nursing case study chf

Want to create or adapt books like this? Learn more about how Pressbooks supports open publishing practices.

This case study involves a 76 year old female named Mary Lou Poppins, who presented to the ED accompanied by her son. She called her son after having symptoms of shortness of breath and confusion. Her past medical history includes hypertension, hyperlipidemia, coronary artery disease, and she was an everyday smoker for 30 years. She reports her home medications are lisinopril, simvastatin, and baby aspirin. Her current lifestyle includes: being a widow of six years, she lives alone, she walks her dog everyday, she drives to her knitting group three days a week, she makes dinner for her grandchildren once a week, she attempts to eat healthy but admits to consuming salty and high fat foods, and she insists on being very independent.

Mary Lou Poppins initial vitals in the emergency department includes a blood pressure of 138/70, heart rate of 108. respiratory rate of 26, temperature 98.9 degrees fahrenheit, and oxygen saturation of 84%. Her initial assessment included alert and oriented to person and place, dyspnea, inspiratory crackles in bilateral lungs, and a cough with pink frothy sputum. Her labs and diagnostics resulted in a BNP of 740 pg/ml, an echocardiogram showing an ejection fraction of 35%, an ECG that read sinus tachycardia, and a chest x-ray that confirmed pulmonary edema.

The Emergency Department physician diagnosed Mary Lou Poppins with left-sided heart failure. The orders included: supplemental oxygen titrated to keep saturation >93%, furosemide IV, enoxaparin subq, and metoprolol PO. Nursing Interventions included: monitoring oxygen saturation, adjusting oxygen route and dosage according to orders, assessing mentation and confusion, obtaining IV access, reassessing vitals, administering medications, and keeping the head of the bed elevated greater than 45 degrees. She was admitted to the telemetry unit for further stabilization, fluid balance monitoring, and oxygen monitoring.

On day one of hospital admission, Mary Lou Poppins required 4L of oxygen via nasal cannula in order to maintain the goal saturation of >93%. Upon assessment, it was determined that she was oriented to person and place. Auscultation of the lungs revealed bilateral crackles throughout, requiring collaboration with respiratory therapy once in the morning, and once in the afternoon. Physical therapy worked with the patient, but she was only able to ambulate for 100 feet. During ambulation, the patient had a decrease of oxygen saturation and dyspnea, requiring her oxygen to be increased to 6L. At the end of the day, strict intake and output monitoring showed an intake of 1200 mL of fluids, with an urinary output of 2L.

On day two of admission, Mary Lou began demonstrating signs of improvement. She only required 2 L of oxygen via nasal cannula with diminished crackles heard upon auscultation. Morning weight showed a weight loss of 1.3 lbs and the patient was oriented to person, place, and sequence of events. During physical therapy, she was able to ambulate 300 feet without required increased oxygen support. Daily fluid intake was 1400 mL with a urinary output of 1900 mL.

On the third and final day of admission, Mary Lou was AOx4 and did not require any type of oxygen support. When physical therapy arrived, the patient was able to ambulate 500 feet, which was close to her pre-hospital status. When the doctor arrived, the patient informed him that she felt so much better and felt confident going home. The doctor placed orders for discharge.

Upon discharge and throughout the patient’s hospital stay, Mary Lou Poppins was educated regarding the disease process of heart failure; symptoms to monitor for and report to her doctor; the importance of daily monitoring of weight, blood pressure, and heart rate; and the importance of adhering to a diet and exercise regime. Education was also provided regarding her medications and the importance of strictly adhering to them in order to prevent exacerbations of heart failure. Smoking cessation was also included in her plan of care. The patient received an informational packet regarding her treatment plan, symptoms to monitor for, and when to call her physician. Upon discharge, the patient was instructed to schedule a follow up appointment with her cardiologist for continued management of her care.

The patient was put in contact with a home health agency to help manage her care. The home health nurse will help to reinforce the information provided to the patient, assess the patient’s home and modify it to meet her physical limitations, and help to create a plan to meet daily dietary and exercise requirements. Regular follow-up appointments were stressed to Mary Lou Poppins in order to assess the progression of her disease. It will be important to monitor her lab values to also assess her disease progression and for any potential side effects associated with her medications. Repeat echocardiograms will be necessary to monitor her ejection fraction; if it does not improve with the treatment plan, an implanted cardiac defibrillator may be necessary to prevent cardiac death.

Open-Ended Questions

• What were the clinical manifestations that Mary Lou Poppins presented with in the ED that suggested the new onset of CHF?
• What factors most likely contributed to the onset of CHF?
• What patient education should Mary Lou Poppins receive on discharge in regards to managing her CHF?

Nursing Case Studies by and for Student Nurses Copyright © by jaimehannans is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

Share This Book

Fastest Nurse Insight Engine

• MEDICAL ASSISSTANT
• Abdominal Key
• Anesthesia Key
• Basicmedical Key
• Otolaryngology & Ophthalmology
• Musculoskeletal Key
• Obstetric, Gynecology and Pediatric
• Oncology & Hematology
• Plastic Surgery & Dermatology
• Clinical Dentistry
• Radiology Key
• Thoracic Key
• Veterinary Medicine
• Gold Membership

