Cover Article

Fluid Management
Strategies in
Heart Failure
Nancy M. Albert, PhD, CCNS, CHFN, CCRN, NE-BC

In patients with chronic heart failure, fluid retention (or hypervolemia) is often may not have classic signs and symp-
the stimulus for acute decompensated heart failure that requires hospitalization. toms of clinical congestion, such as
The pathophysiology of fluid retention is complex and involves both hemodynamic respiratory distress, crackles, inter-
and clinical congestion. Signs and symptoms of both hemodynamic and clinical stitial/alveolar edema, elevated jugu-
congestion should be assessed serially during hospitalization. Core heart failure lar venous pressure or jugular venous
drug and cardiac device therapies should be provided, and ultrafiltration may be
distension, findings on chest radi-
warranted. Critical care, intermediate care, and telemetry nurses have roles in both
ographs, and an S3 heart sound.
assessment and management of patients hospitalized with acute decompensated
Patients may have hemodynamic
heart failure and fluid retention. Nurse administrators and managers have height-
ened their attention to fluid retention because the Medicare performance measure congestion, defined as an increase in
known as the risk-standardized 30-day all-cause readmission rate after heart failure left ventricular filling and/or intravas-
hospitalization can be attenuated by fluid management strategies initiated by cular pressures.3 Hemodynamic con-
nurses during a patient’s hospitalization. (Critical Care Nurse. 2012;32[2]:20-32,34) gestion is a form of fluid retention
that occurs earlier than does clinical
congestion and indicates that the
clinical manifestations of fluid reten-

he term heart failure is tion may be imminent.3 Even when
CEContinuing Education defined as a clinical syn- signs and symptoms of clinical con-
drome of decreased exer- gestion are relieved, patients may
This article has been designated for CE credit.
A closed-book, multiple-choice examination fol- cise tolerance and fluid still have hemodynamic congestion
lows this article, which tests your knowledge of retention due to structural that could lead to progression of
the following objectives:
heart disease (eg, cardiomyopathy or heart failure and worsening progno-
1. Describe the pathophysiological processes sis.3 Thus, optimal assessment of
related to fluid overload (hypervolemia) in
valvular disorders). Acute decom-
heart failure pensated heart failure denotes devel- fluid status and management of both
2. Recognize the signs, symptoms and
diagnostic information needed to determine opment of progressive signs and hemodynamic and clinical conges-
hypervolemia in heart failure symptoms of distress that require tion are integral components of
3. Identify strategies to manage hypervolemia
associated with decompensated heart failure hospitalization in patients with a nursing care.
during hospitalization and after discharge previous diagnosis of heart failure.1 Congestion in any form is a hall-
Although many markers of acute mark of acute decompensated heart
decompensated heart failure are failure that stems from a cyclical
©2012 American Association of Critical-Care Nurses
doi: related to fluid retention,2 patients detrimental process involving low

20 CriticalCareNurse Vol 32, No. 2, APRIL 2012

the integrity of arterial circu. Ohio. Thus. fax. OH 44195 (e-mail: albertn@ccf. Cleveland. reprints@aacn. and general care nurses have that prompts systemic arterial sympathetic nervous system leads many opportunities to assess patients’ vasodilatation and underfilling of to elevated plasma levels of norepi- fluid status. the arterial circulation. intermediate care. However. Phone.3 Angiotensin II has many physio- dysfunction). the high-pressure arterial circulation. causes underfilling of the arterial renal reabsorption of sodium and Critical CriticalCareNurse Vol 32.8 leading to production of angiotensin served ejection fraction. and Linda H. Activation of the metry. Nursing Research and Innovation. Renal excretion of sodium heart failure. aldosterone system. PhD. pulmonary venous pressures causes of patients hospitalized for acute dynamic. and talized patients with decompensated lation is a key factor in euvolemia. circulation or high cardiac output sodium retention. contact The InnoVision Group. hypervolemia at home to optimize combined with impaired systolic istry (ADHERE)5 and Organized health-related clinical outcomes. normal reflexes stimu- and often included dyspnea (89% and water is due to a series of reflexes lated by increased atrial pressure and 90%. diac output). sorption of sodium. in patients with acute II. β-receptors and a clinical nurse specialist in the George M. FCCM. and treating load) increases. decompensated heart failure than 40% (indicating systolic left mone). increase in left ventricular end- ment in Hospitalized Patients with Pathophysiology of diastolic pressure. respectively).8 Normally.7 (Fig. (949) 362-2049. shock was uncommon. total logical effects. CCRN. (indicating heart failure with pre.cardiac output. enhancing proximal tubular reab- To purchase electronic or print reprints. respectively). Angiotensin II increases agement strategies. Further. and volume when atrial pressure increases. Acute assessing. an increase of pressure in the alveoli. (800) 899-1712 or (949) 362-2050 (ext 532). crackles that maintain normal total body are blunted by reflexes initiated in (67% and 65%. enhancing reab- sorption of sodium in the proximal Author Nancy M. Kaufman Center for Heart in the juxtaglomerular apparatus Failure at the Cleveland Clinic Foundation. many of which either decreased cardiac output that synthesis of aldosterone. Hypervolemia in left ventricular end-diastolic and lected data on the clinical features In patients with normal hemo. correct hypervolemia. renal sympathetic tone.10 In addition.8. Accord. and ensure that fluid management compensate. CA 92656.4 In order to nephrine that stimulate α-receptors in the nephron. and dysregulation between patient is discharged.4 stimulation of the sympathetic nerv- heart failure and discuss fluid man.8. accounting with an increase in renal levels of pulmonary congestion occurs. Albert is the senior director. decompensated heart failure. Patients must volume in the venous circulation and the heart and kidneys.4 Two large also understand their roles in systemic vascular resistance (after- US heart failure registries. arterial underfilling. water. APRIL 2012 21 . tele. tubules. Albert. neurohormonal. increased thirst. leading to can be nurse-led or nurse-facilitated. e-mail. 101 Columbia. in acute decompensated hypervolemic states were prevalent ure 1). sodium and water excretion4. blood volume associated with or not the ejection fraction was less nine vasopressin (antidiuretic hor. An acute increase Heart Failure (OPTIMIZE-HF)6 col. NE-BC.9 for 2% or less of all cases. increased release of atrial prompts activation of the renin- ventricular dysfunction) or normal natriuretic peptide. any increase in atrial pressure For example. Patients with heart failure have ous system. 9500 Euclid Ave. stimulate the renin-angiotensin- Corresponding author: Nancy M. an increase in When the absorptive capabilities of ing to both registries. performance also leads to an acute Program to Initiate Lifesaving Treat. monitoring. Aliso Viejo. Nursing Institute. cardiogenic total blood volume is associated the alveoli cells are overwhelmed. Mail code J3-4. strategies are in place before a increased by expansion of blood tems. CCNS. total blood volume is activation of neurohormonal sys. or diastolic However. FAHA. including peripheral In this review. further Cleveland. an increase in total respectively) regardless of whether leads to a diminished release of argi. No. decompensated heart failure. and renal processes.9 Increased afterload Decompensated Heart Failure 2. cardiac. I briefly describe blood volume is not the determinant and renal vasoconstriction (to restore the complex pathophysiological of renal excretion of sodium and arterial pressure and improve car- processes of hypervolemia in hospi. peripheral edema (66% and 65%. and decreased angiotensin-aldosterone system. www.ccnonline.

