The document provides information on competencies for nurses caring for patients with heart failure. It defines heart failure and describes the different clinical classifications. It discusses identifying the underlying causes, nursing management including monitoring clinical parameters, diagnostic tests and biomarkers, medical management with diuretics and inotropes, and lifestyle modifications including diet and risk factor reduction for chronic heart failure patients.

1. Nurses’ Competencies in
Heart Failure
ABIJA V S RN,DCN
STAFF NURSE B -HFICU

2. INTRODUCTION
Competence
Competencies
Indicators
Knowledge, Skills, and Abilities
(KSAs)
A Guiding Frame
Work

3. “Competence of a nurse is a complex combination
of knowledge, function, skills, attitudes, and
values”.

4. Definition of Heart Failure
▪“Heart failure is the pathophysiologic state
in which the heart is unable to pump blood
at a rate to commensurate with the
requirements of the metabolising tissues or
can do so only from an elevated filling
pressure”
…..Eugene Braunwald

5. Clinical classifications of Heart Failure
Systolic: HF with Reduced Ejection Fraction (HFrEF)
 Impaired systolic function of the heart.
 Weakened cardiac Muscle, enlarged heart size.
 Left ventricular ejection fraction (LVEF)<40%
Diastolic: HF with Preserved Ejection Fraction(HFpEF)
 Inability of the heart to relax and fill.
 Stiff and thickened myocardial wall but normal size.
 LVEF ≥ 50%
HFmrEF: HF with Mid –range EF (40-50%)
 Elevated Natriuretic Peptides
 Diastolic dysfunction /LVH/LAE

8. Identifying the aetiology of Heart Failure.
▪ Identifying the aetiological factor-reverse the
ventricular remodelling and improve ventricular
function.
▪ Coronary artery disease ( 70% in Trivandrum registry)
▪ Dilated Cardiomyomapthy -13-18%
▪ Valvular heart disease
▪ Myocariditis
▪ Alchoholic cardiomyopathy
▪ Chemotherapy induced cardiomayopathy.

9. NURSING MANAGEMENT OF
HEART FAILURE

10. The nurse should be able to
conceptualize the clinical care needs for
a patient with heart failure.
Design and implement a care plan with
the interventions, which help to
moderate the disease process and
maintain the hemodynamics for the
patient.

11. ▪ Due to excess fluid accumulation:
▪ Dyspnea (most sensitive symptom)
▪ Tachycardia
▪ Edema
▪ Hepatic congestion
▪ Ascites
▪ Orthopnea,
▪ Paroxysmal Nocturnal Dyspnea (PND)
▪ Due to reduction in cardiac output:
▪ Fatigue (especially with exertion)
▪ Weakness
▪ Jugular vein distention
Clinical Presentation of Heart Failure

12. ▪ Dyspnea/Tachypnea
▪ S3
▪ Jugular venous distention
▪ Hepatojugular reflux
▪ Edema of legs and /or feet
▪ Abdominal ascites
▪ Enlarged Pulsatile liver
▪ Tenderness to palapation in right upper quadrant
▪ Rales (Can be absent)
▪ Anxiety/apprehension
Acute decompensated HF(ADHF)- CLINICAL
FEATURES

13. Acute decompensated HF(ADHF)
▪ Goals of the initial management of ADHF are
1. Hemodynamic stabilization
2. Normalising the fluid status
3. Improving the oxygenation and ventilation,
4. Improve the cardiac output
▪ All aiming at symptom relief and improved outcomes.

14. Hemodynamic monitoring in Acute
decompensated HF(ADHF)
▪ Patients with ADHF are at risk for hemodynamic instability and
arrhythmias, so close monitoring is necessary.
▪ The client is received in the ICCU
▪ Immediately connected to the telemetry to continuously monitor
▪ -ECG, SPO2 ,BP and RR (Continues for at least 24 to 48 hours.)
▪ Clinical parameters monitored
a) Heart Rate
b) Blood Pressure(Including Orthostatic BP)
c) Jugular venous pressure
d) Body Weight
e) Fluid intake and output
f) Abdominal girth if there is evidence of ascites.

15. Heart Rate
 The Heart rate is likely to be high, (Tachycardia) as
a compensatory mechanism to low cardiac output
and hypoxia.
 The volume (pressure of the pulse) is likely to be
shallow, of course due to low cardiac output.
 Furthermore, the patient presents with arrhythmia,
indicating uncoordinated cardiac output by poor
performing heart.

16. Blood Pressure
The blood pressure is likely to be subnormal.
 While the systolic pressure is designated to be lower than
normal, the diastolic pressure may be disproportionately
elevated or low – thus signifying circulatory congestion.
Respiration:
 The respiration may be fast to compensate for hypoxia,
yet it is shallow because of lack of energy in the body

17. Saturation:
 High flow oxygen is recommended in patients with a
capillary oxygen saturation < 90% or PaO2 < 60 mm Hg to
correct hypoxaemia.

