Class	Activity Tolerance
I	Ordinary physical activity with no symptoms
II	Dyspnea with long-distance walking, climbing 2 flights of stairs or strenuous activity
III	Dyspnea and fatigue with short-distance walking or climbing 1 flight of stairs
IV	Dyspnea at rest or with very little activity

Adapted from the New York Heart Association Heart Failure Symptom Classification System. Retrieved from www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/heart-failure.

Etiology

The most common causes of HF are coronary artery disease and uncontrolled hypertension. Other factors that contribute to weakness of the heart muscle are toxins, infection, anemia, myocarditis, dilation from blood backup behind diseased valves, and damage from myocardial infarction (MI) (Concept Map 20-1). Toxins include cocaine, excessive alcohol, certain chemotherapy

Elder Care Points

Heart failure is the most common reason for hospitalization among adults age 65 or older. As life spans continue to extend, more and more elderly adults will develop HF related to hypertension and CAD.

drugs, nonsteroidal anti-inflammatory drugs (NSAIDs), thiazolidinediones used for diabetes, and doxazosin (Cardura) (Coviello, 2009). Cardiac dysrhythmias also can contribute to HF. (Coronary artery disease [CAD] and MI are covered in Chapter 21, along with cardiac surgery.)

Pathophysiology

The key words to understanding HF are congestion and increased pressure. Congestion develops because the heart is unable to move blood as quickly as it should. This may occur because the heart muscle is too weak or because the blood vessels throughout the body are narrowed and constricted (due to atherosclerosis or arteriosclerosis). Therefore the vessels cannot accommodate a normal supply of blood, causing the heart muscle to become exhausted trying to overcome the resistance (pressure) in the vessels. Poorly functioning valves may cause the chambers to dilate from blood backup, causing thinning of the myocardium and decreased pumping ability. Box 20-1 lists factors that precipitate HF.

Elder Care Points

Aging processes also contribute to arteriosclerosis and stiffening of the heart muscle. The combination of high blood pressure, diabetes, and age greatly contributes to the number of older patients who develop HF.

Box 20-1

Factors that Can Precipitate Heart Failure

• Anemia

• Systemic infection (sepsis)

• Pericarditis, myocarditis, or endocarditis

• Thiamine deficiency

• Chronic pulmonary disease

• Physical, emotional, or environmental stress

Heart failure may be classified as right-sided HF or left-sided HF. The heart has two pumps: a right-sided and a left-sided pump. The right-sided pump receives blood from the body and pumps it to the lungs for oxygenation. The left-sided pump receives blood from the lungs and pumps it out to the body. Left-sided failure typically occurs first. Normally, the ventricles of the heart contract, while the atria relax, allowing for the filling and emptying of each chamber. If the muscle wall of the left ventricle cannot contract effectively, some of the blood is left in the ventricle—this residual blood prevents part of the blood in the left atrium from progressing into the ventricle. The blood that cannot leave the left atrium prevents the entrance of some blood from vessels, and, in turn, blood backs up into the pulmonary vessels. The pressure within those vessels increases, and fluid leaks into the lung tissue—producing congestion and, eventually, pulmonary edema. If not corrected, left-sided failure, because of the backup of blood and increased pulmonary artery pressure, will soon lead to failure of the right side of the heart. Table 20-2 compares the signs and symptoms of left-sided and right-sided HF.

Table 20-2

Comparison of Left-Sided and Right-Sided Heart Failure

	Right-Sided Heart Failure	Left-Sided Heart Failure
Selected etiology	Pulmonary stenosis, pulmonary hypertension Severe emphysema, right ventricular MI	Hypertension, coronary artery disease, MI, mitral or aortic valvular disease
Pathophysiology	Increased pump pressure needed to eject blood into pulmonary arteries. The myocardium of the right atrium and ventricle becomes thickened, and contraction strength weakens	Weakness of the left ventricle resulting in reduced cardiac output and backup of blood into the atrium and the pulmonary system
Signs and symptoms	Fatigue; edema in sacrum, legs, feet, ankles; hepatomegaly; abdominal distention as a result of ascites; weight gain; dyspnea	Fatigue; dyspnea; wheezing; orthopnea; sleep apnea; pulmonary edema (pink, frothy sputum); pallor; clammy skin

MI, myocardial infarction.

