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 can’t pump normally, or the ventricle becomes stiff and 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). If the heart isn’t pumping blood effectively to the body, all organ systems will suffer.
In this article:
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 Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section we will cover subjective and objective data related to heart failure.
Subjective Data
Review of health history and complaints
1. Assess the patient’s general symptoms.
Record the patient’s complaints and general symptoms, such as:
- Dyspnea on exertion
- Orthopnea
- Fatigue/weakness
- Edema in lower extremities
- Tachycardia
- Irregular heartbeat
- Exercise intolerance
- Persistent cough
- Wheezing
- Abdominal swelling
- Rapid weight gain
- Nausea
- Lack of appetite
- Decreased alertness
- Chest pain
2. Investigate the underlying cause.
Heart failure typically occurs due to something else (i.e., another condition/disease or possibly a medication) causing damage to 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
- Other long-term, chronic conditions that are poorly managed (such as diabetes mellitus, HIV, hyperthyroidism, or hypothyroidism)
3. Identify the stage of heart failure.
Heart failure classification is used to denote the severity of symptoms.
Stages of Heart Failure:
- Class I: No limitation to physical activity.
- Class II: Activities of daily living can be completed without difficulty; however, exertion causes shortness of breath and some fatigue.
- Class III: Difficulty completing activities of daily living without fatigue, palpitations, or dyspnea.
- Class IV: Shortness of breath occurs at rest.
4. Know the patient’s risk.
Non-modifiable risk factors:
- Age: The heart can become stiff and frail with advanced age. The risk of heart failure is increased in people over 65. Elderly patients are also more prone to various health issues that cause heart failure.
- Gender: Heart failure is twice as likely to occur in men.
- Family history of ischemic heart disease: There is a high risk if a close female relative (mother or sister) had heart disease before age 65 or if a close male relative (father or brother) had it before age 55.
- Race/ethnicity: Heart failure is more common in African-Americans and Latinos than in Caucasian people.
Modifiable risk factors:
- Hypertension: Uncontrolled high blood pressure can result in stiffening and rigid arteries. Coronary artery constriction may impair blood flow.
- Hyperlipidemia/hypercholesterolemia/coronary artery disease: Increased levels of low-density lipoprotein (LDL) or decreasing levels of high-density lipoprotein (HDL) in the blood can increase the risk of atherosclerosis, narrowing the blood vessels.
- Diabetes or insulin resistance: Hardening of the blood arteries and accumulating fatty plaque are effects of diabetes or insulin resistance.
- Heart valve disease: If the heart valves are impaired, the heart must work harder to pump blood throughout the body, which can lead to heart failure.
- Tobacco use: Smoking accelerates the buildup of plaque in blood vessels. Smokers experience heart failure at a rate twice that of non-smokers.
- Obesity: Obesity increases the risk of high blood pressure, raised blood cholesterol, and diabetes. All are risk factors for heart failure.
- Physical inactivity: Those who are physically inactive are almost two times more likely to acquire heart disease than those who are active.
- Diet: A diet high in fatty, processed foods, high-sodium, or sugary foods increases the risk of obesity and chronic diseases that can lead to heart failure.
- Stress: Blood vessels constrict as inflammatory levels rise under stress. Excessive stress hormones secreted can lead to heart failure.
- Alcohol use: Alcohol impairs the heart muscle and alters blood clot formation, resulting in the occlusion of blood vessels.
- Lack of sleep: Stress levels rise with insufficient sleep and cause blood vessels to constrict.
- Bacterial and viral infections: Infections can increase the risk of heart failure, such as:
- Influenza
- Pneumonia
- Urinary tract infections
- Bacteremia
- Covid-19
- HIV
- Endocarditis
5. Review the patient’s treatment record.
Medications and past vascular surgery compromise artery integrity. These medications include:
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Diabetes medications rosiglitazone (Avandia) and pioglitazone (Actos)
- Antihypertensive medications
- Medications for:
- Cancer
- Blood disorders
- Irregular or abnormal heartbeats
- Nervous system disorders
- Mental health issues
- Lung and urinary issues
- Inflammatory diseases
- Infections
Objective Data
Physical assessment
1. Assess the vital signs.
Vital indicators, particularly pulse rate and blood pressure, are anticipated to rise or change due to the heart’s reduced oxygenated blood supply. Monitor Spo2 for changes in oxygen saturation that signal deteriorating perfusion.
