Best Practice and Implications for Nursing Practice

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Congestive Heart Failure is a debilitating disease that can greatly affect a person's ability to perform normal activities of daily living. These patients are prone to rehospitalization, frequent surgeries, and comorbidities, which cost billions of dollars worth of care. With nursing practice, evidence-based care has provided the basis for treating these patients and helping them to live as normal lives as possible. Both the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and Centers for Medicaid and Medicare Services (CMS) have identified CHF as an area in need of improvement in healthcare facilities. Over the years studies have been done that provide evidence that specific nursing interventions and practices have shown to improve the quality of life and increase life span of patients suffering from CHF. The main goals for care of heart failure are to slow its progression, reduce cardiac workload, improve cardiac function, and control fluid retention. Some of the specific practices for nurses include:
  • Hemodynamic Monitoring
    • Evaluate cardiac and circulatory function and the response to interventions
    • Measuring and monitoring venous and pulmonary artery pressure
  • Treating underlying risk factors, including:
    • Hypertension
    • Lipid disorders
    • ACE inhibitor or angiotensin-receptor blocker (ARB) therapy as appropriate
    • Exercise intolerance
    • Salt intake
    • Smoking
    • Alcohol and illicit drug use
    • Control blood glucose in clients with metabolic syndrome
  • Assessing For Home Care:
    • Discuss with patient normal daily activities and assess sleep and rest patterns
    • Assess the environment for safe roads or neighborhoods for walking, access to pharmacy, medical care, and assistive devices
    • Assess diet of the older adult that may have decreased taste (leads to increased use of salt to bring out food flavors)
  • Health Education for the Client and Family
    • Ensure patient is allowing longer warm-up and cool-down periods during exercise
    • Patient should engage in regular exercise such as walking five or more times a week
    • Patient should rest with feet elevated when fatigued
    • Patient should maintain adequate fluid intake
    • Patient should prevent infection through pneumococcal and influenza immunizations



Assessment: Obtain both subjective and objective data when assessing the client with Heart Failure

  • Health History
    • SOB, dyspnea with exertion, decreasing activity intolerance, number of pillows used for sleeping, recent weight gain, presence of a cough, chest or abdominal pain, anorexia or nausea, history of cardiac disease, previous episodes of heart failure, hypertension, diabetes, current medications, usual diet and activity and any recent changes.
  • Physical Examination
    • General appearance, ease of breathing, changing positions, apparent anxiety, vital signs, color of skin and mucous membranes, neck vein distention, peripheral pulses, capillary refill, presence and degree of edema, heart and breath sounds, abdominal contour, bowel sounds, tenderness, liver enlargement.
  • Diagnostic Tests
    • BNP, serum electrolytes, BUN, creatinine, digitalis levels, ABG results, ECG, echocardiogram, and chest x-ray reports.



Priority Nursing Diagnoses

Decreased Cardiac Output: Monitor VS and Oxygen Saturation. Report any trends in BNP levels. Tachycardia at rest is common. Auscultate heart and breath sounds regularly. Administer supplemental oxygen as needed. Administer prescribed medications as ordered. Encourage rest, elevate head of bed to reduce the work of breathing.

Excess Fluid Volume: Assess respiratory status and auscultate lung sounds q4h. Monitor I&O. Notify physician if urine output is less than 30 mL/h. Weigh daily. Record abdominal girth every shift. Monitor and record hemodynamic measurements. Restrict fluids as ordered.

Activity Intolerance: Organize nursing care to allow rest periods. Assist with ADLs as needed. Plan and implement progressive activities. Use passive and active ROM exercises as appropriate. Provide written and verbal information about activity after discharge.

Deficient Knowledge: Low-Sodium Diet Discuss rationale for sodium restrictions. Consult with Dietitian to plan and teach a low-sodium diet. Provide a list of high-sodium, high-fat, and high-cholesterol foods to avoid. Assist client to construct a 2-day meal plan choosing foods low in sodium. Encourage small, frequent meals rather than three heavy meals per day.




References:
LeMone, P. & Burke, K. (2008). Medical-Surgical Nursing: Critical Thinking in Client Care. Fourth Edition. (pp.1023-1039). Upper Saddle River, New Jersey: Pearson Prentice Hall.
(2008). 5 Million Lives Campaign. Getting Started Kit: Improved Care for Patients with Congestive Heart Failure How-to Guide. Retrieved Nov. 27, 2010 from Institute for Healthcare Improvement, Cambridge, Ma. Website: http://www.ihi.org/IHI/Programs/Campaign/CHF.htm