18. Diagnostic Tests and Biomarkers.
A. BNP
▪ With chronic heart failure, atrial myocytes secrete increase amounts of
atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) in
response to high atrial and ventricular filling pressures.
▪ Helps to establish the diagnosis of heart failure (HF) in a patient in the
urgent care setting in whom the diagnosis is uncertain.
BNP
N-Terminal
Pro BNP
100-400pg/ml
< 50 years – 300-450 pg/mL
50-75 years – 300-900 pg/mL
>75 years – 300-1800 pg/mL

19. B. Serum Electrolytes
• Serum Sodium, Potassium and Magnesium- May require more
frequent monitoring in the initial stage when diuresis is rapid
C. Blood urea nitrogen and Serum Creatinine
D.Hb and complete blood count - Since anemia can exacerbate
heart failure.
E. INR if OAC is used or there is congestive hepatitis.
F. Urinalysis –albumin
G.Arterial Blood Gas evaluation is advisable when the patient is
drowsy or there is desaturation as monitored by pulse ox meter
H.LFT – Liver Enzymes and bilirubin
Diagnostic Tests and Biomarkers.

20. I.
▪ A 12 lead ECG should be performed initially on all patients
presenting with HF.
ECG MONITORING AND INTERPRETATION
A competent nurse is able to
1.Correctly prepare patient, equipment and environment for
recording of ECG
2.Describe the basic cardiac anatomy, the conduction system
and the normal PQRST complex.
3.Recognizes basic cardiac arrhythmias,

21. 4. To distinguish abnormal from normal ECG trace and refer to
another member of the Heart failure team
5. Critically analyses the appropriateness of varying interventions on
the ECG.
6. To initiate treatment in response to ECG analysis e.g. Pacing,
atropine, defibrillation, cardioversion,
7. Evaluate the impact of intervention on the ECG and suggests
alternatives

22. To assess
1. Heart size (Cardiomegaly)
2. Pulmonary Congestion
3. Detect other cardiac ,pulmonary diseases
that may cause or contribute to the
patients symptoms.
Non Invasive Cardiac Imaging
Chest x- ray

23. Echocardiogram:
A two dimensional echocardiogram with Doppler should be
performed during initial evaluation of patients to assess
1. Ventricular function
2. Size
3. Wall thickness
4. Wall motion
5. Valve Function.

24. Medical Management and Nursing
considerations

25. Diuretic therapy in ADHF
▪ Reduce fluid overload and congestion
▪ Produce symptom relief.
▪ 90% in ADHERE (Acute Decompensated Heart Failure National
Registry US) and
▪ 93% in THFR (Trivandrum Heart Failure Registry)- Where on
diuretics.
Most commonly used Diuretics are
Furosemide Torsemide
Half life 1.5 -2 hours 3.5 hours
Boluses 8-12 hrly 6 hrly
Initial I/V doses 20-40 mg 10-20 mg

26. How Diuretics Act
▪ Inhibit the reabsorption of sodium or chloride at different specific
sites in the renal tubule
▪ Increased Urinary Volume
▪ Decrease in ECF volume, total body NA and Water
▪ Reduction in filling pressure in the RV and LV
▪ Reduction in pulmonary congestion and peripheral congestion

27. IV Lasix Administration
▪ Direct IV bolus: Administer undiluted (larger doses may be diluted and
administered as intermittent infusion).
▪ Concentration: 10 mg/mL.
▪ Rate: Administer slowly at a rate of 20 mg/min..
▪ Intermittent/ Infusion: Dilute larger doses in 50 mL of D5W, D10W, 0.9% NaCl,
LR,
▪ Infusion stable for 24 hr at room temperature.
▪ Do not refrigerate. Protect from light.
▪ Concentration: 1 mg/mL.
▪ Rate: Administer at a rate not to exceed 4 mg/min (for doses > 120 mg) in adults
to prevent ototoxicity.

28. Inotropes in ADHF
▪ Patients with refractory hypotension should receive
temporary intravenous inotropic support to maintain
systemic perfusion and preserve end organ performance.
▪ Long term therapy with inotropes –Not effective and
may harm

29. ▪ Dobutamine as first line agent if SBP between 70 and 100
mm Hg in the absence of signs and symptoms of shock.
▪ Dopamine is recommended in patients who have the
same systolic blood pressure in the presence of
symptoms of shock.
▪ When response to a medium dose of dopamine or
Dopamine/dobutamine in combination is inadequate, or
the patient’s presenting systolic blood pressure is <70
mmHg, the use of Norepinephrine has been
recommended.
Inotropes in ADHF

