Heart failure (HF), often known as congestive heart failure (CHF), is a chronic, progressive condition where the heart cannot pump enough blood to meet the body’s needs. This inadequacy can stem from issues in the left ventricle, the heart’s primary pumping chamber, leading to left-sided heart failure. In this condition, the left ventricle may lose its contractile strength or become stiff, hindering its ability to relax and fill with blood effectively. Untreated left-sided heart failure frequently progresses to right-sided heart failure. In right-sided HF, the right ventricle weakens, causing blood to back up into the veins, resulting in systemic congestion. When the heart fails to pump blood efficiently, every organ system in the body is compromised.
Nurses are essential in the holistic management of heart failure. Their role extends beyond treatment administration to encompass patient education on crucial lifestyle adjustments that can slow disease progression and prevent complications. A deep understanding of cardiac mechanics and the pathophysiology of heart failure is paramount for nurses to provide effective care, proactively monitor for changes, and mitigate systemic effects.
The Nursing Process in Heart Failure Management
The nursing process provides a structured framework for delivering patient-centered care. In heart failure, this process is crucial for identifying patient needs, planning and implementing care, and evaluating outcomes.
Nursing Assessment: Gathering Subjective and Objective Data
The initial step in the nursing process is a comprehensive nursing assessment. This involves collecting subjective data, what the patient reports, and objective data, what the nurse observes or measures. In heart failure, this assessment is critical for formulating accurate nursing diagnoses.
Review of Health History: Uncovering Clues
1. Evaluating General Symptoms: Begin by documenting the patient’s reported symptoms. Common complaints associated with heart failure include:
- Dyspnea on exertion: Shortness of breath triggered by physical activity.
- Orthopnea: Breathlessness when lying down, often relieved by sitting upright.
- Fatigue and weakness: Persistent tiredness and lack of energy.
- Edema in lower extremities: Swelling in ankles, feet, and legs due to fluid retention.
- Tachycardia: An abnormally rapid heart rate.
- Irregular heartbeat: Palpitations or skipped beats.
- Exercise intolerance: Reduced ability to perform physical activity.
- Persistent cough: A cough that may be dry or produce phlegm, sometimes worse at night.
- Wheezing: A whistling sound during breathing, indicating airway narrowing.
- Abdominal swelling: Ascites, fluid accumulation in the abdomen.
- Rapid weight gain: Sudden increase in weight due to fluid retention.
- Nausea: Feeling sick to the stomach.
- Lack of appetite: Loss of interest in food.
- Decreased alertness: Confusion or reduced awareness.
- Chest pain: Angina, discomfort or pain in the chest, although less common in heart failure itself but important to rule out related conditions.
2. Investigating Underlying Causes: Heart failure rarely arises spontaneously. It is typically a consequence of another condition that damages the heart muscle. Explore potential underlying causes, including:
- Coronary artery disease (CAD): Narrowing or blockage of arteries supplying blood to the heart.
- Myocardial infarction (MI): Heart attack, damage to the heart muscle from blocked blood supply.
- Hypertension: Chronic high blood pressure, straining the heart over time.
- Heart valve disease: Conditions affecting the heart valves, disrupting blood flow.
- Myocarditis: Inflammation of the heart muscle, often caused by viral infections.
- Congenital heart defects: Structural abnormalities of the heart present at birth.
- Cardiac arrhythmias: Irregular heart rhythms, affecting the heart’s efficiency.
- Chronic conditions: Poorly managed diabetes mellitus, HIV, hyperthyroidism, or hypothyroidism can contribute to heart damage.
3. Identifying Heart Failure Stage: The New York Heart Association (NYHA) classification is commonly used to categorize the severity of heart failure based on symptoms:
- Class I: No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain.
- Class II: Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.
- Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain.
- Class IV: Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest can be present. If any physical activity is undertaken, discomfort is increased.
4. Determining Risk Factors: Assess both non-modifiable and modifiable risk factors for heart failure:
Non-modifiable Risk Factors:
- Age: Cardiac function naturally declines with age, increasing heart failure risk, especially in those over 65.
- Gender: Men are statistically more prone to heart failure than women.
- Family history of ischemic heart disease: Genetic predisposition significantly increases risk, particularly if close relatives developed heart disease at a young age.