Case study of a patient with heart failure

13 Case study of a patient with heart failure Chapter aims • To provide you with an example of the nursing care that a patient with heart failure may require • To encourage you to research and deepen your knowledge of heart failure Introduction This chapter provides you with an example of the nursing care that a patient with heart failure may require. The heart failure care plan ( Fig. 13.1 ) has been written by a senior charge nurse for coronary care, Rafael Ripoll, and outlines care for the four stages of heart failure. The case history for Martha will then guide you through the assessment, nursing action and evaluation of a patient with heart failure. Fig 13.1 Heart failure care plan (Reproduced with permission of Rafael Ripoll) Activity A definition of heart failure was given in Chapter 1 and asked you to revise your anatomy and physiology (see Montague et al 2005 ). Before reading the case study, find out the following: 1. What are some of the symptoms of heart failure? 2. What health education could you provide for a patient with heart failure? You can find out the answers to these questions by following the link below. The British Heart Foundation provides free booklets to download: http://www.bhf.org.uk/heart-health/conditions/heart-failure.aspx (accessed July 2011). Patient profile Martha is a 60-year-old lady who is admitted to accident and emergency (A&E) with breathlessness – her respiratory rate is 40 per minute and her oxygen saturation is 89%. On admission, her pulse is 175 beats per minute (bpm) and irregular. Her blood pressure is 90/50 mmHg. Martha is put on high-flow oxygen, a continuous cardiac monitor, hourly observation of vital signs and an intravenous cannula is inserted. Martha is administered intravenous digoxin and furosemide in A&E and is catheterised to enable accurate fluid balance. Martha is married with three grown-up children and smokes 20 cigarettes a day. Martha is then transferred to a medical ward with a cardiac specialty. Assessment on admission Martha is breathless and on oxygen therapy 35% via the mask. She has peripheral oedema and is fluid overloaded. Furosemide is being administered intravenously. She is on stage 2 (see Fig. 13.1 ) of the heart failure care plan but is not receiving glyceryl trinitrate (GTN) due to hypotension. Martha is tachycardic and attached to a cardiac monitor which is showing atrial fibrillation between 110 and 115 bpm. Urinary output is greater than 70 mL/hour. Martha is very distressed but knows where she is and why. She is unable to eat or drink at the moment due to her breathlessness. She is a life-long smoker. She lives with her husband in a third-floor flat with a lift. She still works part time as a cleaner for a local company. Activity See Appendix 4 in Holland et al (2008) for possible questions to consider during the assessment stage of care planning. Many organisations will have a care plan pathway, and Figure 13.1 is an example of one by R. Ripoll (2005 unpublished). This is to ensure that the care of the patient is explicit and standardised. This does not mean that the care becomes less individualised. Martha’s problems Based on your assessment of Martha, the following problems should form the basis of your care plan: • Martha is breathless. • Martha is cardiovascularly unstable due to her condition. • Martha is frightened and distressed. • Martha has a urinary catheter. • Martha is unable to eat or drink adequately due to her condition. • Martha is a life-long smoker and cannot smoke in hospital. Martha’s nursing care plans 1. Problem: Martha is breathless. Goal: To restore normal breathing pattern. Nursing action Rationale Assess Martha’s breathing, respiratory rate and keep oxygen saturation > 95% Observe for signs of cyanosis Administer prescribed oxygen Inform the nurse in charge of any changes to Martha’s condition To observe for any signs of deterioration To ensure that Martha does not become hypoxic Oxygen is a drug and must be prescribed Encourage Martha to sit upright supported by pillows To maximise lung expansion and gaseous exchange To increase comfort Administer any medication as prescribed and ensure that Martha is fully informed about the medication and any side effects For example, explain to Martha why she needs to keep her oxygen mask on Martha is much more likely to comply with her medication if she understands why she needs to have it Refer Martha to the physiotherapist and liaise To maximise gaseous exchange To prevent complications from immobility To ensure consistent treatment from nurses and physiotherapists 2. Problem: Martha is cardiovascularly unstable due to her condition. Goal : To stabilise Martha. Nursing action Rationale Martha needs continuous cardiac monitoring of her condition until it has stabilised Ensure that alarm limits are set within appropriate limits Hourly observations of pulse and blood pressure Inform the nurse in charge and doctor regarding any changes in observations and discuss the frequency of observations required To detect any change in Martha’s condition as soon as possible To be able to respond to these changes and for the team to be informed To check blood urea and electolytes Abnormal potassium levels will increase the risk cardiovascular instability 3. Problem: Martha is frightened and distressed. Goal : To try to relieve Martha’s distress. Nursing action Rationale Spend time with Martha using verbal and non-verbal communication to reassure her Being alone will increase Martha’s distress Always introduce Martha to the nurse who is relieving you or taking over your shift If you need to go to another area, explain to Martha who will be looking after her Explain to Martha how the call bell system works and make sure that it is in easy reach Knowing who is looking after her will help Martha to relax Knowing where her nurse is is important as Martha will know that there is someone identified who is looking after her needs If Martha cannot see her nurse she will understand how to summon help Communicate with Martha’s family and significant others with her permisssion Family and friends may find the environment and equipment daunting Information will help them to understand about Martha’s condition Nurses should never presume that a patient wants her family to know about their condition and it is important to respect Martha’s wishes 4. Problem: Martha has a urinary catheter. Goal: To monitor fluid balance accurately and to prevent infection. Nursing action Rationale Explain to Martha why she requires urinary catheter.   Hourly measurements of urine: if below 30 mL/h or above 200 mL/h, report to the nurse in charge and liaise with the doctors when reducing the frequency of the urine output measurements Document urine output on a fluid balance chart To accurately monitor Martha’s fluid balance. Martha is at risk of fluid overload due to her cardiac condition Provide catheter care and hygiene Check the colour of the urine each shift Report any changes to the nurse in charge Provide privacy when providing catheter care To prevent infection To detect any signs of infection or trauma To ensure that Martha’s privacy and dignity needs are met Monitor temperature, pulse and blood pressure and respirations four times a day while Martha has an indwelling urinary catheter Take a catheter specimen of urine for microscopy, culture and sensitivity testing if Martha’s temperature is > 37.5°C and inform the nurse/doctor To detect any infection and treat as soon as possible 5. Problem: Martha is unable to eat or drink adequately due to her condition. Goal: For Martha to have adequate fluid and dietary intake. Nursing action Rationale Ensure a malnutrition risk assessment is undertaken in the first 24 hours (see Ch. 9 ) To determine Martha’s nutritional status Maintain strict food and fluid balance monitoring Martha may be on fluid restriction Inform Martha about this and provide her with rationale Inform the nurse in charge or doctor if Martha’s diet or fluid intake are below the normal limits Due to her cardiac failure, Martha is at risk of fluid overload To ensure that Martha receives adequate fluids and nutrition To prevent complications of dehydration To ensure that there is effective communication within the multidisciplinary team Ensure that nutritional supplements are explained to Martha and encourage her to drink them To keep Martha fully informed Monitor and document observations of her vital signs (see Ch. 7 ) To detect any deterioration/improvement Administer intravenous therapy as prescribed and ensure that a cannula care plan is in place for this (see Ch. 9 ) To reduce the risk of cannula-associated infection/complications Keep Martha informed of her condition To promote and enhance communication 6. Problem: Martha is a life-long smoker and cannot smoke in hospital. Goal: To help Martha deal with any cravings or withdrawal symptoms. Nursing action Rationale To discuss with Martha how she is feeling and discuss prescribing nicotine supplements with the medical team To prevent Martha from suffering from nicotine withdrawal symptoms Once Martha is feeling better, discuss how she feels about smoking after discharge and whether she would accept a referral to the cardiac rehabilitation/heart failure team or smoking cessation team Provide verbal and written information for Martha and her husband To provide health education and promotion to Martha and her family

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related posts:

• Medical placements
• Revision and future learning
• The end of the journey
• Medicines management

Stay updated, free articles. Join our Telegram channel

Comments are closed for this page.

Full access? Get Clinical Tree

Heart Failure

Learn about the nursing care management of patients with heart failure.

What is Heart Failure?

Heart failure, also known as congestive heart failure, is recognized as a clinical syndrome characterized by signs and symptoms of fluid overload or of inadequate tissue perfusion .

• Heart failure is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients.
• The term heart failure indicates myocardial disease in which there is a problem with contraction of the heart (systolic dysfunction) or filling of the heart (diastolic dysfunction) that may or may not cause pulmonary or systemic congestion.
• Heart failure is most often a progressive, life-long condition that is managed with lifestyle changes and medications to prevent episodes of acute decompensated heart failure.

Classification

Heart failure is classified into two types: left-sided heart failure and right-sided heart failure.

Left-Sided Heart Failure

• Left-sided heart failure or left ventricular failure have different manifestations with right-sided heart failure.
• Pulmonary congestion occurs when the left ventricle cannot effectively pump blood out of the ventricle into the aorta and the systemic circulation.
• Pulmonary venous blood volume and pressure increase, forcing fluid from the pulmonary capillaries into the pulmonary tissues and alveoli, causing pulmonary interstitial edema and impaired gas exchange .

Right-Sided Heart Failure

• When the right ventricle fails, congestion in the peripheral tissues and the viscera predominates.
• The right side of the heart cannot eject blood and cannot accommodate all the blood that normally returns to it from the venous circulation.
• Increased venous pressure leads to JVD and increased capillary hydrostatic pressure throughout the venous system.

The American College of Cardiology and American Heart Association have classifications of heart failure.

• Stage A. Patients at high risk for developing left ventricular dysfunction but without structural heart disease or symptoms of heart failure.
• Stage B. Patients with left ventricular dysfunction or structural heart disease that has not developed symptoms of heart failure.
• Stage C. Patients with left ventricular dysfunction or structural heart disease with current or prior symptoms of heart failure.
• Stage D. Patients with refractory end-stage heart failure requiring specialized interventions.

Pathophysiology

Heart failure results from a variety of cardiovascular conditions, including chronic hypertension , coronary artery disease , and valvular disease.

• As HF develops, the body activates neurohormonal compensatory mechanisms.
• Systolic HF results in decreased blood volume being ejected from the ventricle.
• The sympathetic nervous system is then stimulated to release epinephrine and norepinephrine.
• Decrease in renal perfusion causes renin release, and then promotes the formation of angiotensin I .
• Angiotensin I is converted to  angiotensin II by ACE which constricts the blood vessels and stimulates aldosterone release that causes sodium and fluid retention.
• There is a reduction in the contractility of the muscle fibers of the heart as the workload increases.
• Compensation . The heart compensates for the increased workload by increasing the thickness of the heart muscle.

Just like coronary artery disease, the incidence of HF increases with age.

• More than 5 million people in the United States have HF.
• There are 550, 000 cases of HF diagnosed each year according to the American Heart Association.
• HF is most common among people older than 75 years of age .
• HF is now considered epidemic in the United States.
• HF is the most common reason for hospitalization of people older than 65 years of age.
• It is also the second most common reason for visits to the physician’s office.
• The estimated economic burden caused by HF is more than $33 billion annually in direct and indirect costs and is still expected to increase.

Heart failure can affect both women and men, although the mortality is higher among women.

• There are also racial differences; at all ages death rates are higher in African American than in non-Hispanic whites.
• Heart failure is primarily a disease of older adults, affecting 6% to 10% of those older than 65.
• It is also the leading cause of hospitalization in older people .

