The Nurse's Role in Heart Failure: Early Intervention

The words “heart failure” (HF) are generally modified by a list of depressing adjectives: chronic, progressive, and debilitating. In the United States, more than 5.8 million people have active HF diagnoses.

The journalCritical Care Nursepublished a case study in its August 2017 issue that covers the nurse practitioner’s (NP) role in helping patients who have this life-changing disease. Its focus is 3-fold. First, it describes NPs’ interventions with regard to HF patients. Second, it delineates challenges related to identifying secondary HF in patients with complex comorbidities. Finally, it presents concrete suggestions about improving health-related outcomes and prevent hospital readmission.

HF is the leading cause of hospital admissions and readmissions in patients ages 65 years or older. It is also a leading cause of death in the United States among patients who have been previously hospitalized. This makes HF a target for readmission reduction programs.

Most NPs know the basic signs and symptoms of HF, which are related to impaired myocardial ventricular function. Symptoms are generally classified as vascular congestion-related or target organ hypoperfusion. Advance practice nurses should know HF’s signs and symptoms (shortness of breath, lethargy, fluid retention and associated rapid weight gain, hypertension, adventitious breath sounds) because these symptoms can progress very quickly to acute decompensated HF. These symptoms often occur in a constellation as opposed to individually.

The authors emphasize that nurses and NPs should consider HF in their differential diagnosis process in any acutely ill patient who has multiple cardiac risk factors and comorbidities. These patients need a thorough workup and, potentially, referral for hospitalization. Many go directly to the cardiac intensive care unit.

Numerous risk factors predispose patients to HF and include advancing age, left ventricular hypertrophy, cardiomegaly, slow heart rate, elevated blood pressure, reduced vital capacity, and the presence of hypertension, diabetes, valvular disease, or previous myocardial infarction.

It’s important to note that patients often have little insight into the early signs and symptoms that they’re decompensating. They need extensive education, and clinicians must be vigilant. Once home, patients may or may not follow the advice of their clinicians. They also may have complicating issues, such as poor nutrition. Medication adherence is frequently low, having been complicated by a general trend toward multiple medications that have noteworthy adverse effects.

Patients need to be reminded that symptoms like bilateral lower extremity pruritus, swelling, and itching are red flags for decompensation and are often signals of lower extremity cellulitis.

Retail health care practitioners need to have heightened awareness of the implications of systemic infection, elevated blood pressure, and new arrhythmia in patients at risk for HF. Any of these conditions can galvanize progression to acute decompensated HF. When these happen, it’s important to ask patients very directly how they manage their condition at home and to describe their self-care behaviors.

In HF patients, goal-directed interventions are critical. Patients need to be reminded to monitor their symptoms, and control fluid overload appropriately with fluid restriction, reduced sodium intake, and diuretics. Research is underway to determine how each of these contributes to HF control, but for the time being these are the recommended interventions.

Much of this case study covers nursing considerations for hospitalized patients, but a good portion of it emphasizes the need for solid, aggressive care in community settings that are assessable to the patient. This case study covers patient history, physical assessments, imaging, and laboratory studies and can remind retail health care providers of HF treatment’s nuances.

Here, as with other cardiac diseases, following guidelines is essential. The American College of Cardiology and American Heart Association guideline for the management of HF was last updated in 2013; it’s the go-to guideline for this condition and is available free of charge on the Internet.

Source:Gheorghiu V, Barkley TW Jr. Identification and prevention of secondary heart failure: a case study.Crit Care Nurse.2017;37(4):29-35.