Download Nursing care of acute and chronic heart failure

MODULE 17:
Cardiology
PART 1
Nursing care of
acute and chronic
heart failure
by Kate O’Donovan
Last issue’s article explored the acute medical care of decom-
pensated heart failure which included diuretics, inotropes and
circulatory support. In this issue nursing care from an acute and
chronic management perspective will be addressed.
Acute heart failure
The goals of nursing management are established via a thorough nursing assessment of the patient’s functional capacity and
haemodynamic status and are then used to guide nursing intervention and evaluation. In addition, the nursing assessment may
reveal a disorder or condition that precipitates heart failure.
Nursing goals may include:
• Promote patient comfort and alleviate breathlessness
• Alleviate and prevent signs of fluid overload
• Preserve peripheral perfusion
• Increase patient awareness and education of the condition and
current management
• Attend to self-care deficits that are a result of symptoms, fluid
overload and hypoxia.
Monitoring of the patient should begin as soon as possible
after admission, with the focus on identifying the underlying
cause and the response to treatment. Monitoring includes basic
observations of temperature, respiratory rate, heart rate, blood
pressure, oxygenation, urinary output and serial ECGs.
Advanced monitoring includes placement of invasive monitoring system such as an arterial line or central venous pressure
monitoring. Placement of a central venous catheter allows administration of fluids and medications as well as monitoring of the
central venous pressure. Care of invasive monitoring systems
are according to local nursing guidelines and include preventing infection, maintaining line patency via hourly flushing of the
system and zeroing the system every four hours or on change of
patient position to obtain accurate pressures.
Hourly nursing assessment, or more frequent depending on the
patient’s clinical status, involves a cardiovascular and respiratory
assessment that focuses on response to treatment and identify-
ing signs that indicate deterioration in the patient's condition,
such as an increase in the patient’s heart rate and respiratory
rate, hypotension and decreased peripheral perfusion such as
decreased capillary refill and cool peripheries.
If the patient is responding positively to treatment signs
include an increase in blood pressure, reduction in respiratory
rate and breathlessness, as well as warm peripheries. Based on the
cardiovascular and respiratory assessment findings the patient’s
stage of heart failure may be staged according to the New York
Heart Association Functional Classification System as depicted in
part one of this article. If the patient is breathless supplemental
oxygen may be delivered to achieve an oxygen saturation of >
95%.1 If supplemental oxygen fails to maintain oxygen saturation
> 95% non-invasive ventilation may be implemented and the
nursing care specific to this form of oxygenation is carried out
according to local guidelines.
Other nursing implications may involve putting the patient on
a fluid restriction with diligent monitoring of input and output.
The patient may have a urinary catheter placed so that urinary
output may be monitored closely. The aim is that the patient
has a urinary output greater than 0.5ml/kg/hour, therefore if the
patient weighs 70kg the anticipated urinary output for the hour
would be 35ml. Kidney function and urinary output is a good
indicator of organ perfusion.
In addition to specific nursing interventions that address the
symptoms of heart failure, general nursing measures involve limitation of activities in order to preserve oxygen consumption and
decrease breathlessness.2 The patient may have self-care deficits
where there is an inability to undertake activities such as bathing, dressing or feeding oneself. Nursing care involves identifying
these deficits and attending to them. In relation to bathing, particular attention should be paid to the skin, in particular to pressure
areas such as the heels and sacrum area. A Waterlow Score is
undertaken identifying the risk of developing pressure sores and
the relevant interventions such as a pressure relieving mattress
should be put in place. In addition the patient may experience
peripheral oedema, particularly of the legs, which may predispose the skin to cracking or breaking down. In order to prevent
this the skin is moisturised and legs are elevated when sitting out,
to relieve the oedema and its associated discomfort.