Adapted from Schrier.4 In result of arterial underfilling. a vicious cycle occurs. fluid overload.8 Figure 2 provides a with activation of neurohormonal striction and a reduction in sodium global depiction of interacting events systems leading to worsening car- delivery to the distal nephron.ccnonline. activation of . and edema. ↑ Distal tubule sodium reabsorption aldosterone.7 with permission. norepinephrine. are attenuated by renal vasocon. processes of acute decompensated and urine osmolalities and leads to monal systems leads to worsening heart failure set in motion when 22 CriticalCareNurse Vol 32. Normal cardiac output and effective arterial blood volume + fluid overload ↓ Plasma renin. and water reabsorption in the cells contributes to pulmonary conges- tion of water and sodium. in advanced heart failure. however. and responses that occur in patients diac function and further stimula- nine vasopressin is released as a with reduced cardiac output and tion of neurohormonal systems. Argi.7. Argi. hyponatremia. 2. these effects duct in the kidney. promoting Ultimately. hyponatremia. No. APRIL 2012 www.10 addition to the pathophysiological nine vasopressin increases plasma Thus. and arginine vasopressin ↑ Atrial natriuretic peptide ↑ Extracellular fluid volume ↑ Glomerular filtration rate ↓ Proximal tubule sodium reabsorption Enhanced sodium and water delivery to the distal tubule ↑ Renal sodium and water excretion No edema formation and other signs and symptoms of fluid overload Figure 1 Events in adults with normal cardiac output and effective blood volume when fluid overload occurs. atrial natriuretic peptide increases peripheral arterial vasoconstriction retention of sodium and water that glomerular filtration rate and excre. of the distal tubule and collecting tion.

APRIL 2012 23 . worsened orthopnea. total blood volume increases because hospitalization has been associated failure as the occurrence of at least 2 of arterial underfilling. Patients with any 3 tients with heart failure.7 with permission. 2. worsened paroxysmal nocturnal dys- anisms of neurohormonal activation olemia: orthopnea.2 baseline diuretic dose. Adapted from Schrier. episodes of Assessment of of the 5 signs 6 weeks after discharge clinical exacerbation were assessed Hypervolemia had a 3-fold increase in mortality at 2 over time. of the following: new or worsening ventricular filling (diastolic) pressure cal outcomes. In another study. weight gain. symptoms of fluid overload Figure 2 Events in adults with low cardiac output and ineffective blood volume (arterial underfilling) when fluid overload occurs (high preload). all of which are indica- impair cardiac function. lar dilatation) are also powerful mech. wors- and myocardial stretch (left ventricu. discharge for 5 signs of CriticalCareNurse Vol 32. ling mode Left ven ial re tricu yo card lar m m yo lar In reas cardi icu rload Heart failure with c en t r e afte low cardiac output e a al r fte e tv ea s rlo mod cr and arterial f e Le In ad underfilling lin g + Fluid overload (high preload)* Activation of the arterial baroreceptors Stimulation of sympathetic nervous system Activation of the Nonosmotic renin-angiotension- vasopressor stimulation aldosterone system Renal water ↑ Peripheral arterial ↑ Renal vascular Renal sodium retention resistance resistance retention ↓ Renal sodium and water excretion Edema and other signs and * Hemodynamic congestion. an increased risk of www. increased body weight.ccnonline. and increased jugular venous and hypervolemia that can further edema. increased left with improvement in long-term clini. No. peripheral pnea. need to increase distension. More episodes of clinical Accurate assessment of hyper. In 189 outpa- venous distension.12 investigators increased rate of hospitalization for dom from hypervolemia after defined clinical exacerbation of heart heart failure. Lucas et al11 assessed edema. exacerbation were associated with an volemia is important. and jugular tions of hypervolemia. because free. years after the index hospitalization. patients 4 to 6 weeks after hospital ened dyspnea.

Moreover. even after changes in body weight were not term rather than instantaneous vol- adjustments for patients’ charac.ccnonline. In one in body weight might be associated that BNP levels were not accurate study.24 optimal management with evidence- symptoms commonly associated The biomarker B-type natriuretic based therapies. al17 determined if signs and symp. edema. another study. study.8 reinforce the need elevated jugular venous pressure.1 tion functional class. predictors of serial hemodynamic was associated with increased pul.17. pulmonary artery wedge of patients with chronic heart failure specificity (the probability that pressures can be elevated even though during acute episodes that require signs or symptoms were absent in crackles and edema are absent or hospitalization. weight loss from cachexia. Although thought that BNP values changed hospitalizations for heart failure dyspnea was positively and signifi. hypervolemia. even though failure. APRIL 2012 www. a change in BNP level nuances are worth mentioning.17 the effectiveness of therapies.21. and min. and Albert et blood volume than with changes in ity of life. Fluid Management patients treated in an emergency In a study15 of ambulatory nonede. to use more than 1 method to assess lower extremity edema. Mueller et al16 charac.14 repeated and hospitalized patients.mortality over a 2-year period. The recommenda- patients without worsening heart infrequent. levels was associated with early Although assessment of hyper. were significant predictors of tion may not be associated with decompensated heart failure in physical findings of hypervolemia. hemodynamic or edema. Invasive hemodynamic moni. symptoms (weight gain. although some signs and failure to monitor a patient’s weight. toms differed between ambulatory size was small. O’Neill et al27 found congestion is not benign. and were better for showing long- with all-cause mortality. initial volume status.20 weight with advanced heart failure. offset of weight gain from fluid by Research results1. In patients Failure Society of America28 include ing heart failure) of each sign or with acutely decompensated heart recommendations for management symptom was low. more slowly than did blood volume decompensation were associated cantly associated with edema. including was not associated with a change in . could have many causes. the were not helpful in diagnosing marker of volume status. and body weight in patients with heart correlated better with changes in a greater likelihood of lower qual. pulmonary artery wedge pressure.22 Lack of association of body improvement in hemodynamic volemia is important. and to nocturnal dyspnea. increased blood volume. teristics.18 Hence. ure. in relief of signs and symptoms of Second. with preserved ejection fraction are intracardiac pressures. lower functional status. inform clinical decisions.23. No. physical findings The guidelines of the American (the probability that signs or symp. although changes Likewise. the researchers26 In other studies. Although the sample and poorer exercise tolerance. paroxysmal ished appetite due to ascites. Even increased risk for death or urgent gain may not occur in patients with though an initial decrease in BNP heart transplantation at 1 year. hemodynamic conges. worsening heart failure and corre. and patients’ hemodynamic parameters dynamic status without further 24 CriticalCareNurse Vol 32. nocturia. 2. tions should be followed to ensure failure) was high.19 and repeat hospitalization changes in hospitalized patients monary artery wedge pressure and for worsening heart failure. BNP values. stabilization of hemo- terized daily dyspnea. During both hospi- with decompensated heart failure peptide (BNP) may not be an ideal talization and outpatient care. acute decompensated heart fail.13. routinely associated with dyspnea ume status. ure16. In one aims of fluid management strategies heart failure as the current prob. positive imal weight gain because of dimin.15 increased blood volume with hospitalization for heart fail. to determine hepatojugular reflux. However. Strategies department.25 levels of BNP increased with for left ventricular systolic dysfunc- lem. tion and left ventricular dysfunction toring may be needed to assess lated with New York Heart Associa. signs and sures may not be elevated. of hypervolemia were infrequent College of Cardiology and American toms assessed were present in and were not associated with Heart Association1 and the Heart patients who actually had worsen. failure for 1 month. the overall sensitivity matous patients.26 after treatment. and crackles) Finally.16 Thus. and jugular venous pres. some weight with dyspnea or edema parameters.