2. Systemic assessment approach:
- Neck: distended jugular veins
- CNS: decreased alertness
- Cardiovascular: tachycardia, chest pain, abnormal heart sounds (pathological S3) upon auscultation, arrhythmias
- Circulatory: decreased peripheral pulses, narrow pulse pressure (less than 25 mmHg caused by reduced cardiac output)
- Respiratory: dyspnea on exertion or at rest, tachypnea, orthopnea, persistent or nocturnal cough, crackles or rhonchi in the lung bases upon auscultation
- Gastrointestinal: nausea and vomiting, lack of appetite, abdominal swelling from hepatic congestion and ascites
- Lymphatic: edema in the lower extremities
- Musculoskeletal: neck, arm, back, jaw, and upper body pain, fatigue, muscle weakness, activity intolerance, rapid weight gain from fluid
- Integumentary: cyanotic and pale skin and excessive sweating
Diagnostic procedures
1. Obtain ECG.
ECG findings in heart failure are characterized by P wave changes resulting in left atrial hypertrophy (enlargement).
2. Analyze BNP lab results.
As heart failure occurs, the heart releases B-type natriuretic peptide (BNP) in the blood, causing an elevation in the blood test.
3. Investigate other blood tests.
- Complete blood count with differential indicates the presence of infection (WBC), blood coagulation (platelets), and anemia (low RBC levels).
- Cholesterol levels show a risk for coronary artery disease (a risk factor for heart failure).
- Thyroid levels reflect disturbed thyroid hormones that can cause arrhythmias.
4. Review chest X-ray results.
Chest X-ray shows any changes in the size of the heart. It also reflects fluid accumulation around the heart and lungs.
5. Prepare the patient for an echocardiogram.
An echocardiogram assesses the heart’s structure. This test is used to identify ejection fraction (EF), a percentage that measures how well the ventricles pump blood.
- 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
- EF less than 35% is moderate to severe heart failure
6. Investigate further.
- Exercise treadmill test benefits a patient who is physically capable of exercising and has a normal resting ECG.
- Nuclear stress test shows images of blood flow to the heart muscle using an IV radioactive tracer dye. This is combined with exercise or medication to stimulate the heart rate.
- Stress imaging is for patients who had revascularization, with challenging ECGs to read, or are physically unable to exercise.
- Cardiac CT scan displays calcium deposits and cardiac artery blockages.
- Cardiac catheterization reveals any obstructed cardiac arteries or the presence of coronary artery disease.
- CT coronary angiogram is comparable to a cardiac CT scan but creates a more detailed image using dye (contrast).
- Myocardial biopsy investigates other heart diseases that can cause heart failure.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section you’ll learn more about possible nursing interventions for a patient with heart failure.
Promote Perfusion
1. Relax the blood vessels.
Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) improve blood flow by relaxing the blood vessels. It also lowers blood pressure and cardiac muscle strain.
2. Lower the heart rate and pressure.
Administer beta-blockers to reduce the heart rate and blood pressure, which can improve heart function.
3. Induce diuresis.
Diuretics cause an increase in urination to remove excess fluid from the body.
4. Consider potassium-sparing diuretics.
Aldosterone antagonists are potassium-sparing diuretics that help treat systolic heart failure. It removes the excess fluid in the heart and body.
5. Strengthen the heart contraction.
- Inotropes are typically given IV while hospitalized. These are designed to increase the effectiveness of the heart pumping and maintain blood pressure.
- Digoxin increases the strength of the heart’s contractions. Monitor closely for digoxin toxicity through lab testing.
6. Treat the underlying condition.
- Coronary artery bypass graft surgery (CABG) builds an additional pathway for blood in the heart. The blocked or constricted coronary artery is bypassed using an artery from another part of the body, such as the leg.
- Heart valve repair or replacement fixes or replaces the defective heart valve causing heart failure.