Systemic diseases are usually one of the most common causes of heart failure.

• Coronary artery disease . Atherosclerosis of the coronary arteries is the primary cause of HF, and coronary artery disease is found in more than 60% of the patients with HF.
• Ischemia . Ischemia deprives heart cells of oxygen and leads to acidosis from the accumulation of lactic acid.
• Cardiomyopathy . HF due to cardiomyopathy is usually chronic and progressive.
• Systemic or pulmonary hypertension . Increase in afterload results from hypertension, which increases the workload of the heart and leads to hypertrophy of myocardial muscle fibers.
• Valvular heart disease . Blood has increasing difficulty moving forward, increasing pressure within the heart and increasing cardiac workload.

Clinical Manifestations

The clinical manifestations produced y the different types of HF are similar and therefore do not assist in differentiating the types of HF. The signs and symptoms can be related to the ventricle affected.

Left-sided HF

• Dyspnea or shortness of breath may be precipitated by minimal to moderate activity.
• Cough . The cough associated with left ventricular failure is initially dry and nonproductive .
• Pulmonary crackles . Bibasilar crackles are detected earlier and as it worsens, crackles can be auscultated across all lung fields.
• Low oxygen saturation levels . Oxygen saturation may decrease because of increased pulmonary pressures.

Right-sided HF

• Enlargement of the liver result from venous engorgement of the liver.
• Accumulation of fluid in the peritoneal cavity may increase pressure on the stomach and intestines and cause gastrointestinal distress.
• Loss of appetite results from venous engorgement and venous stasis within the abdominal organs.

Prevention of heart failure mainly lies in lifestyle management.

• Healthy diet. Avoiding intake of fatty and salty foods greatly improves the cardiovascular health of an individual.
• Engaging in cardiovascular exercises thrice a week could keep the cardiovascular system up and running smoothly.
• Smoking cessation . Nicotine causes vasoconstriction that increases the pressure along the vessels.

Complications

Many potential problems associated with HF therapy relate to the use of diuretics .

• Hypokalemia . Excessive and repeated dieresis can lead to hypokalemia .
• Hyperkalemia . Hyperkalemia may occur with the use of ACE inhibitors , ARBs, or spironolactone.
• Prolonged diuretic therapy might lead to hyponatremia and result in disorientation , fatigue, apprehension, weakness , and muscle cramps.
• Dehydration and hypotension . Volume depletion from excessive fluid loss may lead to dehydration and hypotension .

Assessment and Diagnostic Findings

HF may go undetected until the patient presents with signs and symptoms of pulmonary and peripheral edema.

• ECG : May show hypertrophy, axis deviation, ischemia, and damage patterns. Dysrhythmias and ST-T segment abnormalities may be present.
• Chest x-ray : May show enlarged cardiac shadow or abnormal contour indicating ventricular aneurysm .
• Sonograms (echocardiography, Doppler, and transesophageal echocardiography): May reveal chamber dimensions, valvular function/structure, and ventricular dilation and dysfunction.
• Heart scan (MUGA): Measures cardiac volume, ejection fraction, and wall motion.
• Exercise or pharmacological stress myocardial perfusion: Determines presence of myocardial ischemia and wall motion abnormalities.
• PET scan: Sensitive test for evaluating myocardial ischemia and viability.
• Cardiac catheterization : Assesses pressures, differentiates right- versus left-sided heart failure, and evaluates coronary artery patency.
• Liver enzymes: Elevated in liver congestion/failure.
• Digoxin and other cardiac drug levels: Determines therapeutic range.
• Bleeding and clotting times: Identifies clotting risks and therapeutic range.
• Electrolytes : May be altered due to fluid shifts, renal function, or diuretic therapy.
• Pulse oximetry: Measures oxygen saturation, especially in conjunction with COPD or chronic HF.
• Arterial blood gases ( ABGs ): Reflects respiratory and acid-base status.
• BUN/creatinine: Evaluates renal perfusion and function.
• Serum albumin/transferrin: Indicates protein intake and liver function.
• Complete blood count (CBC): Assesses for anemia , polycythemia, and dilutional changes.
• ESR: Evaluates acute inflammatory reaction.
• Thyroid studies: Determines thyroid activity as a potential precipitator of HF.

Medical Management

The overall goals of management of HF are to relieve patient symptoms, to improve functional status and quality of life, and to extend survival.

Pharmacologic Therapy

• ACE Inhibitors . ACE inhibitors slow the progression of HF, improve exercise tolerance, decrease the number of hospitalizations for HF, and promote vasodilation and diuresis by decreasing afterload and preload .
• Angiotensin II Receptor Blockers . ARBs block the conversion of angiotensin I at the angiotensin II receptor and cause decreased blood pressure, decreased systemic vascular resistance, and improved cardiac output.
• Beta Blockers . Beta blockers reduce the adverse effects from the constant stimulation of the sympathetic nervous system.
• Diuretics . Diuretics are prescribed to remove excess extracellular fluid by increasing the rate of urine produced in patients with signs and symptoms of fluid overload.
• Calcium Channel Blockers . CCBs cause vasodilation , reducing systemic vascular resistance but contraindicated in patients with systolic HF.

Nutritional Therapy

• Sodium restriction . A low sodium diet of 2 to 3g/day reduces fluid retention and the symptoms of peripheral and pulmonary congestion, and decrease the amount of circulating blood volume, which decreases myocardial work.
• Patient compliance . Patient compliance is important because dietary indiscretions may result in severe exacerbations of HF requiring hospitalizations.

Additional Therapy

• Supplemental Oxygen . The need for supplemental oxygen is based on the degree of pulmonary congestion and resulting hypoxia.
• Cardiac Resynchronization Therapy. CRT involves the use of a biventricular pacemaker to treat electrical conduction defects.
• Ultrafiltration . Ultrafiltration is an alternative intervention for patients with severe fluid overload.
• Cardiac Transplant . For some patients with end-stage heart failure, cardiac transplant is the only option for long term survival.

Nursing Management

Despite advances in the treatment of HF, morbidity and mortality remains high. Nurses have a major impact on outcomes for patients with HF.

For a more comprehensive nursing care management, please visit 18 Heart Failure Nursing Care Plans

Practice Quiz: Heart Failure

Let’s test what you’ve learned from this study guide with this 5-item quiz for heart failure.

1. The most frequent cause of hospitalization for people older than 75 years old is:

A. Angina pectoris B. Heart failure C. Hypertension D. Pulmonary edema

2. The primary cause of heart failure is:

A. Arterial hypertension B. Coronary atherosclerosis C. Myocardial dysfunction D. Valvular dysfunction

3. The dominant function in cardiac failure is:

A. Ascites B. Hepatomegaly C. Inadequate tissue perfusion D. Nocturia

4. On assessment , the nurse knows that a patient who reports no symptoms of heart failure at rest but is symptomatic with increased physical activity would have a heart failure classification of:

A. Stage I B. Stage II C. Stage III D. Stage IV

5. The diagnosis of heart failure is usually confirmed by:

A. Chest x-ray B. Echocardiogram C. Electrocardiogram D. Ventriculogram

Answers and Rationale

1. Answer: B. Heart failure

• B: Heart failure is the most frequent cause of hospitalization for people older than 75 years old.
• A: Angina pectoris also occurs among people more than 75 years of age but it is not the most frequent cause of hospitalization.
• C: Hypertension also occurs among people more than 75 years of age but it is not the most frequent cause of hospitalization.
• D: Pulmonary edema also occurs among people more than 75 years of age but it is not the most frequent cause of hospitalization.

2. Answer: B. Coronary atherosclerosis

• B: Coronary atherosclerosis is the primary cause of heart failure.
• A: Arterial hypertension is not the primary cause of heart failure.
• C: Myocardial dysfunction is not a cause of heart failure.
• D: Valvular dysfunction is not the primary cause of heart failure.

3. Answer C. Inadequate tissue perfusion

• C: Inadequate tissue perfusion is the dominant function as low oxygenation occurs because of this.
• A: Ascites may occur in cardiac failure but is not considered as a dominant function.
• B: Hepatomegaly is present in heart failure but not a dominant function.
• D: Nocturia is not present in heart failure.