- Race/ethnicity: African Americans and Latinos exhibit a higher incidence of heart failure compared to Caucasians.
Modifiable Risk Factors:
- Hypertension: Uncontrolled high blood pressure is a major contributor to heart failure.
- Hyperlipidemia/hypercholesterolemia/coronary artery disease: Elevated LDL cholesterol and low HDL cholesterol promote atherosclerosis, impeding blood flow.
- Diabetes or insulin resistance: These conditions accelerate blood vessel damage and plaque buildup.
- Heart valve disease: Impaired heart valves force the heart to work harder.
- Tobacco use: Smoking drastically accelerates plaque buildup.
- Obesity: Increases the risk of hypertension, hyperlipidemia, and diabetes, all heart failure risk factors.
- Physical inactivity: Sedentary lifestyles double the risk of heart disease.
- Diet: Diets high in unhealthy fats, sodium, and sugar contribute to obesity and related chronic diseases.
- Stress: Chronic stress elevates inflammatory markers and constricts blood vessels.
- Alcohol use: Excessive alcohol consumption weakens the heart muscle.
- Lack of sleep: Insufficient sleep elevates stress hormones and constricts blood vessels.
- Bacterial and viral infections: Infections like influenza, pneumonia, urinary tract infections, and even COVID-19 can trigger or worsen heart failure.
5. Reviewing Treatment Records: Medications and past vascular surgeries can impact artery integrity and contribute to heart failure. Pay attention to:
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Certain diabetes medications like rosiglitazone and pioglitazone
- Antihypertensive medications (paradoxically, some can worsen HF in certain contexts)
- Medications for cancer, blood disorders, arrhythmias, nervous system disorders, mental health issues, lung and urinary problems, inflammatory diseases, and infections.
Alt Text: Nurse assessing a patient’s lower leg for peripheral edema, a common sign of fluid retention in heart failure.
Physical Assessment: Objective Signs of Heart Failure
1. Vital Signs Assessment: Monitor vital signs closely, as changes can indicate worsening heart failure.
- Pulse rate: Often elevated (tachycardia) as the heart compensates for reduced output.
- Blood pressure: Can be elevated or decreased depending on the stage and type of heart failure.
- Oxygen saturation (SpO2): May be reduced, indicating poor oxygenation.
2. Systemic Physical Examination: Perform a head-to-toe assessment, focusing on systems affected by heart failure:
- Neck: Jugular vein distention (JVD), visible bulging of neck veins, indicates increased central venous pressure and fluid overload.
- Central Nervous System (CNS): Decreased alertness, confusion, or restlessness due to reduced cerebral perfusion.
- Cardiovascular:
- Tachycardia, irregular heart rate.
- Chest pain (angina if CAD is present).
- Abnormal heart sounds, particularly pathological S3 (ventricular gallop) and S4 (atrial gallop) on auscultation. S3 indicates early diastolic filling of a dilated ventricle, and S4 indicates late diastolic filling due to stiff ventricle.
- Arrhythmias detected through auscultation or ECG.
- Circulatory:
- Decreased peripheral pulses, weak or thready pulses in extremities.
- Narrow pulse pressure (less than 25 mmHg), the difference between systolic and diastolic pressure, indicates reduced cardiac output.
- Respiratory:
- Dyspnea on exertion or at rest.
- Tachypnea, rapid breathing.
- Orthopnea.
- Persistent or nocturnal cough, often worse at night.
- Crackles or rhonchi in lung bases on auscultation, indicating pulmonary congestion.
- Gastrointestinal:
- Nausea and vomiting due to venous congestion.
- Lack of appetite, anorexia.
- Abdominal swelling, ascites from hepatic congestion and fluid accumulation.
- Lymphatic: Edema in lower extremities (pitting or non-pitting).
- Musculoskeletal: Fatigue, muscle weakness, activity intolerance, rapid weight gain from fluid retention.
- Integumentary: Cyanotic (bluish) or pale skin, cool and clammy skin, excessive sweating (diaphoresis) due to sympathetic nervous system activation.
Diagnostic Procedures: Confirming Heart Failure and Assessing Severity
Diagnostic tests are crucial for confirming the diagnosis of heart failure, determining its cause, and assessing its severity.
