Page 260 - ACCCN's Critical Care Nursing

Cardiovascular Alterations and Management 237

symptoms when they occur. It involves cognitive decision heart failure physical activity should be undertaken under
making, requiring the recognition of signs and symptoms the supervision of trained heart failure specialists, e.g.
that indicate a change in condition, which is based on physiotherapist or exercise physiologist, who can tailor
knowledge and prior experiences of deterioration. 71-73 the level of exercise to the degree of severity of symptoms.
Many CHF patients have co-morbidities such as arthritis,
Lifestyle Modification and Self-care which make exercise programs difficult, but maintaining
Management general activity should be encouraged.
Patient education is the key to self-management and Dietary sodium intake should be reduced to 2 g/day for
must include family members to be effective. Patient edu- patients with moderate to severe heart failure and to 3 g/
cation should include information on the following: day for mild heart failure. Reduction in sodium intake
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● the disease process. This involves discussing what helps reduce fluid retention, diuretic requirements and
heart failure is, signs and symptoms and why they potassium excretion. A large proportion of an individu-
occur, and strategies to improve their symptoms al’s sodium intake can come from processed foods, so
● lifestyle changes patients are encouraged to read nutrition labels and
● medications and side effects reduce the intake of these foods. Salt intake can also be
● self-monitoring and acute symptoms reduced by avoiding adding salt in cooking or to meals.
● the importance of adherence to their medications and As CHF patients who are overweight increase demands
management plan. on their heart, weight loss by lowering dietary fat intake
may improve symptoms and quality of life. These patients
Restriction of fluid to 1–1.5 L/day is one of the most may require referral to a dietician for weight loss manage-
important strategies that patients can adhere to in order ment. In patients with moderate to severe heart failure,
to improve their symptoms. Patients are encouraged to cardiac cachexia and anaemia are common which further
weigh themselves daily and to identify any increase in exacerbate weakness and fatigue. These patients will
weight as an increase of 1 kg equals 1 litre of excess fluid. require a referral to a dietician for nutritional support.
National guidelines stipulate that if their weight increases Other lifestyle changes are: smoking cessation, ideally no
by 2 kg over 2 days they need to see their local doctor as alcohol otherwise limit alcohol to less than 2 standard
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soon as possible. Patients that adhere to their manage- drinks/day (alcohol is a myocardial toxin and reduces
ment plan and closely monitor their daily weight may contractility), limit caffeinated drinks to 1–2 drinks/day
self-manage their volume status by using a flexible diuretic (to decrease risk of arrhythmias), control diabetes, annual
action plan as developed by their cardiologist. In addi- vaccinations for influenza and regular pneumococcal
tion, patients should be advised of early warning signs of disease vaccinations. 55
excess fluid volume and decompensation, such as increas-
ing dyspnoea, fatigue and peripheral oedema. Palliative care may be more appropriate for patients
with end-stage heart failure who are experiencing signifi-
Sleep apnoea also occurs commonly in CHF patients. cant symptoms, prescribed maximal pharmacotherapy,
There are two types: obstructive sleep apnoea and central frequent hospital admissions and poor response to
sleep apnoea. Obstructive sleep apnoea occurs due to treatment.
airway collapse and is associated with obesity. It can be
treated with weight reduction and night-time continuous
positive airway pressure (CPAP). The use of CPAP for Practice tip
obstructive sleep apnoea results in an improvement in
LVEF due to an increase in left ventricular filling and When considering if a patient is suitable for palliation, discus-
emptying rates, and a decrease in systolic blood pressure sion also needs to include deactivation of their pacemaker
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and left ventricular chamber size. Central sleep apnoea or implantable cardioverter defribillator (ICD).
(Cheyne-Stokes respirations) occurs due to pulmonary
congestion and high sympathetic stimulation in patients
with severe heart failure and may be treated with CPAP. Pharmacotherapy in patients with heart failure is vital,
However, the benefits of oxygen therapy have not been and includes an array of drugs that require careful man-
proven. However, exercise is equally important, to prevent agement. In Australia and internationally, nurse practitio-
the deconditioning of skeletal muscle that occurs in CHF. ners are authorised to titrate some heart failure medications,
Exercise training – including walking, exercise bicycle and including diuretics and beta-adrenergic blocking agents.
light resistance – has been shown to improve functional Pharmacists also provide essential patient education, and
capacity, symptoms, neurohormonal abnormalities, support the optimisation of medication treatments and
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quality of life and mood in CHF. The Heart Foundation management of complex medication schedules. Some
of Australia recommends that all stable CHF patients, major hospitals have a pharmacist outreach program
regardless of age, should be considered for referral to a where a pharmacist visits the patient at home.
tailored exercise program (preferably a heart failure spe-
cific exercise program) or modified cardiac rehabilitation Medications
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program. Heart failure exercise programs comprise Pharmacological management relies on the following
resistance training and have been shown to improve func- categories of drugs: ACE inhibitors, beta-adrenergic
tional capacity, heart failure symptoms and survival and blocking agents, angiotension receptor blocking agents
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reduced hospitalisations. In patients with symptomatic (ARBs), diuretics, digoxin and antiarrhythmic drugs.