How to Recognise Heart Failure: Essential Reading for Nurses and Patients

History and Background: People are living longer with heart failure because the quality of care and treatments are improving. Consequently more patients with heart failure are alive and well. Some of them will invariably be hospitals, retirement homes, and in nursing homes under the care of trained and untrained nurses. Currently there are more than six million patients with heart failure who are alive and relatively well. Each year more than six hundred and seventy thousand new patients are diagnosed. These figures are from the US only.  

Heart failure is one of the most common conditions seen on all wards in all institutional settings – hospitals, nursing homes, and retirement homes. It is important for all nurses to be able to recognize the early signs and symptoms of heart failure. Early detection and appropriate interventions are relatively easy, cheap, and life saving. It is literally a matter of routine to give the patient with heart failure a diuretic for shortness of breath. The patient begins to feel better and there is minimal stress on the nurse and other care givers. Late detection is costly, time consuming, and may result in the patient’s death. This type of situation is very stressful to the nurse and other care givers though they may not display any sign of stress when they are on duty.

As a practising nurse I often go home and think about what I did extremely well and what I could have done better. This practice allows me to register certain activities which are higher on my unwritten list of priorities. I know as a matter of fact that I must attend to and intervene as soon as I see a patient who is in pain, short of breath or is diaphoretic. Preventing bad situations from getting worse allows me uninterrupted time to deal with routine stuff. All nurses know that we use the word routine quite a lot but there is no such a thing as routine. No two days are ever alike.

View of human heart and associated blood vessels. Image via Wikipedia

Definition of Heart failure: Heart failure is said to occur when the heart loses its ability to pump adequate amounts of blood efficiently through to the lungs (pulmonary circulation) or to the body (systemic circulation). Blood circulation is necessary to maintain the metabolic and catabolic body processes; these are collectively called respiratory processes. The blood circulating blood carries oxygen and nutrients to the body parts which need them most. The cells, tissues and organs use the oxygen and nutrients to provide the body with the energy and raw materials it needs for functions of life.

The Heart: The heart is a highly vascular and muscular organ which consists of four chambers. The two upper chambers are small and are called the atria. The lower chambers are larger and are called ventricles. The functioning of all the chambers of the heart is coordinated by an internal nervous system, the SA node, the AV node, sympathetic and parasympathetic nervous system. To make the matter more complex, it must be noted that in the absence external stimuli the atria and the ventricles have their own intrinsic contraction rates.

Pulmonary and Systemic Circulations: The heart is often described as a double pump. Each pump consists of one atrium and one ventricle. Blood is received by the atria and pumped out by the ventricles. The right atrium receives deoxygenated blood from the systemic circulation and the right ventricle pumps this blood to the lungs to be oxygenated. This circulation is called the pulmonary circulation. The left atrium receives oxygenated blood from the lungs and pumps the oxygenated blood to the body. This is called the systemic circulation.

Heart’s Circulation. The heart is richly supplied by oxygenated blood through the coronary arteries. The right and left coronary arteries are the first branches which come off the arch of the aorta. Deoxygenated blood returns to the right atrium through the coronary sinus which is a small opening into the right atria.

Heart failure is said to occur when the heart muscle, technically known as the myocardium, is unable to pump sufficient amount of blood to the body. Heart failure is of many different types and is caused by many factors. Left sided heart failure is said to occur when the left ventricle fails to pump sufficient blood to the body. Right sided failure is said to occur when the right ventricle is unable to pump arriving quantities of blood to the lungs. Lung diseases most frequently cause right sided failure because the workload of the ventricle is increased because it has to force blood through the pulmonary circulation which is occluded by fibrous tissue or other pathology.

                                                        Heart Failure, Types

Left Ventricular Failure (LVF): This type of failure occurs when the left ventricle is unable to pump blood which is arriving from the lungs. This leads to a build up of fluids in the lungs. The first signs and symptoms of left ventricular failure will be those associated with congestion of the lungs.

Right Heart Failure (RVF): Right Ventricular Failure is said to occur when the right ventricle is unable to pump blood which is arriving from the systemic circulation. The first signs and symptoms of right ventricular will be those associated with systemic congestion. Venous pressure will rise in the legs and the abdominal organs. Finally the liver too will be congested.

Complete Heart Failure (CHF) or Complete Cardiac Failure (CCF).This type of failure also called bi ventricular failure. In this condition both ventricles have failed. Bi-ventricular failure is usually comes after left ventricular failure because the back up of accumulated fluid in the lungs eventually affects the right atrium and right ventricle.

Signs & Symptoms of Heart Failure

The left ventricle is the most powerful pump of the heart. When the ventricle fails then Left-sided heart failure is said to occur. Left sided heart failure will produce the following signs and symptoms. Early recognition can prevent a patient from going into complete failure and eventual death.

1. Any patient who coughs frothy sputum is obviously in heart failure. It does not matter how busy the nurse is she must insure that the treating physician is aware of the patient’s condition. Early intervention will save time and energy later. Before you call the physician observe the sputum. If the sputum is blood stained and has greenish mucus in the froth then the patient’s condition is relatively more serious. The physician must be informed of all these, seemingly minor details.
2. Another early sign of heart failure is decreased urine production. This is easy to evaluate if you are doing hourly urine measurements. Each adult patient must produce half his body weight in output each hour. For example, if the patient weighs 80 Kg then he must produce 40 ml of urine each hour. In a patient who is not catheterized this can be hard to evaluate. Fluid balance charts, if accurately maintained can give a good indication of urinary output. I am sure nurses already know that the decreased is due to renal hypotension related to renal perfusion deficit.
     
3. Patients with heart failure often experience difficulty lying down. Patients with chronic heart failure will often tell nurses that they need to sleep with the head elevated to avoid shortness of breath. I have looked after many patients who slept on arm chairs because that was the only way they could get some sleep without drowning in their circulatory fluid due to heart failure.
4. Patients with heart failure often complain of fatigue, weakness, and feeling faint. These symptoms are due to tissue hypoxia. It is for this reason that patients in heart failure are given oxygen therapy.
    
5. Cardiac rhythm disturbances, arrhythmias and tachycardia are frequent. The tachycardia is due to the fact that the heart is trying to increase cardiac output in an effort to correct hypoxia. Radial heart rate will be felt as irregular. Normal heart beats are regular and have good volumes.
6. Most patients suffering from heart failure have enlarged hearts. The can often feel their heart beating. The palpitations may actually keep the patient awake during the night.
7. Shortness of breathis the first classical sign of heart failure. This is due to the accumulation of fluid in the lungs. The standard treatment is the administration of diuretics.
      
8. Many heart failure patients will go to bed feeling fine but with a little pulmonary edema which is of no consequence when the patient is sitting on a chair of standing upright. Patients with severe heart failure usually wake up a few hours later due to shortness of breath. This is called paroxysmal nocturnal dyspnea.This is due to fluid buildup in the alveolus of the lungs. When the patient sits up in bed, coughs a little, and walks a little he will feel better. This is due to the fluid shifting from the alveolus to the ankles.  
9. Patients suffering from heart failure will gain weight from fluid retention. For this reason heart failure patients in the CCU and/or ICU should be weighed each morning and the weight recorded for future comparison. Weight gain means that the patient’s heart will have to work harder. If it has to work harder it is more likely to fail.  

Conclusion: Early detection of heart failure and avoidance of activities which lead to heart failure will lead to improvement in the quality of life and the patient will live longer.

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