1. Electrocardiogram (ECG): An ECG can reveal abnormalities suggestive of heart failure, such as P wave changes indicating left atrial hypertrophy (enlargement). It can also identify arrhythmias and evidence of previous myocardial infarction.
2. B-type Natriuretic Peptide (BNP) or NT-proBNP Lab Results: Elevated BNP or NT-proBNP levels in the blood are hallmark indicators of heart failure. These peptides are released by the heart in response to ventricular stretching and pressure overload.
3. Other Blood Tests:
- Complete blood count with differential (CBC): Can identify infection (elevated WBC), assess blood coagulation (platelet count), and detect anemia (low RBC levels), which can exacerbate heart failure.
- Cholesterol levels: Assess risk for coronary artery disease, a major contributor to heart failure.
- Thyroid levels: Rule out thyroid disorders, as both hyperthyroidism and hypothyroidism can contribute to arrhythmias and heart failure.
4. Chest X-ray: A chest X-ray can reveal cardiomegaly (enlarged heart) and pulmonary congestion (fluid in the lungs), both characteristic of heart failure.
5. Echocardiogram: This ultrasound of the heart is a cornerstone diagnostic test for heart failure. It assesses:
- Ejection fraction (EF): The percentage of blood pumped out of the left ventricle with each beat. EF is a key indicator of heart function:
- Normal EF: 55-70%
- Slightly below normal EF: 40-54% (may not be symptomatic)
- Mild heart failure EF: 35-39%
- Moderate to severe heart failure EF: Less than 35%
- Heart valve function: Detects valve stenosis or regurgitation.
- Chamber size and wall thickness: Identifies hypertrophy or dilation.
- Wall motion abnormalities: Indicates areas of myocardial damage.
6. Further Investigations: More specialized tests may be needed to further evaluate heart function and identify underlying causes:
- Exercise treadmill test: Evaluates heart function during physical exertion in patients capable of exercise and with normal resting ECGs.
- Nuclear stress test (myocardial perfusion imaging): Uses a radioactive tracer to assess blood flow to the heart muscle during stress (exercise or medication-induced).
- Stress imaging (dobutamine stress echocardiogram): Used for patients unable to exercise or with challenging ECGs; uses medication (dobutamine) to stress the heart while imaging is performed.
- Cardiac CT scan: Detects calcium deposits and blockages in coronary arteries.
- Cardiac catheterization (coronary angiography): Invasive procedure to visualize coronary arteries, identify blockages, and measure pressures within the heart chambers.
- CT coronary angiogram: Similar to cardiac CT but provides more detailed images of coronary arteries using contrast dye.
- Myocardial biopsy: Rarely performed, but may be used to investigate specific heart muscle diseases causing heart failure.
Alt Text: Echocardiogram image visualizing the four chambers of the heart, used to assess heart structure and function in diagnosing heart failure.
Nursing Interventions: Promoting Perfusion and Managing Heart Failure
Nursing interventions are crucial for managing symptoms, improving cardiac function, and preventing complications in heart failure.
Promoting Perfusion: Optimizing Cardiac Output
1. Vasodilators (ACE inhibitors and ARBs): These medications relax blood vessels, improving blood flow, reducing blood pressure, and decreasing strain on the heart muscle.
2. Beta-blockers: Reduce heart rate and blood pressure, improving heart function over time.
3. Diuretics: Increase urination to eliminate excess fluid, reducing fluid overload and pulmonary congestion.
4. Potassium-sparing diuretics (Aldosterone antagonists): Help treat systolic heart failure by removing excess fluid while conserving potassium.
5. Strengthening Heart Contractions:
- Inotropes (IV): Administered in hospital settings to enhance heart pumping strength and maintain blood pressure in acute heart failure.
- Digoxin: Oral medication that increases the force of heart contractions; requires careful monitoring for digoxin toxicity.
6. Treating Underlying Conditions: Addressing the root cause of heart failure is essential for long-term management.
- Coronary artery bypass graft surgery (CABG): Surgical procedure to bypass blocked coronary arteries, improving blood supply to the heart.
- Heart valve repair or replacement: Surgical correction of faulty heart valves.
- Cardiac resynchronization therapy (CRT): Uses a biventricular pacemaker to coordinate heart contractions in patients with conduction delays.
- Ventricular assist devices (VADs): Mechanical pumps that support heart function in severe heart failure.
