NURSING PROCESS:THE PATIENT WITH HEART FAILURE
The nursing assessment for the patient with HF focuses on ob-serving for effectiveness of therapy and for the patient’s ability to understand and implement self-management strategies. Signs and symptoms of pulmonary and systemic fluid overload are recorded and reported immediately so that adjustments can be made in ther-apy. The nurse also explores the patient’s emotional response to the diagnosis of HF, a chronic illness.
The nurse explores sleep disturbances, particularly sleep suddenly in-terrupted by shortness of breath. The nurse also asks about the num-ber of pillows needed for sleep (an indication of orthopnea), activities of daily living, and the activities that cause shortness of breath. The nurse also explores the patient’s understanding of HF, the self-management strategies, and the desire to adhere to those strate-gies. The nurse helps patients to identify things that they have lost because of the diagnosis, their emotional response to that loss, and successful coping skills that they have used previously. Family and significant others are often included in these discussions.
The lungs are auscultated to detect crackles and wheezes or their absence. Crackles, which are produced by the sudden opening of small airways and alveoli that have adhered together by edema and exudate, may be heard at the end of inspiration and are not cleared with coughing. They may also sound like gurgling that may clear with coughing or suctioning. The rate and depth of res-pirations are also documented.
The heart is auscultated for an S3 heart sound, a sign that the heart is beginning to fail and that increased blood volume re-mains in the ventricle with each beat. HR and rhythm are also documented. Rapid rates indicate that SV has decreased and that the ventricle has less time to fill, producing some blood stagna-tion in the atria and eventually in the pulmonary bed.
JVD is also assessed; distention greater than 3 cm above the sternal angle is considered abnormal. This is an estimate, not a precise measurement, of central venous pressure.
Sensorium and level of consciousness must be evaluated. As the volume of blood ejected by the heart decreases, so does the amount of oxygen transported to the brain.
The nurse makes sure that dependent parts of the patient’s body are assessed for perfusion and edema. With significant de-creases in SV, there is a decrease in perfusion to the periphery, causing the skin to feel cool and appear pale or cyanotic. If the patient is sitting upright, the feet and lower legs are examined for edema; if the patient is supine in bed, the sacrum and back are assessed for edema. Fingers and hands may also become edematous.
In extreme cases of HF, the patient may develop periorbital edema, in which the eyelids may swell shut.
The liver is 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. If neck vein distention increases more than 1 cm, the test finding is positive for increased venous pressure.
If the patient is hospitalized, the nurse measures output care-fully to establish a baseline against which to measure the effective-ness of diuretic therapy. Intake and output records are rigorously maintained. It is important to know whether the patient has ingested more fluid than he or she has excreted (positive fluid balance), which is then correlated with a gain in weight. The pa-tient must be monitored for oliguria (diminished urine output, <400 mL/24 hours) or anuria (urine output <50 mL/24 hours).
The patient is weighed daily in the hospital or at home, at the same time of day, with the same type of clothing, and on the same scale. If there is a significant change in weight (ie, 2- to 3-lb increase in a day or 5-lb increase in a week), the patient is instructed to notify the physician or adjust the medications (eg, increase the diuretic dose).
• Activity intolerance (or risk for activity intolerance) related to imbalance between oxygen supply and demand because of decreased CO
• Excess fluid volume related to excess fluid or sodium intake and retention of fluid because of HF and its medical therapy
• Anxiety related to breathlessness and restlessness from in-adequate oxygenation
• Powerlessness related to inability to perform role responsi-bilities because of chronic illness and hospitalizations
• Noncompliance related to lack of knowledge
Based on the assessment data, potential complications that may develop include the following:
• Cardiogenic shock
• Pericardial effusion and cardiac tamponade
Major goals for the patient may include promoting activity and reducing fatigue, relieving fluid overload symptoms, decreasing the incidence of anxiety or increasing the patient’s ability to manage anxiety, teaching the patient about the self-care pro-gram, and encouraging the patient to verbalize his or her ability to make decisions and influence outcomes.
Although prolonged bed rest and even short periods of recumbency promote diuresis by improving renal perfusion, they also promote decreased activity tolerance. Prolonged bed rest, which may be self-imposed, should be avoided because of the deconditioning effects and hazards, such as pressure ulcers (especially in edematous pa-tients), phlebothrombosis, and pulmonary embolism. An acute event that causes severe symptoms or that requires hospitaliza-tion indicates the need for initial bed rest. Otherwise, a total of 30 minutes of physical activity three to five times each week should be encouraged (Georgiou et al., 2001). The nurse and patient can collaborate to develop a schedule that promotes pacing and prior-itization 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.
• Begin with a few minutes of warm-up activities.
• Avoid performing physical activities outside in extreme hot, cold, or humid weather.
• Ensure that you are able to talk during the physical activity; if you are unable to do so, decrease the intensity of activity.
• Wait 2 hours after eating a meal before performing the physical activity.
• Stop the activity if severe shortness of breath, pain, or dizzi-ness develops.
• End with cool-down activities and a cool-down period.
