Heart Beats

Detecting decompensated heart failure

By Teresa Seright, PhD, RN, CCRN

Mrs. L opens the door and welcomes me into her sunlit home. Big band music floats into the living room
from the kitchen. Im immediately struck by Mrs. Ls
glow: her skin is beautiful, belying her 80-plus years.
She appears fit and gracefully moves about the room,
while she smiles and eagerly engages me.
At first, Im not sure this patient referral was appropriate. You see, Im at Mrs. Ls home because Im
conducting a pilot study on readiness for discharge in
patients with chronic obstructive pulmonary disease
and heart failure. But Mrs. L seems so healthy, I
wonder if shes really chronically ill with heart failure.
As it turns out, Im not the only person in Mrs. Ls life
who has been fooled by her vitality and strength.

MI to heart failure
Mrs. L and her husband shared more than 50 years
together, which she describes as the best. After
her husbands death 12 years ago, Mrs. L immersed
herself in her children and grandchildrens lives.
She was active with gardening, sewing, and socializing with friends. In fact, Mrs. Ls progression to
heart failure started soon after her husbands death
as she was planning a weekend craft fair excursion
with one of her daughters.
Mrs. L awoke with nausea and abdominal pain the
morning she was to depart for her daughters home.
When her symptoms didnt stop, she called her
daughter and cancelled their plans. Thinking she must
have the flu, Mrs. L retired early in hopes of sleeping
off her symptoms. She awoke the next morning feeling better, not entirely, but well enough to make the
trip to see her daughter. However, as she neared her
daughters home, the abdominal pain returned. She
began sweating heavily and became very nauseous.
Upon arrival to her destination, Mrs. L informed
her son-in-law, I think Im having a heart attack.
He reassured her that it must have been the traffic.
Fortunately, Mrs. Ls daughter arrived home from
her work as an RN. She listened to her mothers
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l Nursing2014Critical Care l Volume 9, Number 2

symptoms, gave her chewable baby aspirin, and

called 911.
Her daughter knew that women, and especially
those with diabetes, like her mother, often present
with atypical symptoms when theyre experiencing
a myocardial infarction (MI). Abdominal pain, nausea, and fatigue are common in these individuals,
rather than the classic radiating chest pain.1,2 That
evening, the cardiologist informed Mrs. L that she
hadnt one, but two MIs. She underwent coronary
artery angioplasty and endovascular stent placement that night.
After her diagnosis, Mrs. L was placed on an
angiotensin-converting enzyme (ACE) inhibitor,
aspirin, and furosemide. She was also given instructions to weigh herself daily, assess her oxygen
saturation, and manage her diabetes with diet,
exercise, and an oral hypoglycemic agent.3,4,5 (SEE
Evidence-based guidelines for heart failure discharge
teaching.) Mrs. Ls heart had incurred enough
damage that she was experiencing early stage heart
failure.
Soon, she was feeling well enough to resume her
busy social and family activities. Mrs. L describes
herself as a rule-follower: I changed my diet. I
weigh myself every morning and if I gain more
than 2 pounds in 1 day, I know I need to call my
doctor. I check my blood sugar and I take my
diabetes medicine the way I should.

Paying attention to context

Like many patients who require specialist care,
Mrs. L sees her cardiologist once a year and
otherwise follows up with her general healthcare
provider for management of her diabetes and
other problems as they occur. She lives in a small
community just blocks from a hospital, but
several hours from her cardiologist. My visit with
Mrs. L is preceded by a hospitalization less than
4 weeks earlier.
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Evidence-based guidelines for heart failure discharge teaching

Guideline topics

What

Why

Diet

Follow a low-sodium (1,500 to 2,000 mg)

diet.

Helps manage high BP and limits fluid

buildup.

Fluid restrictions

Limit fluids to 2,000 mL/day and record

all fluids.

Prevents fluid buildup when the heart and

kidneys are less efficient.

Weight checks

Weigh each morning wearing similar

clothing.

Weight gain may signify fluid retention due

to a less efficient heart and kidneys.

Record your weight each day in a

calendar.
Call your healthcare provider if you gain
2 lb (0.9 kg) in 1 day or 5 lb (2.3 kg) in 1
week.
Activity

Advance your activity as youre able.