- Heart transplant: Considered for end-stage heart failure when other treatments are ineffective.
Cardiac Rehabilitation: Restoring Function and Improving Quality of Life
Cardiac rehabilitation programs play a vital role in the recovery and long-term management of heart failure.
1. Multidisciplinary Team Collaboration: Patients benefit from a team approach involving cardiologists, cardiac rehab nurses, dietitians, social workers, and physical and occupational therapists.
2. Improving Activity Tolerance: Cardiac rehab programs gradually introduce exercises to strengthen the heart and improve exercise capacity after procedures or during chronic management.
3. Strengthening Overall Health: Cardiac rehab aims to improve patients’ physical and emotional well-being, prevent disease progression, and reduce complications.
Reducing the Risk of Complications: Preventing Worsening Heart Failure
Preventive measures and patient education are key to minimizing complications and improving outcomes in heart failure.
1. Regulating Heart Rhythm (Implantable Cardioverter-Defibrillators – ICDs): ICDs monitor heart rhythm and deliver electrical shocks to correct life-threatening arrhythmias, preventing sudden cardiac death.
2. Emphasizing Lifestyle Modifications: Educate patients on the importance of adopting heart-healthy lifestyle changes:
- Regular exercise (within limitations).
- Heart-healthy diet (low sodium, low fat, rich in fruits and vegetables).
- Smoking cessation.
- Avoidance of secondhand smoke.
- Stress management techniques.
- Vaccinations (influenza, pneumonia).
- Limiting alcohol consumption.
- Restful sleep.
3. Activity Guidance: Advise patients on safe exercise levels. Start with short durations (5-10 minutes) of moderate-paced activity and gradually increase as tolerated.
4. Maintaining a Healthy Weight: Weight management is crucial to reduce strain on the heart. Recommend limiting saturated and trans fats.
5. Promoting Treatment Adherence: Emphasize the importance of medication adherence, follow-up appointments, and self-monitoring.
6. Stress Reduction: Teach stress-reduction techniques such as guided imagery, yoga, deep breathing, muscle relaxation, and meditation.
7. Preventing Fluid Accumulation: Educate patients to monitor for edema, weigh themselves daily, and limit sodium intake. Instruct them to report weight gain of more than 2.5 lbs overnight or 5 lbs in a week.
8. Recognizing When to Seek Medical Attention: Instruct patients to seek immediate medical attention for:
- Chest pain.
- Sudden weight gain.
- Fainting (syncope).
- Dyspnea at rest or worsening dyspnea.
- Sudden productive cough with white or pink, foamy sputum.
9. Cardiology Follow-up: Regular visits to a cardiologist and routine tests (blood tests, echocardiograms) are essential for monitoring disease progression and adjusting treatment.
10. Medical Identification: Recommend medical identification bracelets or necklaces to alert emergency responders to the patient’s heart failure history, especially for those living alone.
Common Nursing Diagnoses Related to Heart Failure
Nursing diagnoses provide a standardized language to describe patient health problems that nurses can address. In heart failure, several nursing diagnoses are frequently identified.
Activity Intolerance
Nursing Diagnosis: Activity Intolerance
Related to:
- Imbalance between oxygen supply and demand
- Weakness/deconditioning
- Sedentary lifestyle
As evidenced by:
- Fatigue
- Dyspnea
- Immobility
- Vital sign changes in response to activity (e.g., increased heart rate, decreased SpO2)
- Chest pain on exertion
- Diaphoresis (excessive sweating)
Expected Outcomes:
- Patient will perform activities within their functional limitations without undue cardiac stress.
- Patient will balance activity and rest to accomplish activities of daily living (ADLs).
- Patient will maintain stable vital signs and heart rhythm during activity.
Nursing Assessments:
- Observe cardiopulmonary response to activity: Monitor heart rate, oxygen saturation, and cardiac rhythm during activity to identify signs of overexertion.
- Assess patient’s perception of limitations: Understand the patient’s understanding of their condition and perceived activity limitations to tailor interventions appropriately.
- Assess degree of debility: Evaluate fatigue, weakness, and dyspnea severity to determine the level of assistance needed with ADLs and ensure patient safety.
