Heart Failure Chronic: Nursing care Plans

Heart failure is the inability of the heart to maintain adequate cardiac output to meet the metabolic needs of the body because of impaired pumping ability.

 

Heart Failure Chronic:  Nursing care Plans

 

Care Setting

Although generally managed at the community level, an in-client stay may be required for periodic exacerbation of failure or development of complications. 

Diagnostic Studies for Heart Failure

BLOOD TESTS

  • Atrial natriuretic peptide (ANP): Hormone secreted from right atrial cells when pressure increases.
  • Beta-type natriuretic peptide (BNP): Neurohormone secreted from the cardiac ventricles as a response to ventricular volume and fluid overload.
  • Complete blood count (CBC): Battery of screening tests that includes hemoglobin (Hgb); hematocrit (Hct); red blood cell (RBC) count; morphology, indices, and distribution width index; platelet count and size; white blood cell (WBC) count and differential tests.
  • Liver enzyme tests, alanine aminotransferase (ALT) and aspartate aminotransferase (AST) (formally referred to as SPGT and SGOT): To determine degree of end-organ involvement.
  • Digoxin and other cardiac drug levels: Monitored to determine therapeutic range of medications.
  • Erythrocyte sedimentation rate (ESR): Shows the alteration of blood proteins caused by inflammatory and necrotic processes.
  • Bleeding and clotting times: Clotting factors, prothrombin time (PT), partial thromboplastin time (PTT), platelets.
  • Electrolytes (sodium, potassium, chloride, magnesium, calcium): Elements or chemicals needed for the body and heart to work properly.
  • Blood urea nitrogen (BUN) and creatinine: BUN levels reflect the balance between production and excretion of urea. Creatine is end-product of creatinine metabolism and must be cleared from blood via the kidneys.
  • Albumin and transferrin, total protein: Plasma proteins exert oncotic pressure needed to keep fluid in the capillaries.
  • Thyroid studies: Blood test and scan to evaluate thyroid function. The most commonly used laboratory screening test is the measurement of thyroid-stimulating hormone (TSH).
  • Arterial blood gas (ABG) value: Measures arterial pH, PCO2, and PO2. Evaluates respiratory function and provides a measure for determining acid-base balance.

OTHER DIAGNOSTIC STUDIES

  • Chest x-ray: Evaluates organs and structures within the chest.
  • Electrocardiogram (ECG): Record of the electrical activity of the heart.
  • Stress test (also called exercise treadmill or exercise ECG): Raises heart rate and BP by means of exercise; heart rate can also be raised pharmacologically through the use of such drugs as dobutamine or dipyridamol.

 

Client Assessment Findings

ACTIVITY/REST
• Fatigue, exhaustion progressing throughout the day
• Inability to perform normal daily activities, such as making bed, climbing stairs, and so on
• Exercise intolerance
• Dyspnea at rest or with exertion
• Insomnia, inability to sleep flat
CIRCULATION
• History of hypertension, recent or past MIs, multiple MIs, previous episodes of HF, valvular heart disease, cardiac surgery, endocarditis, systemic lupus erythematosus, anemia, septic shock
• Swelling of feet, legs, abdomen, or “belt too tight”
EGO INTEGRITY
• Anxiety, apprehension, fear
• Stress related to illness or financial concerns (job, cost of medical care)
ELIMINATION
• Decreased voiding, dark urine
• Night voiding
FOOD/FLUID
• History of diet high in salt and processed foods, fat, sugar, and caffeine
• Loss of appetite, anorexia
• Nausea, vomiting
• Significant weight gain (may not respond to diuretic use)
• Tight clothing or shoes
• Use of diuretics
HYGIENE
• Fatigue, weakness, exhaustion during self-care activities

