Heart Failure (HF)

A.  Heart Failure (HF) is the most common cause of hospitalization of adults older than 65 years (Schocken et al., 2008) and is the cause of functional impairment and ultimate morbidity and mortality as well as significant hospital costs (Messerli et al., 2017).

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 (Evangelista et al., 2000; Jurgens et al., 2009; Sethares et al., 2015).

C.  Recognition of risk factors and routine monitoring for potential HF decompensation should be part of the comprehensive nursing care of older adults (Ahmad et al., 2016; Bui et al., 2011; Messerli et al., 2017).

BACKGROUND AND STATEMENT OF PROBLEM

A.  Definition

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 (Miller & Piña, 2009). Acute HF can develop swiftly or over the preceding weeks as the primary initial event. Acute decompensated HF is the result of chronic HF (Harjola et al., 2017).

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: 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 (Harjola et al., 2017; Kemp & Conte, 2012).
  3. Risk factors
    • Predisposing age (65 years and older); severity of illness; comorbidities, such as HTN, coronary artery disease, diabetes, valvular heart disease, and obesity. Additionally, cognitive impairment, depression, sensory impairment, fluid and electrolyte disturbances, and polypharmacy also impose an increased risk (Ahmad et al., 2016; Bell & Goncalves, 2019; Bui et al., 2011; Lastra et al., 2014; Messerli et al., 2017)
    • Precipitating: High-sodium diet; excess fluid intake; sleep-disordered breathing; chronic kidney disease; anemia; cardiotoxins, such as chemotherapeutic agents, NSAIDs, illicit drugs, or alcohol (Schocken et al., 2008)
    • Environmental factors: Low socioeconomic status, psychological stress, and inadequate social support (Schocken et al., 2008)
  4. Outcomes: HF has a downward trajectory that through preventative measures can be delayed; however, not without considerable impact on quality of life (Grady et al., 2000).

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 (Miller, 2017; Tuy & Than, 2013)
  2. Symptoms: Dyspnea, orthopnea, cough, edema; vital signs: BP, HR, and RR (Pickering et al., 2005); physical assessment with signs: rales or “crackles”; peripheral edema, ascites, or pulmonary vascular congestion of chest x-ray (Stevenson & Perloff, 1989)
  3. Medications review: Optimal medical regimen according to ACC/AHA/HFSA guideline unless contraindicated (Riegel et al., 2009; Wing et al., 2003)
  4. Electrocardiogram/telemetry review: HR, rhythm, QRS duration, QT interval (Bertoni et al., 2004; Chyun et al., 2002)
  5. Review echocardiography, cardiac angiogram, MUGA scan, cardiac CT or MRI for left ventricle and valve function: LVEF (Bertoni et al., 2004; Chyun et al., 2002; Lewis et al., 2003)
  6. Laboratory value review (Yancy et al., 2018)
    • Metabolic evaluation: Electrolytes (hyponatremia, hypokalemia), thyroid function, liver function, kidney function
    • Hematology: Evaluation for anemia: Hemoglobin, hematocrit, iron, iron-binding capacity, and B12 folic acid
    • Evaluation for infection (fever, WBCs with differential, cultures)
  7. Impaired mobility/deconditioned status: Physical therapy or structured cardiac rehabilitation inpatient or outpatient

B.  Sensory impairment—vision, hearing—limitations in ability for self-care (Ferdinand et al., 2017; Jonkman et al., 2016)

C.  Signs and symptoms—assess for changes in mental status every shift (Ferdinand et al., 2017; Jonkman et al., 2016)

NURSING CARE STRATEGIES

A.  Obtain HF/cardiology and geriatric consultation (Naylor, 2006; Naylor et al., 2004; Naylor & Keating, 2008; Rich & Kitzman, 2005).

