A nurse is caring for a client who has congestive heart failure and is taking digoxin daily

Learning Outcome

• Understand the clinical signs and symptoms of heart failure

  Inhaltsverzeichnis Show

  • Learning Outcome
  • Introduction
  • Nursing Diagnosis
  • Risk Factors
  • Medical Management
  • Nursing Management
  • When To Seek Help
  • Coordination of Care
  • Health Teaching and Health Promotion
  • Discharge Planning
  • Review Questions
  • Which of the following clients is at risk for developing digoxin toxicity?
  • Which medication places the client at risk for hyperkalemia?
  • What lab value should the nurse expect to monitor for a patient receiving furosemide?
  • Which food would the nurse instruct a client taking dilTIAZem to avoid?

• Understand the pathophysiology of heart failure

• Review the lifestyle modifications recommended for patients with heart failure

Introduction

Heart failure is a common and complex clinical syndrome that results from any functional or structural heart disorder, impairing ventricular filling or ejection of blood to the systemic circulation to meet the body's needs. Heart failure can be caused by several different diseases. Most patients with heart failure have symptoms due to impaired left ventricular myocardial function. Patients usually present with dyspnea, fatigue, decreased exercise tolerance, and fluid retention, seen as pulmonary and peripheral edema.[1]

Heart failure due to left ventricular dysfunction is categorized according to left ventricular ejection fraction (LVEF) into heart failure with reduced ejection fraction (LVEF 40% or less), known as HFrEF, and heart failure with preserved ejection fraction (LVEF greater than 40%); known as HFpEF.[2]

Nursing Diagnosis

• Decreased cardiac output 

• Activity intolerance

• Excess fluid volume

• Risk for impaired skin integrity

• Ineffective tissue perfusion

• Ineffective breathing pattern

• Impaired gas exchange

• Fatigue

• Anxiety

Causes

Heart failure is caused by several disorders, including diseases affecting the pericardium, myocardium, endocardium, cardiac valves, vasculature, or metabolism. The most common causes of systolic dysfunction (HFrEF) are idiopathic dilated cardiomyopathy (DCM), coronary heart disease (ischemic), hypertension, and valvular disease. For diastolic dysfunction (HFpEF), similar conditions have been described as common causes, adding hypertrophic obstructive cardiomyopathy and restrictive cardiomyopathy.[1]

Risk Factors

• Coronary artery disease

• Myocardial infarction

• Hypertension

• Diabetes

• Obesity

• Smoking

• Alcohol use disorder

• Atrial fibrillation

• Thyroid diseases

• Congenital heart disease

• Aortic stenosis

Assessment

Symptoms of heart failure include those due to excess fluid accumulation (dyspnea, orthopnea, edema, pain from hepatic congestion, and abdominal distention from ascites) and those due to a reduction in cardiac output (fatigue, weakness) most pronounced with physical exertion.[1]

Acute and subacute presentations (days to weeks) are characterized by shortness of breath at rest and/or with exertion, orthopnea, paroxysmal nocturnal dyspnea, and right upper quadrant discomfort due to acute hepatic congestion (right heart failure). Palpitations, with or without lightheadedness, can occur if patients develop atrial or ventricular tachyarrhythmias.

Chronic presentations (months) differ in that fatigue, anorexia, abdominal distension, and peripheral edema may be more pronounced than dyspnea. The anorexia is secondary to several factors, including poor perfusion of the splanchnic circulation, bowel edema, and nausea induced by hepatic congestion.[1]

Characteristic features:

• Pulsus alternans phenomenon characterized by evenly spaced alternating strong and weak peripheral pulses.

• Apical impulse: Laterally displaced past the midclavicular line, usually indicative of left ventricular enlargement.

• S3 gallop: A low-frequency, brief vibration occurring in early diastole at the end of the rapid diastolic filling period of the right or left ventricle. It is the most sensitive indicator of ventricular dysfunction.

• Peripheral edema

• Pulmonary rales

New York Heart Association Functional Classification[3]

Based on symptoms, the patients can be classified using the New York Heart Association (NYHA) functional classification as follows: 

• Class I: Symptom onset with more than ordinary level of activity

• Class II: Symptom onset with an ordinary level of activity

• Class III: Symptom onset with minimal activity

• Class IV: Symptoms at rest

Evaluation

Tests used in the evaluation of patients with HF include:

• Electrocardiogram (ECG): Important for identifying evidence of acute or prior myocardial infarction or acute ischemia, rhythm abnormalities, such as atrial fibrillation. 

• Chest x-ray: Characteristic findings are cardiac-to-thoracic width ratio above 50%, cephalization of the pulmonary vessels, Kerley B-lines, and pleural effusions.

• Blood test: Cardiac troponin (T or I), complete blood count, serum electrolytes, blood urea nitrogen, creatinine, liver function test, and brain natriuretic peptide (BNP). BNP (or NT-proBNP) level adds greater diagnostic value to the history and physical examination than other initial tests mentioned above.

