Management of patient

with Heart Failure

Prepared by

Dr. Mervat A. Ghaleb

Assist. Prof. Med. Surg. Nursing

Refer to: Suzanne C. Smeltzer EdD, et al. Brunner & Suddarth's Textbook of Medical Surgical Nursing. 12th Ed. 2010. Lippincott Williams & Wilkins

Learning Objectives:Upon completion of this lecture the student will be able to:

�Define heart failure (HF)

�Classify HF

�List causes of HF

�Differentiate between systolic & diastolic HF

�Describe Pathophysiology HF

�Learning Objectives: Cont.

�Differentiate between the clinical manifestation of left & right sided HF

�Identify different investigations for HF

�Describe the medical management of patient with HF

�Use nursing process as a framework for care of patients with HF

�Definition of Heart Failure (HF) : �Heart failure is the inability of the heart

to pump sufficient blood to meet the needs of tissues for oxygen and nutrients

�

Definition of Heart Failure (HF):Currently HF is recognized as a clinical syndrome characterized by signs and symptoms of fluid overload or of

inadequate tissue perfusion. 

In the past, HF was often referred to as congestive heart failure, because the patients experience pulmonary & / or

peripheral congestion.

Classification of Heart Failure:There are different classifications of HF:

I: Heart Failure can be classified to:

�Left sided heart failure

�Right sided heart failure

�Combined left and right sided heart failure

II: Another classification:

�Acute HF (Pulmonary oedema)

�Chronic HF

III: Recent Classification:

�Systolic HF

�Diastolic HF

Systolic HF:It is an alteration in ventricular contraction which is characterized by weakened heart muscle. (Reduced EF)

It is the more common type.

Diastolic HF:Characterized by a stiff & noncompliant heart muscle, make it difficult for the ventricle to fill

�Ejection fraction is defined as the proportion , or fraction of the blood pumped out of the heart with each beat.(NAPSE, 2001)

Ejection Fraction (EF): (It is about 55-65%)

EF= amount of blood at the end of diastole (130) - amount of blood at the end of systole (75) = 55

EF is a valuable index for ventricular function.

Http://www.naspe-patients.org/patients/ejectionfraction.html

Pathophysiology of HF:

Myocardial Dysfunction due to IHD , HTN, MI CO, BP, Renal

perfusion Activation of renin-

angiotensin aldosterone

system

Vasoconstriction

Activation of sympathetic

nervous system

Afterload, BP, heart rateVentricular remodeling

(Hypertrophy of the ventricle & impaired contractility

Pathophysiology of HF:It can lead to passive increase in left atrial and pulmonary venous pressure.

It also lead to right failure & systemic venous congestion leading to jugular venous

distension, hepatomegaly, ascitis & edema.

Causes of HF:

4. Valvular heart disease

2. Coronary artery disease

Systemic or pulmonary hypertensionDiseases leading to hyperdynamic circulationCauses which lead to right sided HF only (cor pulmonale)

Clinical manifestation:�Dyspnea: dyspnea on exertion; dyspnea at

rest.

�Orthopnea

�Paroxysmal nocturnal dyspnea

�Cough, initially dry, then moist.

�Large quantities of frothy sputum, which is sometimes pink in severe pulmonary

congestion (pulmonary edema).

�Oliguria

�Fatiguability

�Restlessness and anxiety

�Nocturia

�Signs: �Jugular venous distension

�Apex of the heart is shifted to downward & laterally due to cardiomegally

�Fine basal lung crepetitions

�3rd & 4th heard sounds

�Hepatomegally

�Ascitis

�Edema of lower extremities

���

Management:The overall goals of management of HF are:

�To relieve patients’ symptoms

�To prevent complications

Investigations:

Lab. Investigations:ElectrolytesUrine analysisRenal function testsCBCTSHAlbuminuriaLiver function test

the bulge seen on the right side is an enlarged left ventricle

Chest x rayDoppler ultrasound

�To improve patients’ quality of life

�To extent survival.

� I: Medical Management:

�1 . Non- Pharmacologic Therapy :

�Correct reversible causes

�Bed rest

�Sodium restriction less than 2 gm/day

�Water restriction less than 1.5 litre/day

�Increase aerobic exercises

�Avoidance of other risk factors: stop smoking, alcohol and high fat diet.

�2 . Pharmacologic Therapy :

�Angiotensin Converting Enzyme Inhibitor (ACEI):

�ACI inhibitors slow the progression of HF, improve exercise tolerance, and decrease the

number of hospitalization.

�They promote vasodilatation and diuresis by decreasing afterload and preload.

�For example: captopril (Capoten).

�Better to start with smaller doses.

�Side effects: Hypotension, dehydration, hyperkalemia, cough, renal failure if the

patient has renal artery stenosis.

�Angiotensin II receptor blockers:

�ARBs block the conversion of angiotensin I to angiotensin II, block the effects of angiotensin

I at angiotensin II receptors.

�They decrease blood pressure, decrease vascular resistance & improve cardiac output.

� For example: Diovan (valsartan)

�ARBs are usually prescribed as an alternative to ACE inhibitors, when patients cannot

tolerate it because of cough.

�Hydralazine and isosorbid dinitrate (Isordil)

�A combination of Hydralazine (Apresoline) & Isosorbid Dinitrate (Isordil) may be another alternative for patients who cannot take ACE

inhibitors.

�Nitrate causes venous dilatation which reduces the amount of blood return to the

heart and lower preload.

�Hydralazine lowers systemic vascular resistance & left ventricular afterload.