- Cardiac resynchronization therapy (CRT) uses a biventricular pacemaker to correct electrical signals in the heart that causes arrhythmias.
- Ventricular assist devices (VADs) are mechanical pumps that improve heart contraction and pumping in heart failure.
- Heart transplant is recommended for patients with severe heart failure when treatments are no longer effective.
Cardiac Rehabilitation
1. Collaborate with the team.
Patients will work with cardiologists, cardiac rehab nurse specialists, dieticians, social workers, and physical and occupational therapists to meet their health needs.
2. Improve activity tolerance.
Following surgery or a procedure for heart failure, recovery will take time. Cardiac rehab will slowly introduce exercises to strengthen the heart.
3. Strengthen the patient’s health.
Cardiac rehab enhances the patient’s health and quality of life by supporting the patient in restoring strength and preventing HF recurrence and complications.
Reduce the Risk of Complications
1. Regulate the heart rhythm.
Implantable cardioverter-defibrillators (ICDs) are devices that prevent heart failure complications. ICD tracks the heart rhythm and keeps the heart rate regular if an arrhythmia occurs.
2. Repeat the importance of lifestyle modifications.
Adopting lifestyle adjustments can reduce heart failure symptoms and keep the condition from getting worse.
- Regular exercise
- Heart-healthy diets
- Smoking cessation
- Avoiding secondhand smoke
- Stress management
- Vaccinations
- Limiting alcohol consumption
- Restful sleep
3. Advise on activity.
Aerobic exercise regularly improves heart function in persons with heart disease. Physical activity may be difficult or impossible for patients with severe HF. Advise the patient to go for five to ten minutes at a moderate pace and aim to add one or two minutes daily as they can.
4. Keep a healthy weight.
Being overweight can cause fatty deposits to build up in the arteries. Advise the patient to limit saturated or trans fat. Blood pressure, cholesterol, and metabolic activity all improve with weight loss.
5. Promote patient adherence to treatment.
Treatment adherence promotes continuity of care and patient-centered care. Increased patient adherence leads to more efficient HF treatment and prevention of complications.
6. Decrease stress.
Stress raises blood pressure and heart rate. Because the inflammatory response is activated, blood vessels constrict, increasing the risk of HF. Guided imagery, yoga, deep breathing exercises, muscle relaxation, meditation, and getting adequate sleep are examples of stress reduction techniques.
7. Prevent fluid accumulation.
Monitor for any swelling in the lower extremities, which may indicate the presence of edema or fluid accumulation. Instruct on contacting their healthcare team if weight gain of more than 2.5 lbs overnight or 5 lbs in a week is observed. Also, limit sodium (salt) intake to prevent water retention. Fluid accumulation can increase the heart’s workload.
8. Teach the patient when to seek medical attention.
HF signs and symptoms that are a cause for concern are:
- Chest pain
- Sudden weight gain
- Fainting (syncope)
- Dyspnea
- Sudden productive cough with white or pink, foamy secretions
9. Follow up with the cardiologist.
Visits to a cardiologist and regular examinations, such as blood tests and echocardiograms, will aid in monitoring the disease process. Patients with HF are advised to visit their cardiologist every three-six months or as recommended.
10. Emphasize the use of medical identification.
The emergency responders can be alerted about the patient’s history of HF by a medical identity bracelet, necklace, or ID tag. This can be helpful, especially for patients who are living alone.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for heart failure, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section you will find nursing care plan examples for heart failure.
Activity Intolerance
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
Related to:
- Imbalance between oxygen supply and demand
- Weakness/deconditioning
- Sedentary lifestyle
As evidenced by:
- Fatigue
- Dyspnea
- Immobility
- Vital sign changes in response to activity
- Chest pain on exertion
- Diaphoresis
Expected outcomes:
- 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.
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.
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.
