Signs and symptoms:
Dyspnea on exertion (DOE) or at rest, fatigue, decreased exercise tolerance, weakness, orthop- nea (unable to lie flat; may need to sleep on pillows or sitting in a chair), paroxysmal nocturnal dyspnea, wheezing, cough, cyanosis, irregular or rapid HR, sudden weight gain from fluid retention, lower extremity edema, abdominal distention, nausea, early satiety, and nocturia. Associated indicators include chest/anginal pains, palpitations, near-syncope, and syncope. Low-output symptoms include positional lightheaded- ness, weakness, mental status changes, and decreased urine output.
Physical assessment:
Decreased or elevated blood pressure (BP), dysrhythmias, tachycardia, tachypnea, increased venous pulsations, pulsus alternans (alternating strong and weak heartbeats), increased central venous pressure (CVP), jugular venous distention, crackles (rales), wheezes, decreased breath sounds, cardiac gallop and/or murmur, hepatomegaly, ascites, and pitting edema in dependent areas (lower extremities, sacrum).
History/risk factors:
CAD, hypertension, DM, OSA or
other pulmonary disease, recent IV fluid infusions, surgery,
pregnancy, recent/current infectious illness, pneumonia, non-
adherence to medication or diet regimen, obesity, hypercho-
lesterolemia, and recent nonsteroidal antiinflammatory
drug or COX-2 inhibitor use. In addition, see “Other causes
of heart failure,” earlier.PART I: Medical-Surgical Nursing
Oximetry/arterial blood gas (ABG) values:
Measure oxygen levels in the blood. ABGs assess oxygen, carbon dioxide, bicarbonate, and pH levels. Hypoxemia and metabolic/
respiratory acidosis often occur in acute myocardial ischemia, cardiac arrest, and severe HF. Overnight (sleep) oximetry evaluates obstructive sleep apnea.
Serum blood urea nitrogen (BUN), creatinine:
Elevated in renal insufficiency and chronic kidney disease. It may be ele- vated in poor renal perfusion associated with low cardiac output and hypotension. Treatment with diuretics, angiotensin- converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), or aldosterone antagonists also affects these renal markers.
Serum electrolytes:
Altered in multiple cardiac and renal conditions/diseases. Careful monitoring is essential to avoid cardiac arrest due to dysrhythmias caused by alterations in potassium, magnesium, calcium, sodium, and phosphorous.
Cardiac enzymes:
Mild elevation in cardiac troponins (with normal creatinine kinase [CK]) is common in patients
Liver function tests, including serum aspartate amino- transferase and serum bilirubin:
May be elevated in patients with hepatic congestion.
Brain natriuretic peptide (BNP):
Released from the ventri- cles in response to wall stress. This test is useful in differentiat- ing HF from other causes of dyspnea, including pulmonary disease. Negative BNP (less than 100 pg/mL) suggests non-HF etiology. When used in conjunction with standard clinical assessment, elevated BNP may support diagnosis of HF and evaluate the patient’s response to treatment.
Digoxin level:
The goal in patients with HF is a level less than 1.0 ng/mL. Hypokalemia and impaired renal function can predispose patients to digoxin toxicity.
Complete blood count (CBC):
May reveal decreased hemoglobin (Hgb) and hematocrit (Hct) in the presence of anemia.
Thyroid-stimulating hormone level:
To rule out hyperthy- roidism or hypothyroidism, either of which may contribute to HF and dysrhythmias.
Nursing Diagnosis
Impaired Gas Exchange
related to alveolar-capillary membrane changes (fluid accumulation in the alveoli)
Desired Outcome:
Within 30 min of treatment/intervention, the patient has adequate gas exchange as evidenced by normal breath sounds and skin color, presence of eupnea, HR 100 bpm or less, Pa
O280 mm Hg or higher, and Pa
CO245 mm Hg or less.
ASSESSMENT/INTERVENTIONS RATIONALES
Assessalllungfieldsforbreathsounds. Thepresenceofcrackles(rales)maysignalalveolarfluidcongestionand
systolicdysfunctional(left-sided)HF.Decreasedbreathsoundssignifyfluid
overloadordecreasedventilation.Wheezingmaysignifyassociated
bronchitisorasthma.