Primary right-sided heart failure is often caused by chronic pulmonary disease. If the right ventricle does not contract as strongly as it should, the ventricle cannot completely empty and becomes engorged with blood. More blood flow into the engorged ventricle causes overfilling and dilation of the chamber, slowing movement of blood out of the atrium. As blood in the atrium backs up, it prevents normal movement of blood flow from the vena cava, thus increasing the pressure in the vena cava, the neck veins, and all other veins of the body.

As the rate of blood flow slows down and pressure in the vessels increases, the fluid from the intravascular fluid compartment begins to leak into the interstitial compartment. This produces retention of fluid and edema. When the right side of the heart fails, the edema is first evident in the lower extremities (dependent or pitting edema; Figure 20-1). There also is an accumulation of fluid in the liver and abdominal organs, as the portal circulation becomes involved. Congestion of blood flow to and from the kidneys may lead to impaired renal function, preventing normal excretion of urine and causing more accumulation of body fluids. Inadequate circulation to and from the brain may cause mental confusion and irritability, which sometimes progresses to delirium and coma.

The systemic backup of blood that occurs in right-sided HF may eventually lead to left-sided heart failure, as the heart will have to pump against increasing pressure in the aorta and systemic circulation. The circulatory system is exactly that: a system. Failure of one component affects the entire system.

Think Critically

Can you describe the changes that occur with chronic hypertension that may cause heart failure?

Left-sided heart failure is subdivided into systolic and diastolic heart failure. In the cardiac cycle, atria fill and allow blood flow to the ventricles; the ventricles fill and then eject blood into the circulatory system. Different problems cause failure of this process. Here the problems occur in the upper or the lower chambers of the heart.

Systolic Failure

Systolic failure is caused by anything that interferes with ejection of blood from the ventricles. Muscle loss problems from MI, dilated cardiomyopathy, and aortic or pulmonic stenosis may lead to systolic failure.

Diastolic Failure

Diastolic failure occurs when conditions prevent the filling of the heart with blood. Tricuspid and mitral stenosis, cardiac tamponade, or constrictive cardiomyopathy can cause diastolic failure. Decreased filling results in decreased stroke volume and cardiac output. Ejection fraction is normal in primary diastolic failure. Ejection fraction is the percentage of the filling volume pumped out with ventricular contraction. A hallmark of diastolic failure is neck vein (jugular) distention.

Think Critically

Can you explain to a patient in simple terms what happens in the body when systolic HF occurs?

Signs, Symptoms, and Diagnosis

Initially, compensatory mechanisms prevent symptoms of HF. Heart rate rises to increase output and the ventricles hypertrophy in order to pump out more blood with each contraction. In left-sided failure compensatory mechanisms eventually weaken the heart and the blood backs up into the pulmonary vessels, pressure within those vessels increases, and fluid leaks into the lung tissue, producing congestion. Fatigue and shortness of breath (SOB) are first noticed with activity and when lying down. If failure progresses, pulmonary edema occurs. Diagnosis is made on the basis of history, examination, signs and symptoms, chest x-ray, echocardiogram, electrocardiogram (ECG), magnetic resonance imaging (MRI), electrolytes, complete blood count (CBC), and brain natriuretic peptide (BNP). BNP measures the level of a protein released when myocardial cells are stretched. A level greater than 500 pg/mL is consistent with HF when other symptoms are present (see Table 20-2).

Advanced systolic HF signs are S₃ and S₄ heart sounds. Weight gain of 2 lb in 24 hours or 5 lb in 1 week occurs as fluid is retained. Dyspnea and crackles or wheezes are heard in the lungs.

Think Critically

You auscultate the lung sounds of a patient with HF. You hear crackles. Which side of the heart is failing?

Treatment

Treatment of the underlying cause of HF should be initiated. Dysrhythmias are controlled. Surgical correction of valve or septal abnormalities may reverse HF. Medical treatment is largely symptomatic and depends on the type and degree of HF present. Drugs and other therapies are used to reduce or eliminate the symptoms and complications of HF, but they only control the condition; they do not cure it. Efforts are made to (1) reduce the demand for oxygen and the workload of the heart; (2) strengthen the heart’s pumping action; (3) relieve venous congestion in the lungs; and (4) minimize sodium and water retention in the tissues (Jessup et al., 2009).