NEUROSENSORY
• Weakness
• Dizziness
• Fainting episodes
PAIN/DISCOMFORT
• Chest pain
• Chronic or acute angina
• Right upper abdominal pain (right-sided HF)
• Generalized muscle aches and pains
RESPIRATION
• Dyspnea with exertion or rest
• Nocturnal dyspnea that interrupts sleep
• Sleeping sitting up or with several pillows
• Cough with or without sputum production, especially when recumbent
• Use of respiratory aids, for example, oxygen or medications
SAFETY
SOCIAL INTERACTION

• Decreased participation in usual social activities
TEACHING/LEARNING
• Family history of developing HF at young age (genetic form)
• Family risk factors, such as heart disease, hypertension, diabetes
• Use or misuse of cardiac medications
• Use of vitamins, herbal supplements, for example, niacin, coenzyme Q10, garlic, ginkgo, black hellebore, dandelion, or aspirin
• Recent or recurrent hospitalizations
• Evidence of failure to improve
DISCHARGE PLAN CONSIDERATIONS
• Assistance with shopping, transportation, self-care needs, homemaker and maintenance tasks
• Alteration in medication use or therapy
• Changes in physical layout of home
• May need oxygen at home

Nursing Priorities

  • Improve myocardial contractility and systemic perfusion.
  • Reduce fluid volume overload.
  • Prevent complications.
  • Provide information about disease and prognosis, therapy needs, and prevention of recurrences.

Discharge Goals

  • Cardiac output adequate for individual needs.
  • Complications prevented or resolved.
  • Optimum level of activity and functioning attained.
  • Disease process, prognosis, and therapeutic regimen understood.
  • Plan in place to meet needs after discharge.

Decreased Cardiac Output

May be related to

  • Altered myocardial contractility, inotropic changes
  • Alterations in rate, rhythm, electrical conduction
  • Structural changes, such as valvular defects and ventricular aneurysm

Possibly evidenced by

  • Increased heart rate (tachycardia), dysrhythmias, ECG changes
  • Changes in BP (hypotension, hypertension)
  • Extra heart sounds (S3, S4)
  • Decreased urine output
  • Diminished peripheral pulses
  • Cool, ashen skin and diaphoresis
  • Orthopnea, crackles, JVD, liver engorgement, edema
  • Chest pain

Desired Outcomes/Evaluation Criteria

Cardiac Pump Effectiveness

  • Display vital signs within acceptable limits, dysrhythmias absent or controlled, and no symptoms of failure, for example, hemodynamic parameters within acceptable limits and urinary output adequate.
  • Report decreased episodes of dyspnea and angina.

Cardiac Disease Self-Management

Participate in activities that reduce cardiac workload.

Nursing Actions/Interventions

Nursing ActionsRATIONALE
Hemodynamic Regulation

Independent

Auscultate apical pulse; assess heart rate, rhythm, and document dysrhythmia if telemetry available.Tachycardia is usually present, even at rest, to compensate for decreased ventricular contractility. Premature atrial contractions

(PACs), paroxysmal atrial tachycardia (PAT), PVCs,

multifocal atrial tachycardia (MAT), and AF are common dysrhythmias associated with HF, although others may also occur. Note: Intractable ventricular dysrhythmias unresponsive

to medication suggest ventricular aneurysm.

Note heart sounds.S1 and S2 may be weak because of diminished pumping action. Gallop rhythms are common (S3 and S4), produced as blood flows into noncompliant, distended chambers. Murmurs may reflect valvular incompetence and stenosis.
Palpate peripheral pulses.Decreased cardiac output may be reflected in diminished radial, popliteal, dorsalis pedis, and post-tibial pulses. Pulses may be fleeting or irregular to palpation, and pulsus alternans

may be present.

Monitor BP.In early, moderate, or chronic HF, BP may be elevated because

of increased SVR. In advanced HF, the body may no longer

be able to compensate, and profound or irreversible

hypotension may occur. Note: Many clients with HF have

consistently low systolic BP (80 to 100 mm Hg) due to their

disease process and the medications they take, and most

tolerate these BPs without incident (Wingate, 2007).

 

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