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CARE PLAN: HEART FAILURE Cheat Sheet (DRAFT) by

Nursing care plan for the patient with Chronic Heart Failure

This is a draft cheat sheet. It is a work in progress and is not finished yet.

WHAT IS HEART FAILURE?

Accumu­lation of fluid throughout the entire body (R-Sided HF) and/or accumu­lation of fluid in the lungs (L-Sided HF). Causes a decrease in cardiac output, that is unable to meet the metabolic needs of the body.
WHAT'S HAPPENING?
Na+ & H2O retention increases workload of the heart.
Untreated Heart continues to become weaker & enlarged
RESULTS IN Remodeling and now a PERMANENTLY DYSFUNCTIONAL HEART

FEW FACTS

Most common nonfatal conseq­uence of CV disorders
Heart Failure is NOT a disease itself. Instead a group of clinical syndromes characterized by:
Volume Overload
Inadequate tissue perfusion
Poor Exercise Intole­rance
LV usually affected 1st
Chronic HF may have both Left & Right Failure

DIAGNOSIS

Signs & Symptoms determine which ventricle is being affected leading to the diagnosis of Left or Right Heart Failure

LEFT­-SIDED S/S - Pulmonary

SOB while sleeping
Poss. apnea
Dyspnea
Impaired gas exchange
Orthopnea
Trouble breathing while lying down
Inspir­atory Crackles Or Expiratory Wheezes
Pulmonary edema
Constant Cough
Frothy, blood-­tinged sputum

RIGHT-­SIDED S/S - Venous

Swelling of legs & hands
Weight gain (2-3lb­s/day)
Fluid Retention
Pitting Edema
JVD
Estimates Central venous pressure = RV Failure
Ascites
Increased abdominal girth
Enlarged liver (Hepat­ome­galy)
Fluid building up - may cause Nausea, anorexia, & bloating

ASSESS­MENT: NON­MO­DIF­IABLE RISK FACTORS

Age - Elderly often need hospit­ali­zation
Sex - Women tend to have condition later in life, survive longer w/ HF

ASSE­SSMENT: MODIFIABLE RISKS

Smoking
ETOH & Drug Use
Obesity
T2DM
HTN
CAD

HEALTH HISTORY - ASK

Signs & Symptoms of dyspnea, SOB, fatigue, & edema?
Have you been experi­encing unusual fatigue?
Do you have SOB at rest, on exertion?
Address the patient's emotional well-being (Chronic HF is linked to depression & anxi)
Do you have sleep distur­bances? Do you ever wake up suddenly feeling SOB?
How many pillows do you sleep with?
Explore patient's unders­tanding of HF, self-m­ana­gement strategies (diet, exercise, smoking cessation)
Have you ever had a MI?
Have you had recent open heart surgery?
Do you have HTN?
Have you every been diagnosed with a dysrhy­thmia?
Do you take any medica­tions prescribed & OTC?
Do you drink ETOH?
Do you smoke?
Do you use illicit drugs?
Do you exercise?
What is your diet like? Are you on any type of restri­ctions?
Have you noticed acute weight gain? 2-3 lbs/day

PHYSICAL EXAM

SOB
Most common
Mental Confusion, Anxiety, Irritability
Hypoxia
Pale, cyanotic, cool, clammy skin
Poor Perfusion
Peripheral edema
Ankles, feet, sacral area, or throughout body
Inspir­atory Crackles OR Expiratory Wheezes
Left-Sided Failure
JVD
Right-­Sided Failure
Ascites
Passive liver congestion R-Side Failure
Tachypnea
Body compen­sating for hypoxia & decreased CO
Tachyc­ardia
Body compen­sating for hypoxia & decreased CO
S3 or S4 Heart Sound Ventri­cular Gallop
Increased resistance to ventri­cular filling after atrial contra­ction & early rapid ventri­cular filling

NURSING DIAGNOSIS

Impaired cardiac output
R/T
Impaired myocardial function
AEB
Fatigue, Dyspnea, Tachyc­ardia, and/or BP
   
Risk for ineffe­ctive health mainte­nance
R/T
Lack of knowledge regarding diagnostic & lab procedures necessary for monitoring heart failure status
   
Impaired gas exchange
R/T
Fluid overload & pulmonary congestion
AEB
Orthopnea, nocturnal dyspnea & hypoxemia
   
Excess fluid volume
R/T
Compro­mised heart function & renal perfusion
AEB
Peripheral edema, ascites, & weight gain
   
Acute Pain
R/T
Decreased myocardial oxygen­ation
AEB
Reports of chest pain or discomfort exacer­bated by physical exertion or stress
   
Ineffective tissue perfusion
(cardi­opu­lmo­nary)
R/T
Decreased cardiac output
AEB
Altered mental status, cool & clammy skin, decreased urine output
   
Imbalanced nutrition: Less than body requir­ements
R/T
Dietary restri­ctions and fluid management in heart failure
AEB
Confusion about low-sodium diet recomm­end­ations & fluid intake limits
   