Nursing Interventions:
- Provide a calm environment: Reduce anxiety and restlessness associated with dyspnea by creating a cool, quiet, and uncluttered space.
- Encourage participation in care: Promote independence and prevent complications of immobility by encouraging patients to participate in self-care within their limitations.
- Teach energy conservation methods: Educate on strategies to conserve energy, such as grouping tasks, sitting during activities, planning rest periods, and avoiding extreme temperatures.
- Recommend cardiac rehabilitation: Refer patients to cardiac rehab programs for supervised exercise, education, and support.
Decreased Cardiac Output
Nursing Diagnosis: Decreased Cardiac Output
Related to:
- Altered heart rate or rhythm (arrhythmias)
- Altered contractility (weakened heart muscle)
- Structural changes (e.g., aneurysm, valve dysfunction)
As evidenced by:
- Increased heart rate (tachycardia, palpitations)
- Dysrhythmias
- Fatigue
- Shortness of breath
- Anxiety
- Orthopnea
- Jugular vein distention (JVD); edema
- Central venous pressure (CVP) changes
- Murmurs
- Decreased peripheral pulses
- Decreased urine output (oliguria)
- Skin pallor, mottling, or cyanosis
Expected Outcomes:
- Patient will demonstrate hemodynamic stability with vital signs, cardiac output, and renal perfusion within acceptable limits.
- Patient will participate in activities that reduce cardiac workload.
- Patient will report absence of chest pain or shortness of breath.
Nursing Assessments:
- Assess vital signs, cardiac rhythm, and hemodynamic measurements: Continuous cardiac monitoring (telemetry) and regular vital sign checks are essential to detect and respond to changes promptly. Hemodynamic monitoring may be needed in unstable patients.
- Monitor skin and pulses: Assess for signs of decreased tissue perfusion, such as skin mottling, pallor, cyanosis, coolness, clamminess, and weak or irregular peripheral pulses.
- Monitor mental status: Assess for changes in mental status, such as confusion or decreased alertness, which can indicate reduced cerebral perfusion.
Nursing Interventions:
- Apply oxygen: Administer supplemental oxygen to improve oxygen saturation and tissue oxygenation.
- Administer medications: Administer vasodilators, morphine, anti-anxiety medications, and angiotensin receptor blockers (ARBs) as prescribed to reduce cardiac workload and improve cardiac output.
- Instruct on reducing cardiac workload: Educate patients on strategies to reduce cardiac workload, such as rest, activity modification, and assistance with ADLs as needed.
- Educate on risk factors and lifestyle modifications: Provide education on modifiable risk factors for heart failure and lifestyle changes to prevent disease progression.
Decreased Cardiac Tissue Perfusion
Nursing Diagnosis: Decreased Cardiac Tissue Perfusion
Related to:
- Structural impairment of the heart
- Malfunctions of heart structures
- Difficulty of the heart muscle to pump
- Increased exertion in workload
- Inadequate blood supply to the heart
- Inability to contract and relax effectively
- Erratic signals causing chaotic or irregular heart contraction
As evidenced by:
- Decreased cardiac output
- Decreased blood pressure (hypotension)
- Decreased peripheral pulses
- Increased central venous pressure (CVP)
- Increased pulmonary artery pressure (PAP)
- Tachycardia
- Dysrhythmias
- Ejection fraction less than 40%
- Decreased oxygen saturation
- Presence of abnormal S3 and S4 heart sounds upon auscultation
- Chest pain
Expected Outcomes:
- Patient will maintain pulse rate and rhythm within normal limits.
- Patient will demonstrate ejection fraction greater than 40% (if achievable).
- Patient will maintain palpable peripheral pulses.
Nursing Assessments:
- Auscultate the apex of the heart: Assess for abnormal heart sounds (S3 or S4), which can indicate ventricular dysfunction.
- Assist in myocardial perfusion test: Prepare and assist with myocardial perfusion imaging (nuclear stress test) to evaluate blood flow to the heart muscle.
- Check BNP or NT-proBNP levels: Monitor BNP or NT-proBNP levels as indicators of heart failure severity.
- Obtain ECG: Obtain and interpret ECG findings to assess for arrhythmias and other cardiac abnormalities.
- Assist in TEE (Transesophageal Echocardiography): Prepare patient for and assist with TEE to assess ejection fraction, left atrial pressure, and cardiac output.