2. randomized trials that provide evidence of the effectiveness of these strategies have been done. hospitalized patients with or angiotensin II receptor blocker els. metopro- lol succinate. and are indicated to maintain systemic overall fluid volume status must be minimization of preventable recur. Infuse the agent as a continuous intravenous infusion: for example. and worsen. eleva. Administer 2 diuretic agents at the same time: for example. all serious dysrhythmias. assessed so that the dosage of a cardiac output in heart failure in volemia because the interventions diuretic can be titrated to a patient’s clinical trials but were not approved attenuate neurohormonal activa. carvedilol. tion because the medications did promote reversal. (especially when vasodilator therapy outcomes did not differ between converting enzyme inhibitor (eg. have irregu. or bisoprolol).28 pharmacological treatment for because of hypertrophy of distal In patients with hypervolemia. hypervolemia. Urine out. managing hemo. intravenous Based on data from Jessup et al1 and the Heart Failure Society of America. put and signs and symptoms of and levosimenden33 resulted in nization therapies are first-line hypervolemia must be serially removal of excess fluid or improved strategies for managing hyper. furosemide at heart failure often meet indications 5-40 mg/h or bumetanide at 0. • Intravenous chlorothiazide (500-1000 mg). vasopressin receptor antagonists. is used concomitantly). Core medications for daily outpatient dosage. administration is preferred during are provided in Table 1.8 Electrolyte lev.1 Adverse events associated by the Food and Drug Administra- tion and prevent progression. A1 important as managing clinical a dose that is higher than the total adenosine receptor antagonists. directly or indirectly relieve hyper- activation.32 heart failure and cardiac resynchro. research but did not improve short- increased left ventricular filling gestion by lowering left ventricular and long-term quality of life.1.31 congestion.7 Strate- hypervolemia include low cardiac pharmacodynamics. perfusion and preserve or improve carefully monitored and managed. or captopril) ing renal function. given 30 minutes before administration of an intravenous loop diuretic tion therapy and cardiac resynchro.5 mg/h for an aldosterone antagonist (eg.1-0. treatment groups in acutely decom- lisinopril. needs. or with use of diuretics include elec. intravenous gies to overcome diuretic resistance output. 2. hypotension tality rates. lar intestinal absorption and can aldosterone system.8 Some therapies developed to CriticalCareNurse Vol 32. rences of hypervolemia that require end-organ performance. hemodynamic parameters. pensated. and heart failure and stable hemodynamic (eg. valsartan or candesartan) and a β-blocker (eg.damage of cardiac myocytes.1. tion in left ventricular diastolic the early part of hospital therapy. switching or alternating between oral patients have hypoperfusion and furosemide and torsemide diuretic-resistant elevations in car- a No large. Thus.28 Unless contraindicated.30 and decreased Pathophysiological changes in have altered pharmacokinetics and glomerular filtration rate.1.28 Finally. a loop diuretic and an spironolactone or eplerenone) or agent that blocks the distal tubule hydralazine-and-nitrate combina.5 Because oral agents. diac filling pressures. Rotating loop diuretic agents: for example. mor- pressure but no constellation of filling pressures. Patients Table 1 Strategies to overcome diuretic resistancea hospitalized with advanced systolic 1.1 Diuretic resistance is common in hospitalization for heart failure Loop diuretics are the hallmark patients with advanced heart failure decompensation. loop diuretics rapidly relieve signs volemia were promising in early dynamic congestion manifested by and symptoms of pulmonary con. No. loop bidity. arterial underfilling. early clinical patients should take an angiotensin. enalapril. activation of the renin-angiotensin- the iceberg in regard to congestion. of left ventricular trolyte imbalances (hypokalemia not decrease the number of hospi- remodeling that can worsen conges. and neuroendocrine When administered intravenously. Likewise.28 inotropic or vasopressor therapies www.29 increased signs and symptoms are the tip of especially furosemide. • Oral metolazone (2. tubule epithelial cells. and mortality in large-scale signs and symptoms is just as diuretics should be administered at randomized controlled trials.1 Initially.5-10 mg) given with an oral loop agent nization therapy. when 3. APRIL 2012 25 . and hypomagnesemia) leading to talizations for heart failure or mor- tion.

Education before duced by plasma proteins. most strategies used to and in large peripheral veins. ultrafiltration device extracts blood ultrafiltration had greater weight and follow-up programs after dis- from and then returns it to the venous loss. Vascular with very advanced heart failure and prescribed therapies and fewer catheters can be placed in the femoral.43. in 3 of 5 trials of peripheral tality were not well described and Unlike the situation in fluid ultrafiltration with a portable system. the sodium con. and reduced 90-day rate of home. such as (increasing serum levels of urea sorbed from the edematous intersti. continuously or intermittently. hemofilter (a semipermeable mem. peripheral venovenous toms. or ture. maintained in a variety of environ- ated by the filtrate compartments When peripheral ultrafiltration was ments of care. Overall. studies. or subclavian veins was associated with variable fluid However. causing weight loss. 26 CriticalCareNurse Vol 32. excessive vol- intervention and had new atrial tion of renin and activation of ume removal (resulting in arrhythmias in the milrinone group. initiated and response to a pressure gradient cre. and catheter-related who had worsening renal function the same rate at which fluid is reab. which is pri. ultrafiltration rehospitalizations after discharge. 2. cedure. In ultrafiltration.37 filtration has not been better than As a therapeutic procedure.38 However. Nurses must understand medically appropriate care recommendations and advocate for patients during daily rounds with physicians and pharmacy care providers. rinone or placebo. readmission was not improved in 3 Investigators provided a global marily hypotonic. internal jugular.49 programs. therefore are hard to replicate. Whole blood passes across a system became available and the preventing complications. did not prevent wors- and hydrostatic pressures in blood compared with diuretic therapy in ening hypervolemia associated with and also by oncotic pressure pro.status who were randomized to con. No. as a venovenous technique) and an small single-center study39 in patients were associated with adherence to extracorporeal blood pump. rated the usefulness of the treatment. The .40 provide details of key components. which enhances renal secre. therefore. diuretic resistance. or hemorrhage due to not have improved outcomes intravascular hypovolemia does not disconnection of the venous return despite minor improvements in occur and neurohormonal activation catheter. or nurse-led programs. use of milrinone in patients fluid is removed from the blood at nal azotemia). the amount of sodium in the water Other disadvantages of ultrafil- tinuous intravenous infusion of mil. decreased need for vasoactive charge. randomized.48 including transition-to- circulation via separate access points drugs. air nitrogen) during hospitalization did tium.36 The heart failure. Ultrafiltration became a more aggressive intravenous diuretic ther- ultrafiltration is the mechanical clinically relevant option after a apy in improving signs and symp- removal of fluid from the vascula. APRIL 2012 www. and signs and symptoms were overview of programs but did not tent in the ultrafiltrate is equal to significantly reduced in only 1 study.34 More patients diuretic therapy can cause hypo.ccnonline. or system complications.40 To date. Interdisciplinary nurse-physician brane) to yield plasma water in controlled research trial38 corrobo.35 is not stimulated. counseling43-46. and subsequent morbidity and mor- once.47. patients with acute decompensated rehospitalization. component of plasma. hypotension and worsening prere- Further. patients treated with hospital discharge41-43. removal with diuretics. need for training nurses in the pro- sustained hypotension requiring volemia. and renal function worsened minimize preventable hypervolemia procedure can be performed only in 45% of patients during therapy. tration therapy are patients’ costs. prolonged embolism. nurse staffing. in a of remote monitoring48.36 In addition.46 telephone. peripheral ultra- renal function. results of a multicenter. thrombosis. and other forms with large venous catheters (known rehospitalization. neurohormones. portable. infection.

