for educational purpose only..

1. Cardiac Failure
Known as congestive heart failure (CHF), occurs when your heart muscle doesn't pump
blood as well as it should. Conditions such as narrowed arteries in your heart (coronary artery
disease) or high blood pressure gradually leave your heart too weak or stiff to fill and pump
efficiently.
The heart's pumping power is weaker than normal. With heart failure, blood moves
through the heart and body at a slower rate, and pressure in the heart increases. As a result, the
heart cannot pump enough oxygen and nutrients to meet the body's needs. The chambers of the
heart may respond by stretching to hold more blood to pump through the body or by becoming
stiff and thickened. This helps to keep the blood moving, but the heart muscle walls may
eventually weaken and become unable to pump as efficiently. As a result, the kidneys may
respond by causing the body to retain fluid (water) and salt. If fluid builds up in the arms, legs,
ankles, feet, lungs, or other organs, the body becomes congested, and congestive heart failure is
the term used to describe the condition.
Risk factors
In evaluating heart failure patients, the clinician should ask about the following
comorbidities and/or risk factors[5] :
Myopathy
Previous MI
Valvular heart disease, familial heart disease
Alcohol use
Hypertension
Diabetes
Dyslipidemia
Coronary/peripheral vascular disease
Sleep-disordered breathing
Collagen vascular disease, rheumatic fever
Pheochromocytoma
Thyroid disease
Substance abuse history
History of chemotherapy/radiation to the chest

2. Physical exam
The parts of the physical exam that are most helpful in diagnosing heart failure are:
Measuring blood pressure and pulse rate.
Checking the veins in the neck for swelling or evidence of high blood pressure in the veins that
return blood to the heart. Swelling or bulging veins may indicate right-sided heart failure or
advanced left-sided heart failure.
Listening to breathing (lung sounds).
Listening to the heart for murmurs or extra heart sounds.
Checking the abdomen for swelling caused by fluid buildup and for enlargement or tenderness
over the liver.
Checking the legs and ankles for swelling caused by fluid buildup (edema).
Measuring body weight.
Results
Usually, signs of some heart condition are present, such as high blood pressure or a heart
murmur that means heart valve disease.
If you have symptoms typical of heart failure, the physical exam may be all that your doctor
needs to make the diagnosis. But you will have additional tests to determine the specific cause
and type of heart failure so that you can receive appropriate treatment.
Normal
Lung and heart sounds are normal, blood pressure is normal, and you have no sign of fluid
buildup or swollen veins in the neck.
You may have further exams or tests to check for other causes of symptoms.
Abnormal findings that suggest heart failure
High blood pressure (140/90 mm Hg or above) or low blood pressure is present. Low blood
pressure could be a sign of late-stage heart failure.
An irregular heart rate (cardiac arrhythmia)
A third heart sound (indicating abnormal movement of blood through the heart) is heard. Heart
murmurs may or may not be present.
The impulse normally felt from the lower tip of the heart (apex) is not felt in its normal position
on the chest wall, suggesting enlargement of the heart.

3. Swollen neck veins or abnormal movement of blood in the neck veins suggest that blood may be
backing up in the right ventricle.
Noises (pulmonary rales) such as bubbling or crackling are heard, which may point to fluid
buildup in the lungs. Your doctor uses a stethoscope to hear these noises while you take deep
breaths.
You have a swollen liver or have pain in the right upper abdomen, loss of appetite, or bloating.
This suggests that blood may be backing up into the body.
You have swelling in your legs, ankles, or feet or in the lower back when you lie down, and it is
clearly not caused by another condition. Fluid buildup first occurs during the day and goes away
overnight. As heart failure becomes worse, fluid buildup may not go away.
Some people with early symptoms of heart failure have no physical findings.
Diagnosis
A diagnosis of heart failure depends on the whole picture of physical findings, symptoms, and
tests.
If physical findings and your medical history strongly suggest heart failure, you most likely will
have a chest X-ray, an echocardiogram, and electrocardiography to evaluate the heart size, shape,
and function and to evaluate the lungs for signs of fluid buildup.
The most common tests are:
Medical history and physical examination
Electrocardiogram (ECG)
Blood tests
Chest x-ray
Echocardiogram
Additional tests may be able to find out more about your heart failure or identify the cause.
These include:
Lung function tests
Exercise testing
Cardiac Magnetic Resonance Imaging (MRI)
Cardiac catheterisation and angiography
Nuclear medicines techniques
Multi-slice Computer Tomography (MSCT)
Pathophysiologic mechanism
The signs and symptoms of heart failure (HF) are due in part to compensatory
mechanisms utilized by the body in an attempt to adjust for a primary deficit in cardiac output.
Neurohumoral adaptations, such as activation of the renin-angiotensin-aldosterone and
sympathetic nervous systems by the low-output state, can contribute to maintenance of perfusion
of vital organs in two ways:

4.  Maintenance of systemic pressure by vasoconstriction, resulting in redistribution of blood
flow to vital organs.
 Restoration of cardiac output by increasing myocardial contractility and heart rate and by
expansion of the extracellular fluid volume.
In HF, these adaptations tend to overwhelm the vasodilatory and natriuretic effects of
natriuretic peptides, nitric oxide, prostaglandins, and bradykinin [3-5]. Volume expansion is
often effective because the heart can respond to an increase in venous return with an elevation in
end–diastolic volume that results in a rise in stroke volume (via the Frank-Starling mechanism).
Nursing Dx & interventions:
1. Decreased cardiac output r/t altered heart rate and rhythm AEB bradycardia
Assess for abnormal heart and lung sounds.
Monitor blood pressure and pulse.
Assess mental status and level of consciousness.
Assess patient’s skin temperature and peripheral pulses.
Monitor results of laboratory and diagnostic tests.
Monitor oxygen saturation and ABGs.
Give oxygen as indicated by patient symptoms, oxygen saturation and ABGs.
Implement strategies to treat fluid and electrolyte imbalances.
Administer cardiac glycoside agents, as ordered, for signs of left sided failure, and monitor for
toxicity.
Encourage periods of rest and assist with all activities.
Assist the patient in assuming a high Fowler’s position.
Teach patient the pathophysiology of disease, medications
Reposition patient every 2 hours
Instruct patient to get adequate bed rest and sleep
Instruct the SO not to leave the client unattended
2. Excessive Fluid volume r/t decreased cardiac output and sodium and water retention
AEB crackles on both lung field and edema on extremities secondary to CHF and IHD
Establish rapport
Monitor and record VS
Assess patient’s general condition
Monitor I&O every 4 hours
Weigh patient daily and compare to previous weights.
Auscultate breath sounds q 2hr and pm for the presence of crackles and monitor for frothy
sputum production
Assess for presence of peripheral edema. Do not elevate legs if the client is dyspneic.
Follow low-sodium diet and/or fluid restriction
Encourage or provide oral care q2
Obtain patient history to ascertain the probable cause of the fluid disturbance.
Monitor for distended neck veins and ascites
Evaluate urine output in response to diuretic therapy.
Assess the need for an indwelling urinary catheter.
Institute/instruct patient regarding fluid restrictions as appropriate.