�Diuretic Therapy:

�Promotes excretion of Na and water through the kidneys.

�These medications may not be necessary if the patient responds to activity recommendation, avoidance of excessive fluid intake and low Na diet (2gm/day)

�Nursing considerations:

�For patients receiving thiazide diuretics :

�Encourage intake of potassium rich food as fruits for risk of hypokalemia.

�Measure blood pressure in three positions for risk of postural hypotension

�Monitor signs of Na, K & Mg imbalances.

�For patients receiving loop diuretics :

�Monitor signs and symptoms of electrolyte imbalances

�Monitor blood pressure

�For patients receiving potassium sparing diuretics :

�Monitor for hyperkalemia

�Hyperkalemia is high in patients on ACEI & spironolactone

�Administer drug after meal to overcome gastro intestinal upset.

�Digitalis:

�Increases the force of the myocardial contraction and slows the heart rate.

�Increases cardiac output.

�Decreases venous pressure.

�Increase diuresis.

�A maintenance dose is administered daily.

�It is of limited use now except to heart failure accompanied with atrial flutter or fibrillation.

�Hypokalemia and hypoxia may increase its toxicity, so it should be corrected before

intiation digitalis therapy.

Signs of digitalis toxicity:

�Early signs: Fatigue, depression, malaise, anorexia, nausea & vomiting.

�Changes in heart rhythm

�Ventricular dysrhythmias, atrial tachycardia with block, ventiricular tachycardia.

�II: Nursing management :

�1 . Assessment :

�Health history:

�Sleep disturbance due to dyspnea

�Number of pillows needed for sleep

�Activities of daily living activities that cause dyspnea.

� Respiratory:

�Auscultate the lungs to determine the presence or absence of crackles and wheezes,

gurgling.

�Assess the rate and depth of respiration.

�Cardiac :

�Note the rate and rhythm of pulse.

�Apical heart rate is assessed before digitalis is administered .

�If there is slowing in rate or change in rhythm, the medication is withheld and the

physician is notified.

� 

�Sensorium/level of consciousness :

�Assess patient’s level of consciousness, whether confusion is present

�Periphery :

�Assess the dependent parts of the body for edema, feet and lower legs if the patient is sitting upright and sacrum and back if the

patient is in supine position.

�Urinary output :

�Intake and output record is maintained.

�Weigh the patient daily at the same time and on the same scale.

�Electrolyte balance :

�Observe for signs of hyponatremia (Muscle cramps and twitching, fatigue, malaise,

weakness, rapid and thready pulse).

�Observe for signs of hypokalemia (weak pulse, hypotension, muscle flabbiness, diminished tendon reflexes, generalized weakness, and

marked weakening of cardiac contraction.

�Periodic assessment of the electrolyes

�2 . Nursing diagnosis :

�Activity intolerance related to imbalance between O2 supply and demand and fatigue and dyspnea secondary to decreased cardiac

output.

�Fatigue related to heart failure.

�Fluid volume excess related to excess fluid/Na intake or retention secondary to CHF.

�Anxiety related to breathlessness and restlessness secondary to inadequate

oxygenation.

�Altered peripheral tissue perfusion related to venous stasis.

�Non comlpiance related to lack of knowledge.

�Powerlessness related to inability to perform role responsibilities secondary to chronic

illness and hospitalization.

�Potential knowledge deficit of self-care program related to nonacceptance of

necessary lifestyle changes.

�3 . Planning and implementation :

� Goals:

�Promotion of activity

�Reducing fatigue

�Relieve of fluid overload symptoms

�Relief of anxiety

�Attainment of normal tissue perfusion

�Knowledge of self care program

�Absence of complications

�4 . Nursing Intervention :

�� Promoting activity tolerance / Promoting rest :

�Physical and mental rest

�Complete bed rest during acute phase, then encourage gradual activity to increase activity

tolerance and induce diuresis.

�Changing position, deep breathing exercise, use elastic stoking, leg exercises in case of

complete bed rest.

�Avoid long term bed rest to prevent occurrence of complications of

immobility.

�Elevate the head of the bed 20-30 cm or position the patient in armchair.

�If the patient is orthopneic, position him/or her in orthopneic position.

�O2 administeration during acute phase to decrease work of breathing.

�Reducing fatigue:

�Alternate periods of activity with periods of rest.

�Check vital signs before, during and after activity, so heart rate should return to normal

within 3 minutes.

�Avoid two energy consuming activities occur on the same day or same sessions

�Small frequent meals.

�Relieving anxiety:

�Avoid situations that provoke anxiety

�Speak in slow, calm and confident manner.

�Give correct information

�Raise the head of the bed

�Keep a night light and ensure sleepy environment

�Presence of a family member may be helpful

�Promoting normal tissue perfusion:

�Moderate daily exercise

�Effective diuresis

�Adequate rest

�Managing fluid volume:

�In case of severe HF IV diuretics

�In case less severe HF oral diuretics early in the morning

�Monitor patient’s fluid status:

�Auscultate the lungs

�Daily weighing

�Intake and output

�Low Na diet

�Fluid restriction

�Assess skin breakdown and use preventive measures

�Use elastic pressure stocking and leg exercise to prevent skin injury

�Patient education:

�Obtain adequate rest

�Take digitalis, diuretic, vasodilator as prescribed.

�Restrict sodium as directed

�Review activity program

�Be alert to the following symptoms: weight gain, loss of appetite, shortness of breath with activity, swelling of ankles and feet, persistent

cough and frequent urination at night.