MonitoroximetryandABGvaluesandreportsignificantfindings. Oximetryof92%orlessandthepresenceofhypoxemia(decreasedPaO2)and
hypercapnia(increasedPaCO2)signifydecreasedoxygenation.
Assessrespiratoryrate(RR),lungexcursion,useofaccessory
muscles,airhunger,mentalstatuschanges,cyanosis,and
changesinHRorBP.Reportsignificantchanges.
Thesearesignsofincreasingrespiratorydistressthatrequireprompt
intervention.
AssistthepatientintohighFowler’spositionwiththeheadofbed
(HOB)up90degrees.
Thispositiondecreasesworkofbreathing,reducescardiacworkload,and
promotesgasexchange.
Teachthepatienttotakeslow,deepbreaths. Takingdeepbreathsincreasesoxygenationtothemyocardiumandimproves
prognosis.Hypoxiaaddsstresstothealreadydistressedmyocardium.
Administeroxygenasprescribed.Deliveroxygenwithhumidity. InADHF/pulmonaryedema,high-flowO2maybegiveneitherbynon- rebreathingmask,positiveairwaypressuredevices,orendotracheal
intubationandmechanicalventilation.Oncestabilized,O2istitratedto
keeppulseoximetryreadingshigherthan92%.
Humidityhelpspreventoxygen’sconvectivedryingeffectsonoralandnasal
mucosa.
PART I
MEDICAL-SURGICALNURSING:Cardiovascular Care Plans ExcessFluidVolume
Heart Failure171
CardiovascularCarePlans
PART I: Medical-Surgical Nursing
continued
ASSESSMENT/INTERVENTIONS RATIONALES
Administerdiureticsasprescribed. Diureticspromotenormovolemiabyreducingfluidaccumulationandblood
volume.Fluidoverloaddecreasesperfusioninthelungs,causing
hypoxemia.
MonitorK+levels. Thereispotentialforhypokalemia(K+lessthan3.5mEq/L)inpatientstaking
somediuretics,suchasfurosemideandmetolazone.
Administervasodilatorsasprescribed. Vasodilatorsincreasevenouscapacitance(dilation)anddecreasepulmonary
congestion,whichwillimprovegasexchange.
Hydralazineisanoralvasodilatorandafterloadreducer.Itisusedin
combinationwithnitratesinpatientswhoareACEinhibitor/ARBintolerant
becauseofrenaldysfunction.ItimprovesmortalityandHFsymptomstoa
lesserdegreethanACEinhibitorsandcancausereflextachycardia.
Nitratesarecoronaryvasodilatorsusedinconjunctionwithhydralazine(see
above).Theyarealsousedinischemicheartdiseaseasantianginaldrugs.
ACE inhibitors(enalapril,lisinopril,benazepril,captopril,quinapril,ramipril)
suppresseffectsoftherenin-angiotensinsystembyreducingangiotensinII
andcausingdecreasedaldosteronesecretion.ThesedrugslowerBPand
reducepreloadandafterload,decreasingworkoftheleftventricle.
Angiotensin II receptor antagonists(ARBs—losartan,valsartan,candesartan)
areusedforpatientswhodonottolerateACEinhibitorsbecauseofcough
causedbybradykininrelease.
Asindicated,haveemergencyequipment(e.g.,airway,manual
resuscitationbag)availableandfunctional.
PatientswithseverelydecompensatedHFmaysuffercardiacarrest.
Asindicated,preparetotransferthepatienttoICU. Thepatientmayrequireinvasiveand/orclosermonitoring.
Nursing Diagnosis
Excess Fluid Volume
related to compromised regulatory mechanisms occurring with decreased cardiac output
Desired Outcomes:
Within 1 hr of intervention/treatment, the patient demonstrates less shortness of breath and has output greater than intake on intake and output (I&O) monitor- ing. Within 1 day of treatment/intervention, edema is 1+ or less on a 0-4+ scale. Weight becomes stable within 2-3 days.
ASSESSMENT/INTERVENTIONS RATIONALES
AtfrequentintervalsassessI&O,includinginsensiblelossesfrom
diaphoresisandrespirations.
Decreasingurinaryoutputcansignaldecreasedcardiacoutput,which
decreasesrenalbloodflow.
