Chronic heart failure 

 a clinical syndrome resulting from structural or functional carjacked disorders that

impair the ability of the ventricles to fill or eject blood. 
Types: 
 right sided heart failure- right ventricle fails congestion in the peripheral tissues and the
viscera dominates 
 left sided heart failure- left ventricle cannot effectively pump blood out of the ventricle
into the aorta and the systemic circulation. 
 systolic heart failure- left ventricle cannot pump vigorously 
 diastolic heart failure- the left ventricle cannot relax or fill fully 

Pathophysiology:
 The body activates neurohormonal compensatory mechanisms. These mechanisms
represent the body’s attempt to cope with the HF and are responsible for the signs and
symptoms that develop Understanding these mechanisms is important because the
treatment for HF is aimed at correcting them and relieving symptoms.

 Systolic HF results in decreased blood ejected from the ventricle. The decreased blood
flow is sensed by baroreceptors in the aortic and carotid bodies. The sympathetic nervous
system is then stimulated to release epinephrine and norepinephrine, to increase heart rate
and contractility and support the failing myocardium, but the continued response has
multiple negative effects. Causes vasoconstriction in the skin, gastrointestinal tract, and
kidneys. decrease in renal perfusion due to low CO and vasoconstriction then causes the
release of renin by the kidneys.

 Renin converts the plasma protein angiotensinogen to angiotensin I. Angiotensin-

converting enzyme (ACE) in the lumen of pulmonary blood vessels converts angiotensin
I to angiotensin II, a potent vasoconstrictor, which then increases the blood pressure and
afterload.

 Angiotensin-converting enzyme (ACE) in the lumen of pulmonary blood vessels converts

angiotensin I to angiotensin II, a potent vasoconstrictor, which then increases the blood
pressure and afterload. As the heart’s workload increases, contractility of the myocardial
muscle fibers decreases.

 Decreased contractility results in an increase in end-diastolic blood volume in the

ventricle, stretching the myocardial muscle fibers and increasing the size of the ventricle
(ventricular dilation). As cardiac cells die and the heart muscle becomes fibrotic, diastolic
HF can develop, leading to further dysfunction.

 A stiff ventricle resists filling, and less blood in the ventricles causes a further decrease in
CO. All of these compensatory mechanisms of HF have been referred to as the “vicious
cycle of HF” because low CO leads to multiple mechanisms that make the heart work
harder, worsening the HF.

Pharmacologic therapy:
 1. Angiotensin- Converting Enzyme Inhibitors- Decrease the secretion of aldosterone, promote
renal excretion of sodium and potassium. Decrease BP and afterload.
Nursing Consideration:
 Observe for hypotension and hyperkalemia
 Start at low dose

2. Hydralazine and Isosorbide Dinitrate- For patients who cannot take ACE inhibitors. Dilates blood
vessels
Nursing Consideration:
• Observe for symptomatic hypotension

3. Beta- Blockers- Block adverse effect of sympathetic nervous system; relax blood vessel.
Decrease BP, afterload and cardiac workload
Nursing Consideration:
• Observe Heart rate, symptomatic Hypotension, dizziness and fatigue
• Use caution in patients with a history of bronchospastic disease

4. Diuretics- To remove excess extracellular fluid by increasing rate of urine produced in patients
with signs and symptoms of fluid overload
Nursing Consideration:
• Observe for electrolyte abnormalities, renal dysfunction, diuretic resistance, and
decreased BP, carefully monitor I&O and daily weight

5. Digitalis- Improves cardiac contractility

Nursing Consideration:
 Observe for bradycardia and digitalis toxicity

6. Milrinone- Increase Contractility. Decrease Preload and afterload and reduce cardiac workload
Nursing Consideration:
• Caution to patients who are hypovolemic
7. Dobutamine- Stimulates the beta-1 adrenergic receptors. Increase cardiac contractility and renal
perfusion

Nutritional Therapy
• Low- Sodium Diet and avoiding excessive fluid- No more than 2g/day
-Decrease amount of circulating blood volume
Nursing Process:
Assessment:
Health History:
• Sleep Disturbance
• Shortness Of Breath
 • Number of Pillows
• Edema
• ADL
• Mental Status
Physical Examination:

• LOC- evaluated for any changes, as low CO can decrease the flow of oxygen to the brain.

• Auscultation- Lungs are auscultated to detect crackles and wheezes. Crackles are produced by
the sudden opening of edematous small airways and alveoli. Wheezing may also be heard in
some patients who have bronchospasm along with pulmonary congestion.

• RR and depth- assessed along with the effort required for breathing.

• BP evaluation- carefully evaluated, because HF patients may present with hypotension or

hypertension. Patients may be assessed for orthostatic hypotension, especially if they report
lightheadedness, dizziness, or syncope.