To accomplish the goals of medical intervention, the following may be prescribed:

• Angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) decrease the workload of the heart by causing vasodilation; as a result, blood pressure is reduced (Table 20-3). ACE inhibitors and ARBs also play a role in reducing fluid retention.

• Beta-adrenergic blockers (e.g., metoprolol [Toprol XL]) are used to slow the heart rate if tachycardia is causing the HF, thereby decreasing oxygen demand. Beta blockers are used cautiously as they can also cause HF.

• Diuretics, especially loop diuretics, are prescribed to reduce fluid retention in the lungs and lower extremities. Watch for ototoxicity with these drugs. Thiazide diuretics such as hydrochlorothiazide (Diuril) may also be prescribed. Measures are taken to prevent electrolyte imbalances from the use of these drugs.

• Digitalis is occasionally used to increase the force of heart contraction (i.e., an inotropic agent) and slow the rate, thereby increasing cardiac output. The most commonly used drug in this category is digoxin (Lanoxin). Several large doses of the drug are given initially, followed by a lower, regular-maintenance dosage. This drug is not recommended for elderly white women because it increases mortality rates in this group.

• Venous vasodilators such as isosorbide dinitrate (Isordil) and nitroglycerin (NTG), which relax and dilate blood vessels, allow the vessels to accommodate larger percentages of the total blood volume.

• Morphine is prescribed if pulmonary edema is present to relieve anxiety and make breathing easier.

• Benzodiazepines may be used for anxiety and reduction of emotional stress.

• Limited physical activity or bed rest in semi-Fowler’s or high Fowler’s position.

• Oxygen therapy.

• Lifestyle modifications, including regular exercise as tolerated, and possible limitation of sodium intake to 2 to 3 g/day; in severe cases, restriction of fluid intake (Heart Failure Society of America, 2009).

• Dobutamine (Dobutrex) or milrinone (Primacor) may be used intravenously (IV) for acute HF to improve cardiac contractility.

Table 20-3

Drugs Used to Treat Heart Failure *

Classification	Examples	Use
Diuretics		Remove excess fluid
Loop	Furosemide (Lasix), bumetanide (Bumex)
Potassium sparing	Triamterene (Dyrenium), amiloride (Midamor)	Remove fluid but not potassium
Thiazide	Hydrochlorothiazide	Removes fluid but wastes potassium
Angiotensin-converting enzyme inhibitors	Enalapril (Vasotec), captopril (Capoten), lisinopril (Zestril)	Prevent vasoconstriction
Angiotensin-receptor blockers	Losartan (Cozaar), valsartan (Diovan), irbesartan (Avapro)	Produce vasodilation and salt and water excretion
Beta-adrenergic blockers	Atenolol (Tenormin), metoprolol (Lopressor), nadolol (Corgard)	Reduce blood pressure
Calcium channel blockers	Amlodipine (Norvasc), diltiazem (Cardizem), nifedipine (Procardia), verapamil (Calan)	Vasodilation and reduced heart rate
Vasodilators (nitrates)	Nitroglycerine (Nitrostat, Nitro-Bid), isosorbide (Isordil), nitroprusside (Nipride)	Dilate blood vessels; decrease preload and relieve shortness of breath; relieve myocardial ischemia
BNP analog	Nesiritide (Natrecor)	Alleviate dyspnea
Inotropics
Beta-adrenergic agonists	Dobutamine (Dobutrex), dopamine (Intropin)	Increase cardiac contractility and cardiac output
Phosphodiesterase inhibitors	Milrinone (Primacor)	Reduce preload and afterload; vasodilation; increase cardiac contractility
Digitalis	Digoxin

See Table 19-3, Box 19-1, and Table 20-4 for further information and nursing implications for these drugs.
BNP, brain natriuretic peptide.

*The choice of drugs depends on the type of heart failure and whether the left ventricle function is normal.

Nutrition Considerations

Guidelines for a Heart-Healthy Diet

• Limit foods high in saturated fat, trans fat, and cholesterol. Limit meat intake to no more than 6 oz of cooked lean meat, and skinless poultry (singly or in combination) per day. Fix main dishes with pasta, rice, beans, or vegetables mixed with small amounts of lean meat, poultry, or fish to create “low-meat” dishes. Restrict intake of organ meats, such as liver, brains, chitterlings, kidney, gizzards, and sweetbreads, as they are very high in cholesterol.

