3.1 Nursing management of the heart failure patient Listen

The aim of nursing management is to:

  • monitor the health status of the patient including the haemadynamic status
  • promote self-management
  • improve quality of life
  • provide education for the patient and their family
  • reduce unnecessary admissions to acute care

The patient will have regular observations of respiratory rate, pulse rate, oxygen saturations, sitting and standing blood pressure and temperature recorded. Blood pressure should be monitored continuously in the acute phase. Blood pressure may be elevated or reduced and cardiogenic shock can occur with a blood pressure below 90 mmHg systolic which can be seen in left ventricular failure due to myocardial infarction. Heart failure patients can have a rapid heart rate due to the body compensating for a reduced cardiac output. (Dickstein et al. 2008).

  • Respiratory assessment should be conducted for evidence of orthopnoea (breathlessness when lying down) and paroxysmal dyspnoea (sudden waking in the night due to acute shortness of breath). Patients should be nursed in an upright position supported by 3/4 pillows due to their acute shortness of breath. If necessary oxygen therapy should be administered as prescribed. 12 lead ECG – cardiac specialist nurses will observe for cardiac arrhythmias, particularly atrial fibrillation and heart block.
  • Central venous pressure readings (CVP) will be taken by cardiac specialist nurses. Due to increased preload the veins in the neck can become engorged. Normally neck veins are barely visible in a sitting position (45 degrees). In heart failure patients with right heart failure and elevated central venous pressure (> 20 with more Hg / 25 cm H2O) bulging neck veins can be seen.
  • Temperature should be monitored to assess for signs of chest infection or urinary tract infection which can exacerbate the patient’s symptoms.
  • Daily weights will be recorded and action will be taken if weight has increased over the last 3 days by 2-4 kgs (4-8 lbs). A rapid increase in weight can indicate that the patient is becoming fluid overloaded. A physical assessment will also be made to examine for pitting peripheral oedema, sacral, abdominal and pulmonary oedema (Dickstein et al. 2008)
  • A strict fluid balance should be maintained whilst the patient is in the acute phase of the illness.
  • If necessary a fluid restriction of between 1.5 – 2 litres a day will be maintained.
  • Blood samples will be taken to examine for urea and electrolytes, liver function and full blood count to assess for anaemia. Anaemia in heart failure patients can lead to increased morbidity and mortality (Eikeland MCA. in Almås et al. 2010).
  • Nutritional assessment, e.g. MUST score, should be undertaken to ascertain nutritional status
  • Pressure ulcer assessment should be completed using the local policy. Patients may be on bed rest during the acute phase of the illness and are therefore at risk of developing pressure ulcers. Additionally patients with peripheral oedema can have fragile, leaking skin.
  • Cognitive ability can be impaired due to hypoxia and disturbed sleep. The nurse should assess how to ensure effective communication is implemented to support the patient.

The nurse should assess, plan, implement and evaluate the nursing care that the patient requires with activities of daily living whilst promoting patient independence.

Management of acute heart failure

Comprehensive NICE guidance (2014) on managing the patient with acute heart failure is available at the following link:

https://www.nice.org.uk/guidance/cg187/chapter/1-recommendations#initial-pharmacological-treatment

Evidence based medications in heart failure

It is important that an echocardiogram is carried out prior to commencing heart failure medication to assess the type of heart failure the patient is presenting with.

In all types of heart failure the following medications may be prescribed:

  • Diuretics to relieve congestive symptoms and fluid retention. The diuretic will be titrated up and down according to the symptoms.
  • β-blockers are recommended for all patients with left ventricular systolic dysfunction unless otherwise contra-indicated (asthma/bronchospasm). These are used to counter the effects of the sympathetic nervous system (SNS). The fall in cardiac output caused by the failing heart activates the SNS – a response aimed at elevating BP to ensure vital organ perfusion. This is mediated via the adrenergic system – the stimulation results in peripheral vasoconstriction (↑afterload), increased heart rate and myocardial contractility. Peripheral resistance means the heart has to work harder generating further stress on the ventricular wall. The increased heart rate means filling of ventricles and coronary arteries is less efficient.
  • Angiotensin Converting Enzyme inhibitors (ACEI)  and Angiotension Receptor Blockers (ARB) act  to block the effect of  Renin Angiotensin Aldosterone  system (RAAS)  Like the SNS, the RAAS is activated by sudden drop in BP or circulating volume (e.g. haemorrhage) with a response designed to preserve blood flow to the kidneys.  When the heart is failing the reduced cardiac output acts as a trigger to stimulate the RAAS as there is less circulating blood to the kidneys. The RAAS system works rapidly to raise BP and retain salt (Na) and water (H2O) in the following way.
  • Renin acts on angiotensin to produce angiotensin I. This is then converted to angiotensin II a vasoconstrictor which causes a rise in BP and the release of aldosterone. Aldosterone promotes the reabsorption of sodium and water. Aldosterone is also detrimental as it causes myocardial fibrosis. Antidiuretic hormone is also activated causing vasoconstriction and retention of water and sodium. Initially the effect is to increase the cardiac output but only for a short time  as the increased fluid volume  eventually means the heart has to work harder which eventually impairs the function further.

Additionally heart failure patients may be prescribed

  • Anticoagulants
  • Aspirin
  • Intravenous inotropic agents can be used in the short term in acute heart failure.

Comprehensive NICE guidance (2010) on medications used in heart failure is available at the following link:

https://www.nice.org.uk/guidance/cg108/chapter/guidance

Promoting patient self-care

The nurse should ensure that patients and their families  are offered the following information:

  • Information about the disease and treatment, symptoms and context of daily activities.
  • Provide guidance about medications, their effects and side effects.
  • Provide guidance about non-drug treatment e.g. reduced-salt diet, daily weight measurement, physical activity, alcohol consumption, travel information, vaccines, smoking cessation and sexual activity.
  • Inform on how to seek help if there is any change in the patient’s condition.
  • If available refer to the heart failure specialist nurse service for ongoing monitoring and education. Evidence indicated that patients with support from a heart failure specialist nurse have shown increased survival, improved quality of life and fewer hospitalisations.

(Eikeland mfl. in Almås mfl. 2010, s. 229).

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