Teaching tools for heart failure

Authors: Maureen McCafferty, RN, MS, CCRN, and Cindy Welsh, RN, MBA, Oak L a w n a n d Oak Brook, Illinois

eart failure and its m a n a g e m e n t have received

H tremendous attention during the last decade. It
is no longer sufficient to view heart failure in terms of
Table 1
Common signs and symptoms of h e a r t failure
"left versus right" ventricular failure. When teaching
S3 Edema
or treating heart failure, it is vital to determine
Rales t h a t do not clear Ascites
whether the problem is related to systolic or diastolic after coughing Weight gain
dysfunction. Proper identification and treatment provide J u g u l a r vein d i s t e n t i o n Decreased exercise tolerance
patients the best chance for survival. Cough Orthopnea
D y s p n e a , especially Paroxysmal noctumal dyspnea
on exertion Fatigue
Maureen McCafferty is clinical n u r s e specialist/case manager, Tachypnea Unexplained confusion or mental
Cardiovascular Services, Christ Hospital and Medical Center, Oak Tachycardia status change in the elderlyI
Lawn, Illinois. Cindy Welsh is clinical specialist, Clinical Systems
Institute, Advocate Health Care, Oak Brook, Illinois.
For reprints, write M a u r e e n McCafferty, RN, MS, CCRN,
Cardiovascular Services, Christ Hospital and Medical Center, 4440
West 95th St., Oak Lawn, IL 60453.
J E m e r g Nurs 1996;22:451-3.
The following teaching tools may be helpful in
Copyright 9 1996 by the E m e r g e n c y Nurses Association. updating staff on heart failure m a n a g e m e n t (Tables
0099-1767/96 $5.00 + 0 1 8 / 9 / 7 6 5 4 4 1 to 6).

Table 2
S a m p l e q u e s t i o n s for e m e r g e n c y n u r s e s to u s e in a s s e s s i n g p a t i e n t s w i t h c o n g e s t i v e h e a r t failure

Assessment topic Q u e s t i o n s to b e a s k e d

S h o r t n e s s of b r e a t h Do y o u h a v e a " b r e a t h l e s s " feeling, t r o u b l e b r e a t h i n g , difficulty b r e a t h i n g

w i t h y o u r u s u a l activity?
Do a c t i v i t i e s u s u a l l y c a u s e y o u to feel b r e a t h l e s s ?
Cough D e s c r i b e a n y c o u g h y o u m a y h a v e (dry, h a c k i n g ) ?
Is it a n e w or w o r s e n i n g c o u g h ?
D o e s t h e c o u g h c a u s e t i r e d n e s s or p r e v e n t y o u from s l e e p i n g ?
Fatigue D o e s f a t i g u e k e e p y o u f r o m g o i n g o u t of y o u r h o m e ?
D o e s f a t i g u e k e e p y o u f r o m t a k i n g c a r e of y o u r s e l f ?
A c t i v i t i e s of daily living Is t h e r e a n y t h i n g y o u c a n ' t do n o w b u t could do a m o n t h a g o ?
Sleep Do y o u h a v e a n y s l e e p i n g p r o b l e m s ?
Do y o u s l e e p t h r o u g h t h e n i g h t ? De y o u w a k e u p to g o to t h e b a t h r o o m ?
C a n y o u lay fiat or do y o u s l e e p p r o p p e d u p w i t h pillows? H o w m a n y pillows do y o u u s e ?
Do y o u e v e r w a k e u p s h o r t of b r e a t h ?
Weight H o w o f t e n do y o u w e i g h y o u r s e l f ?
Do y o u w e i g h y o u r s e l f e v e r y d a y ? A t w h a t t i m e of d a y ?
Do y o u w e a r t h e s a m e a m o u n t of c l o t h i n g e a c h t i m e y o u w e i g h y o u r s e l f ?
Edema Do y o u feel b l o a t e d ?
Do y o u r c i o t h e s / b e l t / p a n t s feel t i g h t e r ?
Do y o u fill u p q u i c k e r w h e n e a t i n g ?
Cardiac symptoms Do y o u feel dizzy/lightheaded/faint/or p a s s o u t ?
Do y o u h a v e a n i r r e g u l a r h e a r t b e a t , p a l p i t a t i e n s , c h e s t pain, c h e s t discomfort,
or b l u r r e d vision?
Medication compliance Do y o u h a v e a s y s t e m for t a k i n g y o u r m e d i c a t i o n s r e g u l a r l y ?
Do y o u h a v e a n y p r o b l e m s t o l e r a t i n g y o u r m e d i c a t i o n s ?
H a v e y o u r e c e n t l y a d j u s t e d y o u r d o s a g e or s t o p p e d t a k i n g a n y of y o u r m e d i c a t i o n s ?
Do y o u h a v e a w r i t t e n list of y o u r m e d i c a t i o n s a n d c a r r y it w i t h y o u ?
Do y o u k n o w w h a t e a c h of y o u r m e d i c a t i o n s is for?

9 1995 A d v o c a t e H e a l t h Care. U s e d w i t h p e r m i s s i o n .

O c t o b e r 1996 451
JOURNAL OF EMERGENCY NURSlNG/McCafferty and Welsh

Table 3
Heart failure resulting from systolic dysfunction
Pathophysiology
D e c r e a s e d c a r d i a c o u t p u t r e l a t e d to d a m a g e d
m y o c a r d i a l m u s c l e fibers. D e c r e a s e d c o n t r a c t i o n
l e a d s to i n c r e a s e d v o l u m e in t h e left ventricle. T h i s
v o l u m e b a c k s u p into t h e left a t r i u m a n d t h e p u l m o n -
ary v a s c u l a t u r e . A c t i v a t i o n of t h e r e n i n - a n g i o t e n s i n -
aldosterone system occurs.
Main c a u s e s
M y o c a r d i a l infarction, c a r d i o m y o p a t h y , h y p e r t e n s i v e
heart disease 2
Additional clues
C h e s t x - r a y film s h o w s c a r d i o m e g a l y . D i s p l a c e d
p o i n t of m a x i m a l i m p u l s e
Treatment goals
1. R e d u c e p u l m o n a r y a n d p e r i p h e r a l e d e m a
2. I m p r o v e o x y g e n a t i o n
3. I m p r o v e c o n t r a c t i l i t y
4. M o n i t o r c a r d i a c r h y t h m
Medical t r e a t m e n t
Aggressive diuresis
Positive inotropic agents
Angiotensin-converting enzyme inhibitors
Digoxin
Small d o s e s of B-blockers ( i n v e s t i g a t i o n a l )
Morphine sulfate
Oxygen
I s o s o r b i d e d i n i t r a t e / h y d r a l a z i n e 1, 3, 4
Mortality
15% to 20% for N e w York H e a r t A s s o c i a t i o n f u n c -
t i o n a l c l a s s II
50% for N e w York H e a r t A s s o c i a t i o n f u n c t i o n a l c l a s s
IV s
S u d d e n d e a t h is not u n c o m m o n .
References
1. K o n s t a m M, D r a c u p K, B a k e r D, e t al. H e a r t failure: eval-
u a t i o n a n d c a r e of p a t i e n t s w i t h left v e n t r i c u l a r s y s t o l i c
d y s f u n c t i o n . R o c k v i l l e (MD): A g e n c y for H e a l t h C a r e
P o l i c y a n d R e s e a r c h , 1994; P u b l i c H e a l t h S e r v i c e , U S
D e p a r t m e n t of H e a l t h a n d H u m a n S e r v i c e s ; A H C P R p u b -
l i c a t i o n no. 94-0612.
2. F e d e r m a n M, H e s s O. D i f f e r e n t i a t i o n b e t w e e n s y s t o l i c
a n d d i a s t o l i c d y s f u n c t i o n . E u r H e a r t J 1 9 9 4 ; 1 5 ( s u p p l D):2-6.
3. W i l l i a m s J, B r i s t o w M, F o w l e r M, e t al. G u i d e l i n e s for t h e
e v a l u a t i o n a n d m a n a g e m e n t of h e a r t failure: report of t h e
A m e r i c a n College of C a r d i o l o g y / A m e r i c a n H e a r t A s s o c i a t i o n
T a s k F o r c e o n P r a c t i c e G u i d e l i n e s . J A m Coll Cardiol
1995;26:1376-98.
4. O p i e L, S o n n e n b l i c k E, F r i s h m a n W, T h a d a n i U. B e t a
b l o c k i n g a g e n t s . In: O p i e L, editor. D r u g s for t h e h e a r t . 4 t h
e d . P h i l a d e l p h i a : W B S a u n d e r s , 1995:1-30.
5. G a a s c h W. D i a g n o s i s a n d t r e a t m e n t of h e a r t failure o n
t h e b a s i s of left v e n t r i c u l a r s y s t o l i c or d i a s t o l i c d y s f u n c t i o m
J A M A 1994;271:1276-80.
6. Pfeffer M, B r a u n w a l d E, M o y e L, et al. E f f e c t s of c a p t o p r i l
Table 4
Things to r e m e m b e r w h e n treating heart failure in
the e m e r g e n c y d e p a r t m e n t
1. P a t i e n t s w i t h h e a r t failure m a y c o m e to t h e e m e r -
g e n c y d e p a r t m e n t w i t h similar s y m p t o m s c a u s e d b y
different conditions. Gear t r e a t m e n t t o w a r d t h e u n d e r -
lying systolic/diastolic problem.
2. Avoid a n y u n n e c e s s a r y a d m i n i s t r a t i o n of fluids. U s e
saline locks i n s t e a d of s t a n d - b y IV lines. Control all flu-
ids w i t h volumetric p u m p s or o t h e r devices.
3. Blood p r e s s u r e s in p a t i e n t s w i t h h e a r t failure m a y b e
l o w e r t h a n n o r m a l b e c a u s e of t h e i r m e d i c a t i o n s .
T r e a t m e n t is r e c o m m e n d e d for s y m p t o m a t i c h y p o t e n -
sion. 6
4. If b e d availability is a problem, c o n t i n u e t h e p a t i e n t ' s
h e a r t failure m e d i c a t i o n s according to t h e h o m e s c h e d -
ule ff possible. T h e " n o n e m e r g e n c y " m e d i c a t i o n s
s h o u l d n o t b e d e l a y e d until t h e p a t i e n t is a d m i t t e d .
5. T h e condition of p a t i e n t s w i t h chronic h e a r t failure
w h o h a v e o t h e r s y m p t o m s (e.g., after a m o t o r vehicle
accident) c a n b e c o m e u n s t a b l e v e r y quickly. B e w a r e of
routine treatments that may worsen the patient's
h e a r t failure.
6. P a t i e n t s w i t h chronic h e a r t failure m a y require h i g h e r
t h a n a v e r a g e d o s e s of diuretics to initiate a d e q u a t e
diuresis. 7
7. I n v e s t i g a t e t h e u s e of clinical p a t h w a y s to s t r e a m l i n e
t h e care of p a t i e n t s w i t h h e a r t failure in t h e e m e r -
gency department.
Table 5
Heart failure resulting from diastolic d y s f u n c t i o n
Pathophysiology
D e c r e a s e d c a r d i a c o u t p u t d u e to i m p a i r e d r e l a x a t i o n /
filling p h a s e of t h e c a r d i a c cycle. I m p a i r e d r e l a x a t i o n
l e a d s to i n c r e a s e d pressure in t h e left ventricle.
T h i s pressure b a c k s u p into t h e left a t r i u m a n d t h e
p u l n o m a r y v a s c u l a t u r e , c a u s i n g p u l m o n a r y e d e m a . 2,3
Main c a u s e s
H y p e r t e n s i o n , c o r o n a r y a r t e r y d i s e a s e 2,4
Additional clues
Left v e n t r i c u l a r h y p e r t r o p h y o n e l e c t r o c a r d i o g r a m .
Atrial fibrillation, t a c h y c a r d i a / b r a d y c a r d i a
H e a r t failure t h a t a c c o m p a n i e s h i g h b l o o d p r e s s u r e . 4
Treatment goals
1. I d e n t i f y u n d e r l y i n g c a u s e a n d t r e a t it (e.g., t r e a t
high blood pressure).
2. M a i n t a i n n o r m a l s i n u s r h y t h m .
3. R e l i e v e c o n g e s t i v e s y m p t o m s .
4. I m p r o v e c a r d i a c o u t p u t .
Medical treatment
Calcium channel blockers
B-blockers
Gentle diuresis
Oxygen s
Mortality
A p p r o x i m a t e l y 8% a n n u a l l y 4
Long-term prognosis depends on underlying cause. 2

452 V o l u m e 22, N u m b e r 5
 McCafferty and Welsh/JOURNAL OF EMERGENCY NURSING

Table 6
Guidelines for disposition of CHF patient after clinical a s s e s s m e n t : Three options
Chief CHF s y m p t o m s : Edema, s h o r t n e s s of breath, c h e s t p a i n / " t i g h t n e s s "
Option 1: Patient Option 2: Patient
discharged/remains transferred/admitted to Option 3: Patient
home observation bed admitted to hospital

Indications 9 Extremely mild exacerbation 9 Acute failure with b e n i g n or 9 Presentation of n e w - o n s e t CHF

of chronic CHF treatable precipitant
9 ED visit for specific, 9 A b s e n c e of u n s t a b l e
uncomplicated intervention comorbidity, other
(IV diuretic/oxygen/medication contraindications as listed
adjustment) below (see patient admitted)
A s s e s s e d high probability t h a t
short-term t r e a t m e n t will prove
successful, allowing patient to
be discharged safely h o m e
(i.e., patient "clearing up" well
in period since IV diuretic
administered, yet ED physician
uncomfortable releasing patient
from the e m e r g e n c y department)
DisposAion Discharge to h o m e / E C F etc.
9 Clinical conditions cleared
9 No serious d i s e a s e f o u n d after
full evaluation
requiring comprehensive cardiac
workup to determine etiology
9 High severity of illness or high
intensity of service requirement
9 Severe hypoxia
9 Evidence of acute myocardial
infarction
9 Life-threatening a r r h y t h m i a s
9 Hypotensive e m e r g e n c y
9 Cardiac t a m p o n a d e
9 Respiratory failure requiring
intubation
9 Serious precipitating event
(e.g., pneumonia, sepsis,
thyrotoxicosis)
9 Unstable major comorbidity
(e.g., chronic renal failure,
diabetes)
A d m i t to hospital
9 Clinical conditions fail to improve
9 Serious d i s e a s e f o u n d after full
evaluation of s y m p t o m s

CHF, C o n g e s t i v e h e a r t failure; ECF, e x t e n d e d care facility.

From W e l s h C, McCafferty M. C o n g e s t i v e h e a r t failure: a c o n t i n u u m of care. J N u t s Care Qual 1996;10(4):24-32. Copyright 9
1996 A s p e n Publishers, Inc. R e p r i n t e d w i t h p e r m i s s i o n .

on mortality a n d m o r b i d i t y in p a t i e n t s w i t h left ventricular 7. Opie L, Kaplan N, Poole-Wilson R Diuretics 9 In: Opie L.

d y s f u n c t i o n after m y o c a r d i a l infarction: r e s u l t s of t h e sur- editor. D r u g s for t h e heart. 4th ed. Philadelphia: WB
vival a n d ventricular e n l a r g e m e n t trial. N E n g l J M e d S a u n d e r s , 1995:83-105.
1992;327:669-77.

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