• Avoid as much trans fat as possible. Read product labels. Limit food high in saturated fat, including tropical oils and partially hydrogenated vegetable oils.

• Cook using little or no fat; broil, bake, roast, poach, stir fry, microwave, or steam foods rather than frying them.

• Eliminate as much fat as possible by trimming meat and skinning poultry before cooking. After browning meats, drain off all fat. Chill soups, stews, and so on, and then skim off fat before reheating to serve.

• Use fats with no more than 2 g of saturated fat per tablespoon. Olive, canola, corn, or safflower oil and liquid and tub margarines are good choices.

• Eat fish at least twice a week. Fatty fish such as salmon, mackerel, and tuna are best.

• Eat five to seven servings of fruit and vegetables per day. Use fresh or frozen vegetables and fresh fruit or fruit canned in juice rather than high-fructose corn syrup.

• Increase intake of fiber and carbohydrate by eating six or more servings of whole-grain products, such as cereals and breads, per day. Check labels to see that the product really contains whole grains.

• Use skim or 1% fat milk and nonfat or low-fat yogurt, cheeses, and ice creams.

• Limit consumption of egg yolks to three or four per week, including those in baked or cooked items. Check store packages for listing of eggs or egg yolk as an ingredient.

• Eat less than 1500 mg of salt (sodium chloride) per day.

• Have no more than one alcoholic drink per day if you are a woman and no more than two per day if you are a man. Examples of one drink are 12 oz of beer, 4 oz of wine, or 1½ oz of 80-proof spirits.

Note: The heart-healthy diet is promoted by the American Heart Association.

Other treatments may include:

• The pumping action of the atria and ventricles may be synchronized for more efficient pumping by use of the biventricular pacemaker. This procedure is cardiac resynchronization therapy (CRT), in which wires attached to an impulse generator are placed in the heart to send electrical impulses to the right and left ventricles. It is the treatment of choice when drug therapy does not control HF.

• A left ventricular assist device (LVAD) may be used to help with the heart’s pumping action. This device is implanted in the patient’s abdomen and attached to the heart. These devices have proven to be beneficial to adults diagnosed with severe HF. The device may be used while the patient is awaiting transplant and, with continued research, may possibly eliminate the need for transplant in some patients (Figure 20-2).

• Surgery to reduce the size of an enlarged heart (ventricular restoration surgery) may be effective for some patients. The less effective portions of the left ventricle are removed and the remaining muscle is reattached and shaped to form a more efficient pump. Sometimes the heart enlarges again.

• Heart transplant may be the only alternative for patients with advanced HF who do not respond to other medical or drug treatment. Heart transplant is discussed in Chapter 21.

• At least one herb is thought to be helpful for heart failure.

Complementary and Alternative Therapies

Hawthorn Use in Heart Failure and Coronary Artery Disease

The herb hawthorn is thought to improve performance of damaged myocardial tissue and to improve myocardial perfusion. Hawthorn is said to reduce the symptoms of mild to moderate HF. Hawthorn should be used cautiously in the elderly. Hawthorn may increase hypotension when used in combination with antihypertensive drugs. This herb may increase the effects of cardiac glycosides. Cardiovascular status should be monitored closely (Heart Center Online, 2007).

Short-term treatment for HF after an MI or open heart surgery is accomplished with the intraaortic balloon pump (IABP). The IABP is positioned in the descending aorta. The IABP is designed to increase blood supply to the myocardium and allow it to rest. The balloon will inflate during diastole, thus increasing perfusion to the coronary arteries. The balloon deflates during systole, making it easier for the left ventricle to eject blood (Figure 20-3).

Figure 20-3 Intraaortic balloon pump. Balloon is inflated during diastole. Balloon is deflated at beginning of systole to decrease afterload.

Acute Pulmonary Edema

Acute pulmonary edema is a medical emergency that must be treated promptly. The patient with this condition has severe dyspnea; a cough productive of frothy, pink-tinged sputum; tachycardia; and moist, bubbling respirations with cyanosis. Nursing interventions for acute pulmonary edema include placing the patient in high Fowler’s position to relieve the dyspnea; administering oxygen, diuretics, morphine, and other prescribed drugs; limiting and monitoring activity; and assessing cardiopulmonary status.