- Prepare for left heart catheterization or coronary angiography: Prepare patient for these procedures to identify coronary artery blockages or other abnormalities.
Nursing Interventions:
- Set goals with the patient: Collaborate with the patient to establish realistic goals for therapy, focusing on symptom management, improved survival, and reduced hospital readmissions.
- Administer medications as ordered: Administer diuretics, angiotensin system blockers (ACE inhibitors, ARBs, or ARNIs), beta-blockers, and other medications as prescribed.
- Instruct on lifestyle modifications: Educate patients on dietary and nutritional recommendations (low sodium, fluid restriction), weight monitoring, aerobic exercise, and risk factor control.
- Consider device therapy: Educate patients about device therapies such as CRT and ICDs if appropriate.
- Anticipate the possibility of surgery: Prepare patients for potential surgical interventions such as heart transplantation, valve replacement, or catheter ablation if medications are insufficient.
Excess Fluid Volume
Nursing Diagnosis: Excess Fluid Volume
Related to:
- Excessive fluid or sodium intake
- Reduced glomerular filtration rate (kidney dysfunction)
- Increased secretion of antidiuretic hormone (ADH)
As evidenced by:
- Shortness of breath
- Weight gain
- Edema in extremities
- Jugular vein distention (JVD)
- Adventitious breath sounds (crackles, rales)
- High blood pressure
- Oliguria (decreased urine output)
- Tachycardia
- Pulmonary congestion (cough, S3 heart sound)
Expected Outcomes:
- Patient will demonstrate stable fluid volume, evidenced by balanced intake and output, stable weight, and absence of peripheral edema.
- Patient will verbalize understanding of signs and symptoms of fluid overload and when to seek medical help.
- Patient will adhere to dietary recommendations and fluid restrictions.
Nursing Assessments:
- Assess for peripheral edema, anasarca, and JVD: Monitor for signs of fluid retention, including edema in lower extremities, generalized edema (anasarca), and jugular vein distention.
- Monitor breath and heart sounds: Auscultate lungs for crackles and heart sounds for S3 gallop, indicative of fluid overload and pulmonary congestion.
- Monitor urine output and strict I&Os: Accurately measure and document fluid intake and output to assess fluid balance, especially in patients on diuretics.
Nursing Interventions:
- Maintain upright position: Position patient in semi-Fowler’s or Fowler’s position to ease breathing and reduce pulmonary congestion.
- Administer diuretics: Administer diuretics as prescribed to promote fluid excretion and reduce fluid overload. Monitor electrolytes, especially potassium.
- Instruct on sodium and fluid restrictions: Educate patients on low-sodium diets and fluid restrictions, providing practical strategies for adherence.
- Teach fluid overload monitoring: Educate patients on self-monitoring for signs of fluid retention, including daily weight monitoring and recognizing edema.
Impaired Gas Exchange
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Ventilation perfusion imbalance related to altered blood flow
- Changes to the alveolar-capillary membrane (pulmonary edema)
- Pulmonary congestion due to fluid retention
As evidenced by:
- Dyspnea
- Changes in mental status (restlessness, confusion)
- Anxiety
- Abnormal arterial blood gases (ABGs)
- Changes in respiratory rate, depth, or rhythm
- Tachycardia
Expected Outcomes:
- Patient will maintain adequate ventilation and perfusion, as evidenced by ABGs within normal limits or baseline.
- Patient will demonstrate improved ventilation, with oxygen saturation above 95% or patient’s baseline.
- Patient will participate in ambulation and ADLs as tolerated by respiratory status.
Nursing Assessments:
- Auscultate breath sounds: Assess for adventitious breath sounds (crackles, wheezes, diminished breath sounds) indicating pulmonary congestion or airway obstruction.
- Monitor pulse oximetry: Continuously monitor oxygen saturation to detect hypoxemia.
- Monitor arterial blood gases (ABGs): Obtain and interpret ABGs to assess oxygenation and ventilation status.
Nursing Interventions:
- Educate on coughing and deep breathing exercises: Teach and encourage coughing and deep breathing exercises to promote airway clearance and lung expansion.
- Change positions frequently: Reposition patient frequently to facilitate drainage of secretions and prevent atelectasis. Encourage ambulation if tolerated.
