Heart Failure: Early Recognition and Treatment of the Patient at Risk of Hospital Readmission

 

OVERVIEW

A. HF is the most common cause of hospitalization of adults older than 65 years (Centers for Disease Control and Prevention [CDC], 2019; Heidenreich et al., 2022) and is the cause of functional impairment and ultimate morbidity and mortality, as well as significant hospital costs (Diez & Butler, 2022).

B. Hospitalization can be prevented by identifying the high-risk HF patient, early recognition of signs and symptoms of decompensation, and timely initiation or regulation of medical therapy (Ivynian et al., 2020; Lin et al., 2021; Takei et al., 2020).

C. Recognition of risk factors and routine monitoring for potential HF decompensation should be part of a comprehensive nursing care of older adults (Heidenreich et al., 2022; James et al., 2014).

 

BACKGROUND AND STATEMENT OF PROBLEM

A. Definition

  1. HF is the inability of the heart to pump blood sufficient to meet the metabolic needs of the body or it cannot do so without significantly elevated filling pressures (Díez-Villanueva et al., 2021). Acute HF can develop swiftly or over the preceding weeks as the primary initial event. Acute decompensated HF is the result of chronic HF (Normand et al., 2019).

B. Etiology and epidemiology

  1. Prevalence and incidence: There are more than 5.8 million individuals with HF in the United States, and approximately half a million new cases develop every year (“Heart Failure Fact Sheet|Data & Statistics|DHDSP|CDC,” 2019).
  2. Etiology: Etiology includes deficiency in myocardial pump function as a result of nonischemic progressive cardiomyopathy or more prevalent ischemic causes, such as coronary heart disease and MI, with a resulting development of signs and symptoms such as edema, dyspnea, and orthopnea (Normand et al., 2019).
  3. Risk factors include the following:
    • Predisposing: age (65 years and older); severity of illness; comorbidities such as HTN, coronary artery disease, diabetes, and valvular heart disease; cognitive impairment, depression, sensory impairment, fluid and electrolyte disturbances, and polypharmacy additionally imposing an increased risk (Fernandez et al., 2022)
    • Precipitating: high-sodium diet; excess fluid intake; sleep-disordered breathing; chronic kidney disease; anemia; cardiotoxins such as chemotherapeutic agents, NSAIDs, substance use, or alcohol misuse (Diez & Butler, 2022; Roger, 2021)
    • Environmental: low socioeconomic status, psychological stress, and inadequate social support (Alanzi et al., 2023)
  4. Outcomes: HF has a downward trajectory that through preventive measures can be delayed, however not without considerable impact on quality of life.

PARAMETERS OF ASSESSMENT

A. Assess at initial encounter and every shift.

  1. Baseline: health history, NYHA classification of functional status and stage of HF, cognitive and psychosocial support systems (Heidenreich et al., 2022)
  2. Symptoms: dyspnea, orthopnea, cough, edema; vital signs: BP, HR, and RR; physical assessment with signs: rales or “crackles”; peripheral edema, ascites, or pulmonary vascular congestion on chest x-ray
  3. Medications review: optimal medical regimen according to the ACC/AHA/HFSA guideline unless contraindicated
  4. Electrocardiogram/telemetry review: HR, rhythm, QRS duration, QT interval (Cilla et al., 2023)
  5. Review of echocardiography, cardiac angiogram, MUGA scan, cardiac CT or MRI for left ventricle and valve function, LVEF (Cilla et al., 2023; Truby & Rogers, 2020)
  6. Laboratory value review (Heidenreich et al., 2022; Yancy et al., 2018)
    • Metabolic evaluation: electrolytes (hyponatremia, hypokalemia), thyroid function, liver function, kidney function
    • Hematology: evaluation for anemia, including hemoglobin, hematocrit, iron, iron-binding capacity, and B12 folic acid

B. Evaluate for infection (fever, WBCs with differential, and cultures).

  1. Impaired mobility/deconditioned status: physical therapy or structured cardiac rehabilitation, inpatient or outpatient

C. Evaluate for sensory impairment, that is, vision and hearing, and limitations in ability for self-care (Wu & Moser, 2018; Zhao et al., 2021).