4. Answer: A. Stage I

• A: Stage I refer to a patient who reports no symptoms of heart failure at rest but becomes symptomatic with increased physical activity.
• B: Stage II refers to a patient who reports presence of symptoms with increased physical activities.
• C: Stage III refers to a patient who reports presence of symptoms with minimal physical activity.
• D: Stage IV refers to a patient who reports presence of symptoms even during at rest.  

5. Answer: B: Echocardiogram

• B: An echocardiogram is usually performed to confirm the diagnosis of HF, and identify the underlying cause.
• A: Chest x-ray findings are also basis of the diagnosis of HF, but it is not the confirmatory diagnostic test .
• C: ECG is obtained to assist in the diagnosis.
• D: Ventriculogram is not a part of the diagnostic tests for HF.

Posts related to Heart Failure:

• Myocardial Infarction and Heart Failure NCLEX Practice Quiz (70 Items)
• 16+ Heart Failure Nursing Care Plans
• 7 Myocardial Infarction (Heart Attack) Nursing Care Plans

5 thoughts on “Heart Failure”

Great work and keep it up to help nurses. Can you do an app for it on play store or IOS so that we can easily assess it anywhere at any time like medscape did

THANK YOU FOR YOUR WORK, IT HELP US AS NURSES TO BE UPDATED.

Great work keep it up sir. Almighty God blessing you in everything of life.

This is an excellent resource for nurses! However, I think nurses would benefit from an update in the medication section to include angiotensin receptor neprilysin inhibitors (ARNI: sacubitril/valsartan), mineralocorticoid receptor antagonists (MRAs: spironolactone, eplerenone), and sodium-glucose co-transporter-2 inhibitors (SGLT2I: dapagliflozin, empagliflozin). The 2022 AHA/ACC/HFSA Guidelines for Heart Failure Management recommends quadruple therapy (ARNI, BB, MRA, SGLT2I) up-titrated to target or maximally tolerated doses for patients diagnosed with heart failure with a reduced ejection fraction to reverse, stabilize, or slow disease progression. These medications are also used in patients with heart failure and preserved ejection fraction.

Hi Keysha, thank you for sharing this. I’ll add your suggestions and the 2022 AHA/ACC/HFSA Guidelines on our next update for this care plan.

Leave a Comment Cancel reply

3 Sample Nursing Care Plan for CHF [Congestive Heart Failure] (with rationales and case scenario)

Last updated on December 28th, 2023

Sample Nursing Care Plan for CHF [Congestive Heart Failure]

What is congestive heart failure.

Heart failure is a chronic, progressive condition. It occurs when the heart is unable to pump effectively and produce enough cardiac output to successfully perfuse the rest of the body’s tissues and organs. An individual can have right-sided or left-sided heart failure as well as systolic or diastolic heart failure.

Left-sided heart failure is also known as Congestive Heart Failure (CHF) . In CHF, the heart is either unable to contract completely or fill completely during relaxation. It can lead to an inadequate amount of blood pumping out of the heart. Thereby, backing up into the right side and then ultimately to the lungs and throughout the body causing congestion.

Systolic heart failure means the heart is not able to contract completely and affects its ability to pump blood out of the heart.

Diastolic heart failure means the heart is unable to relax fully between heartbeats and allows the appropriate amount of blood into the ventricle.

In this post, we’ll formulate a sample nursing care plan for a patient with Congestive Heart Failure (CHF) based on a hypothetical case scenario .

CHF Case Scenario

A 74-year old Hispanic male presents to the Emergency Department with complaints of increased dyspnea, reduced activity tolerance, ankle swelling, and weight gain in recent days. He has a known history of hypertension and heart failure. He reports over the past 3 days his shortness of breath, particularly with activity, has increased significantly.

He is also now using 3 pillows to sleep at night instead of his usual 1 pillow, and he has experienced a 10-pound weight gain in 3 days. He states he is now only able to ambulate 1 block before needing to stop and rest whereas in the past he could walk half a mile. 

The nurse notes dyspnea upon minimal excretion with position changes.  Upon physical assessment his breathing is shallow and labored, respiratory rate is 30 breaths per minute, heart rate 115 beats per minute, oxygen saturation 83% on room air, blood pressure 179/98 mm Hg, he has +4 pitting edema in bilateral lower extremities, and crackles are heard in his lung fields throughout.

The patient’s lab work reveals an elevated BNP level of 954pg/mL and a chest x-ray shows pulmonary congestion. The last echocardiogram in the patient’s chart (completed 3 months prior) showed an Ejection Fraction (EF) of 40%.

The patient is to be admitted to the hospital for Acute Exacerbation of Congestive Heart Failure (CHF) . 

Case Discussion

The main assessment findings the nurse should be aware of for this patient begin with his vital signs, all of which are listed are abnormal.

The patient has labored, tachypneic, breathing. He is also tachycardic and has a decreased oxygen saturation. This demonstrates to the nurse that the patient is not hemodynamically stable and the main goal is stabilizing the patient’s respiratory status. 

In addition, the nurse should also note the reported weight gain and visibly apparent edema. These assessment findings are able to help the nurse critically think and identify a potential list of differential diagnoses prior to lab and imaging results becoming available.

When assessing this patient, the nurse will want to remember ABCs (airway, breathing, circulation) of care.  The patient’s airway is protected and he is able to breathe on his own.

However, his breathing is compromised due to excessive fluid. Therefore, that becomes the priority for the patient and the nurse should begin by improving his oxygen saturation and breathing status.  

Once the patient’s breathing status is stabilized the next likely task will be to diuresis the patient.  In doing this, it will help to remove additional fluid thereby improving his oxygen and breathing capability further.

#1 Sample nursing care plan for CHF – Impaired gas exchange

Nursing assessment.

Subjective Data:

• Reported increased shortness of breath
• Using 3 pillows to sleep at night (increase from usual 1 pillow)
• Decreased activity level due to shortness of breath

Objective Data:

• Tachypneic, respiratory rate of 30 breaths/minute
• Crackles in lung fields
• Oxygen saturation 83% on room air
• Congestion on chest x-ray
• +4 pitting edema

Nursing Diagnosis [ Impaired gas exchange ]

Impaired gas exchange related to fluid overload as evidenced by labored, tachypneic breathing, decreased oxygen saturation, crackles in lung fields, pitting edema, congestion on chest x-ray.

Short-term goal

To increase oxygen saturation ≥92% prior to transfer from ED and admission to hospital floor unit

Nursing Interventions with Rationales

Long-term goal

To decrease excess fluid by 10 pounds by discharge to return patient to baseline dry weight

Expected Outcome

• This will reduce hypoxemia resulting in improved oxygen saturation and reduce dyspnea.
• Excess fluid will be removed and the patient’s weight will return to baseline.
• Reduced congestion will improve gas exchange.

#2 Sample nursing care plan for CHF – Decreased cardiac output

• Needs 3 pillows at night to sleep
• 10-pound weight gain
• Ankle swelling
• Tachycardia
• Hypertension
• Crackles in lung fields throughout
• Ejection fraction (EF) 40%
• Elevated BNP 954pg/mL
• Congestion seen on chest x-ray

Nursing Diagnosis [ Decreased cardiac output ]

Decreased cardiac output related to altered contractility as evidenced by tachycardia, hypertension, orthopnea, edema, abnormal lab work, and reduced EF.

To stabilize vital signs and maintain adequate oxygen saturation prior to transfer from ED to the hospital unit.

To improve cardiac contractility by discharge

• Maintain oxygen saturation above 92%
• Decrease in blood pressure to patient’s baseline (ideally <120/80)
• Improved contractility by decreasing excess fluid, improvement in breathing status, and stabilization of vital signs

#3 Sample nursing care plan for CHF – Decreased activity tolerance

• Only able to ambulate 1 block
• Reduced activity level
• Dyspnea on minimal exertion
• Tacypnea (RR 30 bpm)
• Tachycardia (PR 115 bpm)
• Decreased oxygen saturation (83% at room air)

Nursing Diagnosis [ Decreased activity tolerance ]

Decreased activity tolerance related to imbalance between oxygen supply and demand as evidenced by dyspnea, tachypnea, tachycardia, decreased oxygen saturation, and fatigue.

To limit activity to decrease oxygen demand while also increasing oxygen supply

To increase activity level to patient’s baseline prior to discharge.