Because some patients may be severely debilitated, they may need to perform physical activities only 3 to 5 minutes at a time, one to four times per day. The patient then should be advised to increase the duration of the activity, then the frequency, before increasing the intensity of the activity (Meyer, 2001).
Barriers to performing an activity are identified, and methods of adjusting an activity to ensure pacing but still accomplish the task are discussed. For example, objects that need to be taken up-stairs can be put in a basket at the bottom of the stairs through-out the day. At the end of the day, the person can carry the objects up the stairs all at once. Likewise, the person can carry cleaning supplies around in a basket or backpack rather than walk back and forth to obtain the items. Vegetables can be chopped or peeled while sitting at the kitchen table rather than standing at the kitchen counter. Small, frequent meals decrease the amount of energy needed for digestion while providing adequate nutri-tion. The nurse helps the patient to identify peak and low peri-ods of energy and plan energy-consuming activities for peak periods. For example, the person may prepare the meals for the entire day in the morning. Pacing and prioritizing activities help maintain the patient’s energy to allow participation in regular physical activity .
The patient’s response to activities needs to be monitored. If the patient is hospitalized, vital signs and oxygen saturation level are monitored before, during, and immediately after an ac-tivity to identify whether they are within the desired range. Heart rate should return to baseline within 3 minutes. If the pa-tient is at home, the degree of fatigue felt after the activity can be used as assessment of the response. If the patient tolerates the activity, short-term and long-term goals can be developed to gradually increase the intensity, duration, and frequency of ac-tivity. Referral to a cardiac rehabilitation program may be needed, especially for HF patients with recent myocardial infarction, recent open-heart surgery, or increased anxiety. A supervised pro-gram may also benefit those who need the structured environ-ment, significant educational support, regular encouragement, and interpersonal contact.
Patients with severe HF may receive intravenous diuretic therapy, but patients with less severe symptoms may receive oral diuretic medication (see Table 30-4 for a summary of common diuretics). Oral diuretics should be administered early in the morning so that diuresis does not interfere with the patient’s nighttime rest. Discussing the timing of medication administration is especially important for patients, such as elderly people, who may have uri-nary urgency or incontinence. A single dose of a diuretic may cause the patient to excrete a large volume of fluid shortly after administration.
The nurse monitors the patient’s fluid status closely— auscultating the lungs, monitoring daily body weights, and as-sisting the patient to adhere to a low-sodium diet by reading food labels and avoiding high-sodium foods such as canned, processed, and convenience foods (Chart 30-4). If the diet includes fluid re-striction, the nurse can assist the patient to plan the fluid in-take throughout the day while respecting the patient’s dietary preferences.
If the patient is receiving intravenous fluids, the amount of fluid needs to be monitored closely, and the physi-cian or pharmacist can be consulted about the possibility of maximizing the amount of medication in the same amount of intravenous fluid (eg, double-concentrating to decrease the fluid volume administered).
The nurse positions the patient or teaches the patient how to assume a position that shifts fluid away from the heart. The num-ber of pillows may be increased, the head of the bed may be elevated (20- to 30-cm [8- to 10-inch] blocks may be used), or the patient may sit in a comfortable armchair. In this position, the venous return to the heart (preload) is reduced, pulmonary con-gestion is alleviated, and impingement of the liver on the di-aphragm is minimized. The lower arms are supported with pillows to eliminate the fatigue caused by the constant pull of their weight on the shoulder muscles.
The patient who can breathe only in the upright position may sit on the side of the bed with the feet supported on a chair, the head and arms resting on an overbed table, and the lumbosacral spine supported by a pillow. If pulmonary congestion is present, positioning the patient in an armchair is advantageous, because this position favors the shift of fluid away from the lungs.
Because decreased circulation in edematous areas increases the risk of skin injury, the nurse assesses for skin breakdown and in-stitutes preventive measures. Frequent changes of position, posi-tioning to avoid pressure, the use of elastic compression stockings, and leg exercises may help to prevent skin injury.
Because patients in HF have difficulty maintaining adequate oxy-genation, they are likely to be restless and anxious and feel over-whelmed by breathlessness. These symptoms tend to intensify at night. Emotional stress stimulates the sympathetic nervous sys-tem, which causes vasoconstriction, elevated arterial pressure, and increased heart rate. This sympathetic response increases the amount of work that the heart has to do. By decreasing anxiety, the patient’s cardiac work also is decreased. Oxygen may be ad-ministered during an acute event to diminish the work of breath-ing and to increase the patient’s comfort.
When the patient exhibits anxiety, the nurse takes steps to promote physical comfort and psychological support. In many cases, a family member’s presence provides reassurance. To help decrease the patient’s anxiety, the nurse should speak in a slow, calm, and confident manner and maintain eye contact. When necessary, the nurse should also state specific, brief directions for an activity.
After the patient is comfortable, the nurse can begin teaching ways to control anxiety and to avoid anxiety-provoking situa-tions. The nurse explains how to use relaxation techniques and assists the patient to identify factors that contribute to anxiety. Lack of sleep may increase anxiety, which may prevent adequate rest. Other contributing factors may include misinformation, lack of information, or poor nutritional status. Promoting phys-ical comfort, providing accurate information, and teaching the patient to perform relaxation techniques and to avoid anxiety-triggering situations may relax the patient.