5. 3. Acute Pain
assess patient pain for intensity using a pain rating scale, for location and for precipitating
factors.
Administer or assist with self-administration of vasodilators, as ordered.
Assess the response to medications every 5 minutes
Provide comfort measures.
Establish a quiet environment.
Elevate head of bed.
Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides.
Teach patient relaxation techniques and how to use them to reduce stress.
Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial
infarction.
4. Ineffective tissue perfusion r/t decreased cardiac output
Assess patient pain for intensity using a pain rating scale, for location and for precipitating
factors.
Administer or assist with self administration of vasodilators, as ordered.
Assess the response to medications every 5 minutes.
Give beta blockers as ordered.
Establish a quiet environment.
Elevate head of bed.
Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides.
Provide oxygen and monitor oxygen saturation via pulse oximetry, as ordered.
Assess results of cardiac markers—creatinine phosphokinase, CK- MB, total LDH, LDH-1,
LDH-2, troponin, and myoglobin ordered by physician.
Assess cardiac and circulatory status.
Monitor cardiac rhythms on patient monitor and results of 12 lead ECG.
Teach patient relaxation techniques and how to use them to reduce stress.
Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial
infarction.
Reposition the patient every 2 hours
Instruct patient on eating a small frequent feedings
5. Hyperthermia RT increased metabolic rate secondary to pneumonia
Assess vital signs, the temperature.
Monitor and record all sources of fluid loss such as urine, vomiting and diarrhea.
Performed tepid sponge bath.
Maintain bed rest.
Remove excess clothing and covers.
Increase fluid intake.
Provide adequate nutrition, a high caloric diet.
Control environmental temperature.
Adjust cooling measures on the basis of physical response.
Provide information regarding normal temperature and control.
Explain all treatments.

6. Administer antipyretics as ordered.
Control excessive shivering with medications such as Chlorpromazine and Diazepam if
necessary.
Provide ample fluids by mouth or intravenously as ordered.
Provide oxygen therapy in extreme cases as ordered.
6. Ineffective breathing pattern r/t fatigue and decreased lung expansion and pulmonary
congestion secondary to CHF
establish rapport
monitor VS
inspect thorax for symmetry of respiratory movement
observe breathing pattern for SOB, nasal flaring, pursed-lip breathing or prolonged expiratory
phase and use of accessory muscles
measure tidal volume and vital capacity
assess emotional response
position patient in optimal body alignment in semi- fowler’s position for breathing
assist patient to use relaxation techniques
7. Activity intolerance r/t imbalance O2 supply and demand AEB limited ROM, generalized
weakness and DOB
Establish Rapport
Monitor and record Vital Signs
Assess patient’s general condition
Adjust client’s daily activities and reduce intensity of level. Discontinue activities that cause
undesired psychological changes
Instruct client in unfamiliar activities and in alternate ways of conserve energy
Encourage patient to have adequate bed rest and sleep
Provide the patient with a calm and quiet environment
Assist the client in ambulation
Note presence of factors that could contribute to fatigue
Ascertain client’s ability to stand and move about and degree of assistance needed or use of
equipment
Give client information that provides evidence of daily or weekly progress
Encourage the client to maintain a positive attitude
Assist the client in a semi-fowlers position
Elevate the head of the bed
Assist the client in learning and demonstrating appropriate safety measures
Instruct the SO not to leave the client unattended
Provide client with a positive atmosphere
Instruct the SO to monitor response of patient to an activity and recognize the signs and
symptoms
8. Ineffective airway clearance RT retained secretions AEB presence of rales on both lung
fields.
Monitor and record vital signs.
Assess patient’s condition.

7. Monitor respirations and breath sounds, noting rate and sounds.
Position head properly
Position appropriately and discourage use of oil-based products around nose.
Auscultate breath sounds and assess air movement.
Encourage deep breathing and coughing exercises
Elevate head of bed and encourage frequent position changes.
Keep back dry and loosen clothing
Observed for signs and symptoms of infection.
Instruct patient have adequate rest periods and limit activities to level of activity intolerance.
Give expectorants and bronchodilators as ordered.
Suction secretions PRN
Administer oxygen therapy and other medications as ordered
Nonpharmacologic therapies include:
dietary sodium and fluid restriction
physical activity as appropriate
attention to weight gain
Pharma Tx:
ACE INHIBITORS
Angiotensin-converting enzyme (ACE) inhibitors are indicated for the treatment of all patients
with heart failure caused by systolic dysfunction.
BETA BLOCKERS
Beta blockade is recommended in patients with heart failure caused by systolic dysfunction,
except in those who are dyspneic at rest with signs of congestion or hemodynamic instability, or
in those who cannot tolerate beta blockers.
ALDOSTERONE ANTAGONISTS
Aldosterone antagonism is indicated in patients with symptomatic heart failure who have rest
dyspnea or a history of rest dyspnea within the past six months (ARR = 11 percent over two
years; number needed to treat [NNT] = 9).
DIRECT-ACTING VASODILATORS
Direct-acting vasodilators were among the first medications shown to improve survival in
patients with heart failure.
DIURETICS
Diuretics are used, and often required, to manage acute and chronic volume overload. Because
diuretics may produce potassium and magnesium wasting, monitoring of these electrolytes is
important.
ARBS
Evidence supports the use of ARBs as a substitute agent in patients with heart failure who cannot
tolerate ACE inhibitors19; the combination of isosorbide dinitrate and hydralazine is also
effective in this population.
DIGOXIN
The collection of drugs that have a beneficial impact on mortality in heart failure is expanding,
and because polypharmacy can become a barrier to compliance, the role that digoxin will
ultimately play in heart failure is unclear. Usual dosage range for digoxin is 0.125 to 0.250 mg
daily

