Lesson 9
HEART FAILURE
CONTENTS
I. Introduction and Physiology of HF
II. Assessment
a. Risk Factors / Predisposing Conditions
b. Clinical Manifestations
c. Diagnostic Examination/ Laboratory Tests
III. Treatment
IV. Nursing Intervention/Goals
V. Self Test / Self Directed Learning / Critical Thinking Drill
VI. References/Further Readings
I. Introduction
Otherwise known as cardiac decompensation, cardiac insufficiency, ventricular failure, or heart
failure
This condition is the inability of the heart to pump adequate amounts of blood into the systemic
circulation to meet tissue metabolic demands; usually occurs as a result of dysrhythmias, acute
MI, or hypertension
Physiology of Heart Failure
A. Left-sided Heart Failure
1. Results from failure of the left ventricle to maintain adequate cardiac output
2. Blood backs up into the left atrium and into the pulmonary veins
3. Increasing pressure in the pulmonary capillary bed causes lungs to become congested, resulting in
impaired gas exchange.
4. Precipitating factors:
a. MI (left ventricular infarct)
b. Hypertension
c. Aortic and mitral valve disease
d. Dysrhythmia
B. Right-sided Heart Failure
1. The right ventricle is unable to maintain adequate output
2. Blood backs up into the systemic circulation and causes peripheral edema
3. Precipitating factors:
a. Left-sided heart failure
b. Chronic pulmonary disease
c. Right ventricular infarction
d. Excessive IV fluids
C. Each side of the heart is dependent on the other for adequate function
1. Left-sided failure results in pulmonary congestion; this causes an increase in pulmonary pressure,
which puts increased workload on the right side of the heart and precipitates failure
2. Although the origin of a problem may begin solely on one side, the majority of clinical situations
involve failure on both sides
D. Cardiac compensatory mechanisms will attempt to maintain the body requirements for cardiac output;
when these mechanisms become ineffective, cardiac decompensation or failure.
E. Edema development in right-sided CHF.
1. With a decrease in the cardiac output, there is a decrease in tissue perfusion
a. Renal perfusion decreases, causing adrenal cortex stimulation to secrete aldosterone, which
retains sodium and water in the body
b. Posterior pituitary gland increases secretion of antidiuretic hormone, retaining sodium and
water
2. The increased secretion of ADH and retention of sodium and water increases circulating fluid
volume in an attempt to increase tissue perfusion
3. With an increase in the venous pressure from the increased circulating volume, there is an
increase in the capillary pressure; and dependent, pitting edema occurs
F. In children, CHF occurs most often as a result of a structural problem of the heart.
1. Ventricular functions may not be impaired
2. Symptoms occur because of impaired pulmonary artery pressure and pulmonary venous
congestion
II. Assessment
A. Risk Factors / Etiology
1. Myocardial diseases
2. Valvular disease
3. Congenital heart diseases
4. Fluid overload
5. Other co-morbidies affecting cardiovascular efficiency
B. Clinical Manifestations
1. Impaired cardiac function
a. Tachycardia
b. Cardiomegaly (from dilatation and hypertrophy
c. S3 or S4 (gallop sounds) caused by impaired ventricular function
d. Poor perfusion: cool extremities, weak pulses, poor capillary refill
e. In infants, failure to thrive and failure to gain adequate weight
2. Pulmonary congestion (left-sided failure)
a. Dyspnea, tachypnea
b. Orthopnea
c. Paroxysmal nocturnal dyspnea occurs while client is asleep
d. Respiratory distress symptoms and hypoxia
e. Cough
f. Congested breath sounds
g. Feeding difficulty in infants caused by dyspnea
3. Systemic congestion (right-sided failure)
a. Hepatomegaly
b. Peripheral pitting edema
c. Ascites
d. Weight gain
d. Increased CVP
e. Neck vein distention
f. Nausea, vomiting, anorexia
g. Dysrhythmia
h. Decreased urinary output, electrolyte imbalance
C. Diagnostic Tests
1. Chest X-ray
2. ECG
3. Echocardiogram
III. Treatment
A. Treatment of the underlying condition
B. Prevention
1. Administration of prophylactic antibiotics to clients with rheumatic heart disease before
medical procedures
2. Effective early treatment of hypertension
3. Early treatment of dysrhythmia
C. Oxygen therapy
D. Bed rest
E. Medications
SPECIAL NOTES:
1. Cardiac glycosides (Digoxin, Lanoxin)
2. Diuretics (Furosemide, Hydrochlorothiazide) Complications of CHF
3. Potassium
Pulmonary edema
4. Vasodilators to decrease the afterload)
Cardiogenic shock
5. Aspirin
Dysrhythmia
F. Decreased sodium diet
G. Fluid restriction due to edema and dyspnea
IV. Nursing Intervention
Goal No. 1: To decrease cardiac demand and improve cardiac function
A. Assess vital signs and compare with other physical assessment data
B. Limit physical activity
C. Maintain normal body temperature; avoid chilling, this increases oxygen demand
D. Provide supplemental oxygen
E. Provide uninterrupted sleep, when possible
F. Minimize crying in children and infants
G. Decrease stress and anxiety, if possible
Goal No. 2: To decrease circulating volume
A. Assess breath sounds; check for distended neck veins and peripheral edema
B. low sodium diet with fluid restriction
C. Evaluate fluid retention by determining accurate weight daily.
D. Accurate intake and output to assess response to diuretics
Goal # 3: To reduce respiratory distress and hypoxia
A. Positioning
1. Position patient to Fowler’s, semi-Fowler’s, or sitting upright in an armchair
2. Infants and children may breathe better in side-lying position with knees drawn to chest
3. Do not elevate client’s legs because it increases venous return
B. Administer oxygen: oxygen hood for infants; cannula or mask to adults and children
C. Evaluate breath sounds and hypoxia
Goal # 4: To maintain nutrition and adequate rest
A. Provide small, frequent feedings of easily digestible feeds; allow client adequate time
B. Bed rest is indicated; activity given only as tolerated
V. Self Test / Critical Thinking Drill
SELF TEST QUESTIONS
1. A patient is admitted to ICU with left-sided CHF. What clinical manifestations does the nurse
anticipate finding when performing an assessment?( Select all that apply)
a. Jugular vein distention
b. Ascites
c. Pulmonary crackles
d. Dyspnea
e. Cough
2. The nurse is performing a respiratory assessment for the patient in left-sided heart failure. What is the
best determinant of the patient’s ventilation and oxygenation status?
a. Pulse oximetry
b. Listening to breath sounds
c. Respiratory rate
d. Arterial blood gas (ABGs
3. The healthcare provider writes orders for a patient to receive an angiotensin II receptor blocker for
treatment of heart failure. What medication does the nurse administer?
a. Digoxin
b. Valsartan
c. Metalazone
CRITICAL THINKING DRILL
d. Carvedilol
Case Study: Pulmonary Edema as a
Complication of Heart Failure
Mr. Wolman is to be discharged from the
hospital to home. He is 79 years old, lives with
his wife, and has just recovered from mild
pulmonary edema secondary to congestive heart
4. In the discharge planning for the client with CHF, the nurse discusses the importance of adequate rest.
What information is important?
a. A warm, quiet room is necessary.
b. Bed rest promotes venous return
c. A hospital bed is necessary
d. Adequate rest decreases cardiac workload
5. The nurse is taking history from a client with CHF caused by hypertension. The nurse identifies what
data as supportive of the client’s medical diagnosis?
a. Dyspnea after walking one block
b. Weight loss of 15 pounds over the last 3 months
c. Lower extremity edema in the evening
d. Dizziness and fainting when rising too quickly