B.  Eliminate or minimize risk factors.

  1. Administer medications according to guidelines and patient assessment (Brenner et al., 2001; Riegel et al., 2009; Wing et al., 2003).
  2. Avoid continuous intravenous infusion, especially of saline (Lancaster et al., 2003; Riegel et al., 2009).
  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 (Lancaster et al., 2003; Riegel et al., 2009).
  4. Ensure daily weights accurately charted (Grady et al., 2000; Riegel et al., 2004, 2009).
  5. Provide adequate nutrition with a 2-g/d sodium diet (see Chapter 13, Nutrition in the Older Adult).
  6. Provide adequate pain control (see Chapter 22, Pain Management in the Older Adult).
  7. Use sensory aids as appropriate.
  8. Regulate bowel/bladder function.

C.  Provide self-care education with maintenance and management strategies (Ferdinand et al., 2017; Jonkman et al., 2016; Naylor, 2006; Pickering et al., 2005).

  1. Encourage activity recommendation as appropriate to functional status. Assess for 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 purpose and importance of daily weights.
  6. Arrange dietician 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

  1. Absence of symptoms of congestion
  2. Hemodynamic status remains stable
  3. Functional status returned to baseline (before acute decompensation)
  4. Improved adherence to medical and self-care regimen
  5. 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

BUN/Cr               Blood urea nitrogen/creatinine ratio

HF                        Heart failure

Hgb/Hct               Hemoglobin and hematocrit

HR                       Heart rate

HTN                     Hypertension

LVEF                   Left ventricular ejection fraction

Na+                      Sodium

NSAIDs               Nonsteroidal anti-inflammatory drugs

NYHA                 New York Heart Association

ROM                    Range of motion

RR                       Respiratory rate

SpO2                    Pulse oxygen saturation

URI                      Upper respiratory infection

UTI                      Urinary tract infection

WBCs                  White blood cells

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Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Chapter 36:  Chakravarthy, A., & Davenport, J. (2021) Fluid Overload: Identifying and Managing Heart Failure Patients at Risk for Hospital Readmission.  In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 659-682).   New York: Springer.

REFERENCES

Ahmad, F. S., Ning, H., Rich, J. D., Yancy, C. W., Lloyd-Jones, D. M., & Wilkins, J. T. (2016). Hypertension, obesity, diabetes, and heart failure–free survival: The cardiovascular disease lifetime risk pooling project. JACC. Heart Failure, 4(12), 911–919. doi:10.1016/j.jchf.2016.08.001. Evidence Level III.

Bell, D. S. H., & Goncalves, E. (2019). Heart failure in the patient with diabetes: Epidemiology, aetiology, prognosis, therapy and the effect of glucose-lowering medications. Diabetes, Obesity & Metabolism, 21(6), 1277–1290. doi:10.1111/dom.13652. Evidence Level V.

Bertoni, A. G., Hundley, W. G., Massing, M. W., Bonds, D. E., Burke, G. L., & Goff, D. C. (2004). Heart failure prevalence, incidence, and mortality in the elderly with diabetes. Diabetes Care, 27(3), 699–703. doi:10.2337/diacare.27.3.699. Evidence Level IV.

Brenner, B. M., Cooper, M. E., de Zeeuw, D., Keane, W. F., Mitch, W. E., Parving, H.-H., … Shahinfar, S. (2001). Effects of Losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. New England Journal of Medicine, 345(12), 861–869. doi:10.1056/NEJMoa011161. Evidence Level II.

Bui, A. L., Horwich, T. B., & Fonarow, G. C. (2011). Epidemiology and risk profile of heart failure. Nature Reviews. Cardiology, 8(1), 30–41. doi:10.1038/nrcardio.2010.165. Evidence Level V.

Centers for Disease Control and Prevention. (2019, January 8). Heart failure fact sheet|Data & statistics|DHDSP|CDC. Retrieved from https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm. Evidence Level III.

Chyun, D., Vaccarino, V., Murillo, J., Young, L. H., & Krumholz, H. M. (2002). Acute myocardial infarction in the elderly with diabetes. Heart & Lung: The Journal of Critical Care, 31(5), 327–339. doi:10.1067/mhl.2002.126049. Evidence Level II.