From a nutritional perspective the patient may experience
anorexia and nausea due to poor perfusion to the digestive system as well as the presence of ascites. A dietary consult should
be sent for appropriate advice on nutrition. In general the patient
will be on a low-salt diet and is advised to eat little and often to
avoid periods of nausea and fullness. An anti-emetic may be prescribed and administered 30 minutes prior to meals to relieve
nausea. Due to poor perfusion to the digestive system the patient
is at risk of constipation and altered bowel habit and therefore it
may be necessary for laxatives or stool softeners to be prescribed
to avoid this problem.
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Continuing Education
Table 1
Nursing implications of acute heart failure – pharmacological management
Treatment
Adverse effects/nursing specific implications
Morphine
• Respiratory depression • Hypotension caused by vasodilatory effects
Diuretics
• Electrolyte Imbalances (hypokalaemia, hyponatraemia)
• Hypotension
• Dehydration • Diuretic resistance if already on oral diuretics
• Headache
Vasodilators
• Hypotension
• Nitrate tolerance (occurs when patient receiving same dose of nitrate for longer than 24 hours)
Inotropes
Type III phosphodiesterase inhibitors
• Increased incidence of atrial and ventricular arrhythmias (due to ventricular irritability and
increased myocardial oxygen consumption secondary to increased contractility)
• Use with caution in those with heart rates > 100 bpm. May cause sympathetic nervous system
stimulation and increase the heart rate further
• Monitor blood pressure
• Weaning the infusions to avoid rebound hypotension /organ hypoperfusion
• Short half life of two minutes
• Dobutamine and milrinone may be administered peripherally
• Administer via central line
Vasopressors
• Monitor for atrial and ventricular arrhythmias
• Observe for excessive vasoconstriction
Pharmacological management
Part one of this article explored the pharmacological management of acute heart failure focusing on diuretics, vasodilators,
inotropes and vasopressors. Table 1 describes the specific nursing
implications applicable to each class of agents. Once the patient
is stabilised the level of activity may be increased, such as gentle
mobilisation. Ownership of self-care is promoted with assistance
initially and then independently. Daily weighing may commence,
usual practice is in the morning prior to breakfast and after the
patient has been to the toilet. It is recommended that the patient
is weighed in the same attire, such as pyjamas and slippers, thus
avoiding discrepancy in subsequent weighing. Patient education
in self-care of heart failure and prevention of exacerbations may
begin at this stage. Self-care is defined as actions aimed at maintaining physical stability, avoidance of behaviour that can worsen
the condition and detection of the early symptoms of deterioration. The principles of self-care are represented in Table 2. For
more information regarding patient education and appropriate
behaviour please refer to the ESC guidelines.1
It is recommended that the patient remains in contact with the
service and if possible enrols in a nurse-led heart failure clinic or
programme. The ESC guidelines describe such programmes as
a multidisciplinary team approach that co-ordinates care along
the continuum of heart failure and throughout the chain of
care delivered by various services within the healthcare system.
The multidisciplinary team may consist of nurses, cardiologists,
primary care physicians, physiotherapists, dieticians, social workers, psychologists, pharmacists, geriatricians, and palliative care
as well as other healthcare professionals. This service is implemented during hospitalisation and continued as an outpatient.
Elements of the service focus on patient education in relation to the topics addressed in Table 2 and drug titration using
treatment algorithms, as well as management of patients with
an implanted device such as implantable defibrillator or biventricular pacemaker. Ease of access is promoted, thus providing
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reassurance and allowing the patient to discuss symptoms, treatment, side-effects and self-care behaviour. The ESC guidelines1
recommend that the following components are integral to the
programme:
• Multidisciplinary team approach frequently led by heart failure
nurses in collaboration with physicians and other related services
• First contact during hospitalisation, early follow up after discharge through clinic and home based visits, telephone support
and remote monitoring
• Target high risk symptomatic patients
• Facilitate access during episodes of decompensation
• Optimised medical management
• Access to advanced treatment options
• Adequate patient education with special emphasis on adherence and self-care management
• Patient involvement in symptom monitoring and flexible diuretic use
• Psychosocial support to patient and family and/or caregiver.
Aside from patient benefits, such as reduction in mortality,
promotion of independence and patient autonomy, these programmes reduce hospitalisation and thus are cost effective.