8. Drugs to avoid in heart failure
Pro-anti-arrhythmics with potentially negative inotropic effects, eg flecainide.
Calcium-channel blockers - eg verapamil, diltiazem (only amlodipine is advisable).
Tricyclic antidepressants.
Lithium.
NSAIDs and cyclo-oxygenase-2 (COX-2) inhibitors.[10]
Corticosteroids.
Drugs prolonging QT interval and potentially precipitating ventricular arrhythmias - eg
erythromycin, terfenadine.
Invasive therapies for heart failure include electrophysiologic intervention such as cardiac
resynchronization therapy (CRT), pacemakers, and implantable cardioverter-defibrillators
(ICDs); revascularization procedures such as coronary artery bypass grafting (CABG) and
percutaneous coronary intervention (PCI); valve replacement or repair; and ventricular
restoration.
When progressive end-stage heart failure occurs despite maximal medical therapy, when the
prognosis is poor, and when there is no viable therapeutic alternative, the criterion standard for
therapy has been heart transplantation. However, mechanical circulatory devices such as
ventricular assist devices (VADs) and total artificial hearts (TAHs) can bridge the patient to
transplantation; in addition, VADs are increasingly being used as permanent therapy
Peri-operative Nsg. Interv.
Preoperative Care
Measure and document the patient’s baseline vital signs.
Monitor baseline laboratory values for abnormalities (eg, serum potassium).
Perform a thorough head-to-toe nursing assessment, which focuses on
adventitious lung sounds,
jugular venous distention,
peripheral edema, and
urinary output.
Measure the patient’s baseline weight.
Ensure adequate IV access.
Institute preoperative warming techniques.
Obtain and review the patient’s medication list and record the last dose taken.
Apply thromboembolic stocking and sequential compression devices, if applicable, for deep
vein thrombosis prophylaxis.
Intraoperative Care
Monitor the patient’s vital signs closely for changes from baseline values.
Ensure patency and accessibility of IV lines.
Monitor the patient closely for signs of fluid overload, such as
respiratory crackles on auscultation,
jugular venous distension,
shortness of breath, or
increased respirations.