Beneficial for managing BP and weight.

Cardiac rehab may be beneficial.

Call your healthcare provider or seek
immediate help if you experience chest
pain, a worsening cough, shortness of
breath, or if you cough up blood.
Medications

Your medicines may or may not include these listed here. Follow your healthcare
providers directions and dont take other medications, including over-the-counter drugs,
vitamins, or supplements, unless you check with your healthcare provider first.
ACE inhibitors

Reduce high BP

Beta-blockers

Reduce the workload of the heart

Aldosterone antagonists

Reduce water retention

Diuretics

Reduce water retention

Statins

Improve good cholesterol; reduce bad cholesterol, and reduce plaque buildup in arteries

Aspirin

Reduces likelihood of blockages in arteries

Other medications

Digoxin, anticoagulants

Helps the heart pump better; helps prevent

blood clots

Medications to avoid

Calcium channel blockers

Worsen heart and kidney function, which

worsens heart failure

Nonsteroidal anti-inflammatory drugs

COX-2 inhibitors
Appointments

Bring weight log and medication list

Write out questions ahead of time

Its very important to keep follow-up

appointments and come prepared

Bring someone you trust with you to

your appointments
Sources: Bonow RO, Ganiats TG, Beam CT, et al. ACCF/AHA/AMA-PCPI 2011 performance measures for adults with heart failure: a report of the American
College of Cardiology Foundation/American Heart Association Task Force on Performance Measures and the American Medical Association-Physician
Consortium for Performance Improvement. Circulation. 2012;125(19):2382-2401.
Manning S. Bridging the gap between hospital and home: a new model of care for reducing readmission rates in chronic heart failure. J Cardiovasc Nurs.
2011;26(5):368-376.
Suter PM, Gorski LA, Hennessey B, Suter WN. Best practices for heart failure: a focused review. Home Healthc Nurse. 2012;30(7):394-405; quiz 406-407.

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Heart Beats

Mrs. L describes the events leading up to her

hospital stay: I was going along really goodfor
a long time! Then one day, I noticed...I didnt
feel so great. My stomach, oh, it hurt. I wasnt
hungry. I would feel tired and my breathing
seemed harder. I just thought maybe I had the
flu. But, I also wondered if it was my heart. I
weighed myself, but I was not gaining weight
and yet, my pants were tight! After a few days of
this, I went to the doctor. She listened to my
heart and lungs, and thought maybe I just had an
allergy to whey.
Mrs. L left her office visit with instructions to
follow a dairy-free diet. She was weighed, but
with her reduced appetite and intake, the scale
didnt reveal any weight gain. Her healthcare
provider assured her that her lungs were clear.
Mrs. L continues: I went home and tried to do
my gardening, but I just couldnt. I checked my
oxygen level and it was 88%. I thought, I will

just rest. That night, I lay in bed and I couldnt

get my breath. I checked my oxygen level and it
was 78% or 79%. I called my son. He took me to
the ER and they gave me medications to get rid
of my water.
The individual with heart failure may maintain
or be in a compensated stateuntil something in
his or her regimen or disease process changes,
causing a decompensation. This was the case with
Mrs. L. Decompensated heart failure refers to a
deterioration, which may present either as an acute
or chronic episode.
Acute decompensated heart failure, marked by
pulmonary edema, is a medical emergency that
requires urgent interventions.5,6 Chronic decompensation is less obvious and often presents as
lethargy and malaise, a reduction in exercise
tolerance, and increasing breathlessness on exertion.5,6 If left untreated, chronic decompensated
heart failure will also progress to respiratory
distress, often but not
always due to pulmonary
Compensatory mechanisms in heart failure
edema, and eventual shock
from prolonged low cardiac
The Frank-Starling mechanism, sympathetic reflexes, renin-angiotensin-aldosterone
output.
mechanism, and left-ventricular hypertrophy help to maintain cardiac output for
The cause or causes of
the failing heart.7
decompensation must be
identified to guide treatment. Causes may include
Vascular resistance
recurrent ischemia, cardiac
(afterload)
dysrhythmias (such as atrial
fibrillation), infections, elecFrank-Starling
Cardiac contractility
mechanism
trolyte disturbances, nonadHeart rate
herence to medications, and
Cardiac
changes in diet.
Sympathetic
output
reflexes
Mrs. Ls history of atypical
Myocardial
presentation of myocardial
hypertrophy and
infarction provides the conremodeling
Renal blood flow
Vascular
tone
text for how she might presVenous return
ent with further damage.
Renin(preload)
angiotensinMore important, shes a
Angiotensin II
aldosterone
patient who has demonstratmechanism
ed a willingness to follow
Aldosterone
directions for heart failure
care: She watches her diet,
Adrenal
gland
weighs herself, keeps her
blood glucose levels under
Vascular volume
Sodium and
control, and checks her oxywater retention
gen saturation.