D. Assess for signs and symptoms, including changes in mental status every shift (Ryan, 2019; Wu & Moser, 2018).

NURSING CARE STRATEGIES

A. Obtain HF/cardiology and geriatric consultation (Naylor et al., 2004; Naylor & Keating, 2008).

B. Eliminate or minimize risk factors.

  1. Administer medications according to guidelines and patient assessment (Brenner et al., 2001).
  2. Avoid continuous intravenous infusion, especially of saline.
  3. Maintain euvolemia once fluid overload is treated. Prevent/promptly treat fluid overload, dehydration, and electrolyte disturbances. Maximize oxygen delivery supplemental oxygen, blood, and BP support as needed.
  4. Ensure daily weights are accurately charted.
  5. Provide adequate nutrition with a 2 g/d sodium diet.
  6. Provide adequate pain control.
  7. Use sensory aids as appropriate.
  8. Regulate bowel/bladder function.

C. Provide self-care education with maintenance and management strategies (Zhao et al., 2021).

  1. Encourage activity recommendation as appropriate to functional status. Assess safety in ambulation hourly rounds with encouragement to toilet.
  2. Facilitate rest with schedule of diuretic medications for limited nocturia.
  3. Maximize mobility. Involve occupational therapy and physical therapy and limit use of urinary catheters.
  4. Communicate clearly; provide explanations.
  5. Emphasize the purpose and importance of daily weights.
  6. Arrange dietitian referral for educational needs regarding sodium.

D. Identify primary care partner. Reassure and educate.

  1. Foster care support of family/friends.
  2. Assess willingness and ability of care partner to assist with self-care: dietary needs of sodium restriction, daily weight logging, symptom recognition, and medical follow-up.

EVALUATION/EXPECTED OUTCOMES

A. Patient

  • Absence of symptoms of congestion
  • Hemodynamic status remains stable
  • Functional status returned to baseline (before acute decompensation)
  • Improved adherence to medical and self-care regimen
  • Discharged to same destination as prehospitalization

B. Healthcare provider

  1. Regular use of self-care HF index screening tool
  2. Increased detection of symptoms of acute decompensation
  3. Implementation of appropriate interventions to prevent/treat volume overload
  4. Improved nurse awareness of patient/caregiver self-care confidence and ability
  5. Increased management using guideline-directed therapy

C. Institution

  1. Staff education and interprofessional care planning
  2. Implementation of HF-specific treatments
  3. Decreased overall cost
  4. Decreased preventable readmission and length of hospital stay
  5. Decreased morbidity and mortality
  6. Increased referrals and consultation to previously specified specialists
  7. Improved satisfaction of patients, families, and nursing staff

FOLLOW-UP MONITORING OF CONDITION

A. Decreased frequency of readmission as a measure of quality care

B. Incidence of decompensated HF to decrease

C. Patient days with symptoms of congestion to decrease

D. Staff competence in prevention, recognition, and treatment of HF

E. Documentation of a variety of interventions for HF

ABBREVIATIONS

ACC/AHA/HFSA   American College of Cardiology/American Heart Association Task Force/Heart Failure Society of America

BP                         blood pressure

HF                        heart failure

HFrEF                   heart failure with reduced ejection fraction

HR                        heart rate

HTN                      hypertension

LVEF                     left ventricular ejection fraction

MI                        myocardial infarction

MUGA                  multigated acquisition

NSAIDs                nonsteroidal anti-inflammatory drugs

NYHA                   New York Heart Association

RR                        respiratory rate

WBCs                   white blood cells

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Updated: January 2025

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti, PhD, RN, FAAN, E.A., & Fulmer PhD, RN, FAAN, T. T. (2025). Evidence-Based Geriatric Nursing Protocols for Best Practice (7th ed.). Springer Publishing. Retrieved December 17, 2024, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826152763.html#tableofcontents

Chapter 27, Chakravarthy, A. (2025) Fluid Overload: Identifying and Managing Heart Failure Patients at Risk for Hospital Readmission

 

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Schwartz, J. E., Muntner, P., Kronish, I. M., Burg, M. M., Pickering, T. G., Bigger, J. T., & Shimbo, D. (2020). Reliability of office, home, and ambulatory blood pressure measurements and correlation with left ventricular mass. Journal of the American College of Cardiology, 76(25), 2911–2922. https://doi.org/10.1016/j.jacc.2020.10.039. Evidence Level VI.

Takei, M., Harada, K., Shiraishi, Y., Matsuda, J., Iwasaki, Y., Yamamoto, Y., Matsushita, K., Miyazaki, T., Miyamoto, T., Iida, K., Tanimoto, S., Nagatomo, Y., Hosoda, T., Kohsaka, S., Yamamoto, T., Nagao, K., & Takayama, M. (2020). Delay in seeking treatment before emergent heart failure readmission and its association with clinical phenotype. Journal of Intensive Care, 8, 65. https://doi.org/10.1186/s40560-020-00482-z. Evidence Level III.