• Improved oxygenation status (≥92%)
• Patient’s activity level will return to baseline

It is vital to monitor patients admitted with congestive heart failure closely.  In particular, detailed and accurate intake and output records should be kept to show the progress and success of treatments being administered.

This will also help to determine if additional medications are warranted or dosage adjustments need to be made.

Close monitoring of types of food and drinks is also important. Because some food may cause patient to retain more fluid than others. Providing proper patient education is key for these patients to support them in understanding their condition and diagnosis.  

Likewise, education will help the patient to be aware of specific things to avoid at home in terms of food or drink and why these should be avoided.

Click here to see a full list of Nursing Diagnoses related to Congestive Heart Failure (CHF).

Congestive heart failure is a chronic condition that can progress over time. Acute exacerbations of this chronic condition can also be very common especially if an individual is not following or is unaware of the appropriate guidelines and recommendations.

It is important for nurses to understand the various symptoms a patient may present with when experiencing an acute exacerbation. It is also imperative that the nurse assesses the individual’s airway and breathing status immediately and prioritizes this above any other nursing intervention. 

Lastly, providing thorough patient education both verbally and in writing is essential for these individuals to help them understand their diagnosis and what measures they can take at home to prevent additional exacerbations.

Ackley, B.J., Ladwig, G.B., Flynn-Makic, M.B., Martinez-Kratz, M.R., & Zanotti, M. (2020). Nursing Diagnosis Handbook: An Evidence-based Guide to Planning Care [eBook edition]. Elsevier.

Comer, S. and Sagel, B. (1998). CRITICAL CARE NURSING CARE PLANS . Skidmore-Roth Publications.

Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing Care Plan: Guidelines for Individualizing Client Care Across the Lifespan [eBook edition]. F.A. Davis Company.

Herdman, T., Kamitsuru, S. & Lopes, C. (2021). NURSING DIAGNOSES: Definitions and Classifications 2021-2023 (12th ed.). Thieme.

Comments are closed.

Medical & Legal Disclaimer

All the contents on this site are for entertainment, informational, educational, and example purposes ONLY. These contents are not intended to be used as a substitute for professional medical advice or practice guidelines. However, we aim to publish precise and current information. By using any content on this website, you agree never to hold us legally liable for damages, harm, loss, or misinformation. Read the  privacy policy  and  terms and conditions.

Privacy Policy

Terms & Conditions

© 2024 nurseship.com. All rights reserved.

• Previous Article
• Next Article
• Background of CHF
• Sophie’s Story
• Patient Characteristics
• Nurse Competencies

AACN Synergy Model for Patient Care : Case Study of a CHF Patient

• Article contents
• Figures & tables
• Supplementary Data
• Peer Review
• Cite Icon Cite
• Get Permissions

Sonya Hardin , Leslie Hussey; AACN Synergy Model for Patient Care : Case Study of a CHF Patient . Crit Care Nurse 1 February 2003; 23 (1): 73–76. doi: https://doi.org/10.4037/ccn2003.23.1.73

Download citation file:

• Ris (Zotero)
• Reference Manager

The AACN Synergy Model for Patient Care describes a framework for nursing practice. The key to this model is the linkage of patient characteristics with nurse competencies to achieve optimal patient outcomes. 1 The Synergy Model is readily adaptable to the acute care or critical care setting when the patient is critically ill and the intensive care nurse links his or her own competencies to the patient’s characteristics. However, not all acute care is conducted within the walls of the hospital setting. Today’s healthcare environment mandates that patients with serious diseases live in their homes, causing the need for acute and critical care settings to reach out to their patients not only to assist them in maintaining a quality of life but also to decrease costs of hospital readmissions. This situation is especially true for patients with chronic heart failure (CHF). In the United States, many patients with CHF regularly...

AACN Account

Sign in via your institution, short-term access, email alerts, affiliations.

• About Critical Care Nurse
• CE Articles
• Individual Subscriptions
• Institutional Subscriptions
• Sign up for Alerts
• Submit an Article
• Online ISSN 1940-8250
• Print ISSN 0279-5442
• AACN Advanced Critical Care (ACC)
• American Journal of Critical Care (AJCC)
• Critical Care Nurse (CCN)
• AACN Membership
• Privacy Policy
• Advertising
• Permissions
• Tel: (800) 899-1712
• Tel: (949) 362-2000
• Cookie Policy
• Terms & Conditions
• Get Adobe Acrobat Reader
• © Copyright 2024 American Association of Critical-Care Nurses

This Feature Is Available To Subscribers Only

Sign In or Create an Account

• © 2023

Managing Heart Failure in Primary Care: A Case Study Approach

• K. Melissa Smith Hayes   ORCID: https://orcid.org/0000-0001-8731-4325 0 ,
• Nicole R. Dellise 1

Assistant Professor, Vanderbilt University School of Nursing, Nashville, USA

You can also search for this editor in PubMed   Google Scholar

Director, Structural Heart Program, Director, Center for Advanced Heart Failure Therapy, Centennial Heart, Nashville, USA

Includes a comprehensive review of physical exam findings and common diagnostic testing used to diagnosis heart failure

Reviews best practice for transitioning the heart failure patient from hospital to home

Offers many didactical case studies

Provides a clear and concise overview of the management of heart failure for primary care clinicians

Offers “Practice Pearls” for the primary care provider treating heart failure

Discusses goals of care and end of life considerations for patients with heart failure

Addresses special heart failure considerations in the management and treatment of common diagnoses seen in primary care

Reflects current heart failure treatment guidelines outlined by AHA/HFSA

9048 Accesses

30 Altmetric

• Table of contents

About this book

Editors and affiliations, about the editors, bibliographic information.

• Publish with us

Buying options

• Available as EPUB and PDF
• Read on any device
• Instant download
• Own it forever
• Compact, lightweight edition
• Dispatched in 3 to 5 business days
• Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Other ways to access

This is a preview of subscription content, log in via an institution to check for access.

Table of contents (19 chapters)

Front matter, pathophysiology of heart failure, heart failure across the population, comprehensive heart failure history.

• Leah A. Carr, Lisa D. Rathman, Roy S. Small

Physical Exam for Presence and Severity of Heart Failure

• Jessica B. Williams, Donna Harmon, JoAnn Lindenfeld

The Cardiology Referral for Heart Failure: Work-up and Expectations

• Kaushik Amancherla, Lisa Mendes

Heart Failure with Reduced Ejection Fraction

• Terri L. Allison, Beth Towery Davidson

Heart Failure with Preserved Ejection Fraction

• Anupam A. Kumar, Deepak K. Gupta

Transitions of Care and Self-Care Strategies for the Heart Failure Patient

• Kelly D. Stamp, Marilyn A. Prasun

Goals of Care for the Heart Failure Patient

• Christine M. Hallman, Krista R. Dobbie

Atrial Fibrillation and Heart Failure

• Tara U. Mudd

Cardiorenal Syndrome, Chronic Kidney Disease, Anemia, and Heart Failure

• Michelle Mason Parker, Mark Wigger

Diabetes and Heart Failure

• Angelina Anthamatten

Chronic Obstructive Pulmonary Disease, Obstructive Sleep Apnea, and Heart Failure

• J. Travis Dunlap, Melissa Glassford, Leslie W. Hopkins

Pulmonary Hypertension in Heart Failure

• Douglas J. Pearce

Liver Disease and Heart Failure

• Mary Lauren Pfieffer, Julie Hannah
• Heart failure
• Ejection Fraction
• Co-morbidity
• End of life
• Transitional care
• Diagnostics
• Case studies

K. Melissa Smith Hayes

Nicole R. Dellise

Book Title : Managing Heart Failure in Primary Care: A Case Study Approach

Editors : K. Melissa Smith Hayes, Nicole R. Dellise

DOI : https://doi.org/10.1007/978-3-031-20193-6

Publisher : Springer Cham

eBook Packages : Medicine , Medicine (R0)

Copyright Information : The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023

Softcover ISBN : 978-3-031-20192-9 Published: 30 March 2023

eBook ISBN : 978-3-031-20193-6 Published: 29 March 2023

Edition Number : 1

Number of Pages : XIX, 328

Number of Illustrations : 10 b/w illustrations, 10 illustrations in colour

Topics : Nursing , Cardiology , Pharmacology/Toxicology

Policies and ethics

• Find a journal
• Track your research

NurseStudy.Net

Nursing Education Site

Congestive Heart Failure (CHF) Nursing Diagnosis and Care Plan

Last updated on February 20th, 2023 at 08:45 am

CHF can affect either both sides of the heart or just one side. The three types of CHF are biventricular, left-sided, and right-sided heart failure. In left-sided heart failure, the left ventricle becomes enlarged (hypertrophy) and becomes dilated together with the left atrium in order to compensate for the increased pressure.

