Clinical Protocol Nursing Practice Manual John Dempsey Hospital Department of Nursing The University of Connecticut Health Center

r PROTOCOL FOR: POLICY: Congestive Heart Failure (CHF): Care of the Patient with

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1. All patients admitted with a primary diagnosis of Congestive Heart Failure (CHF) should have the CHF order set initiated. 2. All patients admitted with a primary diagnosis of CHF will have the following consults: a. Social Work consult b. Dietary consult c. Pharmacy consult 3. All patients admitted with a primary diagnosis of CHF will elevate their legs while at rest. 4. All patients admitted with a primary diagnosis of CHF will receive CHF teaching.

DESIRED PATIENT OUTCOMES:

1. Patient will maintain adequate perfusion. 2. Patient will exhibit improved oxygenation. 3. Patient will achieve/maintain desired dry weight. 4. Patient will demonstrate/verbalize understanding of disease process, disease management, and self assessment skills.

CLINICAL ASSESSMENT AND CARE:

A. General: 1. Patients will have vital signs taken every 4 hours, and a full assessment every 8 hours or per practitioner order/unit standard. Assess blood pressure for lowered systolic pressure and narrowing of pulse pressure. 2. Assess color, consistency, and frequency of sputum production. 3. Evaluate complaints of dyspnea in relation to activity, rest or if it awakens patient from sleep. 4. Assess radial and pedal pulses every 8 hours or per practitioner orders or PRN. Note any alterations between strong and weak pulses. 5. Maintain continuous ECG monitoring as ordered and document per unit protocol. B. Fluid Balance: 1. Monitor and record strict intake and output (I&O) every shift or per practitioner order. 2. Obtain and record the daily weight as ordered. Document in kilograms in the medical record and in pounds on the patients

Clinical Protocol Nursing Practice Manual John Dempsey Hospital Department of Nursing The University of Connecticut Health Center PROTOCOL FOR: Congestive Heart Failure (CHF): Care of the Patient with

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Daily Weight Chart. Notify practitioner of a weight gain of 3 lbs (1.3 kgs) in 1 day or 5 lbs (2.3 kgs) in a week. 3. Ask the patient if his/her abdomen feels full. for protuberance. 4. Assess for edema in legs, ankles and feet. bound assess sacral area for edema. 5. Maintain fluid restriction as ordered. 6. Initiate Ultrafiltration if ordered. C. Gas Exchange 1. Initiate actions to decrease patients anxiety. 2. Place patient in mid-high Fowlers position with legs dependent. 3. Administer diuretics, inotropes and vasodilators as ordered. 4. Obtain and monitor ABGs and pulse oximetry as ordered. 5. Administer oxygen as ordered-titrate per order. 6. Encourage deep breathing exercises and use of incentive spirometer every 2 hours. 7. Observe for altered respiratory patterns. 8. Observe/report new onset of cough. D. Medication Therapy 1. Monitor lab results for hypoxia, electrolyte disturbances, acidosis/alkalosis, serum digoxin, and or antidysrhythmic agent levels. 2. Administer, assess and document effect of medications on perfusion and heart failure. a. ACE inhibitors will reduce afterload and therefore reduce blood pressure. Beta blockers will improve diastolic function but will lower HR and BP. Positive inotropes may be used to increase C.O. and decrease afterload. Examine abdomen

If the patient is bed-

b.

c.

3. Assess activity tolerance with new medications bearing in mind patients existing ejection fraction. Refer to IV Medication Guidelines for recommendations for cardiac monitoring. 4. Notify practitioner immediately of any dysrhythmias.

Clinical Protocol Nursing Practice Manual John Dempsey Hospital Department of Nursing The University of Connecticut Health Center PROTOCOL FOR: Congestive Heart Failure (CHF): Care of the Patient with

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5. Assess for medication side effects: dysrhythmias, anorexia, nausea, dizziness, orthostatic hypotension, vomiting, diarrhea, bradycardia, headache, visual changes, malaise, behavioral changes, increasing CHF and/or lack of response to medication. 6. Administer diuretics as ordered and observe for side effects: a. b. c. d. e. f. PATIENT TEACHING: hypokalemia and hyponatremia hypovolemia lethargy postural hypotension muscle cramps metabolic alkalosis

1. Explain disease process to patient, family and/or significant other, initiate heart failure education materials a. Heart Failure Zones b. Heres How to Manage Your Heart Failure Booklet c. Heart Failure Magnet d. Daily Weight Record 2. Teach signs and symptoms of worsening CHF: shortness of breath, weight gain, swelling of feet, ankles or abdomen, persistent cough, tiredness, loss of appetite, activity in tolerance, orthopnea. 3. Review medication regimen with patient or caretaker. Validate patient/care taker understanding of medications. Distribute handouts as appropriate on all discharge medications. 4. Initiate heart failure daily weight log on admission, educate and include patient in daily use. 5. Initiate CHF Patient Family Teaching Record. 6. Review diet restrictions-reinforce dietary education a. Provide rationale for sodium restriction. b. Encourage small frequent meals versus 3 large meals/day. c. Consult Dietary to provide patient with sample menus. d. Advise patient to look at all labels to ascertain Na content, including medications. e. Advise the patient to avoid salt substitutes in the presence of renal disease. 7. Verify that patient has a follow-up appointment within 7 days of discharge. The appointment should be scheduled at the time of discharge. For evening, weekend and holiday discharges, an attempt to schedule an appointment must be made. If unable to schedule an appointment, document in the medical record and inform the patient.

Clinical Protocol Nursing Practice Manual John Dempsey Hospital Department of Nursing The University of Connecticut Health Center PROTOCOL FOR: REPORTABLE CONDITIONS: Congestive Heart Failure (CHF): Care of the Patient with

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1. Notify practitioner of: a) Chest pain b) Respiratory distress c) Urinary output less than 50ml/hr d) Abnormal lab values from baseline e) Vital sign changes from baseline f) Presence of cyanosis or dyspnea g) New or increased edema h) Increased weight gain of 3 lbs (1.3 kgs) in 1 day or 5 lbs (2.3 kgs) in a week

APPROVAL:

Nursing Standards Committee Congestive Heart Failure Committee 2/89 2/90, 10/90, 12/90, 1/92, 1/93, 4/94, 8/94, 1/95, 8/96, 3/98, 9/99, 9/00, 5/03, 9/05, 8/17/11

EFFECTIVE DATE: REVISION DATES: