med-sur Chapter 26

Chapter 26: Nursing Care of Patients with Heart Failure

Learning Outcomes

• Understand the pathophysiology of left- and right-sided heart failure.

• Define acute heart failure.

• List causes of acute and chronic heart failure.

• Identify signs and symptoms of acute and chronic heart failure.

• Assist in planning nursing care for patients undergoing diagnostic tests for heart failure.

• Explain medical treatments used for acute and chronic heart failure.

• Plan nursing care and education for patients and their families with heart failure.

Heart Failure Overview

• Definition: Heart failure (HF) is a syndrome resulting from the progressive inability of the heart to pump enough blood to meet the body’s oxygen and nutrient needs.

• Older Term: Previously referred to as Congestive Heart Failure (CHF), as congestion is not always present.

Causes of Heart Failure

• Most Common Cause: Coronary artery disease.

• Other Causes:

  • Cardiomyopathy

  • Hypertension (HTN)

  • Heart valve disorders

  • Myocardial infarction

Pathophysiology of Heart Failure

• Ventricular Function: Both ventricles pump equal amounts of blood. Impairment in one leads to an overall decrease in pump effectiveness.

• Progression: Typically, the left ventricle weakens first which can lead to the failure of the right ventricle.

Left-Sided Heart Failure

• Afterload: The force generated by the left ventricle to eject blood into the aorta.

  • HTN increases afterload, causing additional strain on the left ventricle.

• Consequences: Blood backs up into the lungs, causing alveolar edema and impairing gas exchange.

Signs and Symptoms of Left-Sided Heart Failure

• Paroxysmal nocturnal dyspnea

• Elevated pulmonary capillary wedge pressure

• Restlessness and confusion

• Orthopnea (difficulty breathing when lying flat)

• Pulmonary congestion indicated by:

  • Cough (sometimes blood-tinged)

  • Crackles and wheezes

  • Tachypnea (rapid breathing)

• Tachycardia

• Fatigue and cyanosis

Right-Sided Heart Failure

• Mainly results from left-sided heart failure.

• Cor Pulmonale: Right ventricle hypertrophies and fails due to increased pressures in the pulmonary artery.

• Backward Build-up: Causes peripheral edema due to increased venous pressure.

Signs and Symptoms of Right-Sided Heart Failure

• Fatigue

• Increased peripheral venous pressure

• Ascites and hepatosplenomegaly (enlarged liver and spleen)

• Distended jugular veins

• Anorexia and GI distress

• Dependent edema (swelling in hands and fingers)

Compensatory Mechanisms in Heart Failure

• Cardiac Output: Low cardiac output triggers compensatory mechanisms:

  • Sympathetic nervous system activation increases heart rate.

  • Renin-angiotensin-aldosterone system causes fluid retention.

  • Heart chambers enlarge and muscle mass increases (hypertrophy).

• However, these mechanisms ultimately worsen heart failure by increasing oxygen demands.

Acute Heart Failure (Pulmonary Edema)

• Definition: A severe condition with life-threatening fluid congestion in the alveoli.

• Signs and Symptoms:

  • Classic presentation includes pink, frothy sputum.

  • Severe dyspnea (difficulty breathing) and rapid respirations using accessory muscles.

  • Crackles, wheezes, anxiety, and clammy skin.

• Diagnosis:

  • Important diagnostic tools include arterial blood gases, pulmonary pressures, and chest X-ray.

• Therapeutic Interventions:

  • Positioning (semi-Fowler or Fowler), oxygen therapy, diuretics, inotropic agents, and vasodilators.

Nursing Diagnoses for Acute Heart Failure

• Impaired gas exchange

• Decreased cardiac output

• Excess fluid volume

• Acute pain

Chronic Heart Failure

• Definition: A progressive condition where signs and symptoms may worsen over time.

• Signs and Symptoms:

  • Fatigue, exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, cough.

  • Auscultation may reveal crackles/wheezes and tachycardia.

  • Patients may experience chest pain, Cheyne-Stokes respiration, edema, anemia, nocturia, cyanosis, altered mental status, and malnutrition.

Complications of Heart Failure

• Enlarged organs (hepatomegaly and splenomegaly)

• Pleural effusion (fluid surrounding lungs)

• Risk of thrombosis and emboli

• Cardiogenic shock due to inadequate blood flow.

Diagnostic Tests for Heart Failure

• Screening Tests: Serum BNP, BUN, creatinine, liver function tests.

• Diagnostic imaging: Chest X-ray, echocardiography, ECG, cardiac stress testing, catheterization, sleep studies.

Therapeutic Intervention Goals

• Optimize heart function and reduce oxygen demand:

  • Identify and correct underlying causes,

  • Improve contraction strength,

  • Maintain fluid and sodium balance,

  • Decrease heart workload.

Medication Therapy for Heart Failure

• Oxygen therapy,

• ACE inhibitors, ARBs, or angiotensin receptor neprilysin inhibitors,

• Beta-blockers,

• Diuretics,

• Inotropic agents,

• Vasodilators,

• Ivabradine (to slow heart rate),

• Anticoagulants.

Digoxin Toxicity Signs

• Hypokalemia, hypomagnesemia, and hypercalcemia:

  • Symptoms include abdominal pain, nausea, vomiting, anorexia, visual changes, bradycardia.

Other Therapeutic Interventions

• Activity management, sodium and weight control, and device implantation (e.g., pacemakers, implantable cardioverter-defibrillators).

Surgical Interventions for Chronic Heart Failure

• Coronary artery bypass grafting,

• Valve replacement,

• Ventricular reconstruction.

Nursing Diagnoses for Chronic Heart Failure

• Impaired gas exchange,

• Decreased cardiac output,

• Acute pain,

• Anxiety,

• Excess fluid volume.

Nursing Interventions for Chronic Heart Failure

• Administration of oxygen,

• Guiding patient rest and activity levels,

• Fluid management and education on lifestyle changes (low-sodium diet, weight control).

Case Study Example

• Patient: Mrs. Garcia, 72, diagnosed with HF 3 years ago, presents with dyspnea and bilateral ankle swelling related to missed diuretic doses.

• Vital signs indicate hypoxic conditions affecting care plan and management strategies.

Cardiac Transplantation

• Indicated for end-stage heart failure, involving strict selection criteria, immunosuppressive therapy, and lifelong anti-rejection medications.

Complications of Cardiac Transplantation

• Risks include rejection, infection, malignancies, and side effects of anti-rejection medicines.