The patient may also be referred to a cardiac rehabilitation programme which has been shown to improve functional capacity,
recovery and emotional wellbeing and to reduce hospital admissions. It is acknowledged that heart failure is a chronic progressive
syndrome where the aim of treatment is to alleviate symptoms
and slow its progression.
Despite advances in medical and interventional therapies it is
recognised that it is a palliative condition. Patients with clinical
features of advanced heart failure who continue to experience
symptoms, despite optimal evidence based therapy, have a poor
short-term prognosis and should be considered for a structured
palliative care approach. This may be challenging as heart failure
has an unpredictable disease trajectory and it is often difficult
to identify a specific time point to introduce palliative care to
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Continuing Education
Table 2
Essential topics in patient education
Educational Topics
Skills and self-care Behaviour
Definition and cause of heart failure
• Understand the cause of heart failure and why symptoms occur
Signs and symptoms
• Monitor and recognise signs and symptoms
• Record daily weight and recognise rapid weight gain
• Report sudden unexpected weight gain > 2kgs in three days
• Know how and when to contact the heart failure nurse specialist or service
• Use flexible diuretic therapy if appropriate and recommended
Pharmacological treatment
• Understand indications dosing and effects of drugs
• Recognise the common side-effects of each drug prescribed
Risk factor modification
• Understand the importance of smoking cessation
• Monitor blood pressure if hypertensive
• Maintain good glucose control if diabetic
Diet recommendations
• Sodium restriction if prescribed
• Monitor alcohol intake
Exercise recommendations
• Avoid obesity
• Avoid excessive fluid intake
• Monitor and prevent malnutrition
• Be reassured and comfortable about exercise
• Understand the benefits of exercise
• Undertake exercise regularly
Sexual activity
• Be comfortable about engaging in sexual activity and discuss problems with heart failure
nurse specialist or healthcare provider
• Understand specific sexual problems and various coping strategies
Immunisation
• Receive immunisation against infections such as influenza and pneumococcal disease
Sleep and breathing disorders
(central or obstructive sleep apnoea)
• Recognise preventive behaviour such as reducing weight if obese, smoking cessation and
abstinence from alcohol
• Learn about treatment options if appropriate
Adherence
• Understand the importance of following treatment strategies and maintaining motivation
to follow prescribed treatment
Psychosocial approach
• Understand that depressive symptoms are common in heart failure and the importance
of social support
• Learn about treatment options if appropriate
Prognosis
• Understand important prognostic factors and make realistic decisions
• Seek psychosocial support
Pregnancy and contraception
• Pregnancy can deteriorate heart failure
• Family planning and contraception discussed
• Risk vs benefit to baby and mother made explicit
Travelling
• High altitudes (> 1500m ) and very hot/humid destinations discouraged
• Planned travel discussed with heart failure team
patient management. Interventions should focus on improvement in quality of life, symptom control, early detection and
treatment of deterioration and on pursuing a holistic approach to
patient care, encompassing physical, psychosocial, social and spiritual wellbeing. Currently there is an action research project being
undertaken in relation to palliative care in heart failure that aims
to identify a framework of care for this patient population. Heart
failure is a chronic progressive syndrome that negatively impacts
on patient’s functional capacity and quality of life. Heart failure
programmes promote patient autonomy and have been shown
to reduce episodes of hospitalisation via a multidisciplinary
approach and a role for palliative care has been acknowledged.
Kate O'Donovan is course co-ordinator for the postgraduate diploma in
cardiovascular nursing in the Mater Hospital, Dublin
References
1. Dickstein K, Cohen-Solal A, Filippatos G. ESC guidelines for the diagnosis and treatment
of acute and chronic heart failure. 2008 Eur Heart J 2008; 29: 2388-2442
2. RN Expert Guides. Degenerative disorders. Cardiovascular Care. Wolters Kluwer Health –
Lippincott Williams and Wilkins: Philadelphia, 2008: 381-42
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