Nursing Management

Assessment (Data Collection)

The effects of HF can range from very mild to extremely serious. A thorough nursing assessment can help identify specific patient care problems. Data guide the physician in the evaluation of the patient’s response to medical treatment and the decision to continue or change prescribed drugs and other therapies. It is important to ask the patient if her clothes, rings, or shoes fit tighter than previously, indicating edema. Is pedal edema worsening or improving? Obtain an accurate weight. What has the trend of weight been? Feelings of breathlessness or having to catch the breath in midsentence may indicate fluid in the lungs and left-sided HF. Are crackles present in the lungs? Inquire how much activity causes SOB. Does the patient have paroxysmal nocturnal dyspnea (wakes up at night with SOB)? Ask about medication compliance and any problems or side effects noted. Assess the diet to determine usual sodium, fat, and calorie intake and obtain a smoking history.

Clinical Cues

For the patient who has been diagnosed with HF, but is well controlled (compensated), it is very important to weigh daily at home and to write down the weight. If the patient can see that fluid weight gain is occurring, she may be able to avert a trend back into decompensated HF by adjusting diuretic medication, lowering sodium intake, treating infection, and decreasing activity and resting.

Significant Findings Indicating Heart Failure is Occurring

Left-Sided Failure

• Increasing fatigue

• Dyspnea and a dry, hacking cough.

• Crackles heard on auscultation of the lungs.

• Pale, cool, and clammy skin, which are signs of poor peripheral circulation.

• Diminished peripheral pulses.

• Dizziness, confusion, restlessness, and difficulty concentrating and remembering due to diminished blood flow to the brain.

• Gradually increasing heart rate, even when the patient is at rest; increased heart rate occurs when the heart attempts to remove blood from a distended ventricle.

• Extra heart sound (S₃, S₄).

• Decreased blood pressure as ventricle fails.

Right-Sided Failure

• Weight gain without a change in caloric intake.

• Dependent, pitting edema (assess feet and ankles in ambulatory patient or one sitting up most of the time). Assess thighs and sacral region in patient confined to bed. Patient may feel “bloated” and experience a loss of appetite and nausea due to diminished venous return from abdominal organs, liver enlargement resulting from increased pressure in the portal veins, edema in the intestine, and accumulations of fluid in the abdominal cavity.

• Jugular venous distention; visible jugular vein pulsation more than 4.5 cm above the clavicle when patient is in semi-Fowler’s position. Complaint of feeling “warm” when others are comfortably cool because of vasoconstriction and poor circulation, which prevents removal of body heat.

• Reduced urinary output, which reflects the kidney’s response to poor perfusion by retaining sodium and water.

• Blood pressure increased from fluid overload.

Elder Care Points

Elderly patients who have little cardiac reserve can be at risk for HF from any condition that increases the body’s demand for blood or oxygen. Pneumonia, generalized infection, severe trauma, or other conditions that increase the metabolic rate and demand for oxygen can be the precipitating factor, because the heart that is already having difficulty meeting normal body oxygen demands cannot respond. When the elderly patient has an infection, carefully assess the lungs for signs of crackles that might indicate beginning HF. Your quick action can save the patient from considerable problems. Assess urinary output of elderly patients. Renal function is decreased due to the aging process. Loss of perfusion related to HF will place the patient at greater risk of renal insufficiency or failure.

Nursing Diagnosis and Planning

The main nursing diagnoses for the patient with HF are listed in Nursing Care Plan 20-1 (see also Table 18-4). Plan extra time when caring for the patient with HF because fatigue, possible lack of mobility, and oxygen deficit cause the patient to move slowly and need more time to accomplish the activities of daily living. Specific outcome criteria are written for each individual’s nursing diagnoses.

Nursing Care Plan 20-1

Care of the Patient with Heart Failure

Scenario

Miguel Garcia, age 60, is admitted to the nursing unit with exacerbation of left- and right-sided heart failure. Physical examination reveals 3+ pitting edema of the right lower extremity and 4+ pitting edema of the left lower extremity. He is in acute respiratory distress and is positioned in high Fowler’s to facilitate breathing. He has oxygen per simple mask at 8 L/min. T 98° F (36.6° C), P 96, R 28, BP 160/90, PO₂ 90%, Wt. 255 (20-lb increase).

Problem/Nursing Diagnosis

Dyspnea/Impaired gas exchange related to fluid in lung tissue, PO₂ 90% on 8 L oxygen.