- Maintain semi-Fowler’s position: Elevate the head of the bed to promote lung expansion and reduce dyspnea.
- Administer supplemental oxygen as needed: Administer oxygen therapy as prescribed to maintain adequate oxygen saturation.
- Administer medications as ordered: Administer diuretics and other medications to address underlying causes of impaired gas exchange, such as fluid overload.
Ineffective Health Maintenance
Nursing Diagnosis: Ineffective Health Maintenance
Related to:
- Lack of understanding of heart failure and prognosis
- Difficulty in following recommended treatment plan
- Poor motivation to make lifestyle changes
- Insufficient resources (access to healthcare, finances)
- Lack of social support
As evidenced by:
- Demonstrates lack of knowledge about heart failure
- Continues inappropriate diet or behaviors despite education
- Inconsistent with keeping appointments, taking medications, etc.
Expected Outcomes:
- Patient will actively seek information to prevent worsening heart failure.
- Patient will identify at least three lifestyle modifications to improve heart failure management.
- Patient will demonstrate increased responsibility for their health outcomes by identifying areas for improvement.
Nursing Assessments:
- Assess level of understanding: Evaluate the patient’s knowledge of heart failure, risk factors, symptoms, treatments, and prognosis to tailor education effectively.
- Assess support system: Determine the availability of social support and resources to facilitate treatment adherence and lifestyle changes.
Nursing Interventions:
- Educate on normal vs. impaired heart function: Explain heart failure in understandable terms, comparing normal heart function to their current condition to enhance understanding.
- Reinforce rationale for treatments: Clearly explain the reasons behind treatments, such as fluid restrictions, daily weights, and medications, to improve adherence.
- Educate on exercise benefits: Emphasize the importance of regular exercise within limitations for maintaining strength and improving heart function. Ensure exercise plans are safe and approved by the provider.
- Review medications: Conduct thorough medication reconciliation and review, explaining medication names, dosages, frequencies, side effects, and special considerations.
Risk for Unstable Blood Pressure
Nursing Diagnosis: Risk for Unstable Blood Pressure
Related to:
- Conditions that compromise blood supply
- Structural impairment of the heart
- Malfunctions of heart structures
- Difficulty of the heart muscle to pump
- Increased exertion in workload
- Inadequate blood supply to the heart
- Inability to contract and relax effectively
- Erratic signals causing chaotic or irregular heart contraction
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred; interventions are aimed at prevention.
Expected Outcomes:
- Patient will maintain blood pressure within normal limits.
- Patient will not experience hypotension with activity.
- Patient will adhere to antihypertensive medication regimen as prescribed.
Nursing Assessments:
- Closely assess blood pressure: Regularly monitor blood pressure to identify trends and detect instability. Target blood pressure for heart failure patients is often around 130/80 mmHg.
- Obtain blood samples for lab tests: Monitor lab values, including BUN, creatinine, electrolytes, thyroid function, cholesterol, blood glucose, and liver function, to assess for contributing factors to unstable blood pressure.
- Review treatment regimen: Review medications and herbal remedies to identify potential interactions or agents that could exacerbate heart failure or affect blood pressure.
- Identify underlying conditions: Assess for underlying conditions such as coronary artery disease, hypertension, diabetes, and other systemic diseases that contribute to heart failure and blood pressure instability.
Nursing Interventions:
- Treat underlying condition: Focus on managing underlying conditions such as hypertension, diabetes, and coronary artery disease to stabilize blood pressure.
- Educate on when to seek emergency care: Instruct patients to recognize and seek immediate medical attention for symptoms of hypertension or hypotension, such as rapid heartbeat, dizziness, fainting, sweating, headache, blurred vision, or chest pain.
- Instruct on accurate blood pressure monitoring: Teach patients how to accurately monitor blood pressure at home, including proper technique and cuff size.
- Advise patient to keep BP logs: Encourage patients to maintain blood pressure logs to track trends and share with their healthcare team for monitoring treatment effectiveness.
By understanding these common nursing diagnoses related to heart failure, nurses can provide comprehensive, patient-centered care that addresses the complex needs of individuals living with this chronic condition. This holistic approach, encompassing thorough assessment, targeted interventions, and patient education, is essential for improving outcomes and enhancing quality of life for patients with heart failure.