Right-sided heart failure usually happens after left-sided heart failure. Pooling of blood in the left heart chambers causes an increase in pressure, impairing the normal blood drainage from the lungs to the left atrium.

The pressure in the pulmonary veins increases, causing the right ventricle to compensate by pumping more vigorously.

In time, the cardiac muscles of the right chambers wear down, causing right-sided heart failure. Failure of both sides of the heart is called biventricular heart failure.

Congestion is one of the common features of heart failure, thus the term “congestive heart failure” is still used by many medical professionals.

Signs and Symptoms of Heart Failure

• Dyspnea ( shortness of breath ) upon exertion or lying down
• Jugular vein distention (JVD)
• Fatigue and reduced ability to exercise
• Peripheral edema (swelling of limbs, ankles, and feet)
• Pulmonary edema
• Ascites (swelling of the abdominal cavity)
• Irregular and/or rapid heartbeat
• Cough and wheezing – may come with white or blood-tinged sputum
• Nausea and lack of appetite
• Decreased level of alertness and concentration
• Increased urinary frequency at night
• Chest pain if the HF is caused by myocardial infarction (heart attack)

Causes of Heart Failure

• Myocardial Infarction (heart attack) and Coronary Artery Disease (CAD). These are the most common causes of heart failure. Fat buildup on the arterial walls leads to the reduction of blood flow, resulting to cardiac arrest.
• Hypertension . Having a high blood pressure causes the heart to work harder than normal in order to facilitate the blood circulation throughout the body. This makes the cardiac muscles stiffer and/or weaker, leading to heart failure.
• Alcohol, tobacco, and drug abuse. The toxic effects of alcohol, nicotine, and drugs (e.g. cocaine) may lead to the damage of the cardiac muscles known as cardiomyopathy .
• Congenital heart defects. Faulty heart chambers or valves at birth can directly affect the functionality of the heart.
• Other heart conditions. Viral infections such as COVID-19 may cause inflammation of the cardiac muscles known as myocarditis .
• Chronic diseases. HIV , diabetes , arrythmias, and thyroid problems may lead to heart failure.
• Certain medications. Non-steroidal inflammatory drugs (NSAIDS) , several anaesthesia drugs, chemotherapy agents, and some antihypertensives puts a person at a higher risk for heart problems which may eventually lead to heart failure.

Complications of Heart Failure

• Kidney damage. A reduction of blood flow from the heart to the kidneys may result to reduce capacity of the kidneys to remove toxic waste. If left untreated, this may lead to kidney failure which may require the patient to undergo dialysis .
• Liver damage. Fluid build up may result to an increased pressure to the liver . If left untreated, this may result to liver damage known as scarring.
• Other cardiac issues. Heart failure may result to faulty heart valves and arrythmias if there is an increased pressure in the heart or enlargement of the heart.

Diagnostic Tests for Heart Failure

• Physical examination – crackles heard upon auscultation, signs of edema upon inspection
• Blood tests – CBC, biochemistry, N-terminal pro-B-type natriuretic peptide (NT-proBNP)
• Imaging – Chest X-Ray, Echocardiogram, CT scan, MRI, coronary angiogram (insertion of a catheter and injecting a dye for visualization)
• Electrocardiogram
• Stress test – letting the patient walk on a treadmill while attached to an ECG machine
• Myocardial biopsy – insertion of a biopsy cord in a vein in the neck or groin to take heart muscle tissue samples

Treatment for Heart Failure

• Medications. Several medications are used in combination to treat heart failure. These include:
• Angiotensin-converting enzyme ( ACE ) inhibitors – promotes vasodilation of the blood vessels, lowering the pressure and improving the blood flow (e.g. lisinopril and enalapril).
• Beta blockers – reduces heart rate and blood pressure (e.g. bisoprolol and carvedilol).
• Angiotensin II receptor blockers – similar to ACE inhibitors and can be used if the patient does not tolerate ACE inhibitors (e.g. losartan and valsartan).
• Digitalis or digoxin – improves the contraction of heart muscles, regulate heart rhythm and reduces heartbeat.
• Inotropes – to improve the function of the heart to pump blood in severe heart failure.
• Diuretics – to facilitate elimination of excess fluid in the body through urination (e.g. furosemide and spironolactone).
• Inotropes. These are intravenous medications used in people with severe heart failure in the hospital to improve heart pumping function and maintain blood pressure.

2. Surgical interventions. These include coronary bypass surgery, heart valve repair or replacement, and heart transplant. It may also involve the insertion of medical devices such as implantable cardioverter-defibrillators (ICDs), cardiac resynchronization therapy (CRT), and ventricular assist devices (VADs).

3. Lifestyle changes. A crucial part of the treatment plan for a patient with heart failure is to change several habits that are linked to the disease. These include smoking cessation, blood pressure control, diabetes management, dietary changes, stress management, exercise and increase in physical activity.

CHF Nursing Diagnosis

Chf nursing care plan 1.

Nursing Diagnosis: Decreased Cardiac Output related to increased preload and afterload and impaired contractility as evidenced by irregular heartbeat, heart rate of 128, dyspnea upon exertion, and fatigue.

Desired outcome: The patient will be able to maintain adequate cardiac output.

CHF Nursing Care Plan 2

Nursing Diagnosis: Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures as evidenced by shortness of breath, SpO2 level of 85%, and crackles upon auscultation.

Desired Outcome: The patient will have improved oxygenation and will not show any signs of respiratory distress.

CHF Nursing Care Plan 3

Nursing Diagnosis: Deficient Knowledge related to new diagnosis of Congestive Heart Failure as evidenced by patient’s verbalization of “I want to know more about my new diagnosis and care”

Desired Outcome: At the end of the health teaching session, the patient will be able to demonstrate sufficient knowledge of congestive heart failure and its management.

CHF Nursing Care Plan 4

Nursing Diagnosis: Activity intolerance related to imbalance between oxygen supply and demand as evidenced by fatigue, overwhelming lack of energy, verbalization of tiredness, generalized weakness, and shortness of breath upon exertion

Desired Outcome: The patient will demonstration active participation in necessary and desired activities and demonstrate increase in activity levels.

CHF Nursing Care Plan 5

Nursing Diagnosis: Excess Fluid Volume related to decreased cardiac output and increased glomerular filtration rate (GFR) as evidenced by S3 heart sound, blood pressure level of 190/85, orthopnea, pitting edema of the ankles, and weight gain

Desired Outcome: The patient will demonstrate a balanced input and output, and stabilized fluid volume

CHF Nursing Care Plan 6

Nursing Diagnosis: Acute Pain related to decreased myocardial blood flow as evidenced by  pain score of 10 out of 10, verbalization of pressure-like/ squeezing chest pain (angina), guarding sign on the chest, blood pressure level of 180/90, respiratory rate of 29 cpm, and restlessness

Desired Outcome: The patient will demonstrate relief of pain as evidenced by a pain score of 0 out of 10, stable vital signs, and absence of restlessness.

CHF Nursing Care Plan 7

Nursing Diagnosis: Ineffective Breathing Pattern related to pulmonary congestion secondary to CHF as evidenced by shortness of breath, SpO2 level of 85%, cough, respiratory rate of 25 bpm, and frothy sputum

Desired Outcome: The patient will achieve effective breathing pattern as evidenced by normal respiratory rate, oxygen saturation within target range, and verbalize ease of breathing.

With proper use of the nursing process, a patient can benefit from various nursing interventions to assess, monitor, and manage heart failure and promote client safety and wellbeing.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020).  Nursing diagnoses handbook: An evidence-based guide to planning care . St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022).  Nursing care plans: Diagnoses, interventions, & outcomes . St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018).  Medical-surgical nursing: Concepts for interprofessional collaborative care . St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020).  Saunders comprehensive review for the NCLEX-RN examination . St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

Leave a Comment Cancel reply

This site uses Akismet to reduce spam. Learn how your comment data is processed .