Portable. macy care providers. appropriate care recommendations ables. The impedance the adherence of health care tional class (Table 2). A valuable report provides data about the pres. not all In lieu of invasive hemodynamic pressure and low intrathoracic programs were effective in prevent. Nurses should values measured by using an tions for use of cardiac devices. No.65 For patients Nurses must understand medically of assessment or on only a few vari. monitoring to measure intracardiac impedance. APRIL 2012 27 . Severe Physical activity cannot be carried out A: Patient cannot climb more than 1 or a few steps without taking without symptoms. Dis- Because of the nuances of hyper. clinicians Fluid Management self-care. study66 of 23 patients. but patient does not need to stop III.68. predict intravenous fluid of care in heart failure at both the nurses must not base decisions on responsiveness. fatigue. Asymptomatic Ordinary physical activity does not cause A: Patient can climb 2 full flights (basement to second floor) with symptoms out symptoms developing B: Patient is not limited II. such as worsen.48-51 can be trained to use other technol. Physical signs and symptoms rillators that also measure intratho. should also participate in quality events. handheld. providers’ use of heart failure med- assessment variable for hypervolemia ence of thoracic congestion. or preparing meals. In a ications chosen on the basis of may be history of recent hospitaliza. preparing meals.8 kg (24 lb) at rest B: Symptoms occur during or after washing. Mild Ordinary physical activity may be slightly A: Symptoms occur after climbing 1 full flight (12 regular steps) or limited by symptoms but no symptoms 8 steps while carrying 10. a gap exists between ogy. patient needs to take a break IV.67. detect pericardial effu. correlation between high wedge standing. 2. Additionally. dressing. and tips for assessing hypervolemia raphy. loaded by using a wand system participate in quality improvement ing exercise intolerance or changes similar to that used to download programs that focus on monitoring in New York Heart Association func. pacemaker data. with implantable cardioverter defib. sions. symptoms occur at rest a break because of symptoms B: Symptoms occur when patient initiates personal grooming behaviors a Signs and symptoms: dyspnea. palpitations. Moderate Physical activity is markedly limited because A: Patient cannot climb 1 full flight without stopping of symptoms B: Symptoms occur during washing.ccnonline. pocket. patient67-69 and hospital level. impedance data rounds with physicians and phar- subjective perceptions of clinical (on intrathoracic fluid) can be down. Specific issues noninvasively by using echocardiog- assessment methods used to deter. function. even if patients pressures and definitively determine had improvement in knowledge or hemodynamic congestion. parities are prevalent in the quality volemia assessment in heart failure. Nurses ask patients about recent hospital implantable cardioverter defibrilla. and advocate for patients during daily must be assessed along with patients’ racic impedance. dressing.70 volume status on a single method tant valvular defects. impedance research evidence and recommenda- tion for heart failure. Currently. and identify CriticalCareNurse Vol 32. Table 2 New York Heart Association functional classificationa and examples Example A: Stair climbing Functional status Definition Example B: Personal grooming I.64. The results indicated a strong mine and enhance patients’ under. the depth or breadth of content than a single health care center to artery wedge pressures measured delivered (program intensity). clinical expectations for use of Nursing Implications sized ultrasound machines can be evidence-based treatment recom- Assessment used to determine left ventricular mendations and actual practice. are provided in Table 3. chest pain. ing hospitalizations. Nurses should changes in status. or meet health needs. especially if patients use more tor were compared with pulmonary improvement programs that focus www.

28. APRIL 2012 www.1 µg/L) could indicate cardiac myocyte damage as the precipitant of hypervolemia. increase awareness of nonpharmacological plan of care. No.59 • Assess health literacy. adherence to early (7-day) lines for management of heart tive care before patients are follow-up care. and interdisciplinary collaborative patients and informal caregivers prepare patients and informal care- teams to implement strategies to from hospital to home and focus on givers to adhere to the plan of care. ask the patient about ◦ Change in dietary behaviors (eating away from home or a change in purchasing practices) ◦ Change in food preparation (new meal planner or cook) ◦ Recent nonadherence to medications for heart failure ◦ New or worsening thirst leading to increased fluid intake ◦ Use of ibuprofen or other over-the-counter drugs that cause sodium and water retention • Use noninvasive and internal monitoring features of cardiac devices to aid in assessment when elevations in pulmonary artery wedge pressure cannot be directly assessed. .For example. social issues (caregiver support. to develop and participate in pro. 28 CriticalCareNurse Vol 32. which are highly sensitive markers of myocardial injury.Report core medications not prescribed for heart failure. in a variety of ways.62. • Assess worsening burden of comorbid conditions that could cause acute deterioration in renal function (eg.55-58 • Carefully assess patient’s rationale for nonadherence.53 . • Obtain an individualized history of events that might be the reason for new or worsening signs and symptoms of hypervolemia. patient-specific causes that may be related to or beyond knowledge and skills deficits.63 • Assess creatinine clearance (estimated glomerular filtration rate). Table 3 Hypervolemia assessment issues and tips Issue 1: Insensitivity of common signs and symptoms of heart failure15-17 • Ask multiple questions.For example. you might learn that he or she has nocturia. on the understanding of patients improve quality of care and con.61 Issue 4: Be aware of laboratory and clinical parameters that may be helpful in determining hypervolemia. assess thoracic impedance levels. • Assess serum sodium level for hyponatremia. The need is great for nurses discharged.8 or other medical conditions associated with decreased cardiac output and neuroendocrine activation leading to hyper- volemia. or severe) of signs and symptoms. moderate. . . if a patient complains of difficulty sleeping. Issue 3: Nonadherence to self-care program for heart failure may have multiple. Consider economic issues (transportation or costs of care). • Assess for elevated blood pressure that may be associated with stimulation of the sympathetic nervous system. . Elevated values (troponin I >1 µg/L or troponin T >0. . disease management. do not just ask if it had worsened before the patient came to the hospital or outpatient clinic. renal dysfunction that aggravates . Nurse-led ini- and patients’ families of education formity with recommended guide.1. patients’ and informal caregivers’ Nurses should participate on grams that ease the transition of barriers to optimal self-care.Report findings and patient’s rationale for not taking medications as prescribed.1 Issue 2: Neuroendocrine activation leading to hypervolemia could be due to nonoptimal medication regimen or medication nonadherence.When measurement of thoracic impedance is available as a feature of an implantable cardioverter-defibrillator device.60 • Assess number of heart failure health care provider services as patients may be receiving mixed or confusing advice. ◦ Ask what activities the patient has given up or is doing more slowly or less frequently because of dyspnea.57 psychological issues (depression.28. • Assess hemoglobin level for presence of anemia that could be due to hemodilution. 2. when assessing dyspnea.52 . • Assess serum levels of troponins I and T.54 • Obtain medication reconciliation related to therapies used before hospitalization. to obtain a well-rounded picture of the incidence and level (mild.ccnonline. anxiety). ◦ Ask if caregivers have changed behaviors to minimize patient’s dyspnea. worsening diabetes or hypertension).1. Patients may decrease activity level to prevent worsening of dyspnea.If respiratory distress or clinical evidence of impaired perfusion and intracardiac filling pressures cannot be assessed clinically. . use invasive hemodynamic monitoring. • Assess increases ion serum levels of urea nitrogen and creatinine during hospitalization.58 and cognition issues. loneliness). • Assess QRS duration ≥120 ms associated with cardiac dyssynchronization that can lead to mitral regurgitation and pulmonary congestion as well as hypervolemia from neuroendocrine activation associated with poor cardiac performance. and adherence to the failure. which is a marker of an increase in plasma levels of arginine vasopressin (and water retention).Report identified contraindications to medications for heart failure.Report medications not for heart failure that could worsen heart failure. Once the problem is identified.26. tiatives can facilitate safe and effec- received.