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Although allergies to food can cause nausea and

abdominal pain, Mrs. Ls past medical history points
to other, more likely, causes of her symptoms.
However, you may be wondering why her weight
didnt increase and why her lungs were clear at her
clinic visit.

A subtle presentation
Dont be fooled into thinking that all patients
with decompensating heart failure will present
with classic signs and symptoms including peripheral edema, pulmonary crackles, and hypotension
(see Clinical manifestations of decompensated heart
failure). Initially, many patients may be able to compensate and wont always have pulmonary edema.
Anorexia from nausea can mask weight gain secondary to edema, pointing to fluid volume excess.
In Mrs. Ls case, she was well controlled on her
diuretic and ACE inhibitor and, according to her, My
heart doctor said my heart still pumped pretty good.
Interstitial pulmonary edema can develop in
patients with right- and left-sided heart failure.
Dyspnea may be present, but pulmonary congestion may not readily be detected.7 Interstitial edema

Clinical manifestations of
decompensated heart failure
Volume excess
Decreased exercise tolerance
Shortness of breath, especially with exertion
Edema
Weight gain
Right-upper quadrant tenderness
Pulmonary crackles (not always present)
Increased jugular venous pressure
Hepatojugular reflux
S3
Low cardiac output
Decreased exercise tolerance
Fatigue
Malaise
Weight loss
Anorexia
Cachexia
Narrow pulse pressure
Cool extremities
Tachycardia
S3 and S4

Initial diagnostic studies for suspected decompensation

Diagnostic study

Rationale

Serum electrolytes, serum creatinine,

blood urea nitrogen

Assess renal function

Complete blood cell count

Assess for anemia

Thyroid function panel

Exclude thyroid disease

Liver function tests

Assess for right-sided heart failure or worsening left-sided heart failure

Urinalysis

Assess for nephrotic syndrome

BNP

Greater than 100 pg/mL indicates worsening heart failure; rises in proportion to severity of heart failure

Serum cardiac troponins

Evaluates ongoing myocardial injury

CXR

Assess for pulmonary infiltrates/congestion

Echocardiogram

Evaluate for wall motion and valvular abnormalities, determine ejection

fraction (less than 35-40% indicates heart failure)

SpO2

Less than 90% indicates hypoxia

Arterial blood gases (ABGs)

Evaluate acid-base balance, oxygenation, and ventilation

Electrocardiogram (EKG)

Evaluate for dysrhythmias, left-ventricular hypertrophy, and myocardial

ischemia, injury, and infarction

Sources:
1) UCLA Heart Failure Clinical Practice Guideline Summary-2011. http://medres.med.ucla.edu/Practices/CHFmg11a.pdf
2) Jessup et al. (2009). 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the
American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: Developed in Collaboration With the
International Society for Heart and Lung Transplantation http://circ.ahajournals.org/content/119/14/1977.full.pdf

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Heart Beats

must be confirmed by chest X-ray (CXR). In Mrs. Ls

case, an CXR wasnt obtained.
B-type natriuretic peptide (BNP) analysis is an
important diagnostic study.5,6,8 BNP naturally produced by the body in response to fluid volume overload as sensed by the cells in the ventricles. When
elevated, BNP indicates the body is attempting to
gain or maintain balance in the face of decompensating heart failure. Other diagnostic studies that
may have revealed Mrs. Ls decompensation include
serum cardiac biomarkers, a 12-lead ECG, liver
function tests, a complete blood cell count, and
serum chemistries5,6,8 (see Initial diagnostic studies
for suspected decompensation). According to Mrs. L,
no blood work was drawn at her office visit.

