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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.


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


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


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
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.

Schematic Diagram

Below is a schematic diagram to help you visualize the pathophysiology of Heart Failure:

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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

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.
from Cardiovascular Mnemonics

Left-sided HF

Dyspnea or shortness of breath may be precipitated by minimal to moderate

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. from Cardiovascular


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.


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
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: Ventricular or atrial hypertrophy, axis deviation, ischemia, and damage

patterns may be present. Dysrhythmias, e.g., tachycardia, atrial fibrillation,
conduction delays, especially left bundle branch block, frequent premature
ventricular contractions (PVCs) may be present. Persistent ST-T segment
abnormalities and decreased QRS amplitude may be present.
Chest x-ray: May show enlarged cardiac shadow, reflecting chamber
dilation/hypertrophy, or changes in blood vessels, reflecting increased
pulmonary pressure. Abnormal contour, e.g., bulging of left cardiac border,
may suggest ventricular aneurysm.
Sonograms (echocardiography, Doppler and
transesophageal echocardiography): May reveal enlarged chamber
dimensions, alterations in valvular function/structure, the degrees of
ventricular dilation and dysfunction.
Heart scan (multigated acquisition [MUGA]): Measures cardiac volume during
both systole and diastole, measures ejection fraction, and estimates wall
Exercise or pharmacological stress myocardial perfusion (e.g., Persantine
or Thallium scan):Determines presence of myocardial ischemia and wall
motion abnormalities.
Positron emission tomography (PET) scan: Sensitive test for evaluation of
myocardial ischemia/detecting viable myocardium.
Cardiac catheterization: Abnormal pressures are indicative and help
differentiate right- versus left-sided heart failure, as well as valve stenosis or
insufficiency. Also assesses patency of coronary arteries. Contrast injected
into the ventricles reveals abnormal size and ejection fraction/altered
contractility. Transvenous endomyocardial biopsy may be useful in some
patients to determine the underlying disorder, such as myocarditis or
Liver enzymes: Elevated in liver congestion/failure.
Digoxin and other cardiac drug levels: Determine therapeutic range and
correlate with patient response.
Bleeding and clotting times: Determine therapeutic range; identify those at risk
for excessive clot formation.
Electrolytes: May be altered because of fluid shifts/decreased renal function,
diuretic therapy.
Pulse oximetry: Oxygen saturation may be low, especially when acute HF is
imposed on chronic obstructive pulmonary disease (COPD) or chronic HF.
Arterial blood gases (ABGs): Left ventricular failure is characterized by mild
respiratory alkalosis (early) or hypoxemia with an increased Pco 2 (late).
BUN/creatinine: Elevated BUN suggests decreased renal perfusion. Elevation of
both BUN and creatinine is indicative of renal failure.
Serum albumin/transferrin: May be decreased as a result of reduced protein
intake or reduced protein synthesis in congested liver.
Complete blood count (CBC): May reveal anemia, polycythemia, or dilutional
changes indicating water retention. Levels of white blood cells (WBCs) may be
elevated, reflecting recent/acute MI, pericarditis, or other inflammatory or
infectious states.
ESR: May be elevated, indicating acute inflammatory reaction.
Thyroid studies: Increased thyroid activity suggests thyroid hyperactivity as
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.
from Cardiovascular Care Nursing Mnemonics.

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

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.

Nursing Assessment

The nursing assessment for the patient with HF focuses on observing for the
effectiveness of therapy and for the patient’s ability to understand and implement self-
management strategies.

Health History

Assess the signs and symptoms such as dyspnea, shortness of breath, fatigue,
and edema.
Assess for sleep disturbances, especially sleep suddenly interrupted by
shortness of breath.
Explore the patient’s understanding of HF, self management strategies, and the
ability and willingness to adhere to those strategies.

Physical Examination

Auscultate the lungs for presence of crackles and wheezes.

Auscultate the heart for the presence of an S3 heart sound.

Assess JVD for presence of distention.
Evaluate the sensorium and level of consciousness.
Assess the dependent parts of the patient’s body for perfusion and edema.
Assess the liver for hepatojugular reflux.
Measure the urinary output carefully to establish a baseline against which to
assess the effectiveness of diuretic therapy.
Weigh the patient daily in the hospital or at home.

Based on the assessment data, major nursing diagnoses for the patient with HF include
the following:

Activity intolerance related to decrease CO.

Excess fluid volume related to the HF syndrome.

Anxiety related to breathlessness from inadequate oxygenation.
Powerlessness related to chronic illness and hospitalizations.
Ineffective therapeutic regimen management related to lack of knowledge.

Planning & Goals

Main Article: 16+ Heart Failure Nursing Care Plans

The care plan necessary for HF focuses on:

Promoting physical activities.

Reducing fatigue.
Relieving fluid overload symptoms.
Decreasing anxiety.
Increasing the patient’s ability to manage anxiety.
Encouraging the patient to verbalize his or her ability to make decisions and
influence outcome.
Teaching the patient about self-care program.

Nursing Interventions

Nursing interventions for a patient with HF focuses on management of the patient’s

activities and fluid intake.

Promoting activity tolerance. A total of 30 minutes of physical activity every

day should be encouraged, and the nurse and the physician should
collaborate to develop a schedule that promotes pacing and prioritization of
Managing fluid volume. The patient’s fluid status should be monitored closely,
auscultating the lungs, monitoring daily body weight, and assisting the patient
to adhere to a low sodium diet.
Controlling anxiety. When the patient exhibits anxiety, the nurse should
promote physical comfort and provide psychological support, and begin
teaching ways to control anxiety and avoid anxiety-provoking situations.
Minimizing powerlessness. Encourage the patient to verbalize their concerns
and provide the patient with decision-making opportunities.
Nursing Priorities

1. Improve myocardial contractility/systemic perfusion.

2. Reduce fluid volume overload.
3. Prevent complications.
4. Provide information about disease/prognosis, therapy needs, and prevention
of recurrences.


For the expected patient outcomes, the following are evaluated:

Demonstration of tolerance for increased activity.

Maintenance of fluid balance.

Less anxiety.
Decides soundly regarding care and treatment.
Adherence to self-care regimen.

Discharge and Home Care Guidelines

The nurse should provide education and involve the patient in the therapeutic regimen.


Patient education. Teach the patient and their families

about medication management, low-sodium diets, activity and exercise
recommendations, smoking cessation, and learning to recognize the signs and
symptoms of worsening HF.
Encourage the patient and their families to ask questions so that information can
be clarified and understanding enhanced.

Discharge Goals

Cardiac output adequate for individual needs.

Complications prevented/resolved.
Optimum level of activity/functioning attained.
Disease process/prognosis and therapeutic regimen understood.
Plan in place to meet needs after discharge.

Documentation Guidelines

The following data should be documented appropriately:

Assessment findings

I&O fluid balance

Degree o f fluid retention
Results of laboratory tests and diagnostic studies.
Response to interventions, teachings, and actions performed.
Attainment or progress toward desired outcomes.