OPTIMIZE-HF Investigators and With Heart Failure: Impact on Patients’ heart failure may decrease practice Coordinators. Adams KF Jr. Patients’ nonadherence to meth. and follow-up been associated with acute decom. tion and counseling related to fluid programs after discharge from the pensated heart failure leading to management (weight monitoring. medication. Heart Failure Writing on Behalf of the 2005 Heart Failure Writing Committee. and preliminary observations from the first monitoring hypervolemia. improve adherence to regimens for to recognize when common signs 3. 2009 help was identified by 35% of family Focused update: ACCF/AHA guidelines for caregivers as the most important Summary the diagnosis and management of heart failure in adults: a report of the American intervention. Dei Cas L. dence and Update the 2005 Guideline for findings should be the basis for the Management of Patients with Chronic missions. Hypervolemia (both hemody. Chen HH. Am J Med. 2. heart failure therapies as the pri. Burnett J. Adequate professional standards of clinical care. No. create or contribute to cite other diseases. Attention to emerging knowl. syndromes: an essential target of evaluation Research results highlight the tion are not manifested during an and treatment. reasons for hospitalization.296:2217-2226. Albert NM. Abraham WT. During acute decompensated sion by 25% of patients and 26% of of interventions to manage heart heart failure. CCN hospitalization.119(12 suppl 1): patients’ nonadherence with the later than elevated left ventricular S11-S16.ajcconline. 119(14):1977-2016. Bristow MR. None reported. Am Heart J. need for greater vigilance in optimal acute congestive exacerbation. 2. Congestion in acute heart failure managing heart failure. only failure (including those targeting forms to the recommendations of 14% of cardiologists and 13% of clinicians and informal caregivers) evidence-based guidelines to recon- heart failure nurses thought nonad. Nurses must ensure Nurse-led or nurse-facilitated educa- ods for managing heart failure has consistency of hospital-based educa. 2005. Am J Med. www. APRIL 2012 29 . Abraham WT. Gheorghiade M. CriticalCareNurse Vol 32. 2006. Nurses have an opportunity talization for heart failure. Jessup M. physiology of acute heart failure—it is a lot and a responsibility to help patients tality. nursing care that con- informal caregivers. Systolic blood pressure at Families” by Hwang et al in the American admission. 2006. and givers’ knowledge and expectations diet. provides important and generalizable 2009 Writing Group to Review New Evi- mary intervention to prevent read. to an online discussion about this topic using eLetters. 4.72 33% of lies and patients’ informal caregivers. Cardiologists and click “Submit a response” in either the full-text or PDF view of the deficits. knowledge edge and evidence-based practices is Just visit www. necessitating use of comes of patients hospitalized for heart fail- multiple measures and methods of ure in the United States: rationale. al. 2008. Metra M. 2011.ccnonline.72 Cardiologists and ing clinical outcomes and cost of heart failure nurses were more likely care so that deficiencies can be cor- Now that you’ve read the article. De Luca L. and in assessment of the effective. and out- Journal of Critical Care. or fluid restriction low-sodium diet). read “Caregiving for Patients delivery of interventions to manage 6. Filippatos G. gaps associated with worsening comes in patients hospitalized with acute Available at www.119(12 suppl 1):S3-S10. Hypervolemia can be difficult about fluid accumulation. College of Cardiology Foundation/Ameri- can Heart Association Task Force on Prac- fied 2 primary interventions as namic and clinical congestion) is an tice Guidelines: Developed in Collaboration equally important: improving import predictor of worsening heart With the International Society for Heart and Lung Transplantation. heart failure due to hypervolemia. et al. Am Heart J. ure patients. medical regimens. nonoptimal rected. ADHERE Scientific Advisory Committee individualized approach can be and Investigators. et al. To learn more about caring for heart fail. Emerman CL. and symptoms of clinical conges. hospital promote patients’ and care- hospitalization. et heart failure plan of care so that an filling pressure (hemodynamic con. Gheorghiade M.20: 431-442. Schrier RW.ccnonline. adherence and adequate professional failure. tion. 100 000 cases in the Acute Decompensated Nurse-led or nurse-facilitated Heart Failure National Registry (ADHERE). heart failure. Among focused on patients. JAMA. 2009. Casey DE.71-73 Nonadherence to fluid restriction when ordered. Circulation. and mor. patients’ fami- Financial Disclosures participants in the study. patients and 23% of heart failure Revised national guideline recom- nurses cited improving adherence to mendations and new research that References 1. Pathophysiology of volume overload in acute heart failure syn- assessment of possible causes of Clinical congestion often occurs dromes. Nurses must also for adherence to heart failure self- was cited as a reason for readmis. developed. promote improved outcomes. 155:1-5. 2006. morbidity leading to hospi. Fonarow GC.149:209-216. clinical characteristics. and delay in seeking help as paramount to a successful program article. Characteristics and out- gestion) does. cile and prevent hypervolemia may herence was the primary reason for ness of the interventions by ensure consistency in the delivery care. design. counseling.72 However. The patho- help.

