CONGESTIVE HEART FAILURE

Running head: CONGESTIVE HEART FAILURE !1

Caring for Congestive Heart Failure in Geriatric Nursing

Aleece Churney

James Madison University

Abstract

This paper provides an overview of Congestive Heart Failure (CHF) within the context of

geriatric nursing care. Pathophysiology, risk factors, signs and symptoms, diagnostic procedures,

and nursing considerations for the management of CHF are presented. Current best practice

recommendations specific to clinical geriatric care in the treatment of CHF are outlined with

empirical support from recent scholarly and peer reviewed research articles. Nursing

interventions for CHF centralize the importance of alleviating symptoms related to pulmonary

congestion and pain, improving mobility, decreasing risk of skin breakdown due to edema,

restoring fluid and electrolyte balance, and optimizing nutrition (Eliopoulos, 2018). Rationale for

the importance of understanding CHF within the geriatric nursing care setting are discussed.
CONGESTIVE HEART FAILURE !3

Caring for Congestive Heart Failure in Geriatric Nursing

Congestive Heart Failure (CHF) is a frequently encountered condition in geriatric nursing

care and the primary diagnosis for hospitalized individuals 65 years and older (Kemper, Carmin,

Mehta, & Binkley, 2016). Despite the prevalence of CHF, the five year survival rate remains at

50% and has not improved over the past two decades (Kemper et al., 2016). In addition to the

significant fatality rates, CHF is a financial burden in the United States that amounts to $30.7

billion dollars annually (Centers for Disease Control and Prevention, 2019). A major reason for

the hefty cost associated with CHF is the high incidence of hospital readmission that stems from

inadequate treatment and management of the condition (Kemper et al., 2016). According to the

American Heart Association (AHA), there are significant discrepancies in knowledge about CHF

and the cardiovascular system among nursing professionals. The AHA recommends healthcare

facilities provide nurses with educational opportunities to address common gaps in

understanding CHF including pathophysiology, risk factors, recognizing edema and reduced

cardiovascular output, diagnostic procedures, pharmacological interventions, and developing a

plan of care (Jurgens et al., 2015). An informative overview of geriatric nursing care for CHF

and current recommendations based on empirical research findings are provided.

Nursing Assessment for CHF

The pathophysiology and risk factors for CHF involve the interplay of modifiable

lifestyle behaviors and unmodifiable genetic predispositions. Traditionally, the primary

precipitating conditions for CHF were solely hypertension and coronary artery disease (Stamp et

al., 2018). Among older adults, hypertension typically manifests in women while men frequently

present with coronary artery disease (CAD). While the prevalence of hypertension exceeds
CONGESTIVE HEART FAILURE !4

double that of CAD, there is an 87% greater chance of developing CHF following a diagnosis of

CAD. The etiology of CHF among the elderly can also be related to valvular heart disease,

cardiomyopathy, pericardial disease, prolonged anemia, hyperthyroidism, and arteriovenous

shunting. Natural changes related to the aging process that lead to CHF include reduced

endothelial function, thinning capillaries, and decreased resiliency of the heart (Jurgens et al.,

2015). The modern exemplary CHF patient typically presents with several chronic medical

diagnoses coupled with other known predisposing stressors that contribute to increased cardiac

load including obesity, diabetes mellitus, kidney disease, albuminuria, sleep problems that

impact breathing, dyslipidemia, substance abuse, limited physical activity, and psychological

distress (Stamp et al., 2018; Eliopoulos, 2018). Awareness of the aforementioned contributing

factors for CHF can lead to timely nursing interventions that improve health trajectories for

individuals at risk.

In addition to understanding risk factors, it is important for nursing professionals to be

knowledgeable of CHF symptoms to advocate for patients and provide appropriate interventions

that support successful treatment. Due to the variability in the etiology of CHF, diagnosis is

based on the characteristic symptom profile of the condition coupled with laboratory evaluation.

Individuals with CHF often present with edema in the legs and feet, crackling sounds in the

lungs, and prominence of the jugular vein. Hallmark symptoms reported by CHF patients include

difficulty breathing and marked tiredness. Elderly patients with CHF most often present with

difficulty breathing when engaging in physical activity, as well as, confusion, nocturnal

wandering, agitation, depression, loss of appetite, and pulmonary wheeze. Nursing professionals

are advised to communicate these symptoms to the attending medical doctor for further
CONGESTIVE HEART FAILURE !5

evaluation (Eliopoulos, 2018). In addition to the aforementioned signs and symptoms, recent

research highlights novel considerations for the the diagnosis and treatment of CHF. A group of

researchers conducted a longitudinal mixed methods study to determine the reliability of

patients’ perception of their CHF symptoms and medical data collected from physical

examinations performed by healthcare providers. The results of the study uncovered that nearly

half of the enrolled patients demonstrated significant deficits in recognizing their CHF symptoms

(Riegel et al., 2018). Nursing professionals are tasked with the important responsibility of

cultivating an understanding of CHF symptomatology to best diagnose and treat these patients.