Triposkiadis, F., Xanthopoulos, A., & Butler, J. (2019). Cardiovascular aging and heart failure: JACC Review topic of the week. Journal of the American College of Cardiology, 74(6), 804–813. https://doi.org/10.1016/j.jacc.2019.06.053. Evidence Level V.

Tsao, C. W., Aday, A. W., Almarzooq, Z. I., Beaton, A. Z., Bittencourt, M. S., Boehme, A. K., Buxton, A. E., Carson, A. P., Commodore-Mensah, Y., Elkind, M. S. V., Evenson, K. R., Eze-Nliam, C., Ferguson, J. F., Generoso, G., Ho, J. E., Kalani, R., Khan, S. S., Kissela, B. M., Knutson, K. L., …, Martin, S. S. (2022). Heart disease and stroke statistics—2022 update: A report From the American Heart Association. Circulation, 145(8), e153–e639. Evidence Level IV.

Tromp, J., Westenbrink, B. D., Ouwerkerk, W., van Veldhuisen, D. J., Samani, N. J., Ponikowski, P., Metra, M., Anker, S. D., Cleland, J. G., Dickstein, K., Filippatos, G., van der Harst, P., Lang, C. C., Ng, L. L., Zannad, F., Zwinderman, A. H., Hillege, H. L., van der Meer, P., & Voors, A. A. (2018). Identifying pathophysiological mechanisms in heart failure with reduced versus preserved ejection fraction. Journal of the American College of Cardiology, 72(10), 1081–1090. https://doi.org/10.1016/j.jacc.2018.06.050.Evidence Level V.

Truby, L. K., & Rogers, J. G. (2020). Advanced heart failure: Epidemiology, diagnosis, and therapeutic approaches. JACC Heart Failure, 8(7), 523–536. https://doi.org/10.1016/j.jchf.2020.01.014. Evidence Level V.

Umehara, T., Kaneguchi, A., Katayama, N., Kawakami, W., Kuwahara, D., Kito, N., & Kakehashi, M. (2023). Frailty in elderly patients with acute heart failure increases readmission. Heart & Lung: The Journal of Critical Care, 57, 102–109. https://doi.org/10.1016/j.hrtlng.2022.08.021. Evidence Level VI.

Virani, S. S., Alonso, A., Benjamin, E. J., Bittencourt, M. S., Callaway, C. W., Carson, A. P., Chamberlain, A. M., Chang, A. R., Cheng, S., Delling, F. N., Djousse, L., Elkind, M. S. V., Ferguson, J. F., Fornage, M., Khan, S. S., Kissela, B. M., Knutson, K. L., Kwan, T. W., Lackland, D. T., & American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. (2020). Heart disease and stroke statistics-2020 update: A report from the American Heart Association. Circulation, 141, e139–e596. https://doi.org/10.1161/CIR.0000000000000757. Evidence Level IV.

Wing, L. M. H., Reid, C. M., Ryan, P., Beilin, L. J., Brown, M. A., Jennings, G. L. R., Johnston, C. I., McNeil, J. J., Macdonald, G. J., Marley, J. E., Morgan, T. O., West, M. J., & Second Australian National Blood Pressure Study Group. (2003). A comparison of outcomes with angiotensin-converting— Enzyme inhibitors and diuretics for hypertension in the elderly. The New England Journal of Medicine, 348(7), 583–592. https://doi.org/10.1056/NEJMoa021716. EvidenceLevel II.

Wu, J. R., & Moser, D. K. (2018). Medication adherence mediates the relationship between heart failure symptoms and cardiac event-free survival in patients with heart failure. Journal of Cardiovascular Nursing, 33(1), 40–46. https://doi.org/10.1097/JCN.0000000000000427. PMID: 28591004; PMCID: PMC5714687. Evidence Level VI.

Yancy, C. W., Januzzi, J. L., Allen, L. A., Butler, J., Davis, L. L., Fonarow, G. C., Ibrahim, N. E., Jessup, M., Lindenfeld, J., Maddox, T. M., Masoudi, F. A., Motiwala, S. R., Patterson, J. H., Walsh, M. N., & Wasserman, A. (2018). 2017 ACC expert consensus decision pathway for optimization of heart failure treatment: Answers to 10 pivotal issues about heart failure with reduced ejection fraction: A report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. Journal of the American College of Cardiology, 71(2), 201–230. https://doi.org/10.1016/j.jacc.2017.11.025. Evidence Level I.

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