Fouad-Tarazi F. Cadnapaphornchai MA. 2007. 28. Troughton RW. Stevenson LW. Lakier JB. Cardiology. et al. “Dose. Adams KF Jr. Katz SD. Lamas GA. Stukel TA. Zhang J. Di Silvestri A. Am J Cardiol. 35. Campbell RL. of unrecognized hypervolemia in chronic PROTECT Investigators and Committees. trial. Weight changes venous Milrinone for Exacerbations of monitoring of heart failure patients.363:1419-1428. et al. 21. Clin J Am Soc Nephrol. in health and disease: a unifying hypothesis. 2001. Am J Cardiol.287(12):1541-1547. 2010. Miller AB. 2010. 20. symp- of the Trans-European Network-Home-Care ization for worsening heart failure predict toms. 2010. Car. Redfield MM. Lang E. et al. hemodynam. 2002. and self-care behaviors. B-type natriuretic peptide levels are acute decompensated heart failure. Albert NM.347(3):161-167. 1989. . tify patients at higher risk of subsequent tive heart failure. J Am Geriatr Soc. et al. 2008. Perruchoud AP. Kasper EK. 2002. The limited relia. HFSA 2010 Com. Nowak RM. et al. 52. Rogers JG. Am 36. O. failure and subsequent re-hospitalization Investigators. 56:372-378. Gurevich AK. Soran OZ. 2007. Eur J 33. Eyler W. Androne AS. Sarraf M. Pilot study of a Web-based compliance Association of weight change with subse. Blue L.297:1883-1891. failure. Maislin G. Massie BM. O’Connor CM. 26. Red.ccnonline. Amoateng-Adjepong dependent” impact of recurrent cardiac Med. 2005. Mehta RH. Shin JT. Konstam MA. O'Connor CM. 2001. 44. 2009. Dracup KA. Com- Chakko SC. et tration versus intravenous diuretics for heart failure. Mebazaa A. et al. 40. JAMA. chronic heart failure. BL. 1990. Schrier RW.150:983e7-983e12. Li J. Greene EL. Lennie TA. prehensive Heart Failure Practice plified education program improves knowl- Repeated hospitalizations predict mortality Guideline. Circulation.96:155-168. 1989. et al. Setoguchi S. Auricchio A. Heart Lung. et al. Feldschuh J. refractory heart fail- Weinberger HD. et al. Patterns of weight change pensated heart failure: the SURVIVE Ran. 2010. Lauri G. Efficacy of Vasopressin Antagonism in domized clinical trial of the clinical effects nosis of congestive heart failure: impact of heart Failure Outcome Study with Tolvap. 2005. Diuretics: still the inpatient education and discharge planning failure. Circu.6:60-65. Ann Intern Med. 2005. Schrier RW. Hudaihed A. Blair JE. Moser DK. et al. Laule. extracorporeal ultrafiltration in refractory PARTNERS HF (Program to Access and 30 CriticalCareNurse Vol 32. 149:363-369. controlled Daily variability in dyspnea. 16. 2008. 2008. dynamics in chronic heart failure. Hasselblad V. 19(5):443-452.e6. Bott-Silverman CE. congestive heart failure. A meta-analysis of remote EVEREST Investigators. Williams AW. Varini S. nism in Heart Failure Outcome Study with Transitional care of older adults hospitalized 18. 48. 2008. Goldberg LR. 7. 22. Anderson C. Artinian NT. Can J Cardiol.113(2):155-159. TEN-HMS Investigators. J Cardiol. Am Heart J. J Card Fail. Heart pitalized with worsening heart failure and Card Fail. 37. Heart J. Lin S. The pathophysiology of diagnosis of heart failure. results from Efficacy of Vasopressin Antago. Rolofylline. 2005. Bedogni F. 51. Schwartz JS. Aaron- 12. 2004. PARTNERS study investigators. Admission or study of the effect of video education on using daily weight measurement: analysis changes in renal function during hospital. an adenosine A1-receptor ised controlled trial of specialist nurse inter- ics. Marenzi GC. dynamics during management of patients 41. 2007. Hryniewicz K. Discharge education improves clin- Samaha FF.103:76-81. Cardiology. Eur J Heart Fail. dobutamine for patients with acute decom. J Am Coll Cardiol. ultrafiltration device as a treatment strategy 10. Albert NM. Outcomes of a Prospective Trial of Intra. Am J Med. Acute decompensated heart fail. et al. Caldwell MA. with severe heart failure. erly patients with congestive heart failure. Body fluid volume regulation 24. Am Heart J. Coyne JC. 49. Nieminen MS. Pathophysiol. Harden JK. Ultrafil- diorenal syndrome in acute decompensated 25. edge. Zarich S. A ran- Kilian K. body weight in heart failure patients. Use of a novel accumulation? Am Heart J. Adams KF.155(1):9-18. JAMA.37:28-35. Schrier RW. Klein R. A sim- 13. Cotter G. 2005. Y. Gabutti G. Leimberger JD. Relation 31. Ultrafiltration should not 11. J Am Coll Cardiol. Li J. disciplinary care in heart failure outpatients Krumholz HM. Randomized pitalization due to worsening heart failure OPTIME-CHF Investigators. Albert NM. and patient outcomes.2:505-511. postdischarge survival: results from the Couns. Congest Heart Fail. Radiographic failure. for Outcomes of a Prospective Trial of Intra. Riegel B. death and rehospitalization in patients hos. Stevenson LW. BMJ. Saltzberg MT. 2001. Circulation. self-care behavior. 45. Predicting hos. Hiniker AR. Tolvaptan (EVEREST) program. Trochelman K. Al-Khatib SM. Rodriguez D. Karon acute heart failure—is it all about fluid 2002. edema and 2010. 34. O’Connor CM. Short-term intravenous milri. Mueller C. Emergency diag.52:675-684. Packer M.16(6):e1-e194.63: latory response to fluid overload removal by heart failure hospitalizations: results from 625-627.11(4):420-427. Liang KV. 226-233. Lucas C. Brooten DA. JG. heart failure: a randomized controlled trial. Chaudhry SI. Causes of a computer-based telephonic monitoring 21:921-924. et al. Greene EL. 14. Patient Educ Management System (TEN-HMS) study. 2009. Crit Care 43. J 17. Kronenberg MW.11(6):315-321. Benefits of comprehensive events on mortality in patients with heart 30. Grazi M. Hamilton MA. Gottlieb SS.261:884-888. Masoumi A.154:260-266. Klein L. Random- heart failure to clinical status. Heart Lung.159:841-849. Mancini D. Perloff JK. Ousdigian KT. Breathing Not Properly Multinational patients hospitalized for acute decompen- 2013-2026.14:711-717. Long- and mortality in the EVEREST trial. Califf RM.e1-984. Felker M. O’Neill JO. 47. et al. 2009. Ronco C.93:1254-1259. Clinical exacerbations as a sur. of heart failure. failure. 2007. Williams AW. J Am Coll Cardiol. Lamanca J. antagonist. failure. UNLOAD trial investigators. 23.12(9):707-714. Mahdyoon H. 36(1 suppl):S89-S94. 718. bility of physical signs for estimating hemo. Cuffe MS. Gheorghiade M. Klersy C. at high risk of hospital readmission. Austin PC. failure signs and symptoms: are you asking reduced left ventricular ejection fraction: 46. Am Heart J. Peters KJ. Blair JE.225:715- 2004. 42. Cardiovasc Nurs. Goode KM. Regoli F.38:963-968.30:1666-1673. Koelling TM. Cuddihy PE. McCauley KM.36(1 suppl):S75-S88. combined with outpatient support in eld- 15. et al. Cleland JAMA. Deepak BV. 2006. et al. Costanzo MR. Wang Y. 2007. J Am preceding hospitalization for heart failure. 2008. of enhanced heart failure monitoring using signs and symptoms. 8. N Engl J Med. in acute heart failure. Sayers SL. Blood for diuretic resistant. Metra M.150:984. No. 2009. APRIL 2012 www. Heart Failure Society of America. replace diuretics for the initial treatment of Freedom from congestion predicts good et al.39:471-480. Med. Circ monitoring device for patients with conges- quent outcomes in patients hospitalized Heart Fail. volume and brain natriuretic peptide in ure: initial clinical experience in a single ogy of sodium and water retention in heart congestive heart failure: a pilot study. Gill TM.54:1683-1694. feld J. the right questions? Am J Crit Care. Ferrante D.4: al. Heart Fail. McRae AT. SURVIVE Investigators. Milo-Cotter B-type natriuretic peptide in the emergency 49:675-683. Krishnaswamy P. and disease severity in the community population with heart 29. 27. 2009. Am center.69(1-3):129-139. Am Heart J.140:840-847. ment of overhydration and congestive heart et al. Liang KV. field MM. Maisel AS. Am Heart J. J Card Fail. Webel AR. Cody RJ. Lee DS. venous Milrinone for Exacerbations of et al. 2009.111(5):179-185. Frana B. 32. Thomas D. Gerstenblith G. in heart failure patients in rural settings. heart failure healthcare utilization. 2003. bined heart failure device diagnostics iden- pulmonary congestion in end-stage conges. Crit Care Med. Rapid measurement of sated heart failure. Dec GW. Circ survival despite previous class IV symptoms not a surrogate marker for invasive hemo. system in older minorities and women. Whellan DJ. Macchia A. Soltis D. ical outcomes in patients with chronic heart rogate end point in heart failure research. Schneeweiss S.122:162-169. Concato J.116:1549-1554. 2009. mainstay of treatment. McMurray JJ. Wang DJ. Khan S. 9. 2008. Study Investigators. Hefter G. Extracorporeal ultrafiltration for the treat. ure and the cardiorenal syndrome. 2005. Coll Cardiol. tive heart failure. Bellomo R.32(4): with acute decompensated heart failure. Pína IL. domized Trial. 2001. Levosimendan vs A randomized trial of the efficacy of multi- 19.96:122-131. James KB. 38. Johnson W. Naylor MD. 2000. Johnson ML. Chronic Heart Failure (OPTIME-CHF). 2007. 2. son KD. Frazier SK. Buchsbaum R. Guglin ME. J Am after hospitalization for worsening heart Chronic Heart Failure (OPTIME-CHF) Coll Cardiol. N Engl J vention in heart failure. Eur none for acute exacerbation of chronic term results after a telephone intervention in Heart J. with heart failure: a randomized. Ricci Z. 50. tan (EVEREST) investigators. Massie BM.1:25-33. Linden. et al.

