Fluid Overload: Identifying and Managing Heart Failure Patients at Risk of Hospital Readmission   30  

Judith E. Schipper

OVERVIEW

HF is the most common cause of hospital admission in the older adult (Funk & Krumholz, 1996; Krumholz, Wang, et al., 1997; Roger et al., 2012). Hospitalizations for HF account for approximately 50% of all cardiovascular hospital admissions (Krumholz, Wang, et al., 1997; Lloyd-Jones et al., 2010). The evidence-based literature demonstrates that as many as half of these admissions are readmissions and are preventable (Lloyd-Jones et al., 2004; Rich et al., 1995; Ross et al., 2008). The epidemic in HF prevalence is commensurate with an aging population and has stimulated a focus of research to identify those patients at high risk of hospitalization and readmission. Early identification of patients at risk of rehospitalization during the hospital stay provides opportunity for interventions to impact the readmission rate. Symptoms of HF compel patients to seek medical aid; however, evidence to date has shown that HF patients postpone seeking medical assistance 12 hours to 14 days before recognition of these changes as harmful to bodily functioning (Koenig, 1998; Rich & Kitman, 2005). The delay causes further deterioration in cardiac status requiring acute hospitalization. This chapter presents the complex nature and pathophysiology of HF symptoms, with nursing management strategies to reduce hospital readmission rates. A detailed protocol for nursing practice of the aging population is presented highlighting the nursing assessment and management of HF.

BACKGROUND AND STATEMENT OF PROBLEM

HF is a public health problem affecting an estimated 5.8 million Americans yearly (Lloyd-Jones et al., 2010; Thom et al., 2006). Cardiovascular disease (CVD), which includes hypertension (HTN) and HF, valvular heart disease and arrhythmias, along with the atherosclerotic disease that causes coronary heart disease (Hay et al., 1993), stroke, and peripheral vascular disease (PVD), is the major contributor to mortality and comorbidity in older adults. CVD accounts for 40% of all deaths in those aged 75 to 85 years, and 48% of all deaths in those 85 years and older (Lloyd-Jones et al., 2010; Thom et al., 2006). Acute or chronic HF is the leading cause of hospital admission in patients older than 65 years, with readmission rates to acute care facilities averaging 17.2% nationally in 1996, which increased to 23.6% in 2010 (Funk & Krumholz, 1996; Lloyd-Jones et al., 2010). Risk of readmission has been shown to be four times higher in older adults aged 80 years and older, higher in ethnicities other than Whites, and higher with lower economic status (Giamouzis et al., 2011).

The prevalence of HF increases with age, and more than 75% of those affected are older than 65 years of age. Development of HF is higher with male sex, lower level of education, low levels of physical activity, cigarette smoking, overweight, diabetes mellitus (DM), HTN, valvular heart disease, left ventricular hypertrophy (LVH), and atherosclerosis of the coronary arteries (coronary heart disease [CHD]). HTN is a precursor in 75% of individuals diagnosed with HF (Thom et al., 2006). Both the incidence and prevalence of HF continue to increase as the population ages.

Risk Factors for Developing HF in Older Adults

The primary clinical risk factors for developing HF are advancing age, male sex, HTN, myocardial infarction (MI), DM, valvular heart disease, and obesity. HTN is the most common cause of HF in patients without CHD, accounting for 24% of the cases of HF (Ho, Pinsky, Kannel, & Levy, 1993). HTN is also extremely common in type 2 DM, as it occurs in 40% to 60% of older adults with type 2 DM (Hypertension in Diabetes Study Group, 1993). Women with DM are at extremely high risk for developing HF (Levy, Larson, Vasan, Kannel, & Ho, 1996). Individuals with HTN and DM often develop HF with preserved left ventricular (LV) systolic function (heart failure with a preserved ejection fraction [HFpEF]) or so-called diastolic HF, rather than LV systolic dysfunction (heart failure with reduced ejection fraction [HFrEF]; Piccini, Klein, Gheorghiade, & Bonow, 2004). HFpEF is a clinical syndrome in which LV filling pressures are elevated, the LV ejection fraction (LVEF) is normal, and yet the heart is unable to satisfy the systemic oxygen needs of an individual.

Other related clinical risk factors of HF include smoking, dyslipidemia of genetic and dietary etiology, sleep-disordered breathing or obstructive sleep apnea (OSA), chronic kidney disease, albuminuria, sedentary lifestyle, low socioeconomic status, and psychological stress. Toxic substances, such as chemotherapeutic agents (anthracyclines, cyclophosphamide, 5-FU, trastuzumab), illicit drugs (amphetamines, cocaine), and medications (nonsteroidal anti-inflammatory drugs [NSAIDs], thiazolidinediones [TZDs], alcohol), can precipitate HF (Schocken et al., 2008).

DM is a CVD equivalent and, as such, is an important contributor to HF. Women and those individuals treated with insulin are at the greatest risk for ischemic etiology of both HFrEf and HFpEF. In a sample of older Medicare patients with type 2 DM, 22% had a diagnosis of HF, and this prevalence increased with advancing age (Bertoni et al., 2004). In addition, the presence of type 2 DM is associated with higher HF-related morbidity and mortality. After MI or coronary revascularization procedures, individuals with type 2 DM also have a high morbidity and mortality, which is largely caused by the development of HF. An earlier analysis of outcomes in Medicare patients 1 year after an MI revealed that 11% of patients without DM had HF, whereas 17% of patients with DM on oral agents and 25% of those treated with insulin were admitted for HF exacerbation (Chyun, Vaccarino, Murillo, Young, & Krumholz, 2002).

