What is a major goal of nursing management of a patient with heart failure?

Last issue’s article explored the acute medical care of decompensated heart failure which included diuretics, inotropes and circulatory support. In this issue nursing care from an acute and chronic management perspective will be addressed.

Acute heart failure
The goals of nursing management are established via a thorough nursing assessment of the patient’s functional capacity and haemodynamic status and are then used to guide nursing intervention and evaluation. In addition, the nursing assessment may reveal a disorder or condition that precipitates heart failure.

Nursing goals may include:

• Promote patient comfort and alleviate breathlessness
• Alleviate and prevent signs of fluid overload
• Preserve peripheral perfusion
• Increase patient awareness and education of the condition and current management
• Attend to self-care deficits that are a result of symptoms, fluid overload and hypoxia.

Monitoring of the patient should begin as soon as possible after admission, with the focus on identifying the underlying cause and the response to treatment. Monitoring includes basic observations of temperature, respiratory rate, heart rate, blood pressure, oxygenation, urinary output and serial ECGs.

Advanced monitoring includes placement of invasive monitoring system such as an arterial line or central venous pressure monitoring. Placement of a central venous catheter allows administration of fluids and medications as well as monitoring of the central venous pressure. Care of invasive monitoring systems are according to local nursing guidelines and include preventing infection, maintaining line patency via hourly flushing of the system and zeroing the system every four hours or on change of patient position to obtain accurate pressures.

Hourly nursing assessment, or more frequent depending on the patient’s clinical status, involves a cardiovascular and respiratory assessment that focuses on response to treatment and identifying signs that indicate deterioration in the patient's condition, such as an increase in the patient’s heart rate and respiratory rate, hypotension and decreased peripheral perfusion such as decreased capillary refill and cool peripheries.

If the patient is responding positively to treatment signs include an increase in blood pressure, reduction in respiratory rate and breathlessness, as well as warm peripheries. Based on the cardiovascular and respiratory assessment findings the patient’s stage of heart failure may be staged according to the New York Heart Association Functional Classification System as depicted in part one of this article. If the patient is breathless supplemental oxygen may be delivered to achieve an oxygen saturation of > 95%.1 If supplemental oxygen fails to maintain oxygen saturation > 95% non-invasive ventilation may be implemented and the nursing care specific to this form of oxygenation is carried out according to local guidelines.

Other nursing implications may involve putting the patient on a fluid restriction with diligent monitoring of input and output. The patient may have a urinary catheter placed so that urinary output may be monitored closely. The aim is that the patient has a urinary output greater than 0.5ml/kg/hour, therefore if the patient weighs 70kg the anticipated urinary output for the hour would be 35ml. Kidney function and urinary output is a good indicator of organ perfusion.

In addition to specific nursing interventions that address the symptoms of heart failure, general nursing measures involve limitation of activities in order to preserve oxygen consumption and decrease breathlessness.2 The patient may have self-care deficits where there is an inability to undertake activities such as bathing, dressing or feeding oneself. Nursing care involves identifying these deficits and attending to them. In relation to bathing, particular attention should be paid to the skin, in particular to pressure areas such as the heels and sacrum area. A Waterlow Score is undertaken identifying the risk of developing pressure sores and the relevant interventions such as a pressure relieving mattress should be put in place. In addition the patient may experience peripheral oedema, particularly of the legs, which may predispose the skin to cracking or breaking down. In order to prevent this the skin is moisturised and legs are elevated when sitting out, to relieve the oedema and its associated discomfort.

From a nutritional perspective the patient may experience anorexia and nausea due to poor perfusion to the digestive system as well as the presence of ascites. A dietary consult should be sent for appropriate advice on nutrition. In general the patient will be on a low-salt diet and is advised to eat little and often to avoid periods of nausea and fullness. An anti-emetic may be prescribed and administered 30 minutes prior to meals to relieve nausea. Due to poor perfusion to the digestive system the patient is at risk of constipation and altered bowel habit and therefore it may be necessary for laxatives or stool softeners to be prescribed to avoid this problem.

Pharmacological management
Part one of this article explored the pharmacological management of acute heart failure focusing on diuretics, vasodilators, inotropes and vasopressors. Table 1 describes the specific nursing implications applicable to each class of agents. Once the patient is stabilised the level of activity may be increased, such as gentle mobilisation. Ownership of self-care is promoted with assistance initially and then independently. Daily weighing may commence, usual practice is in the morning prior to breakfast and after the patient has been to the toilet. It is recommended that the patient is weighed in the same attire, such as pyjamas and slippers, thus avoiding discrepancy in subsequent weighing. Patient education in self-care of heart failure and prevention of exacerbations may begin at this stage. Self-care is defined as actions aimed at maintaining physical stability, avoidance of behaviour that can worsen the condition and detection of the early symptoms of deterioration. The principles of self-care are represented in Table 2. For more information regarding patient education and appropriate behaviour please refer to the ESC guidelines.1

Nursing implications of acute heart failure – pharmacological managementTreatmentAdverse effects/nursing specific implications
Morphine

• Respiratory depression
• Hypotension caused by vasodilatory effects

Diuretics

• Electrolyte Imbalances (hypokalaemia, hyponatraemia)
• Hypotension
• Dehydration
• Diuretic resistance if already on oral diuretics

Vasodilators

• Headache
• Hypotension
• Nitrate tolerance (occurs when patient receiving same dose of nitrate for longer than 24 hours)