tives of patients.x. Remme WJ. Abraham WT. Culp BC. 2009. 63. Vergara G. 2008. Difficulty taking med. APRIL 2012 31 . The pocket echocardiograph: validation and fea- sibility.158:451-458. et al.25(3):217-222. Mock JD. Europace. et al. Cirrincione C. et al. 2009. Focused transthoracic echocardiography. White MM. restriction. geriatricians. J Emerg Nurs. for readmission in heart failure: perspec- 58. Jhanjee R. Fonarow GC. et al. Howie-Esquivel J. Havranek EP. Sheahan SL. Landolina M.1111/j. and opportunities. Correlation to Symptoms in Patients With Get With the Guidelines steering commit- Heart Failure) study. et al. talization for heart failure in the presence of 59. talizations in patients with heart CriticalCareNurse Vol 32. Age. 2010. Smalligan RD. Nagatomo Y. 2008. Lowe AM. 64.168(8):847-854.16(1):9-16. Fields B. Heart fail. Luttik ML. Choi HJ. Morgan AL.27(7): 759- 764. Fonarow GC. and primary care physicians. Caldwell MA. Weekend hospital admis- 55(17):1803-1810. 2010. Sattiraju S. 62. et al. ment. Heart Vessels. OPTIMIZE-HF investigators and hospitals. 2008. depression. et al.12(1): New York Heart Failure Consortium. Review Trending Information and Evaluate 68. Liang L. Dai D. J Am Coll Cardiol.43:1432-1438. Consortium (CORC). 2010. heart disease in rural and urban hospitals 25(1):7-12. 2002.105:139-143. McKelvie RS. for the Cardiovascular Outcomes Research and heart failure nurses. JAMA. family members hinder as much as they 72. Maurer M. 70. 2010. an implantable defibrillator reduces hospi. Ambardekar AV.01125. 65. Annema C. Abraham WT. beliefs. McMurray JJ. Demers C. (from Get With the Guidelines-Coronary 56. tee and hospitals. 2009. et al. Khasawneh FA. Characteristics and treatment of patients Am J Cardiol. Maines M. et al. Patterson CJ. caregivers. 2009.302:1658-1665. Reasons help? Chronic Illn.ccnonline.28(2):126-131. Am Heart J. cardiologists. Horwich TB. Rasmusson KD. Use of aldosterone antagonists in heart failure. J Am Coll Cardiol. Catanzariti D.12(5):680-685. results of the New York Heart Failure Reg- ure and cognitive impairment: challenges istry. Lunati M. Masoudi FA. Piette JD. internists. Heisler M. Heckman GA. Jaarsma T. 2010. 2010. et al. Comisso J. Valsecchi S. 2009. Hobbs FD. J Am 71. doi:10. et al. Am J Cardiol. J Card Fail. ications. Echocardiography. 61. Culp WC. Chiles CD. Postgrad Med. 2. 2010. 60. of care and outcomes of patients hospital- 54. Elevated troponin T on discharge predicts poor outcome of decompensated heart fail- ure. Silveira Factors identified as precipitating hospital MJ. 67. ized with heart failure (from OPTIMIZE-HF). 2009. Sodium dietary Artery Disease Program).2009. 2010. Albert NM. Schooler MP.1540-8175. Health literacy and the patient with heart failure—implications for patient care and research: a consensus statement of the Heart Failure Society of America. Liang L. Albert NM. 2010. outcomes.32(3):363-70. ent adults with diabetes or heart failure: do Arch Intern Med. Klapholz M. J Card Fail. Templeton GA. making behavior of older females. Get With The Guidelines steering commit- 55.20(4):217-224. 66. St a normal left ventricular ejection fraction: Onge J. 38:427-434. Heiser RM. 29(14):1739-1752. Acad Nurse Pract. Laramee AS. Evangelista LS. Relationship of paroxysmal atrial tachy- arrhythmias to volume overload: assessment by implanted transpulmonary impedance monitoring. 2007. and health status in 73. Yoshikawa T. Yancy CW. 2(2):209-218. J Cardiovasc Nurs. Albert NM.104:107-115. hospital outcomes in patients with coronary tion: a diary analysis. Hernandez AF. Clin Interv Aging.6(1):22-33. tee and hospitals. Welsh JD. www. Family influences on self. No. et al. Koide K. 57. OPTIMIZE-HF investigators and hospitals. and decision. Quality of care and in- Improving heart failure symptom recogni. Intratho- racic impedance and pulmonary wedge pressure for the detection of heart failure deterioration. Hospi- 54-60. SHAPE study group. Turpie ID. sion and discharge for heart failure: 53.2(5):488-494. with heart failure in the emergency depart.and gender-related differences in quality Pacing Clin Electrophysiol. Monitoring intrathoracic impedance with 69. Eur Heart J. knowledge. Rosland AM. Heart Lung. Catanzariti D. Awareness and per- ception of heart failure among European cardiologists. Circ Arrhythm Electrophysiol. association with quality of care and clinical Italian Clinical Service Optivol-CRT group. Fonarow GC. 2006. 2004. heart failure patients.122(3):230-237. outcomes: findings from OPTIMIZE-HF. admissions for heart failure and clinical management among functionally independ. et al.