Assessdailymorningweight;recordandreportsteadylossesorgains. Thisassessmenthelpsidentifyfluidretentionandfluidloss,enabling
titrationofdiuretics.
Assessforedema(interstitialfluids),especiallyindependentareassuch
astheanklesandsacrum.
Thepresenceofweightgainandedemaisakeydeterminantoffluid
retention.Ifdiligentassessmentismaintainedandearlyintervention
ispracticed,theoccurrenceofrehospitalizationcanbedecreased
dramatically.
Assesstherespiratorysystemforindicatorsoffluidextravasation,such
ascrackles(rales)orpink-tinged,frothysputum.
Thesearesignsoffluidvolumeexcessandsystolicdysfunction
(left-sided)HF.
Monitorforjugularveindistention,peripheraledema,andascites. Theseareotherindicatorsoffluidoverload.
Monitorlaboratoryresultsforincreasedurinaryspecificgravity,
decreasedHct,increasedurineosmolality,hyponatremia,
hypokalemia,andhypochloremia.
Thesefindingsareindicatorsoffluidimbalance.
PART I: Medical-Surgical Nursing
MonitorIVrateofflow.Useaninfusioncontroldevice. ThesemeasuresareessentialtopreventvolumeoverloadduringIV
infusion.
Unlesscontraindicated,provideicechipsoricepops.Recordamounton
theI&Orecord.Providefrequentmouthcaretoreducedrymucous
membranes.
Thesemeasureshelpthepatientcontrolthirstwhileprovidingminimal
amountsoffluid.Note:Somecarecentersadvocatesmallamounts
ofroom-temperaturewaterinsteadbecauseitmayrelievethirst
better.
Administerdiureticsasprescribed,andrecordthepatient’sresponse. Diureticspromotenormovolemiabyreducingfluidaccumulationand
bloodvolume.
Loop diuretics(furosemide,bumetanide,torsemide):Theseagents
promoteexcretionofwaterandsodium,reducepreload,andprevent
fluidretention.InADHF,thesediureticsareadministeredviaIVbolus
orindripformuntilstabilizationoccurs.Thesedrugscancause
neurohormonalactivationandaggravatepreexistingrenal
dysfunctionorhypokalemia.
Thiazide diuretics(hydrochlorothiazide,metolazone):Hydrochlorothiazide
maybeusedformildfluidretention.Metolazoneisapotentdrug
that,whengiven12hrbeforeloopdiuretics,markedlypotentiates
diuresisandthereforeisreservedformoreseverevolumeoverload
inADHForlate-stageHF.Hyponatremia,hypokalemia,and
worseningofrenalfunctionmayoccurandnecessitatecareful
assessment.
Administermorphinesulfateifprescribed. Morphineinducesvasodilationanddecreasesvenousreturntothe
heart.
Teachpatientsandfamiliesabouttheimportanceofadheringtoa
low-sodiumdiet.
Hypernatremiacanpromoteexcessfluidretention.A2-g-per-day
sodiumdietisrecommendedformostpatients.
Nursing Diagnosis
Risk for Decreased Cardiac Tissue Perfusion
related to interrupted blood flow occurring with decreased cardiac output
Desired Outcome:
By at least the 24-hr period before hospital discharge, the patient has adequate tissue perfusion as evidenced by BP within 20 mm Hg of baseline BP; HR 100 bpm or less with regular rhythm; RR 20 breaths/min or less with normal depth and pattern (eupnea); brisk capillary refill (less than 2 sec); and significant improvement in mental status or orientation to person, place, and time.
ASSESSMENT/INTERVENTIONS RATIONALES
AssessBPq15minormorefrequentlyifunstable.Bealerttodecreases
greaterthan20mmHgoverpatient’sbaselineorassociated
changessuchasdizzinessandalteredmentation.
HypotensionisasideeffectofmanyHFmedications,aswellasa
consequenceofaggressivediuresis.Carefulmonitoringisessentialto
avoiddecreasedperfusiontovitalorgans.
AssessHRq15-30min.Monitorforirregularities,increasedHR,or
skippedbeats.
Thesesignsmaysignaldecompensationanddecreasedfunctionofthe
heart.
Assesstheextremitiesforpulsepresenceandamplitude,capillaryrefill,
edema,color,andtemperature.