Supporting Assessment Data

Subjective: States has difficulty breathing while lying down.

Objective: PO₂ 90%, elevated respiratory rate, sitting up to facilitate breathing.

Goals/Expected Outcomes	Nursing Interventions	Selected Rationale	Evaluation
PO₂ 95% on room air.	Assess vital signs and SpO₂ q 2 hr. Report increase in respiratory rate or decrease in oxygen saturation.	Change in vital signs and oxygen saturation may indicate improvement or deterioration of condition.	SpO₂ remains within 93%-95%. The respiratory rate is 12-22/min. The heart rate remains between 60 and 100.
	Increase oxygen to maintain SpO₂ at level specified by physician.	Maintain oxygen saturation at levels that indicate effective gas exchange.	SpO₂ 94%. O₂ at 5 L/min.
	Assess lung sounds at least q 4 hr.	Changes in lung sounds indicate positive response to therapy or need to modify treatment plan.	Lung sounds clear on right, fine crackles on left.
	Maintain high Fowler’s position as needed for comfort. Teach patient pursed-lip breathing.	Promotes optimum expansion of thoracic cavity to facilitate breathing and improve gas exchange.	Head of bed at 45 degrees. Continue plan.

Problem/Nursing Diagnosis

Fatigue: unable to complete activities of daily living without assistance/Activity intolerance related to fluid in lungs, fluid retention in lower extremities.

Supporting Assessment Data

Subjective: States feet have become more swollen over the past 3 days.

Objective: Pitting edema both lower extremities, dyspnea on exertion, crackles in bases bilaterally.

Goals/Expected Outcomes	Nursing Interventions	Selected Rationale	Evaluation
Patient will be able to complete activities of daily living and personal hygiene without fatigue.	Assess activity tolerance.	Provide guideline for planning care activities.	Able to complete partial bath. Becomes fatigued, requires assistance.
	Assist with personal hygiene initially.	Conserve patient energy.
	Monitor oxygen saturation.
	Provide frequent rest periods.	Avoid overtiring by scheduling activities to maximize energy use.	Patient remains fatigued.
	Coordinate care with other health care providers to conserve energy.	Prevents fatigue.	Continue plan; reassess readiness to meet goals.

Problem/Nursing Diagnosis

Fluid retention lower extremities, crackles in lung fields/Fluid volume excess related to pulmonary and venous congestion.

Supporting Assessment Data

Subjective: Patient reports nonproductive cough.

Objective: 3–4+ edema both lower extremities; crackles in lung bases on auscultation.

Goals/Expected Outcomes	Nursing Interventions	Selected Rationale	Evaluation
Lung fields will be clear, pitting edema in lower extremities 0–1+.	Assess lung sounds q 4 hr.	Identifies changes in condition.	Fine crackles on auscultation. Less distress.
	Assess lower extremities each shift.	Identifies effectiveness of drug therapy.	2+ pitting edema bilaterally.
	Administer diuretics as prescribed by the physician.	To reduce fluid retention through diuresis.	Urinary output 2500 mL q 8 hr.
	Maintain accurate intake and output.	Identify positive or negative response to treatment.	Continue plan. Weight 245 lb.
	Daily weights.

Critical Thinking Questions

1. List three additional nursing diagnoses that are appropriate for this patient.

2. List five items to be included in the discharge teaching plan for this patient.

3. What assessment data might indicate a worsening of this patient’s condition?

4. What assessment data might indicate improvement of this patient’s condition?

Implementation

Heart failure is a chronic disease. Patients with mild HF may not be hospitalized, but they do require instruction in self-care. Instruction includes balancing rest with physical activity, limiting sodium intake, and following other dietary restrictions. The entire family should be included in dietary teaching. Teach self-administration of medications and awareness of adverse side effects that must be reported. Review the dangers of drug-drug interaction when taking nonprescription drugs, particularly NSAIDs. Reconcile medications. Immunize the patient against seasonal flu and pneumonia. Modify lifestyle, as needs indicate (diet, smoking, physical activity). Teach symptoms that should be reported to the physician if they become worse or appear for the first time. An objective of Healthy People 2020 is to reduce hospitalizations of elderly adults with HF as the principal diagnosis. Thorough patient teaching and nursing follow-up helps achieve this objective.