Nursing management: Heart Failure

Nursing management: Heart Failure

  • Nursing Assessment
    • Subjective data
      • Health information
        • Past health history:
          • CAD (including recent MI)
          • Hypertension
          • Cardiomyopathy
          • Valvular or Congenital heart disease
          • Diabetes mellitus
          • Hyperlipidemia
          • Renal disease
          • Thyroid or lung disease
          • Rapid or irregular heart rate
        • Medications:
          • Use of and adherence with any heart drugs.
          • Use of diuretics, estrogens, corticosteroids, nonsteroidal anti-inflammatory drugs, over-the-counter drugs, herbal supplements
      • Functional health pattern
        • Health perception–health management:
          • Fatigue, depression, anxiety
        • Nutritional-metabolic:
          • Usual sodium intake. Nausea, vomiting, anorexia, stomach bloating. Weight gain, ankle swelling
        • Elimination:
          • Nocturia, decreased daytime urine output, constipation
        • Activity-exercise:
          • Dyspnea, orthopnea, cough (e.g., dry, productive). Palpitations, dizziness, fainting
        • Sleep-rest:
          • Number of pillows used for sleeping. Paroxysmal nocturnal dyspnea, insomnia, sleep apnea
        • Cognitive-perceptual:
          • Chest pain or heaviness. RUQ pain, abdominal discomfort. Behavioral changes, visual changes
    • Objective data
      • Integumentary
        • Cool, diaphoretic skin. Cyanosis or pallor. Peripheral edema (right-sided heart failure)
      • Respiratory
        • Tachypnea, crackles, wheezes. Frothy, blood-tinged sputum
      • Cardiovascular
        • Tachycardia, S3, S4, murmurs. Pulsus alternans. PMI displaced inferiorly and posteriorly, lifts and heaves, jugular venous distention
      • Gastrointestinal
        • Abdominal distention, hepatosplenomegaly, ascites
      • Neurologic
        • Restlessness, confusion, decreased attention or memory
      • Possible Diagnostic Findings
        • Altered serum electrolytes (especially Na+ and K+)
        • Increased BUN, creatinine, or liver function tests
        • Increased NT-proBNP or BNP
        • Chest x-ray demonstrating cardiomegaly, pulmonary congestion, and interstitial pulmonary edema.
        • Echocardiogram showing increased chamber size, decreased wall motion, decreased EF or normal EF with evidence of diastolic failure.
        • Atrial and ventricular enlargement on ECG.
        • Decreased O2 saturation