9. Assess positioning of the patient and consider using the lawn chair position during induction, if
possible.
Institute thermoregulatory techniques (eg, use of a temperature-regulating blanket during
surgery).
Communicate the patient’s status to his or her family members, when possible.
Postoperative Care
Monitor the patient’s vital signs closely for changes from baseline values.
Maintain the patient’s airway.
Monitor telemetry for changes in heart rhythm.
Monitor the patient closely for signs of pain and provide adequate pain relief.
Elevate the head of the bed according to the patient’s comfort level.
Continue to monitor closely for signs of fluid overload.
Continue thermoregulatory techniques (eg, use a temperature-regulating blanket, put on
patient’s socks).
Monitor for signs of deep vein thrombosis, such as
swelling in one or both legs or
warmth, redness, tenderness or discolored skin in the affected leg.
Monitor for signs of pulmonary embolism, such as
sharp, stabbing chest pain or
sudden shortness of breath.
Communicate the patient’s status to his or her family members.
Bioethics
Cultural Competency: Considering the Diversity of Patients
Adherence to Low Risk Lifestyle Reduces Risk of Cardiac Events
Talking about lifestyle change with patients can be very frustrating for both parties.
Facilitating Lifestyle and Behavior Change
DISCUSSION POINTS:
So, what do we know about facilitating lifestyle and behavior change?
Advice from a medical provider is important and sought after by most patients.
For some, it is enough to motivate change, usually around 5% of people.
Make the most of your professional opinion and advice, be clear, caring, and compelling.
Asking Permission/Patient Autonomy: Sample Questions
• “I know you came in today for your Pap, and I’m really concerned about your blood
pressure. Would it be alright if we talked about that also?”
• “I realize that you are in the driver’s seat here with your diabetes. I want to let you know
that I am very concerned about _______. I believe that the new medication will help if that is
something you are willing to try.”
• “You are the only one who can decide what, if anything, you want to do; and as your
provider, ______ is the number one thing you could do to improve your health.
Talking About Change
• If a person talks about her desire, reason, ability, and need to change, she is more likely
to change. If she is given the chance to say out loud what she intends to do, she is more likely to
do it.

10. • Ask directly for a response.
o What concerns do you have about _____?
o What do you think will work best for you? Why?
o Where would you like to start?
o Is this what you are going to do?
Discharge planning
Recognition of escalating symptoms and concrete plan for response to particular symptoms.
The patient/caregiver(s) should be able to identify specic
signs and symptoms of heart failure, and explain actions
to take when symptoms occur. Actions may include a -exible
diuretic regimen or -uid restriction for volume overload.
Example of signs and symptom include:
• Shortness of breath (dyspnea)
• Persistent coughing or wheezing
• Buildup of excess -uid in body tissues (edema)
• Tiredness, fatigue, decrease in exercise and activity
• Lack of appetite, nausea
• Increased heart rate
Activity/exercise recommendations. In order to reduce
chances of readmissions, and to improve ambulatory status,
it is important for the patient to follow specic exercise
recommendations provided by the patient educator.
Instructions should include how to carry out the activity/
exercise, how long to carry out the activity/exercise, expected
physiological changes with exercise (moderate increase in
heart rate, breathing effort and diaphoresis), type and length
of time completing warm-up exercises and type and length
of time completing cool-down exercises.
Indications, use, and need for adherence with each
medication prescribed at discharge. Patients require
guidance on how to institute an individualized system
for medication adherence. Nonadherence with heart failure
medications can rapidly and profoundly adversely affect the
clinical status of patients. During the patient education period,
it is important for the educator to reiterate medication name,
dosing schedule, basic reason for specic medications,
expected side effects, and what to do if a dose is missed.
Importance of daily weight monitoring.
Sudden weight gain or weight loss can be a sign of heart
failure or worsening of condition.

11. Modify risks for heart failure progression. Below are
some of the modiable risk factors to discuss, as needed,
prior to patient discharge:
• Smoking cessation: If the patient is a smoker, then the
educator should provide counseling on the importance of
smoking cessation. A smoking cessation intervention may
include smoking cessation counseling (eg, verbal advice
to quit, referral to smoking cessation program or counselor)
and/or pharmacological therapy).
• Maintain specific body weight that promotes a “normal” body
mass index.
Specific diet recommendations: individualized
low-sodium diet; recommendation for alcohol intake.
 Sodium Restriction: Patient/caregiver(s) should be able to
understand and comply with sodium restriction
 Alcohol: Patients/Caregiver(s) should be able to understand
the limits for alcohol consumption or need for abstinence
if history of alcoholic cardiomyopathy.
Follow-up Appointments: Patients/Caregiver(s) should
understand the rationale of the follow-up appointment in
improving the patient’s quality of life and reducing readmission
even if the patient feels fine.