Evangelista, L. S., Dracup, K., & Doering, L. V. (2000). Treatment-seeking delays in heart failure patients. The Journal of Heart and Lung Transplantation, 19(10), 932–938. doi:10.1016/S1053-2498(00)00186-8. Evidence Level III.

Ferdinand, K. C., Senatore, F. F., Clayton-Jeter, H., Cryer, D. R., Lewin, J. C., Nasser, S. A., … Califf, R. M. (2017). Improving medication adherence in cardiometabolic disease: Practical and regulatory implications. Journal of the American College of Cardiology, 69(4), 437–451. doi:10.1016/j.jacc.2016.11.034. Evidence Level VI.

Grady, K. L., Dracup, K., Kennedy, G., Moser, D. K., Piano, M., Stevenson, L. W., & Young, J. B. (2000). Team management of patients with heart failure: A statement for healthcare professionals from The Cardiovascular Nursing Council of the American Heart Association. Circulation, 102(19), 2443–2456. doi:10.1161/01.cir.102.19.2443. Evidence Level VI.

Harjola, V.-P., Mullens, W., Banaszewski, M., Bauersachs, J., Brunner-La Rocca, H.-P., Chioncel, O., … Mebazaa, A. (2017). Organ dysfunction, injury and failure in acute heart failure: From pathophysiology to diagnosis and management. A review on behalf of the Acute Heart Failure Committee of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). European Journal of Heart Failure, 19(7), 821–836. doi:10.1002/ejhf.872. Evidence Level I.

Jonkman, N. H., Westland, H., Groenwold, R. H., Ågren, S., Atienza, F., Blue, L., … Hoes, A. W. (2016). Do self-management interventions work in patients with heart failure? Circulation, 133(12), 1189–1198. doi:10.1161/CIRCULATIONAHA.115.018006. Evidence Level I.

Jurgens, C. Y., Hoke, L., Byrnes, J., & Riegel, B. (2009). Why do elders delay responding to heart failure symptoms? Nursing Research, 58(4), 274–282. doi:10.1097/NNR.0b013e3181ac1581. Evidence Level III.

Kemp, C. D., & Conte, J. V. (2012). The pathophysiology of heart failure. Cardiovascular Pathology: The Official Journal of the Society for Cardiovascular Pathology, 21(5), 365–371. doi:10.1016/j.carpath.2011.11.007. Evidence Level V.

Lancaster, K. J., Smiciklas-Wright, H., Heller, D. A., Ahern, F. M., & Jensen, G. (2003). Dehydration in black and white older adults using diuretics. Annals of Epidemiology, 13(7), 525–529. doi:10.1016/s1047-2797(03)00004-8. Evidence Level IV.

Lastra, G., Syed, S., Kurukulasuriya, L. R., Manrique, C., & Sowers, J. R. (2014). Type 2 diabetes mellitus and hypertension: An update. Endocrinology and Metabolism Clinics of North America, 43(1), 103–122. doi:10.1016/j.ecl.2013.09.005. Evidence Level V.

Lewis, E. F., Moye, L. A., Rouleau, J. L., Sacks, F. M., Arnold, J. M., Warnica, J. W., ... Pfeffer, M. A. (2003). Predictors of late development of heart failure in stable survivors of myocardial infarction: The CARE study. Journal of the American College of Cardiology, 42(8), 1446–1453. Evidence Level II.

Messerli, F. H., Rimoldi, S. F., & Bangalore, S. (2017). The transition from hypertension to heart failure: Contemporary update. JACC. Heart Failure, 5(8), 543–551. doi:10.1016/j.jchf.2017.04.012. Evidence Level V.

Miller, A. B., & Piña, I. L. (2009). Understanding heart failure with preserved ejection fraction: Clinical importance and future outlook. Congestive Heart Failure, 15(4), 186–192. Evidence Level V.

Miller, W. L. (2017). Assessment and management of volume overload and congestion in chronic heart failure: Can measuring blood volume provide new insights? Kidney Diseases, 2(4), 164–169. doi:10.1159/000450526. Evidence Level V.

