage of secretions which can decrease the risk of complications such as atelectasis and/or pneumonia. If the patient is able to ambulate, this should be encouraged multiple times per day.
3. Maintain semi-Fowler’s position.
Keeping the head of the bed elevated maintains an open airway. This can also be based on the patient’s comfort as some cannot tolerate high-Fowler’s positioning. If the patient is able to sit in a chair this is recommended.
4. Administer supplemental oxygen as needed.
Apply oxygen per provider orders and to maintain the oxygenation of the patient. Patients may need oxygen titrated up or down or may require more significant interventions such as BiPap or mechanical ventilation.
5. Administer medications as ordered.
If the impaired gas exchange is in relation to excess fluid volume, medications such as diuretics may be required to treat the underlying cause.
Ineffective Health Maintenance Care Plan
Poor patient understanding or management of their condition can result in worsening symptoms and outcomes.
Nursing Diagnosis: Ineffective Health Maintenance
- Lack of understanding of heart failure and prognosis
- Difficulty in following recommended treatment plan
- Poor motivation to make lifestyle changes
- Insufficient resources (access to cardiologist, finances)
- Lack of support from family to encourage or monitor condition
As evidenced by:
- Demonstrates a lack of knowledge of heart failure
- Continues with inappropriate diet or behaviors despite education
- Inconsistent with keeping appointments, taking medications, etc.
- Patient will seek out information to prevent worsening heart failure
- Patient will identify (3) lifestyle modifications to improve heart failure
- Patient will take responsibility for their health outcomes by identifying areas for improvement
Ineffective Health Maintenance Assessment
1. Assess the level of understanding of the disease process.
Determine the patient’s present knowledge of risk factors, symptoms, treatments, and goals in order to tailor teaching to meet their needs.
2. Assess support system.
Management of chronic conditions can be very challenging for patients and having a strong support system can assist in better adherence to the treatment plan.
Ineffective Health Maintenance Interventions
1. Educate on normal heart function compared to the patient’s current heart function.
Understanding the disease process can help the patient understand the goals of treatment and improve adherence. Explaining results of testing, such as the EF, or reviewing the HF classification system helps them feel more involved in their care.
2. Reinforce the rationale of treatments.
Furthermore, patients may not grasp the reasoning for certain treatments such as fluid restrictions, weighing themselves daily, or the importance of medications. Explain in simple terms and provide written education if appropriate.
3. Educate on the importance and benefits of regular exercise.
This will assist with maintaining muscle strength and organ function to strengthen the heart. Ensure exercise programs are safe for the patient and cleared by their provider.
4. Review medications.
Thorough medication reconciliation and review is required before discharge or after each provider visit. The nurse should review changes and instruct on frequencies, side effects, and any considerations with each medication.
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