• school Campus Bookshelves
• menu_book Bookshelves
• perm_media Learning Objects
• login Login
• how_to_reg Request Instructor Account
• hub Instructor Commons
• Download Page (PDF)
• Download Full Book (PDF)
• Periodic Table
• Physics Constants
• Scientific Calculator
• Reference & Cite
• Tools expand_more
• Readability

selected template will load here

This action is not available.

5: Case Study #4- Heart Failure (HF)

• Last updated
• Save as PDF
• Page ID 9899
• 5.1: Learning Objectives
• 5.2: Patient- Meryl Smith
• 5.3: In the Supermarket
• 5.4: Emergency Room
• 5.5: Day 0- Medical Ward
• 5.6: Day 1- Medical Ward
• 5.7: Day 2- Medical Ward
• 5.8: Day 3- Medical Ward

Congestive Heart Failure (CHF) [NextGen]

Watch More! Unlock the full videos with a FREE trial

Included In This Lesson

Study tools.

Access More! View the full outline and transcript with a FREE trial

Pathophysiology: In heart failure, the heart does not pump effectively. This can occur because of many reasons but usually, because there has been damage to the heart tissue. The heart is not able to pump enough fluid forward so fluid then backs up. This fluid backup increases work on the heart as it tries to keep up and cannot.

The heart is a pump, circulates blood throughout the body. Heart failure = pump failure. Heart failure occurs when the heart cannot pump enough blood to supply the body’s needs.

Nursing Points

• Decreased perfusion forwards
• Increased congestion backwards
• Dead muscle can’t pump
• ↑ afterload = ↑ stress on heart muscle
• Blood not moving in right direction
• Inefficient pump
• BNP (Brain Natriuretic Peptide) – stretch of LV
• Ejection Fraction
• Can diagnose valve disorder
• Cardiomegaly
• Pulmonary Edema
• Exacerbations
• Arrhythmias
• Impaired Kidney Function
• ↓ oxygenation
• ↓ activity tolerance
• Peripheral Edema
• Weight Gain
• Liver / GI Congestion
• Skin pale or dusky
• ↓ Peripheral pulses
• Slow  capillary refill
• ↓ urine output
• Kidney Injury / Failure
• Pink/frothy sputum
• SOB on Exertion
• Anxiety/restlessness

Therapeutic Management

Goal is to decrease workload on heart while still increasing cardiac output. Discussed in more detail in Therapeutic Management Lesson

• Decrease Preload
• Decrease Afterload
• Increase Contractility

Patient Education

Discussed in more detail in Therapeutic Management Lesson

• Diet & Lifestyle Changes
• Medication Instructions
• Activity Restrictions
• Frequent Follow-Ups

View the FULL Outline

When you start a FREE trial you gain access to the full outline as well as:

• SIMCLEX (NCLEX Simulator)
• 6,500+ Practice NCLEX Questions
• 2,000+ HD Videos
• 300+ Nursing Cheatsheets

“Would suggest to all nursing students . . . Guaranteed to ease the stress!”

BNP Heart Failure Guidelines

Heart failure chest x-ray.

Clinical Signs of Heart Failure

Complications of Heart Failure

• The first is water retention because of aldosterone and ADH. The kidneys see a lack of flow and think they need to hold onto water! So it is increasing the preload (or stretch) on ventricles whose preload is already sky-high!
• The second is vasoconstriction . This is the body trying to pull blood towards the heart to increase the blood pressure - this increases afterload (the force the heart has to pump against) - in a patient whose heart is already struggling as it is!
• And the third is the RAAS activates the Sympathetic Nervous System - it’s basically telling the heart to work harder and faster - which it cannot do! The end result is MORE volume overload, MORE stress on the heart muscle, and a perpetuated cycle that never ends.

View the FULL Transcript

**nextgen practice and understanding.

Welcome to the NURSING.com NextGen Practice Course. This FREE course is designed to provide an understanding of the forthcoming new Nextgen question types and a chance to practice taking them. As you go through these lessons, take a practice quiz to experience what these new formats will look and feel like on the NCLEX, starting April 2023. You can do this!

NextGen Practice Lessons

• 10 Questions

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• v.29(6); 2022

Congestive heart failure clinics and telemedicine: The key to reducing hospital readmissions in the United States

Devyani ramgobin.

1 Touro College of Osteopathic Medicine, Middletown, New York, United States

Reshma Golarmari

2 Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States

3 Indiana University School of Medicine, Bloomington, Indiana, United States

The United States healthcare system currently faces an economic challenge related to frequent hospital readmission rates. As such, hospitals have begun implementing strategies to reduce readmission rates for specific medical conditions such as congestive heart failure, which had a 30-day readmission rate of 23.2% in 2014. Patient education and frequent monitoring of symptoms have since allowed patients to work together with doctors and nurses to take charge of their healthcare management. Due to heart failure clinics and the rise of telemedicine and telemonitoring, heart failure readmission rates have since decreased.

Introduction

Readmission is a major concern for the United States (US) healthcare system. Under the Affordable Care Act’s Hospital Readmission Reduction Program (HRRP), hospital systems are penalized monetarily if they have a higher than expected 30-day readmission for 6 conditions [ 1 ]. The Center for Medicare and Medicaid Services (CMS) can withhold anywhere from 1% to 3% of Medicare reimbursements for the readmissions of congestive heart failure (CHF), coronary artery bypass graft surgery, acute myocardial infarction, elective primary total hip/knee arthroplasty, pneumonia, and chronic obstructive pulmonary disease. Under the HRRP, CMS evaluated a total of 3129 hospitals for the fiscal year 2020, and 2583 (83%) of these hospitals will face penalties, which is estimated at $563 million dollars over the course of 1 year [ 2 ]. In a 2014 comparison of 7-day and 30-day readmissions by Fingal et al. [ 3 ], nearly 10% of Medicaid patients with a diagnosis of either CHF or schizophrenia were readmitted within 7 days of discharge. The top 5 diagnoses with the highest 30-day readmission rates (n = 27,698,101) were as follows: CHF (23.2%), schizophrenia (22.9%), respiratory failure (21.6%), alcohol-related disorders (21.5%), iron deficiency and other anemias (21.2%) ( Fig. 1 ) [ 3 ]. In the US, CHF affects 2–3% of the population, with a slightly higher prevalence in males (10%) compared to females (8%) [ 1 ]. Given that the CMS can withhold at least 1% of Medicare reimbursement for a diagnosis such as heart failure (HF), and the 30-day readmission rate for HF is 23.2%, the American healthcare system is becoming increasingly burdened with juggling between optimizing patient care and preventing readmissions.

Top diagnoses with the highest 30-day readmission rates out of 27,698,101 readmissions. Red bar: congestive heart failure (CHF) accounts for 23.2% of all readmissions within 30 days.

Pathophysiology of congestive heart failure

Congestive heart failure is an accumulation of myocardial injury that ultimately leads to counterproductive remodeling of the heart [ 4 ]. CHF results in reduced cardiac output, leading to compensatory effects by the body through neurohumoral activation and activation of the sympathetic nervous system ( Fig. 2 ). There are two types of HF that commonly present in patients: systolic and diastolic. Systolic heart failure is referred to as HF with reduced ejection fraction (HFrEF), which presents with lower-thannormal left ventricular ejection fraction on echocardiogram [ 5 ]. The myocardium is unable to contract adequately and, as a result, ejects less oxygen-rich blood into the body. Fatigue and shortness of breath are common symptoms. In diastolic HF, also known as HF with preserved ejection fraction (HFpEF), patients present with left ventricular diastolic dysfunction [ 6 ]. In HFpEF, the myocardium contracts normally but a thickened left ventricle reduces compliance, resulting in decreased filling capacity and thus cardiac output. Decreased cardiac output results in deactivation of the carotid baroreceptors and activation of the renin–angiotensin system [ 7 ]. Angiotensin II increases afterload by activating vasoconstriction to the blood vessels, aldosterone increases preload by increasing sodium and water retention, and antidiuretic hormone stimulates water retention [ 8 ]. Without B-type natriuretic peptide and atrial natriuretic peptide, the water retention exacerbates the symptoms of CHF, leading to damage of left ventricular remodeling to compensate for the increased peripheral resistance [ 7 ]. The body compensates by stimulating the sympathetic nervous system to increase heart rate and contractility, which increases stress on the heart. Increasing contractility increases the cardiac workload resulting in dilation and hypertrophy of the cardiac heart muscle. In a failing heart, the compromised ventricles are unable to pump the blood forward to the rest of the body, resulting in fluid accumulation into the lungs and the rest of the boy.