Decreased Cardiac Output
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
Related to:
- Altered heart rate/rhythm
- Altered contractility
- Structural changes (aneurysm, rupture)
As evidenced by:
- Increased heart rate (palpitations)
- Dysrhythmias
- Fatigue
- Shortness of breath
- Anxiety
- Orthopnea
- Jugular vein distention; edema
- Central venous pressure changes
- Murmurs
- Decreased peripheral pulses
- Decreased urine output
- Skin pallor, mottling, or cyanosis
Expected outcomes:
- 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.
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.
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.
Decreased Cardiac Tissue Perfusion
Decreased cardiac tissue perfusion associated with heart failure can be caused by insufficient blood flow resulting from impaired cardiac function.
Nursing Diagnosis: Decreased Cardiac Tissue Perfusion
Related to:
- Structural impairment of the heart
- Malfunctions of the heart structures
- Difficulty of the heart muscle to pump
- Increased exertion in workload
- Inadequate blood supply to the heart
- Inability to contract and relax effectively
- Erratic signals causing chaotic or irregular heart contraction
As evidenced by:
- Decreased cardiac output
- Decreased blood pressure (hypotension)
- Decreased peripheral pulses
- Increased central venous pressure (CVP)
- Increased pulmonary artery pressure (PAP)
- Tachycardia
- Dysrhythmias
- Ejection fraction less than 40%
- Decreased oxygen saturation
- Presence of abnormal S3 and S4 heart sounds upon auscultation
- Chest pain
Expected outcomes:
- Patient will manifest pulse rate and rhythm within normal limits.
- Patient will demonstrate ejection fraction >40%.
- Patient will maintain palpable peripheral pulses.
Assessment:
1. Auscultate the apex of the heart.
Determine if an abnormal heart sound S3 or S4 can be detected by auscultating the left lower sternal border. Children and athletes may naturally produce an S3 heart sound, but it is an abnormal finding in older adults and those with heart failure. Blood ejecting into a rigid ventricle causes the S4 heart sound.
2. Assist in myocardial perfusion test.
Myocardial perfusion imaging (nuclear stress test) demonstrates how efficiently blood flows through the heart muscle. Additionally, it displays how efficiently the heart is pumping.
3. Check the BNP or NT-proBNP.
B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) diagnoses heart failure (HF). It also supports the diagnosis of acutely decompensated HF in hospitalized patients or those treated in emergency rooms.
4. Obtain EKG.
EKG can help rule out HF with a high sensitivity but low specificity. It can reveal the cause (such as a history of previous MI) and offer therapeutic indications (such as anticoagulation for atrial fibrillation).
5. Assist in TEE.
Transthoracic echocardiography (TEE) can be useful in determining ejection fraction, left-atrial pressure, and cardiac output.
6. Prepare for a left heart catheterization or coronary angiography.
Left-heart catheterization or coronary angiography is done to identify blockages or abnormalities with blood vessels in the heart to guide interventions.
Interventions:
1. Set the goal with the patient.
Therapy aims to increase survival and symptoms, shorten hospital stays and avoid HF readmission, minimize morbidity, prevent HF-related organ damage, and suppress symptoms in patients with asymptomatic heart failure.
2. Administer medications as ordered.
The following medications are included in the pharmacologic treatment of HF:
- Diuretics
- Angiotensin system blockers (ACE inhibitors, ARBs, or ARNIs)
- Hydralazine with nitrate as an alternative if angiotensin system blockers are not tolerable
- Beta-blockers
3. Instruct on lifestyle modifications.
Behavioral and lifestyle modifications include the following:
- Dietary and nutritional consultation
- Limit sodium to 2 to 3 g/day
- Fluid restriction to 2 L/day
- Weight monitoring
- Aerobic exercise training
- Control of existing risk factors (such as DM and lipid disorders)
- Smoking/alcohol/illicit drug use cessation
4. Consider device therapy.
Device therapies include cardiac resynchronization treatment (CRT) and implanted cardioverter-defibrillators (ICD). Patients should receive ACE inhibitors/ARB plus beta-blockers for at least three months prior to surgery.
5. Anticipate the possibility of surgery.
Heart transplantation, heart valve replacement, catheter ablation, and more are procedures to remodel, repair, or replace all or part of the heart’s function in treating HF. Surgery is often considered when medications aren’t effective.
