5.8 Heart Failure

Overview

The heart is a hard-working muscle that pumps about 1.5 gallons of blood per minute, and over 2,000 gallons of blood per day. Heart failure (HF) occurs when the heart loses its effectiveness in pumping blood and is referred to as decreased cardiac output. When the heart is not pumping effectively, classic symptoms of fatigue, shortness of breath, edema, or lung congestion can occur.

Chronic HF is a progressive disorder that can be represented on a continuum. The continuum ranges from individuals who are at risk for HF but are asymptomatic, to individuals who have end-stage heart failure and require hospice care. Therapeutic goals and medical treatment are based on where the individual falls on this continuum.^[1] 

Causes of HF

There are many common causes of HF, including CAD, myocardial infarction (MI), hypertension, valve disorders, and cardiomyopathy.^[2] CAD that causes ischemia weakens the cardiac muscle tissue. If an MI occurs, depending on the location of the infarct, muscle tissue dies. If the infarct affects the left ventricle, the heart’s ability to pump is severely affected.

Hypertension is another common cause of HF. Hypertension causes vascular resistance that the heart must overcome to pump blood throughout the body. This increased force causes the ventricles to become thickened and lose their pumping effectiveness.

Heart valve conditions and cardiomyopathy are also common causes of heart failure. Cardiomyopathy has many causes, either acquired or hereditary, that weaken the heart’s muscle tissue. Valve conditions cause narrowing and/or backflow of blood through the valves. Ineffective value function may be identified through the presence of a heart murmur. Both conditions impair the heart’s ability to pump blood.

In addition to these disease processes, various risk factors impacting cardiac health can also lead to the emergence of HF. Smoking, obesity, alcohol, and substance abuse can weaken heart tissue and increase the risk of heart failure. As individuals age, the heart experiences age-related strain on the valves and muscle tissues. Finally, family history of heart disease and ethnicity may can also contribute to increased risk for HF.^[3] Non-hispanic Black individuals have the highest death rate per capita.^[4]

Signs and Symptoms of Chronic Heart Failure

HF is characterized by symptoms of fatigue, fluid retention, and shortness of breath, depending on which side of the heart is not pumping effectively. Left-sided and right-sided heart failure are two distinct but interrelated conditions that affect the heart’s ability to pump blood effectively. Some clients develop symptoms of both left- and right-sided heart failure. Causes, symptoms, and potential complications of right- and left-sided heart failure differ, but treatment is often similar and often includes diuretics, ACE inhibitors, beta-blockers, vasodilators, and oxygen therapy. See Table 5.8 for a comparison of the signs, symptoms, and potential complications of left- and right-sided heart failure.

Table 5.8. Left- and Right-Sided Heart Failure^[5],[6]

Functional Classifications of Heart Failure

Because HF is a progressive disease, clients are classified into four categories based on their limitations of physical activity based on the New York Heart Association (NYHA) Functional Classification. The NYHA Functional Classification categories include the following^[7]:

• Class I: No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or shortness of breath.
• Class II: Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, shortness of breath, or chest pain.
• Class III: Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, shortness of breath, or chest pain. Palliative care may be prescribed to enhance the client’s quality of life.
• Class IV: Symptoms of heart failure at rest. Any physical activity causes further discomfort. This stage is also commonly referred to as “end-stage heart failure” that qualifies for hospice care.

As clients undergo treatment, the care team can evaluate the effectiveness of treatment based on the client’s current category of NYHA Functional Classification. It is helpful for nurses to know a client’s baseline NYHA Functional Classification to know what assessment findings to expect and what findings indicate worsening clinical status.

Acute Decompensated Heart Failure

Acute decompensated heart failure (ADHF) is the sudden or gradual onset of worsening signs or symptoms of heart failure requiring unplanned office visits, emergency room visits, or hospitalization. It occurs when the heart’s ability to pump a sufficient amount of oxygenated blood to the body’s tissue is no longer sufficient.

Up to 50% of cases of ADHF have no known cause. Potential causes include nonadherence to medications or salt restrictions, side effects of medications, uncontrolled hypertension, arrhythmias, and exacerbation of chronic obstructive pulmonary disease. Other contributing factors include noncardiac conditions such as kidney disease, diabetes mellitus, and anemia.

