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.

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