Excess Fluid Volume
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
Related to:
- 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
- Oliguria
- Tachycardia
- Pulmonary congestion
- Cough
- S3 heart sound
Expected outcomes:
- 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.
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.
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
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
Related to:
- Ventilation perfusion imbalance related to altered blood flow
- Changes to the alveolar-capillary membrane
- Pulmonary congestion due to fluid retention
As evidenced by:
- Dyspnea
- Changes in mental status
- Restlessness
- Anxiety
- Abnormal ABGs
- Changes in respiratory rate, depth, or rhythm
- Tachycardia
Expected outcomes:
- 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.
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.
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
Poor patient understanding or management of their condition can result in worsening symptoms and outcomes.
Nursing Diagnosis: Ineffective Health Maintenance
Related to:
- 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.
Expected outcomes:
- 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.
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.
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.
Risk for Unstable Blood Pressure
Risk for unstable blood pressure (BP) associated with heart failure can be caused by impaired structure and function of the heart muscle to pump blood effectively throughout the body.
Nursing Diagnosis: Risk for Unstable Blood Pressure
Related to:
- Conditions that compromise the blood supply
- Structural impairment of the heart
- Malfunctions of the heart structures
- Difficulty of the heart muscle to pump
- Increased exertion in workload
- Inadequate blood supply to the heart
- Inability to contract and relax effectively
- Erratic signals causing chaotic or irregular heart contraction
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred and the goal of nursing interventions is aimed at prevention.
Expected outcomes:
- Patient will maintain blood pressure within normal limits.
- Patient will not experience hypotension with activity.
- Patient will maintain strict adherence to antihypertensive medications as ordered.
Assessment:
1. Closely assess the patient’s blood pressure.
Heart attack and stroke can result from high systolic and diastolic blood pressure. Advise treating hypertension in heart failure with decreased ejection fraction. The target blood pressure is 130/80 mmHg.
2. Obtain blood samples for lab tests.
The following blood tests determine the risk for unstable blood pressure in patients with heart failure:
- Blood urea nitrogen and serum creatinine
- Electrolyte levels
- Thyroid function
- Cholesterol (lipid) levels
- Blood glucose levels
- Liver function
3. Review the patient’s current treatment.
Medications and herbal remedies aggravate or induce heart failure because they affect the blood pressure and heart muscles’ ability to pump blood and interact with other treatments and medications for heart failure. Examples of medications include:
- Spironolactone, angiotensin-converting enzyme (ACE) inhibitor, and furosemide can lead to electrolyte imbalances and renal failure
- Opioids and stimulants disturb the natural balance of certain neurotransmitters in the body and brain (catecholamines)
- Ashwagandha, blue cohosh, and Yohimbe are herbs sold in the United States that can cause cardiac toxicity
4. Identify underlying conditions.
Systemic diseases, cardiac disorders, and some genetic defects can result in heart failure. The most prevalent underlying causes of heart failure are coronary artery disease, hypertension, and a previous heart attack.
Interventions:
1. Treat the underlying condition.
Treatment of heart failure starts with prevention by reducing the risk factors. Patients should work to manage their blood pressure through exercise, weight loss, diet, medications, and smoking cessation.
2. Alert the patient when to seek emergency care.
Symptoms of hypertension or hypotension include:
- A rapid heartbeat
- Dizziness or fainting
- Profuse sweating
- Headache
- Blurred vision
- Chest pain
3. Instruct on how to take an accurate blood pressure reading.
If the patient is monitoring their blood pressure at home, ensure they adhere to the following:
- Try to take the blood pressure at the same times each day
- Rest for 5-10 minutes to allow the blood pressure to return to baseline
- Do not cross your legs or ankles while taking a blood pressure
- Do not talk while taking a blood pressure
Ensure the patient and/or family member are using the correct size cuff and placing it correctly on the arm.
4. Advise the patient to keep BP logs.
Heart failure (HF) patients’ usual clinical practice includes checking their blood pressure regularly. It is generally recognized that increased BP predicts cardiovascular risk. Advise the patient to keep accurate records to allow the healthcare team to monitor the effectiveness of treatment.
References
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