Decreasedpulseamplitude,delayedcapillaryrefill(morethan
2sec),pallor,andcoolnessareindicatorsofperipheral
vasoconstriction(fromSNScompensation).Edemaisevidence
offluidoverload.
Reportanyassessmentchangesimmediatelytothehealthcare
provider.
Significantalterationsmaybelifethreatening.
Assessforrestlessness,anxiety,mentalstatuschanges,confusion,
lethargy,stupor,andcoma.Institutesafetyprecautionsaccordingly.
Theseareindicatorsofdecreasedcerebralperfusionandhypoxiaand
shouldbeaddressedpromptlyforrapidintervention.
PART I
MEDICAL-SURGICALNURSING:Cardiovascular Care Plans DecreasedCardiacOutput
Heart Failure173
CardiovascularCarePlans
PART I: Medical-Surgical Nursing
continued
ASSESSMENT/INTERVENTIONS RATIONALES
Administerinotropicmedicationsandvasodilatorsasprescribed.
Monitoreffectsclosely.Bealerttoproblemssuchashypotension
andirregularheartbeats.
IVinotropicmedications(dobutamine,dopamine,milrinone)increase
strengthofcontractionsandarereservedforuseinADHF-associated
low-cardiacoutputandcardiogenicshockuntilthepatientisstabilized.
Theymaybeusedlongerterminadvanced-stageHFasabridgeto
transplantationorforpalliationofsymptoms.Usemaybeassociated
withincreasedmortalityandventriculardysrhythmias.Administration
ofinotropicmedicationsmayrequiretransfertothecoronarycareunit
(CCU)tomonitorforhemodynamiceffectsanddysrhythmias.
IVvasodilators(nitroglycerin[NTG],nitroprusside,nesiritide)areusedin
ADHFtodecreasecardiacworkloadbyreducingventricularfilling
pressuresandsystemicvascularresistance(SVR,afterload).These
medicationsareavoidedinlow-outputHF,cardiogenicshock,and
systolicbloodpressure(SBP)lessthan90mmHg.
- Nesiritide:Balancedarterialandvenousvasodilator.Thismedication
canalleviateacutedyspneaandreducepulmonarycapillarywedge
pressure(PCWP)withinthefirst30minoftherapy.Itpromotes
diuresisandnatriuresisbutdoesnotreplaceneedfordiuretic
therapy.Itimprovescardiacoutputbyoff-loadingtheheartand
decreasesneurohormonalactivation.ItdoesnotrequireCCU
monitoring.
- NTG:Arterialandvenousvasodilator.ItalsoreducesPCWPandmay
requireICU/CCUmonitoring.Becauseoftachyphylaxis(tolerance),
patientsmayneedescalatingdosestoachievethedesiredeffect.
- Nitroprusside:Potentarterialandvenousvasodilatorandafterload
reducer.Itmustbeadministeredinintensivecareduetotheneedfor
continualhemodynamicmonitoring.
- Morphine sulfate:AcoronaryvasodilatorthatmaybegiveninADHF
oracutepulmonaryedematodecreaseanxietyandworkofbreathing
andtorelieveanginaifischemicheartdiseaseispresent.
Nursing Diagnosis
Decreased Cardiac Output
related to negative inotropic changes in the heart (decreased cardiac contractility)
Desired Outcomes:
By at least the 24-hr period before hospital discharge, the patient exhibits adequate cardiac output as evidenced by SBP at least 90 mm Hg, HR 100 bpm or less, urinary output at least 30 mL/hr (0.5 mL/kg/hr), stable weight, eupnea, normal breath sounds, and edema 1+ or less on a 0-4+ scale. By at least 48 hr before hospital discharge, the patient is free of new dysrhythmias, does not exhibit significant changes in mental status, and remains oriented to person, place, and time.
ASSESSMENT/INTERVENTIONS RATIONALES
Assessforjugularvenousdistention,extraheartsoundssuchasS3,
changesinmentalstatusorlevelofconsciousness,cool
extremities,hypotension,tachycardia,andtachypnea.
Theseareindicatorsofdecreasedcardiacoutput,whichshouldbereported
promptlyfortimelyintervention.