In cases of confusion and anxiety reactions that affect the pa-tient’s safety, the use of restraints should be avoided. Restraints are likely to be resisted, and resistance inevitably increases the car-diac workload. The patient who insists on getting out of bed at night can be seated comfortably in an armchair. As cerebral and systemic circulation improves, the degree of anxiety decreases, and the quality of sleep improves.
Patients need to recognize that they are not helpless and that they can influence the direction of their lives and the outcomes of treatment. The nurse assesses for factors contributing to a sense of powerlessness and intervenes accordingly. Contributing factors may include lack of knowledge and lack of opportunities to make decisions, particularly if health care providers and family mem-bers behave in maternalistic or paternalistic ways. If the patient is hospitalized, hospital policies may promote standardization and limit the patient’s ability to make decisions (eg, what time to have meals, take medications, prepare for bed).
Taking time to listen actively to patients often encourages them to express their concerns and ask questions. Other strategies in-clude providing the patient with decision-making opportunities, such as when activities are to occur or where objects are to be placed, and increasing the frequency and significance of those op-portunities over time; providing encouragement while identifying the patient’s progress; and assisting the patient to differentiate be-tween factors that can be controlled and those that cannot. In some cases, the nurse may want to review hospital policies and standards that tend to promote powerlessness and advocate for their elimi-nation or change (eg, limited visiting hours, prohibition of food from home, required wearing of hospital gowns).
The nurse provides patient education and involves the patient in implementing the therapeutic regimen to promote understand-ing and adherence to the plan. When the patient understands or believes that the diagnosis of HF can be successfully managed with lifestyle changes and medications, recurrences of acute HF lessen, unnecessary hospitalizations decrease, and life expectancy increases. Patients and their families need to be taught to follow the medication regimen as prescribed, maintain a low-sodium diet, perform and record daily weights, engage in routine physi-cal activity, and recognize symptoms that indicate worsening HF. Although noncompliance is not well understood, interventions that may promote adherence include teaching to ensure accurate understanding. A summary of teaching points for the patient with HF is presented in Chart 30-5.
The patient and family members are supported and encouraged to ask questions so that information can be clarified and under-standing enhanced. The nurse should be aware of cultural factors and adapt the teaching plan accordingly. Patients and their fami-lies need to be informed that the progression of the disease is in-fluenced in part by choices made about health care and the decisions about following the treatment plan. They also need to be informed that health care providers are there to assist them in reaching their health care goals. Patients and family members need to make the decisions about the treatment plan, but they also need to understand the possible outcomes of those decisions. The treat-ment plan then will be based on what the patient wants, not just what the physician or other health care team members think is needed. Ultimately, the nurse needs to convey that monitoring symptoms and daily weights, restricting sodium intake, avoiding excess fluids, preventing infection with influenza and pneumococ-cal immunizations, avoiding noxious agents (eg, alcohol, tobacco), and participating in regular exercise all aid in preventing exacerba-tions of HF.
Depending on the patient’s physical status and the availability of family assistance, a home care referral may be indicated for a patient who has been hospitalized. Elderly patients and those who have long-standing heart disease with compromised phys-ical stamina often require assistance with the transition to home after hospitalization for an acute episode of HF. It is important for the home care nurse to assess the physical environment of the home. Suggestions for adapting the home environment to meet the patient’s activity limitations are important. If stairs are the concern, the patient can plan the day’s activities so that stair climbing is minimized; for some patients, a temporary bedroom may be set up on the main level of the home. The home care nurse collaborates with the patient and family to maximize the benefits of these changes.
The home care nurse also reinforces and clarifies information about dietary changes and fluid restrictions, the need to monitor symptoms and daily body weights, and the importance of obtain-ing follow-up health care. Assistance may be given in scheduling and keeping appointments as well. The patient is encouraged to gradually increase his or her self-care and responsibility for ac-complishing the therapeutic regimen.
Expected patient outcomes may include:
1) Demonstrates tolerance for increased activity
a) Describes adaptive methods for usual activities
b) Stops any activity that causes symptoms of intolerance
c) Maintains vital signs (pulse, blood pressure, respira-tory rate, and pulse oximetry) within the targeted range
d) Identifies factors that contribute to activity intolerance and takes actions to avoid them
e) Establishes priorities for activities
f) Schedules activities to conserve energy and to reduce fatigue and dyspnea
2) Maintains fluid balance
a) Exhibits decreased peripheral and sacral edema
b) Demonstrates methods for preventing edema
3) Is less anxious
a) Avoids situations that produce stress
b) Sleeps comfortably at night
c) Reports decreased stress and anxiety
4) Makes decisions regarding care and treatment
a) States ability to influence outcomes
5) Adheres to self-care regimen
a) Performs and records daily weights
b) Ensures dietary intake includes no more than 2 to 3 g of sodium per day
c) Takes medications as prescribed
d) Reports any unusual symptoms or side effects