• HR and rhythm- auscultated for an S3 heart sound, which is an early sign that increased blood
volume fills the ventricle with each beat. Heart rate and rhythm are also documented, and
patients are often placed on continuous ECG monitoring in the hospital setting. When the heart
rate is rapid or very slow, the CO decreases and potentially worsens the HF.

• JVD- assessed with the patient sitting at a 45° angle; distention greater than 4 cm above the
sternal angle is considered abnormal and indicative of right ventricular failure.

• Skin- color and temperature. With significant decreases in SV, there is a decrease in perfusion to
the periphery, decreasing the volume of pulses and causing the skin to feel cool and appear pale
or cyanotic.

• Feet, Lower Leg, Sacrum- examined for edema

• Abdomen- examined for tenderness and hepatomegaly. The presence of firmness, distention,
and possible ascites is noted. The liver may be assessed for hepatojugular reflux. The patient is
asked to breathe normally while manual pressure is applied over the right upper quadrant of the
abdomen for 30 to 60 seconds

• Weight- increased weight means there is a fluid retention

• I&O- assess for oliguria and anuria
Diagnosis:
• Activity intolerance related to decreased CO
• Excess fluid volume related to the HF syndrome
• Anxiety related to clinical manifestations of HF
• Powerlessness related to chronic illness and hospitalizations
 • Ineffective family health management
Planning and goals
Major Goals:
• Promote Activity
• Reduce Fatigue
• Decrease Anxiety or increasing Patient’s Ability to manage anxiety
• Encouraging to verbalize ability to make decisions and influence outcomes
• Educating the Patient and family about health management

Nursing Interventions:
PROMOTING ACTIVITY TOLERANCE:

Reduced physical activity caused by HF symptoms leads to physical deconditioning that worsens the
patient’s symptoms and exercise tolerance. Prolonged inactivity, which may be self-imposed, should be
avoided because of its deconditioning effects and risks, such as pressure ulcers (especially in edematous
patients) and venous thromboembolism.

• Exercise Training
• Walking regimen

• Pacing and Prioritization of activities- The primary provider, nurse, and patient collaborate to
develop a schedule that promotes pacing and prioritization of activities. The schedule should
alternate activities with periods of rest and avoid having two significant energy-consuming
activities occur on the same day or in immediate succession.

• Exercise Program-
Guidelines:
• Begin with low impact activities-
• Start with warm up activities
• Follow with cool down activities
• Avoid performing outside hot, cold or humid weather
• Ensure pt. is able to talk during activity
• Stop activity if: severe shortness of breath, pain, dizziness develops
Managing Fluid Volume:
• Monitor fluid status- Weight gain in a patient with heart failure almost always reflect fluid
retention
 • Adherence to low- sodium diet- If diet includes fluid restriction the nurse can assist the patient to
plan fluid intake through out the day while respecting patient’s dietary preferences
• Plan Fluid intake-
• Monitor IV fluid
• Patient Positioning- Increase pillow and evaluate head, may sit in a recliner to reduce preload to
the heart, pulmonary congestion and pressure in the diaphragm
Controlling anxiety:
• Physical comfort- sitting position; Oxygen may be given
• Psychological Support- patient with heart failure rely on their families for many aspects of care
Minimizing Powerlessness:
• Help Recognize choices- patient may feel overwhelmed in the diagnosis and treatment regimen
leading to feelings of powerlessness
• Listen actively to patient
• Screen for Depression- Related in part to physiologic changes with heart failure. Depressive
symptoms are known to increase as the disease worsens
Promoting Home, Community- Based, and Transitional care:
• Educate about Self Care- Instruct patient about medication management. Low sodium diet ans
smoking cessation. Pt. should have a written copy of instructions
• Assess readiness to learn and potential barriers
• Transitional Care Programs- Telephone- to assess patient on a frequent basis
• Home Visits- Trained HF nurse provide assessment and management tailored to specific
individualize patient needs.
• Provide assistance- through scheduling and appointments
• Referral to HF clinics (EBP HF guideline Recommendation)- gives the patient ready access to
continuing education, professional nursing and medical staff and timely adjustment in treatment
regimen
Assisting Patients and Family to effectively Manage Health:
• Develop comprehensive teaching and discharge plan
EBP Components:
• Comprehensive and pt. Centered instructions
• Follow- up visits
• Telecommunication
End of life Considerations:
 • Ventricular Assist Device- failed medical therapy; show to extend survival and increase quality of
life in some patients with end- stage HF
• Discussions concerning use of technology, preferences for end-of-life and participate and express
preferences
Evaluation:
• Demonstrate Tolerance for desired activity
• Maintains fluid balance
• Decreased anxiety
• Makes sound decisions regarding care and treatment
• Patients and Family members adhere to healthy regimen