given 30 minutes before administration of an intravenous loop diuretic • Oral metolazone (2. Administer 2 diuretic agents at the same time: for example. Abraham WT. HFSA 2010 Comprehensive Heart Failure Practice Guideline. No. A valuable assessment variable for provided. a loop diuretic and an agent that blocks the distal tubule • Intravenous chlorothiazide (500-1000 mg).ccnonline.32(2):20-32.1-0. furosemide at 5-40 mg/h or bumetanide at 0. leading to improvement in volume status. Nurses should ask patients about recent tion. 2009 Focused update: namic status without further damage of cardiac myocytes.5 mg/h 2. Infuse the agent as a continuous intravenous infusion: for example. Jessup M. Heart Failure Society of America. Signs and assessed along with patients’ subjective perceptions of symptoms of both hemodynamic and clinical congestion clinical changes in status. Rotating loop diuretic agents: for example. hypervolemia may be history of recent hospitalization ence to heart failure medications improves cardiac func.5-10 mg) given with an oral loop agent 3. switching or alternating between oral furosemide and torsemide a No large. the single health care center to meet health needs. Crit Care . in heart failure. CCN aims of fluid management strategies for left ventricular systolic dysfunction and left ventricular dysfunction References 1. such as worsening exercise should be assessed serially during hospitalization. stabilization of hemody. randomized trials that provide evidence of the effectiveness of these strategies have been done. Physical signs and symptoms must be both hemodynamic and clinical congestion.34. Casey DE. 2009. Fluid management strategies in heart failure. The ume status on a single method of assessment or on only pathophysiology of fluid retention is complex and involves a few variables.119(14):1977-2016. Lindenfeld J. 2012. decompensation.CCN Fast Facts CriticalCareNurse The journal for high acuity. 2. Adher. et al. 2005 Heart Failure Writing Committee. 2009 Writing Group to with preserved ejection fraction are relief of signs and Review New Evidence and Update the 2005 Guideline for the Manage- ment of Patients with Chronic Heart Failure Writing on Behalf of the symptoms of hypervolemia. nurses must not base decisions on vol- pensated heart failure that requires hospitalization. Table Strategies to overcome diuretic resistancea 1. Circulation. especially if patients use more than a During both hospitalization and outpatient care. tion/American Heart Association Task Force on Practice Guidelines: Developed in Collaboration With the International Society for Heart volemia that require hospitalization for heart failure and Lung Transplantation. 2010. resistance are provided in the Table. hospital events.2 Strategies to overcome diuretic 2. 32 CriticalCareNurse Vol 32. et al.1.2 Albert NM. Core intolerance or changes in New York Heart Association heart failure drug and cardiac device therapies should be functional class. Based on data from Jessup et al1 and the Heart Failure Society of America. progressive. for heart failure. ACCF/AHA guidelines for the diagnosis and management of heart fail- ure in adults: a report of the American College of Cardiology Founda- and minimization of preventable recurrences of hyper. APRIL 2012 www. J Card Fail. Albert NM. and ultrafiltration may be warranted. and critical care Fluid Management Strategies in Heart Failure Facts In patients with chronic heart failure.16(6):e1-e194. fluid retention Because of the nuances of hypervolemia assessment (or hypervolemia) is often the stimulus for acute decom.

Production of cortisol by the adrenal gland b. Which factor has been associated with long-term improvement in heart failure patients? 11. Glomerular filtration rate d. Hyponatremia and antidiuretic hormone a. Normal kidney function b. Angiotensin-converting enzyme inhibitor system b. Which of the following are physiological effects of angiotensin II? d. Ensuring patients know how to record daily weight and report changes d. symptoms and diagnostic information needed to determine hypervolemia in heart failure 3. or fluid restriction as the reason for b. Freedom from hypervolemia after hospitalization a. . CCRN. Weight gain was commonly reported when even mild dyspnea was present. Card # Expiration Date Aliso Viejo. CCNS. You may photocopy this form. q a 9. 1. thiazide diuretic. Weight loss when overweight. After initial treatment (first 24 hours) of hypervolemia in patients structural heart disease? with acute decompensated heart failure. 46% and 38%. Potassium c. California (#01036). Loop diuretic 4. Hypocalcemia and hyperkalemia d. What is the key factor to ensure euvolemia in heart failure patients? unless otherwise contraindicated? a. 2014 Contact hours: 1. Activates renal vasoconstriction and stimulates the sympathetic nervous a. obese. Angiotensin-converting enzyme inhibitor or angiotensin II receptor c. Diet class provided to family members after discharge 6. medications. $0. a. 12% and 15%. Hypovolemia and decreased exercise tolerance 8. Weight gain was associated with systolic dysfunction (ejection fraction readmission? of <40%). Drinking fluids to prevent thirst prescribed therapies and preventing rehospitalization? b. AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062). Weight gain was commonly observed in patients with edema. RN. respectively d. q a 10. MSN. respectively c. Digoxin. β-blocker. Describe the pathophysiological processes related to fluid overload (hypervolemia) in heart failure 2. 2. $10 Passing score: 9 correct (75%) Synergy CERP: Category A Test writer: Diane Byrum. q a 2. nonmembers. and Louisiana (#ABN12). 1/St RN Lic. B-type natriuretic peptide c. q a qb qb qb qb qb qb qb qb qb qb qb qb qc qc qc qc qc qc qc qc qc qc qc qc qd qd qd qd qd qd qd qd qd qd qd qd Test ID: C122 Form expires: April 1. Aldosterone inhibitor aldosterone system? a. loop diuretic. Keeping serum sodium levels between 130-135 mmol/L c. Test answers: Mark only one box for your answer to each question. What did multiple researchers find to be true regarding weight gain in acute decompensated heart failure? 12. Which strategies were most effective for promoting adherence to a. Activates peripheral vasoconstriction and sodium excretion b. Hypermagnesemia and hypercalcemia 5. Decreased levels of B-type natriuretic peptide blocker and β-blocker d. 101 Columbia q easy q medium q difficult To complete this program. b. CA 92656. Which statement best defines features of heart failure due to 7. β-Blocker. q a 4. Identify strategies to manage hypervolemia associated with decompensated heart failure during hospitalization and after discharge 1. The integrity of the arterial circulation a. β-Blocker c. What percentage of patients and informal caregivers cited non- a. Recognize the signs. and angiotensin-converting enzyme inhibitor b. q a 3. q a 11. q a 7. Inhibits the release of antidiuretic hormone and B-type natriuretic peptide logical treatment for hypervolemia in heart failure? d. Hypokalemia and hypomagnesemia c. 25% and 26%. What class of medication is considered the hallmark pharmaco- c. what laboratory value is a. Aldosterone inhibitor. β-Receptors in juxtaglomerular apparatus of the kidney c. Cough and orthopnea b. respectively d. d. even if dyspnea or edema are present. Orthopnea and sleep disordered breathing not an accurate predictor of heart failure status? b.ccnonline. or extremely obese b. Decreased exercise tolerance and fluid retention a. it took me hours/minutes. What adverse events are associated with the use of loop diuretics? b. FCCM Program evaluation Name Member # Yes No Address Objective 1 was met q q Objective 2 was met q q City State ZIP Objective 3 was met q q For faster processing. q a 6. Sodium d. Activates renal vasodilatation and sodium retention 9. Weight gain may not occur in patients. q a 8. take Content was relevant to my Country Phone nursing practice q q this CE test online at E-mail My expectations were met q q www.CE Test Test ID C122: Fluid Management Strategies in Heart Failure Learning objectives: 1. Signature The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. and angiotensin-converting enzyme inhibitor 3. adherence to This method of CE is effective RN Lic. q a 12. Sending patients home with written self-care materials c.0 Fee: AACN members. Decrease in arterial volume 10. What is the mechanism for the stimulation of the renin-angiotensin. q a 5. Hyperphosphotemia and hyponatremia d. Education before discharge and remote monitoring d. What medications should all patients with heart failure take. 14% and 46%. and hydralazine/nitrate combination a. respectively c. 2/St (“CE Articles in this issue”) for this content q q or mail this entire page to: The level of difficulty of this test was: Payment by: q Visa q M/C q AMEX q Discover q Check AACN. AACN programming meets the standards for most other states requiring mandatory continuing education credit for relicensure. Increased level of renin c.