Activity intole­rance
R/T
Imbalance between oxygen supply & demand
AEB
Reports of fatigue, dyspnea on exertion & decreased endurance
   
Anxiety
R/T
Changes in health status & uncert­ainty about the future due to their condition, noticeable restle­ssness, frequent questions about their prognosis, and expressed concerns regarding the effects of their illness on family roles and respon­sib­ilities

INTERVENTIONS R/T NURSING DIAGNOSIS

Decrease in Cardiac Output
CAUSE: Heart muscle weakens or becomes stiff, impairing it's ability to contract & relax properly.
Prevent the progression of the disease & decrease the risk of complications
GOAL: Early recogn­ition & management of decreased CO improves patient outcomes & quality of life.
 
INTERV­ENTIONS
RATIONAL
1. Auscultate apical pulse & assess HR
- Body's 1st defense to compensate for reduced CO
Objective Tachyc­ardia = early sign of HF
Persistent tachycardia is harmful & may worsen HF
2. Obtain a compre­hensive health history focusing on HF symptoms & self-m­ana­gement strategies
Understanding patient's health history helps ID S/S of worsening HF
 
Also IDs patient's understanding and adherence to self-management strategies
3. Note heart sounds
An extra heart sound is caused by a large volume of fluid entering ventricle at the beginning of diastole
Objective S3 (ventr­icular gallop)
Indicates worsening HF
4. Assess rhythm & document dysrhythmias
A-Fib is common & promotes thrombus formation within the atria
Subjective "­Patient reports fast HR"
Occurrence increases with HF severity
5. Assess for palpitations or fast HR
Palpitations occur due to dysrhythmias.
Subjective "­Patient reports fast HR, "­"­flu­tte­r" feelin­g"
Fast HR may be compen­sation mechanism trying to get more blood flow back to the heart
6. Palpate peripheral pulses
Decreased CO may diminish radial, popliteal, dorsalis pedis, and post-tibial pulses.
Objective Decreased pulse volume, cool, pale or cyanotic skin = decreased CO
Evaluation helps determine adequacy of peripheral perfusion
 
7. Monitor BP
Chronic HF, BP is used as a parameter to determine the adequacy or excess dosage of meds (ACEi)
8. Inspect the skin for mottling
R/T decreased perfusion to the skin
Objectiveblue/grey skin coloring
In chronic HF increased capillary oxygen extraction, skin appears dusky
9. Inspect skin for pallor or cyanosis
R/T to diminished perfusion
Objective Cool, clammy skin
10. Monitor urine output, noting decreasing output & concentrated urine
R/T decreased renal perfusion
Subjective Oliguria
Fluid shifts into tissues during the day
Subjective Nocturia
Increased renal perfusion during supine position
11. Examine LE for edema and rate it's severity
Helps evaluate fluid status & guide diuretic therapy & fluid management
Objective Pitting Edema
12. Assess the abdomen for tender­ness, hepato­megaly, and ascites
Provides info on potential compli­cat­ions, guides interv­entions & Tx
13. Assess jugular vein distention
Estimates central venous pressure & IDs RV failure.
Objective Distention greater than 4 cm
14. Monitor Labs & Diagno­stics
Goal in diagnosis is to find the underlying cause of HF & patient's response to Tx
15. Monitor O2 sats & ABGs
Useful in establ­ishing Dx & severity of HF
 
Provides info regarding the heart's ability to perfuse distal tissues w/ O2 blood
16. Give O2 as indicated by the patient's symptoms, O2 sats, & ABGs
Increases O2 availa­bility to the myocardium
 
Helps relieve symptoms of hypoxemia, ischemia, & subsequent activity intole­rance
17. Provide a restful enviro­nment
Minimizing contro­llable stressors & unnece­ssary distur­bances reduces the cardiac workload
 
Providing physical & emotional rest allows patient to conserve energy
18. Assist the patient into a High-F­owler's position
Allows better chest expansion = improved pulmonary capacity
 
Reduced venous return to the heart
 
Relieves pulmonary congestion
 
Minimizes pressure on the diaphragm
19. Check for calf tender­ness, diminished pedal pulses, swelling, local redness or pallor of extremity
Prolonged sedentary position increases the risk of thromb­oph­leb­itis, reduces CO, and increases venous pooling
20. Encourage activity as tolerated
**Chronic HF patient's should aim for 30 mins of physical activity daily
21. Monitor for S/S of:
Fluid Imbalance
Fluid shifts & diuretics can cause excessive diuresis, leading to HYPOKA­LEMIA
Electr­olyte Imbalances
S/S HYPOKA­LEMIA: VTach, Hypote­nsion, Gen. weakness
 
ACEi & ARBs can cause HYPERK­ALEMIA
22. Monitor Tele monitor & CXR
Can indicate underlying cause of HF
 
CXR: May show enlarged heart & pulmonary congestion