30. Drug Dosage Comments
Dobutamine 2.5 – 5 µg/kg/min Decrease SVR
5 – 20 µg/kg/min No effect on SVR
Dopamine 5 -10 µg/kg/min No effect on SVR
10 -20 µg/kg/min Increases SVR
Milrinone 0.125 to 0.75
µg/kg/min
Bolus 25 – 75 µg/kg
over 10 -20 min
Potent positive
inotropic and
vascular smooth
muscle-relaxing agent
in vitro.
Inotropes Dosages

31. Levosimendan: A New Dual-Acting, Non-Arrhythmogenic
Drug in Decompensated Congestive Heart Failure
▪ levosimendan enhances myocardial contractility without
increasing oxygen requirements, and causes coronary
and systemic vasodilation.
▪ IV levosimendan appears to offer therapeutic benefits
without risk of arrhythmogenesis and/or uncertain
impacts on survival.
▪ Levosimendan was given as 10-minute loading dose (6
or 12 µg/kg) followed by a 24-hour infusion (0.1 or 0.2
µg/kg/min)

32. Chronic Heart Failure
Risk Factor Modification

33. Life styles modification for the patient
Teach the patient
to modify his/her
lifestyle, and
maintain ideal
body weight
Monitor and
maintain Blood
pressure and Blood
sugar levels (exp in
diabetes)
The patient should
be advised to avoid
both Active and
Passive smoking.
Advice to avoid
consumption of
alcohol because
alcohol compounds
to already retained
metabolic wastes
and as a result,
increases the risk
for metabolic
acidosis

34. Diet modification for the patient
Client needs to comply with the
golden rule of low salt Diet
Sodium intake 2g per day
While at the hospital, the patient is
provided with meals that are salt
free and fat free.
Salt free diet minimizes the risk of
fluid retention which places a load on
the ailing heart and fat free diet
minimizes the risk for ischemic heart
diseases.

35. Diet modification for the patient
The food should be soft
In a patient with a compromised body metabolism. Small
servings of meals are recommended.
Large meals place pressure on the heart, thus increases the
workload.
The patient should be advised to maintain a Semi-Fowler
position after every meal in order to alleviate pressure on the
heart.
Caloric food should be provided to supplement the energy.
Vitamin rich food should be offered to improve the patient’s
immunity because the patient’s immunity is low owing to the
low body metabolism

36. Fluid Intake
Fluid restriction of 1.5-2 l/day may be
considered in patients with severe symptoms
of Heart failure especially with Hyponatremia.
Routine fluid restriction in all
patients with mild to
moderate symptoms does not
appear to confer clinical
benefit.

37. Daily Weighing
Weigh your
client at the
same time
each day,
using the
same scale.
Ask the
client not to
wear shoes
Ensure that
the client
wears the
same dress
to check the
weight.
The best
time is in the
morning
after your
client go to
the
bathroom.
Check
weight daily
before
breakfast.
Have the patient record their weight using a
daily weight monitoring sheet.
A weight gain of 2 Kg over two days or 2.5 kg in
one week should be reported immediately.

38. PHYSICAL ACTIVITY AND EXERCISE TRAINING
 Regular, moderate daily activity is recommended for all patients
with heart failure.
 Exercise training is recommended, if available, to all stable
chronic HF patients.
 Regular aerobic exercise is encouraged in patients with heart
failure to improve functional capacity and symptoms

39. MEDICATIONS
The nurse’s task is to administer the medications
according to the prescription.
However, the nurse is expected to have the
knowledge of the therapeutic and side effects of
medications, in order to ensure progress of the
patient and to prevent treatment related setbacks.

40. Order of Therapy
1. ACE inhibitor (or ARB if not tolerated)
2. Beta blockers
3. Aldosterone blockers
4. Loop diuretics
5. Hyponatremia management
6. ARNI(Angiotensin Receptor Blocker+ Nephrilysin
Inhibitor
7. Ivabradine
8. Digoxin

41. Applications of ethical principles in caring
for the patient with heart failure
Patients are human beings with personal values, beliefs and
cultural principles.
Therefore, a patient with heart failure as an individual should
be provided professional care which is appropriate to his/her
needs for care, ethically guided and relevant to his or her
context.

42. Provision of counseling and health education to the
patient and the family
 Patients with heart failure should be counselled to accept and adapt
to their health status.
 Acceptance helps the patient to make use of the potential he/she is
left with,
 Make a constructive adaptation and therefore to live positively with
the illness

43. Health education for a patient with heart failure should
be organized around the issues of:
▪ Self-monitoring,
▪ Lifestyle modification,
▪ Diet,
▪ Medication self-administration
▪ And follow-up treatment,

44. Home Maintenance Plan :- Patient family education
about the following
 Sodium restriction
 Fluid limitation
 Medication schedule and effects
 Exercise prescription
 When to call health care provider for problems.
 Clinic appointment within 7 to 14 days