Collaborative care
Patients who show signs and symptoms of decompensation (acute or chronic) should receive interventions to support their oxygenation, perfusion,
and comfort (see Immediate interventions for decompensated heart failure). In some cases of severe acute
decompensation, the patient may require intra-aortic balloon counterpulsation or biventricular pacing.
Intra-aortic balloon counterpulsation improves cardiac output by decreasing afterload (the pressure
against which the left ventricle must pump) and
increases coronary artery blood flow. Biventricular
pacing restores ventricular synchrony which
improves cardiac output.
The most important part of the nursing process
we can implement on behalf of our patients is to
first and foremost listen to them, while performing
an appropriate focused physical assessment.1,2,4,6-10
A patient with a history of diabetes, previous heart
damage from an MI, and subsequent heart failure
is at risk for decompensation. This may occur
acutely or gradually in the patient with chronic
heart failure.
REFERENCES
1. Mayer, D. & Rosenfeld, A. (2006). Symptom interpretation in women
with diabetes and myocardial infarction: A qualitative study. Diabetes
Educator. http://tde.sagepub.com/content/32/6/918 DOI: 10.1177/
0145721706294262
2. Devon, H., Ryan, C., Ochs, A., & Shapiro, M. (2008). Symptoms
across the continuum of acute coronary syndromes: Differences between
women and men. American Journal of Critical Care (AM J CRIT CARE),
2008 Jan; 17 (1): 14-25.
3. Manning, S. (2011). Bridging the gap between hospital and home:
A new model of care for reducing readmission rates in chronic heart

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l Nursing2014Critical Care l Volume 9, Number 2

Immediate interventions for

decompensated heart failure
Oxygenation
Raise the head of the bed, unless medically
contraindicated.
Assess ABG results and provide oxygen therapy as
prescribed; some patients may require endotracheal
intubation and mechanical ventilation.
Administer diuretics as prescribed.
Perfusion
Administer ACE inhibitors as prescribed.
Aldosterone antagonists may also be given to
eliminate excess fluid and improve perfusion.
Administer vasodilators, as prescribed, to decrease
preload, afterload, or both.
Comfort
Provide reassurance and patient teaching.
Position the patient for easiest breathing (usually
with the head of the bed elevated).
Administer drug therapy as prescribed, including
I.V. diuretics and supplemental oxygen.
Reduce myocardial oxygen demand by planning
nursing interventions and other activities around
adequate rest periods.
failure. The Journal of Cardiovascular Nursing, 26(5), p. 368-376.
doi:10.1097/JCN.0b013e318202b15c
4. Bonow, R.O. et al. (2012). ACCF/AHA/AMA-PCPI 2011 Performance measures for adults with heart failure. Circulation 125:
2382-2401
5. Owens, A. & Jessup, M. (2012). The year in heart failure. Journal of
American College of Cardiology, 60(5), p. 359-368. doi.org/10.1016/j.jacc.
2012.01.064
6. UCLA Cardiology Clinical Guidelines: HYPERLINK http://www.
med.ucla.edu/champ www.med.ucla.edu/champ
7. Porth CM (2010) Essentials of Pathophysiology, 3E, North
American Edition p. 492.
8. King, M., Kingery, J. & Casey, B. (06/15/2012). Diagnosis and
evaluation of heart failure. American Family Physician (0002-838X),
85 (12), p. 1161. http://www.aafp.org/afp/2012/0615/p1161.html
9. Sauer, J., et al. (2010). Nurses performance in classifying heart
failure patients based on physical exam: comparison with cardiologists physical exam and levels of N-terminal pro-B-type natriuretic
peptide. Journal of Clinical Nursing, 19, 3381-3389 3381 doi: 10.1111/
j.1365-2702.2010.03403.x
10. Suter PM, Gorski LA, Hennessey B, Suter WN. Best practices
for heart failure: a focused review. Home Health Nurse.
2012;30(7):394-405; quiz 406-407.
Teresa Seright is an associate teaching professor of nursing at Montana
State University, in Bozeman, Mont.
Adapted and updated from Seright T. Detecting decompensated heart failure.
Nursing Made Incredibly Easy, 2013;11(3):12-16.
The author has disclosed that she has no financial relationships related to
this article.
DOI-10.1097/01.CCN.0000444006.46306.7a

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