Inotropes
Type III phosphodiesterase inhibitors

• Increased incidence of atrial and ventricular arrhythmias (due to ventricular irritability and increased myocardial oxygen
  consumption secondary to increased contractility)
• Use with caution in those with heart rates > 100 bpm. May cause sympathetic nervous system stimulation and increase
  the heart rate further
• Monitor blood pressure
• Weaning the infusions to avoid rebound hypotension /organ hypoperfusion
• Short half life of two minutes
• Dobutamine and milrinone may be administered peripherally

Vasopressors

• Administer via central line
• Monitor for atrial and ventricular arrhythmias
• Observe for excessive vasoconstriction

It is recommended that the patient remains in contact with the service and if possible enrols in a nurse-led heart failure clinic or programme. The ESC guidelines describe such programmes as a multidisciplinary team approach that co-ordinates care along the continuum of heart failure and throughout the chain of care delivered by various services within the healthcare system. The multidisciplinary team may consist of nurses, cardiologists, primary care physicians, physiotherapists, dieticians, social workers, psychologists, pharmacists, geriatricians, and palliative care as well as other healthcare professionals. This service is implemented during hospitalisation and continued as an outpatient.

Elements of the service focus on patient education in relation to the topics addressed in Table 2 and drug titration using treatment algorithms, as well as management of patients with an implanted device such as implantable defibrillator or biventricular pacemaker. Ease of access is promoted, thus providing reassurance and allowing the patient to discuss symptoms, treatment, side-effects and self-care behaviour.

The ESC guidelines1 recommend that the following components are integral to the programme:

• Multidisciplinary team approach frequently led by heart failure nurses in collaboration with physicians and other related services
• First contact during hospitalisation, early follow up after discharge through clinic and home based visits, telephone support and remote monitoring
• Target high risk symptomatic patients
• Facilitate access during episodes of decompensation
• Optimised medical management
• Access to advanced treatment options
• Adequate patient education with special emphasis on adherence and self-care management
• Patient involvement in symptom monitoring and flexible diuretic use
• Psychosocial support to patient and family and/or caregiver.

Essential topics in patient educationEducational TopicsSkills and self-care BehaviourDefinition and cause of heart failure

• Understand the cause of heart failure and why symptoms occur

Signs and symptoms

• Monitor and recognise signs and symptoms
• Record daily weight and recognise rapid weight gain
• Report sudden unexpected weight gain > 2kgs in three days
• Know how and when to contact the heart failure nurse specialist or service
• Use flexible diuretic therapy if appropriate and recommended

Pharmacological treatment

• Understand indications dosing and effects of drugs
• Recognise the common side-effects of each drug prescribed

Risk factor modification

• Understand the importance of smoking cessation
• Monitor blood pressure if hypertensive
• Maintain good glucose control if diabetic
• Avoid obesity

Diet recommendations

• Sodium restriction if prescribed
• Avoid excessive fluid intake
• Monitor alcohol intake
• Monitor and prevent malnutrition

Exercise recommendations

• Be reassured and comfortable about exercise
• Understand the benefits of exercise
• Undertake exercise regularly

Sexual activity

• Be comfortable about engaging in sexual activity and discuss problems with heart failure nurse specialist or healthcare provider
• Understand specific sexual problems and various coping strategies

Immunisation

• Receive immunisation against infections such as influenza and pneumococcal disease

Sleep and breathing disorders
(central or obstructive sleep apnoea)

• Recognise preventive behaviour such as reducing weight if obese, smoking cessation and abstinence from alcohol
• Learn about treatment options if appropriate

Adherence

• Understand the importance of following treatment strategies and maintaining motivation to follow prescribed treatment

Psychosocial approach

• Understand that depressive symptoms are common in heart failure and the importance of social support
• Learn about treatment options if appropriate

Prognosis

• Understand important prognostic factors and make realistic decisions
• Seek psychosocial support

Pregnancy and contraception

• Pregnancy can deteriorate heart failure
• Family planning and contraception discussed
• Risk vs benefit to baby and mother made explicit

Travelling

• High altitudes (> 1500m ) and very hot/humid destinations discouraged
• Planned travel discussed with heart failure team

Aside from patient benefits, such as reduction in mortality, promotion of independence and patient autonomy, these programmes reduce hospitalisation and thus are cost effective.

The patient may also be referred to a cardiac rehabilitation programme which has been shown to improve functional capacity, recovery and emotional wellbeing and to reduce hospital admissions. It is acknowledged that heart failure is a chronic progressive syndrome where the aim of treatment is to alleviate symptoms and slow its progression.

Despite advances in medical and interventional therapies it is recognised that it is a palliative condition. Patients with clinical features of advanced heart failure who continue to experience symptoms, despite optimal evidence based therapy, have a poor short-term prognosis and should be considered for a structured palliative care approach. This may be challenging as heart failure has an unpredictable disease trajectory and it is often difficult to identify a specific time point to introduce palliative care to patient management. Interventions should focus on improvement in quality of life, symptom control, early detection and treatment of deterioration and on pursuing a holistic approach to patient care, encompassing physical, psychosocial, social and spiritual wellbeing. Currently there is an action research project being undertaken in relation to palliative care in heart failure that aims to identify a framework of care for this patient population. Heart failure is a chronic progressive syndrome that negatively impacts on patient’s functional capacity and quality of life. Heart failure programmes promote patient autonomy and have been shown to reduce episodes of hospitalisation via a multidisciplinary approach and a role for palliative care has been acknowledged.

Kate O'Donovan is course co-ordinator for the postgraduate diploma in cardiovascular nursing in the Mater Hospital, Dublin

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