• Transthoracic echocardiogram: To determine ventricular function and hemodynamics.

Medical Management

Diuretics, beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitor, hydralazine plus nitrate, digoxin, and aldosterone antagonists can produce an improvement in symptoms and are indicated for patients with HF based on their functional classification and severity of symptoms. Combination therapy with these agents improves outcomes and reduces hospitalizations in patients with HF.[3]

Improved patient survival has been documented with the use of beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor neprilysin inhibitor, hydralazine plus nitrate, and aldosterone antagonists. More limited evidence of survival benefit is available for diuretic therapy. Diuretic therapy is mainly used for symptom control. Angiotensin receptor neprilysin inhibitors should not be given within 36 hrs of angiotensin-converting enzyme inhibitors dose.[3]

In African-Americans, hydralazine plus oral nitrate is indicated in patients with persistent NYHA class III to IV HF and LVEF less than 40%, despite optimal medical therapy (beta-blocker, angiotensin-converting enzyme inhibitors, ARB, aldosterone antagonist (if indicated), and diuretics.[3]

Device therapy: Implantable cardioverter-defibrillator (ICD) is used for primary or secondary prevention of sudden cardiac death. Cardiac resynchronization therapy with biventricular pacing can improve symptoms and survival in selected patients who are in sinus rhythm and have a reduced left ventricular ejection fraction and a prolonged QRS duration. Most patients who satisfy the criteria for cardiac resynchronization therapy implantation are also candidates for an implantable cardioverter-defibrillator and receive a combined device.[3]

A ventricular assist device (bridge to transplant or as a destination therapy) or cardiac transplant is reserved for those with severe disease despite all other measures.

Nursing Management

The nursing care plan for patients with HF should include:[4]

• Relieving fluid overload symptoms

• Relieving symptoms of anxiety and fatigue

• Promoting physical activity

• Increasing medication compliance

• Decreasing adverse effects of treatment

• Teaching patients about dietary restrictions

• Teaching patient about self-monitoring of symptoms

• Teaching patients about daily weight monitoring

When To Seek Help

Prompt assessment by the medical team is indicated in the following situations:

• Worsening symptoms of fluid overload

• Worsening hypoxia 

• Uncontrolled tachycardia regardless of the rhythm

• Change in cardiac rhythm

• Change in mental status

• Decreased urinary output despite diuretic therapy

Monitoring

Patients with HF require frequent monitoring of vital signs, including oxygen saturation. They may also require constant monitoring of the heart rate and rhythm via telemetry monitoring. Frequent assessment and monitoring for symptoms is also indicated. All patients with HF require daily weight monitoring.

Coordination of Care

Heart failure is a serious disorder best managed by an interprofessional team that includes the primary care physician, emergency department physician, cardiologist, radiologist, cardiac nurses, internist, and cardiac surgeons. It is imperative to treat the cause of heart failure. Healthcare workers who look after these patients must be familiar with current guidelines on treatment. The risk factors for heart disease must be modified, and the clinical nurse should educate the patient on the importance of medication compliance and lifestyle modifications. When the condition is not managed appropriately, it is associated with high morbidity and mortality, including poor quality of life.[5]

Health Teaching and Health Promotion

Nursing care plans for patients with HF must include patient education to improve clinical outcomes and reduce hospital readmissions. Patients need education and guidance on self-monitoring of symptoms at home, medication compliance, daily weight monitoring, dietary sodium restriction to 2 to 3 g/day, and daily fluid restriction to 2 L/day. In addition, patients with HF need aggressive treatment for underlying risk factors and the potential triggers for HF exacerbations. Modifiable risk factors include diabetes mellitus, hypertension, obesity, nicotine use, alcohol use disorder, and recreational drug use, especially cocaine. Patients with sleep apnea and HF should be encouraged to use continuous positive airway pressure (CPAP) therapy as uncontrolled sleep apnea can also increase HF-associated morbidity and mortality.  

Discharge Planning

Discharge planning for patients with HF must include patient education on medication management, medication compliance, low-sodium diet, fluid restriction, activity and exercise recommendations, smoking cessation, and learning to recognize the signs and symptoms of worsening HF. Discharge planning for patients with HF must also include follow-up appointments to ensure patients have a close medical follow-up after discharge. Nurse-driven education at the time of discharge has been shown to improve compliance with therapy and improve patient outcomes in heart failure.[6]

Review Questions

Figure

congestive heart failure. Image courtesy S Bhimji MD

References

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Which of the following clients is at risk for developing digoxin toxicity?

Which medication places the client at risk for hyperkalemia?

What lab value should the nurse expect to monitor for a patient receiving furosemide?

Which food would the nurse instruct a client taking dilTIAZem to avoid?