Signs and symptoms of ADHF include worsening dyspnea, edema, lung sounds, and mental status. The client may also have decreased urine output (oliguria). Nurses must rapidly recognize these unexpected findings in clients with heart failure and promptly report them to the health care provider. Clients with ADHF often require hospitalization and treatment with intravenous diuretics, oxygen therapy, and other medications to maintain adequate cardiac output and perfusion of the kidneys, brain, and heart tissue.

Assessment

When assessing a client with chronic heart failure, it is important to understand the differences between expected findings for that client and signs of an acute exacerbation. Expected findings are based on New York Heart Association Functional Classification, as well as recently documented and communicated status from other members of the health care team. In order to recognize potential clinical deterioration, the nurse caring for a client who has been diagnosed with heart failure, it is vital to know their baseline status in terms of edema, lung sounds, mental status, and kidney function.

Diagnostic Testing

Common tests used to diagnose heart failure, as well as acute decompensated heart failure, include brain natriuretic peptide (BNP), chest X-ray (CXR), echocardiogram, and electrocardiogram (ECG)^[8],[9]:

• BNP is a protein created by the heart and blood vessels. Elevated levels commonly indicate heart failure.
• A chest X-ray examines the size and shape of the heart and identifies fluid accumulation in the lungs.
• An echocardiogram evaluates the structure and function of the heart chambers and valves, as well as blood flow throughout the heart. The ejection fraction measures the amount of blood the left ventricle of the heart pumps out to the body with each heartbeat. A normal heart’s ejection fraction is between 55 and 70 percent. Clients with left-sided heart failure have ejection fraction measurements less than 55 percent. Clients with right sided heart failure often have a normal ejection fraction.
• An ECG identifies irregular cardiac rhythms that could be contributing to decreased cardiac output associated with HF.

Nursing Problems and Diagnoses

Nursing priorities for clients with heart failure (HF) include addressing respiratory status, fluid retention, fatigue, activity intolerance, and self-management of chronic disease to promote quality of life.

Common nursing diagnoses for clients with HF include the following^[10]:

• Decreased Cardiac Output R/T impaired cardiac function
• Decreased Activity Intolerance R/T weakness, fatigue, shortness of breath
• Fatigue R/T disease process with decreased cardiac output
• Impaired Gas Exchange R/T excessive fluid in interstitial space of lungs
• Excess Fluid Volume R/T impaired secretion of sodium and water
• Readiness for Enhanced Health Management

Outcome Identification

Outcome identification involves setting short and long-term goals and creating expected outcome statements tailored to the client’s specific needs. These outcomes should be measurable and responsive to nursing interventions.

Sample expected outcomes for common nursing diagnoses related to HF are as follows:

• The client will maintain oxygenation saturation readings above 92%.
• The client will demonstrate a reduction of pitting edema in the lower extremities within one week.
• The client will exhibit improved exercise tolerance by walking on a flat surface for at least ten minutes without chest pain or excessive shortness of breath within two weeks.
• The client will demonstrate the use of relaxation techniques to manage anxiety before discharge, such as deep breathing exercises.
• The client will verbalize an understanding of the importance of a low-sodium diet and will list three specific dietary changes they plan to make at home.

Interventions

Medical Interventions

Medical interventions play an important role in managing the signs and symptoms of heart failure (HF), preventing acute exacerbations, and improving quality of life for individuals with HF. Common medical interventions used to treat HF include medication therapy, lifestyle modifications, cardiac rehabilitation, and surgical interventions.

Medication Therapy

Several classes of medications are used to treat heart failure:

• Diuretics: Reduce fluid retention and edema by increasing urine production. However, diuretics can cause hypokalemia and other electrolyte imbalances, so electrolytes must be monitored carefully. Potassium supplementation may be required.
• ACE Inhibitors and Angiotensin II Receptor Blockers (ARBs): Relax systemic blood vessels, thus reducing systemic resistance and increasing cardiac output.
• Beta-Blockers: Slow the heart rate and allow for increased ventricular filling before each contraction. However, beta-blockers can worsen HF, so they must be monitored carefully.
• Aldosterone Antagonists: Reduce fluid retention.
• Inotropes: Strengthen the heart’s contractions.