Nursing Diagnosis for CHF

Preliminary diagnostic evidence for CHF relies on a thorough physical examination and

review of the patient’s health history. The AHA recommends nursing professionals to focus on

edema and reduced cardiac output when assessing for CHF. Edema manifests in the form of

adventitious pulmonary sounds, presence of cough that worsens in the supine position, shortness

of breath, jugular vein distention, difficulty sleeping, anorexia, voiding at night, and fatigue.

Reduced cardiac output presents with inefficient perfusion to limbs and organs and is associated

with peripheral vascular disease, complaints of gastrointestinal upset, reduced kidney function,

myocardial infarction, transient ischemic attack, and stroke (Jurgens et al., 2015). Laboratory

testing for CHF measures blood levels of creatinine to determine renal health, a protein in the

blood known as albumin, as well as, electrolytes such as sodium and potassium (American Heart

Association, 2019). Collection of brain natriuretic peptide (BNP) levels are also recommended to

provide conclusive evidence supporting or eliminating a CHF diagnosis. BNP hormone levels

circulating in the blood are indicative of heart muscle strain (Yancy et al., 2017). An x-ray of the
CONGESTIVE HEART FAILURE !6

thorax region can provide confirmatory evidence for the presence of congestion in the lungs

associated with CHF (Jurgens et al., 2015). Following a CHF diagnosis, a nursing plan of care is

developed to provide comprehensive and appropriate treatment interventions.

Nursing Plan of Care for CHF

The nursing plan of care for CHF addresses skin integrity, mobility, medication

management, nutrition, fluid and electrolyte balance, and education. Patients with CHF are at an

increased risk of experiencing skin breakdown due to edema and reduced tissue perfusion.

Nursing interventions to prevent skin integrity issues include repositioning patients, reducing

moisture, using compression devices on the lower extremities, and consulting with dietary to

ensure adequate nutritional needs are supported (Eliopoulos, 2018). The risk for skin breakdown

can also be reduced through increasing the patient’s mobility. Mobility is especially difficult for

patients with CHF due to the reduced ability of the heart to adapt to physical activity, leading to

the rapid onset of fatigue and shortness of breath. The AHA recommends the integration of

aerobic, resistance, and inspiratory muscle training to improve mobility for CHF patients.

Neuromuscular electrical stimulation is a novel intervention for increasing mobility among CHF

patients; however, preliminary results are commensurate and permit implementation within the

clinical setting (Jurgens et al., 2015). Medications for CHF are interrelated to skin integrity and

mobility as they aid in alleviating associated symptoms of edema, fatigue, and dyspnea on

exertion.

The AHA recommends that nursing professionals are abreast of medications routinely

prescribed for the treatment of CHF. Diuretics are implemented to reduce edema and congestion

of the lungs. Of particular importance in geriatric care is the elevated risk of complications from
CONGESTIVE HEART FAILURE !7

diuretics in elderly patients including kidney dysfunction and electrolyte imbalances that cause a

reduction of magnesium, potassium, and sodium. Evidence suggests that neurohormones are

stimulated by diuretics in geriatric patients which raises the likelihood of mortality and

hospitalization. Angiotensin-converting enzyme inhibitors (ACEI) are associated with lowered

death rates and improvement in tolerance to physical activity. Beta-adrenergic blockers decrease

mortality, hospitalizations, and potentially lower risk of abnormal heart rhythms. However, some

patients report experiencing symptom exacerbations or abnormally low heart rate.

Mineralocorticoid receptor agonists demonstrate decreased death rates and hospitalizations. This

group of medications are more suitable for treating patients with advanced CHF and are not

advised for patients with co-morbid prolonged kidney dysfunction. Hydralazine and nitrates are

proven to be effective for African American patients with CHF, as well as, an alternative regimen

when the aforementioned medications are ineffective or produce adverse reactions. Lastly,

digoxin is typically administered when other medications are ineffective in treating CHF.