Assesslungsforadventitiousbreathsoundsandshortnessofbreath. Dyspnea,crackles,andshortnessofbreathsignalfluidaccumulationinthe
lungsandmaybeadirectindicatorofventricularfailureanddecreased
cardiacoutput.CardiacoutputdecreasesasHFprogresses.
MonitorI&O;weighthepatientdaily. Decreasingurineoutputandweightgaincanoccurasaresultofdecreased
cardiaccontractility,whichcancausedecreasedrenalperfusionand
fluidretention.
PART I: Medical-Surgical Nursing
Assessforperipheral(sacral,pedal)edema. Edemacanoccurwithdiastolicdysfunction(right-sided)HF/myocardial
infarction.
Assistwithactivitiesofdailylivingandfacilitatecoordinationof
healthcareproviders,allowing90minforundisturbedrest.If
necessary,limitvisitors.
Restdecreasescardiacworkload.
Administermedicationsasprescribed,suchasbeta-blockers,
calciumchannelblockers,andantidysrhythmicagents.
Beta-blockers(metoprololXL)andalpha/beta-adrenergic blockers
(carvedilol):BlockeffectsofSNSandtoxiceffectsofneurohormoneson
themyocardium.ThesemedicationsdecreaseHRandBP,thereby
decreasingcardiacworkload.
Calcium channel blockers:MaybeusedindiastolicHFtoassistwith
relaxationandfillingandreduceoutflowtractobstruction(hypertrophic
cardiomyopathy).Exceptforamlodipineorfelodipine,calciumchannel
blockersareavoidedinLVsystolicdysfunctionbecausetheydecrease
cardiaccontractility.
AmiodaroneisanexampleofanantidysrhythmicgivenforpatientswithHF.
Explainthepotentialfordysrhythmiamanagementunderthe
guidanceofanelectrophysiologist/cardiologist.
Dysrhythmiashavebecomeamajorfactorinquality-of-lifeissuesand
rehospitalizationinpatientswithHF.Manyofthesepatientsrequirean
implantablecardioverter-defibrillator(ICD)becauseofrepeated
life-threateningepisodesofventriculartachycardiafromanirritable
myocardium.Patientswithventricularasynchrony,asseeninbundle
branchblocks,maybenefitfromabiventricularpacer.Pacingeach
ventricleinsynchronymayresultinbettercardiacoutput.
Assistthepatientintoapositionofcomfort,usuallysemi-Fowler’s
position(HOBup30-45degrees).
Thispositiondecreasesworkofbreathingandreducescardiacworkload.
Nursing Diagnosis
Activity Intolerance
related to imbalance between oxygen supply and demand occurring with a decrease in cardiac muscle contractility
Desired Outcome:
During activity, the patient rates perceived exertion at 3 or less on a 0-10 scale and exhibits cardiac tolerance to activity as evidenced by RR 20 breaths/min or less, SBP within 20 mm Hg of resting range, HR within 20 bpm of resting HR, and absence of chest pain and new dysrhythmias.
ASSESSMENT/INTERVENTIONS RATIONALES
Assessthepatient’sphysiologicresponsetoactivityandreport
significantfindings.
Chestpain,newdysrhythmias,increasedshortnessofbreath,HR
increasedgreaterthan20bpmoverrestingHR,andSBPgreaterthan
20mmHgoverrestingSBParesignificantfindingsofdecreased
cardiacoutputorcardiacfailurethatcanmanifestduringactivity.
Askthepatienttorateperceivedexertion(RPE)(seep.62fora
description).
Optimally,patientsshouldnotexperienceRPEofmorethan3.Ifthis
happens,intensityoftheactivityshouldbedecreasedanditsfrequency
increaseduntilRPEof3orlessisachieved.
Assessvitalsignsq4h,andreportsignificantfindings. FindingssuchasirregularHR,HRgreaterthan100bpm,ordecreasingBP
maybesignsofcardiacischemia.
Beforehospitaldischargeteachthepatientself-measurementofHR
forgaugingexercisetolerance.
AnHRthatistoohighincreasesmyocardialO2demand;anHRthatis
toolowmaycausemoreischemia.Patientsshoulduseanexertion
scaleandapainscaletogaugeexercisetoleranceandensurethat
HRislessthan20bpmoverbaselineorasprescribedbythehealth
careprovider.