Mechanism of congestive heart failure; ADH — antidiuretic hormone; ANP — atrial natriuretic peptide; ATII — angiotensin II; BNP — B-type natriuretic peptide; RAAS — renin–angiotensin–aldosterone system; SNS — sympathetic nervous system.

Congestive heart failure morbidity and mortality rates

In a 2020 updated report from the American Heart Association, an estimated 6.2 million Americans over the age of 20 years have HF. In 2016, hospital discharges with a diagnosis of CHF numbered 809,000, and in 2017 the mortality rate from CHF was 80,480, a 42% increase from 56,565 in 2007 [ 9 , 10 ]. As has been shown, there has been a steady increase in mortality from HF ( Fig. 3 ). Heidenreich et al. [ 11 ] estimated that the medical cost of CHF admissions will increase from $20.9 billion in 2012 to $53.1 billion in 2030, with the majority (80%) being attributed to hospitalization. Similarly, their projections show the prevalence of HF increasing by 46% from 2012 to 2030 [ 11 ]. Among Medicare patients, the prevalence of HF was 44% in 2010, with HF admissions being the costliest preventable hospitalization at an average $10,775 [ 12 ].

Heart failure mortality rates in the United States from 2007 to 2017. Trendline shows an increase in mortality over a 10-year period.

Several factors play roles in the high readmission rate of CHF. In an analysis done by Inamdar, some of the major causes of readmission were shown to be due to medication noncompliance, smoking, diet noncompliance, failure of documentation of discharge information and patient education, and comorbidities such as hypertension and diabetes mellitus [ 1 ]. Under the HRRP, hospitals have since been incentivized to come up with strategies to decrease the number of readmissions. Some of these strategies include multidisciplinary HF clinics, visiting nurse services, physician-directed HF transitional care programs, telemonitoring at home, and 1-week follow-ups. Inamdar also reports that HF clinics reduced all cause readmission rates by 50% [ 1 ]. During the HRRP implementation phase the 30-day risk-adjusted readmission rate declined from 20% to 18.4%; however, the 30-day mortality rate increased from 7.6% to 9.3% [ 13 ].

Congestive heart failure clinics and outcomes

An important reason why readmission rates have effectively decreased is due to outpatient HF clinics, home intervention methods, and medications. Because HF disproportionately affects the older population, the management goals focus on maintaining and optimizing patient capabilities ( Central illustration ). Several classes of drugs have been indicated in the treatment of HF, such as diuretics, angiotensin converting enzyme inhibitors, and more ( Table 1 ). For CHF patients to remain stable after discharge, fluid balance, blood pressure, and heart rate must be medically optimized [ 14 ]. This can be monitored during clinic follow-up or at home via implantable devices that transmit data to healthcare providers. CHF clinics, commonly known as HF clinics, have been developed to help patients diagnosed with CHF manage their condition. By educating patients on their disease and encouraging active participation in their treatment, one goal is to reduce the need for readmission to hospitals for CHF exacerbations. It is important that patients being discharged also have a strong support system and home environment so that they can maintain functional independence. Caregivers may also accompany patients to clinic appointments, thus ensuring proper follow-up after discharge. Outpatient clinics can help in educating patients and caregivers on weight management, medication compliance, dietary changes, and exercise regimens. By seeing a multidisciplinary team at an HF clinic, a patient’s care is tailored to their specific needs. Multidisciplinary teams include a cardiologist, specialized HF nurses, pharmacists, physiotherapists, social workers, dieticians, and other allied health professionals [ 15 ]. It is especially important for patients being discharged to be followed up at either their doctor’s office or an outpatient clinic for management of their condition. Outpatient clinic visits with a physician or healthcare provider after discharge prove to be important in reducing readmission for HF. In a Taiwanese study of 13,577 HF patients, early follow-up with a physician within 7 days of discharge was associated with a lower readmission rate ( Table 2 ) [ 16 ]. Similarly, an extensive observational analysis conducted by Hernandez et al. [ 17 ] showed that patients who were discharged and received early follow-up with a physician had lower 30-day readmission rates. In a study comparing patients followed in outpatient management vs. no management, only 4 (n = 27) managed outpatients were readmitted 5 times, whereas 85 (n = 111) patients who did not have follow-up accounted for a total of 187 readmissions (p < 0.001) [ 18 ].

Key proponents in reducing readmission rates related to congestive heart failure (CHF).

Drugs commonly used in the treatment of heart failure (HF), their mechanisms of action, and effects.

Summary of studies done to evaluate the readmission rates between patients who had physician follow-up compared to those without follow-up.

CI — confidence interval; HF — heart failure; HR — hazard ratio; HTM — home telemonitoring; NTS — nurse telephone support

Advent of telemedicine

Due to advancements in digital technology and Internet access, coupled with ever changing circumstances, telemedicine has recently become increasingly popular. Telemedicine is the use of video and audio technology, such as phones and webcams, to electronically connect a patient to a health care provider remotely [ 19 ]. Telemedicine is used to deliver patient care and provide follow-up and education to patients who may not be able to visit a doctor’s office as soon as possible. It is not only cost effective but it also provides healthcare professionals the opportunity to see and talk to their patients in real time [ 20 ]. The efficacy and ease of seeing a healthcare professional in the comfort of your own home is an opportunity many do not pass on. Not only can patients visit with a doctor, but they can also talk to behavioral health counselors, dieticians, social workers, and other professionals while at home. In the management of CHF, telemedicine could be utilized to follow up patients leaving the hospital, ensuring they are receiving adequate care. Healthcare providers can also remotely telemonitor and review vitals from patient’s in-home devices such as blood pressure monitors and pulse oximetry. Telemonitoring is the continuous assessment of a medical condition by way of home monitoring systems or implantable devices that automatically transmit vital signs and other physiological data to medical professionals. Vital signs can be used to check for decompensated HF by measuring parameters such as heart rate, blood pressure, heart rate variability, urine output, and weight gain [ 21 ]. Remote data collection can also be done by patient questionnaires that monitor vital signs and symptoms daily. It is not only non-invasive but also much easier for a patient to continue care in their own home. Home telemonitoring has been found to reduce the average number of days spent in the hospital, and patients who received home telemonitoring or nurse telephone support had a better 1-year mortality outcome than patients who received usual care (p = 0.032) [ 22 ]. In a meta-analysis by Tse et al. [ 21 ], telemonitoring reduced hospitalization rates of HF patients (n = 31,501) by 24% over a 6-month period, and by 27% over a 12-month period. Providers can also utilize hemodynamic monitoring by way of implantable cardiac devices, such as CardioMEMS and HeartPOD, which continuously transmit cardiac or vascular pressures to a remote system that can be reviewed. Here, doctors can assess increases in intracardiac and pulmonary arterial pressures, which may indicate oncoming decompensation of HF [ 21 ]. Therefore, both telemedicine and telemonitoring can be utilized by healthcare professionals to effectively assess patients being discharged from the hospital. These interventions can reduce 30-day readmission rates by decreasing the likelihood of CHF exacerbations.

Conclusions

Heart failure costs the US healthcare system billions of dollars annually. Hospitalizations are expensive, and readmission rates have increased the burden on hospitals due to decreased compensation for readmissions. On the other hand, patients who are discharged and do not follow up with a provider for management often have poorer outcomes than those who do undergo follow-up. Outpatient clinics and telemedicine/telemonitoring are crucial for reducing the readmissions rates of patients with HF and for achieving better health outcomes. Given that some HF patients have significant barriers to accessing medical care outside of the hospital, such as physical inability, lack of transportation, or residing in a rural area, telemedicine provides the ability to receive the care they need. Together, clinics and telemedicine/telemonitoring interventions help to create a system that works with patients to achieve their health goals. We are hopeful that telemedicine and outpatient clinics will continue to reduce patient’s readmissions and mortality and play a key role in caring for the aging population.

Conflict of interest: None declared