Lifestyle Modifications

Lifestyle modifications focus on reducing fluid retention and fatigue, while maximizing heart function:

• Dietary Changes: Reducing sodium intake is crucial for managing fluid retention. Recommended sodium intake is less than 2 – 3 grams daily.^[11]
• Fluid Restriction: In advanced stages of HF or in acute exacerbations with pulmonary edema, fluid intake is often restricted to less than 1.5 to 2 liters/day.
• Exercise: A structured exercise program can improve heart function and reduce fatigue.
• Weight Management: Maintaining a healthy weight reduces strain on the heart.
• Smoking Cessation: If the client smokes, quitting smoking improves overall cardiovascular health.

Cardiac Rehabilitation

Cardiac rehabilitation programs offer supervised exercise, health teaching, and counseling to help clients with HF regain strength, manage their conditions effectively at home, and reduce hospitalizations.

Surgical Interventions

Clients with advanced heart failure may have surgical interventions and/or devices implanted to assist with cardiac output.^[12],[13]

• Left Ventricular Assist Device (LVAD): A mechanical pump is implanted to assist the heart’s pumping function. LVADs are commonly used when a client is awaiting heart transplantation.
• Heart Transplantation: For clients with end-stage HF, a heart transplant may be considered, based on the client’s overall health and other chronic conditions.
• Heart Valve Surgery: If a client is experiencing heart failure due to damaged heart valves, repair or replacement of valves be performed to alleviate symptoms.
• Coronary Artery Bypass Grafting (CABG): For clients where coronary artery disease is a contributing factor, CABG surgery may be necessary to improve blood flow to the heart muscle.

Nursing Interventions

Nursing interventions for heart failure (HF) focus on medication management, health teaching, and psychosocial support to promote quality of life while the client copes with a chronic disease.

Medication Management

Prescribed medications are safely administered, and teaching is provided about medications and their role in improving heart function. In hospitalized clients, therapeutic effects of medications are evaluated, and monitoring is performed for common side effects, such as electrolyte imbalances.

Health Teaching

Nurses provide health teaching to clients about self-management of HF to avoid acute exacerbations and hospitalization. Clients are taught to promptly report the following symptoms  to their health care provider^[14]:

• Increased shortness of breath or fatigue during their regular daily routine
• Feelings like their heart rate is racing or throbbing
• Weight gain of more than two or three pounds in a 24-hour period or more than five pounds in a week, indicating worsening fluid retention. Clients are encouraged to track daily weights in a journal and bring the journal to follow-up appointments.
• Worsening edema in the ankles, feet, and lower legs
• Increased home blood pressure readings. Clients are taught to track blood pressure readings in a journal and bring the journal to follow-up appointments.
• Confusion or impaired thinking. These symptoms might be first noticed by family members
• Trouble sleeping due to dyspnea
• Decreased appetite or swelling in the abdomen making their waistband feel tight

Health teaching is also provided about heart-healthy food choices and sodium restrictions to prevent fluid retention. Smoking cessation is encouraged, and information about relaxation techniques to manage anxiety is provided.

Clients with orthopnea are instructed to sleep with their head elevated on pillows or in a recliner to promote lung expansion. Clients experiencing fatigue are encouraged to balance periods of activity with periods of rest to conserve energy.

Psychosocial Support

Nurses address the emotional and psychological impact of HF by providing emotional support and encouraging positive coping strategies. Referrals to mental health professionals are provided for additional support, if needed. Clients are encouraged to participate in support groups and cardiac rehabilitation programs.

Evaluation

During the evaluation stage, nurses determine the effectiveness of nursing interventions for a specific client. The previously identified expected outcomes are reviewed to determine if they were met, partially met, or not met by the time frames indicated. If outcomes are not met or only partially met by the time frame indicated, the nursing care plan is revised. Evaluation should occur every time the nurse implements interventions with a client, reviews updated laboratory or diagnostic test results, or discusses the care plan with other members of the interprofessional team.