Naylor, M. D. (2006). Transitional care: A critical dimension of the home healthcare quality agenda. Journal for Healthcare Quality: Official Publication of the National Association for Healthcare Quality, 28(1), 48–54. doi:10.1111/j.1945-1474.2006.tb00594.x. Evidence Level VI.

Naylor, M. D., Brooten, D. A., Campbell, R. L., Maislin, G., McCauley, K. M., & Schwartz, J. S. (2004). Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatrics Society, 52(5), 675–684. doi:10.1111/j.1532-5415.2004.52202.x. Evidence Level I.

Naylor, M. D., & Keating, S. A. (2008). Transitional care: Moving patients from one care setting to another. The American Journal of Nursing, 108(9 Suppl.), 58–63. doi:10.1097/01.NAJ.0000336420.34946.3a. Evidence Level V.

Pickering, T. G., Hall, J. E., Appel, L. J., Falkner, B. E., John, G., Hill, M. N., … Roccella, E. J. (2005). Recommendations for blood pressure measurement in humans and experimental animals. Hypertension, 45(1), 142–161. doi:10.1161/01.HYP.0000150859.47929.8e. Evidence Level VI.

Rich, M. W., & Kitzman, D. W. (2005). Third pivotal research in cardiology in the elderly (PRICE-III) symposium: Heart failure in the elderly: Mechanisms and management. The American Journal of Geriatric Cardiology, 14(5), 250–261. doi:10.1111/j.1076-7460.2005.04658.x. Evidence Level V.

Riegel, B., Moser, D. K., Anker, S. D., Appel, L. J., Dunbar, S. B., Grady, K. L., … Whellan, D. J. (2009). State of the science: Promoting self-care in persons with heart failure: A scientific statement from the American Heart Association. Circulation, 120(12), 1141–1163. doi:10.1161/CIRCULATIONAHA.109.192628. Evidence Level II.

Riegel, B., Naylor, M., Stewart, S., McMurray, J. J. V., & Rich, M. W. (2004). Interventions to prevent readmission for congestive heart failure. Journal of the American Medical Association, 291(23), 2816; author reply 2816-2817. doi:10.1001/jama.291.23.2816-a. Evidence Level II.

Schocken, D. D., Benjamin, E. J., Fonarow, G. C., Krumholz, H. M., Levy, D., Mensah, G. A., … Hong, Y. (2008). Prevention of heart failure: A scientific statement from the American Heart Association Councils on Epidemiology and Prevention, Clinical Cardiology, Cardiovascular Nursing, and High Blood Pressure Research; Quality of Care and Outcomes Research Interdisciplinary Working Group; and Functional Genomics and Translational Biology Interdisciplinary Working Group. Circulation, 117(19), 2544–2565. doi:10.1161/CIRCULATIONAHA.107.188965. Evidence Level I.

Sethares, K. A., Chin, E., & Jurgens, C. Y. (2015). Predictors of delay in heart failure patients and consequences for outcomes. Current Heart Failure Reports, 12(1), 94–105. doi:10.1007/s11897-014-0241-5. Evidence Level V.

Stevenson, L. W., & Perloff, J. K. (1989). The limited reliability of physical signs for estimating hemodynamics in chronic heart failure. Journal of the American Medical Association, 261(6), 884–888. doi:10.1001/jama.1989.03420060100040. Evidence Level II.

Tuy, T., & Than, M. (2013). Fluid-volume assessment in the investigation of acute heart failure. Current Emergency and Hospital Medicine Reports, 1(2), 126–132. doi:10.1007/s40138-013-0010-x. Evidence Level V.

Wing, L. M. H., Reid, C. M., Ryan, P., Beilin, L. J., Brown, M. A., Jennings, G. L. R., … West, M. J. (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. doi:10.1056/NEJMoa021716. Evidence Level II.

Yancy, C. W., Januzzi, J. L., Allen, L. A., Butler, J., Davis, L. L., Fonarow, G. C., … 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. doi:10.1016/j.jacc.2017.11.025. Evidence Level I.