Geriatric patients, particularly women, necessitate reduced therapeutic dosing due to kidney

dysfunction and decreased body fat associated with aging (Jurgens et al., 2015). Although

pharmacotherapy interventions are necessary for managing CHF, nutritional deficiencies are a

common side effect.

Diuretics commonly lead to imbalances in vitamins that are water-soluble, such as

thiamine, as well as, minerals including calcium and magnesium. The majority of geriatric

patients experience deficiencies in vitamin D and E which leads to reduced functional ability,

stimulation of the renin-angiotensin system, enlarged and thickened ventricles, inflammation,

and decreased antioxidant functioning. These consequences have negative implications for CHF
CONGESTIVE HEART FAILURE !8

and result in deterioration of the condition. Patients diagnosed with CHF typically experience an

increase in metabolism which necessitates consumption of three to seven more calories per

kilogram of body weight per day to reach adequate nutritional needs. Roughly 20% more protein

compared to the average adult is needed to compensate for increased metabolic demands.

Sodium is contraindicated for CHF patients and reducing intake is associated with decreased

edema, fatigue, water retention, and readmission to the hospital. Providing meals with reduced

sodium and permitting patients to add salt at their own discretion has shown to be more effective

in decreasing total sodium consumption than prohibiting access to salt. Compliance with sodium

and other dietary restrictions relies on effective patient and caregiver education. Education about

vaccines including influenza and pneumonia, cessation of tobacco use, and dental hygiene are

also recommended for geriatric patients diagnosed with CHF (Jurgens et al., 2015). Addressing

the aforementioned topics with the patient and caregiver aid in improving adherence to self-care

guidelines for CHF.

Conclusion

CHF is a prevalent diagnosis in geriatric nursing practice and requires extensive

resources to adequately manage the condition. This topic is central to geriatric care due to the

commonality of CHF and the increasing prevalence of the condition with age (Kemper et al.,

2016). CHF is a complex diagnosis that interferes with systemic functioning of the body with

significant deficits in nutrition, mobility, and skin integrity. To complicate the condition further,

preliminary symptom presentation sometimes appears as a seemingly unrelated manifestation of

alternative diagnoses (i.e., genitourinary, sleep, or gastrointestinal disorders) (Eliopoulos, 2018).

In addition to geriatric care, patients with CHF are frequent visitors of acute care settings,
CONGESTIVE HEART FAILURE !9

especially within the hospital environment (Jurgens et al., 2015). For nursing professionals, CHF

is an especially unavoidable condition that is only increasingly common the older the population

becomes.
CONGESTIVE HEART FAILURE !10

References

American Heart Association. (2019). Common tests for heart failure. In American Heart

Association. Retrieved from https://www.heart.org/en/health-topics/heart-failure/

diagnosing-heart-failure/common-tests-for-heart-failure

Centers for Disease Control and Prevention. (2019). Heart failure fact sheet. In Centers for

Disease Control and Prevention. Retrieved from https://www.cdc.gov/dhdsp/

data_statistics/fact_sheets/fs_heart_failure.htm

Eliopoulos, C. (2018). Gerontological nursing (9th ed., pp. 277-280). Philadelphia, PA: Wolters

Kluwer.

Jurgens, C., Goodlin, S., Dolansky, M., Ahmed, A., Fonarow, G., Boxer, R., ... Rich, M. (2015).

Heart failure management in skilled nursing facilities. Journal of Cardiac Failure, 21(4),

263-299. doi:10.1016

Kemper, K., Carmin, C., Mehta, B., & Binkley, P. (2016). Integrative medical care plus

mindfulness training for patients with congestive heart failure: Proof of concept. Journal

of Evidence-Based Contemporary & Alternative Medicine, 21(4), 282-290. doi:

10.1177/2156587215599470

Riegel, B., Dickson, V., Lee, C., Daus, M., Hill, J., Irani, E., Lee, S., Wald, J., ... Moelter, S.

(2018). A mixed methods study of symptom perception in patients with chronic heart

failure. Hear & Lung, 47, 107-114. doi: 10.1016/j.hrtlng.2017.11.002

Stamp, K., Prasun, M., Lee, C., Jaarsma, T., Piano, M., & Albert, N. (2018). Nursing research in

heart failure care: A position statement of the American Association of Heart Failure

Nurses (AAHFN). Heart & Lung, 47, 169-175. doi:10.1016

Yancy, C., Jessup, M., Butler, J., Colvin, M., Drazner, M., Filippatos, G., ... Westlake, C. (2017).

2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the

management of heart failure. Journal of Cardiac Failure, 23(8), 628-651. doi:10.1016/

j.cardfail.2017.04.014