The initial diagnosis of HF is most often an acute index event requiring hospitalization. Patients at risk of readmission after initial diagnosis of HF include the following (Bertoni et al., 2004; Chyun et al., 2002; Lewis et al., 2003):

Pathophysiology of HF

Understanding the pathophysiology of HF provides insight into the rationale for treatment. HF is defined as the inability of the heart to pump blood sufficient to metabolic needs of the body or the inability to do so without significantly elevated filling pressures (Miller & Piña, 2009). The inability of the left ventricle to eject blood sufficiently represents LV systolic HF or HFrEF and is diagnosed with a measurement of EF less than 50%. Diastolic dysfunction and failure result in high LV filling pressures, yet inadequate ability of LV to deliver oxygenated blood to fulfill the body’s needs. Diastolic HF is also more descriptively named HF with preserved systolic function or HFpEF because the EF is essentially normal: approximately 60%. The symptoms of HF are directly related to impairment in the filling and ejecting of the blood in the left ventricle (Owan et al., 2006).

All of the risk factors and disease entities listed previously can cause direct damage to the myocardium, as in MI and toxic exposure, or subject it to an increased level of wall stress, as in HTN or valvular lesions. Such an insult initiates compensatory actions by the heart that are mediated by the neurohormones of the sympathetic nervous system (SNS) and the renin–angiotension–aldosterone system (RAAS), which are active, both systemically and directly, in the myocardium. Rather than offering benefit, the SNS (epinephrine and norepinephrine) and RAAS (angiotensin II, vasopressin, aldosterone) hormones promote cardiac remodeling and hypertrophy, causing dilatation of the ventricle and buildup of fibrous tissue that weakens the cardiomyocytes. These changes occur during compensated (asymptomatic) as well as decompensated (symptomatic) failure. The overexpression of neurohormones causes salt and water retention and vasoconstriction, which in turn produces increased hemodynamic stress on the left ventricle. These factors are cyclical unless treated. Untreated, there is further disruption of left ventricle architecture and performance (Miller & Piña, 2009).

Because this process begins without symptoms, for patients at risk, it is essential to identify factors that are a hazard to cardiovascular health and initiate treatment before significant damage to the myocardium occurs. The American College of Cardiology/American Heart Association Task Force (ACC/AHA) developed guidelines to classify HF in four stages (Hunt et al., 2005) based on the structural changes and damage to the heart:

Atherosclerosis and ischemia in CHD are the most common etiology of HF in the United States, followed closely by HTN alone and valvular disease. Thyroid dysfunction and excessive alcohol intake may also lead to HF. In the absence of known CVD, systolic function of the heart remains relatively unchanged in older adults, as does exercise tolerance. Diastolic dysfunction, however, is predominately a disease of older adults and may be present even in the absence of HTN or cardiomyopathy, which are also known to contribute to diastolic failure (Bhatia et al., 2006; Olsson et al., 2006; Yancy, Lopatin, Stevenson, De Marco, & Fonarow, 2006). The prevalence of HFpEF is increasing as the population of those older than 65 years grows along with the burden of lifestyle risk factors of diabetes and obesity (Anderson & Vasan, 2014; Butler et al., 2014). The archetypical patient presenting with diastolic HF is 70 to 80 years of age, female, obese, diabetic, and often has atrial fibrillation (Coats, 2001). Diastolic dysfunction is characterized by an exaggerated HR with activity, which is often one of the first clinical findings. The severity of symptoms varies among patients and may not correlate with LVEF as exercise capacity and quality of life are similarly reduced in HFrEF and HFpEF (Brucks et al., 2005; Farr et al., 2008; Lewis et al., 2007).

HTN, CHD, and hypertrophic cardiomyopathy are all abnormalities that are exacerbated by tachycardia, underscoring the importance of avoiding a high HR in all older individuals. Diastolic abnormalities caused by HTN, aortic stenosis, hypertrophic cardiomyopathy, or CHD may precipitate HF. Patients with either systolic or diastolic HF are at risk of fluid overload. Although discussed as two separate entities, many older adults have components of both systolic and diastolic dysfunction (Gheorghiade et al., 2010).

ASSESSMENT OF THE PROBLEM

For older adults diagnosed with HF, the health history and physical assessment are directed at monitoring symptoms and assessing cardiovascular function. For the nurse assessing and managing the patient with HF, it is important to note that the recognition of fluid overload is not always straightforward. Unlike the classic picture of HF observed in younger adults, the symptoms of fluid overload can be subtle and elusive in older adults (Coviello, 2004). Once symptoms become pronounced in the older adult, the nurse has a challenging task to resolve the HF, especially if it is of a long-standing duration (Giamouzis et al., 2011). Monitoring parameters must be established in which the patient and nurse actively identify subtle changes and seek intervention as early as possible (Grady et al., 2000).

The Health History

HF has both symptomatic and nonsymptomatic phases. When symptoms occur, they are related to intravascular and interstitial fluid overload and inadequate tissue perfusion. Symptoms become evident with exertion and in severe HF, even at rest. The New York Heart Association (NYHA) functional capacity is an important standardized classification of the HF patient according to how much activity patients are able to accomplish without symptoms (Table 30.1). Classifying patients according to their physical symptoms offers evidence of the extent of volume overload and limitation caused by symptoms, which then leads the nurse to recognize the severity of the disease. Patients, with proper treatment, can improve their functional status and classification as their symptoms improve from a NYHA class III to class II or even class I; however, once identified at an advanced stage, C or D, earlier stages are not reclaimed. For example, a stage C patient does not return to stage B. Although current therapies are shown in studies to improve mortality, success in returning diseased myocardium to health has not yet been achieved.

TABLE 30.1

New York Heart Association Functional Capacity Classification

Adapted from American Heart Association (1994).

Both patients and providers frequently attribute symptoms of fluid overload to aging. When symptoms occur during exertion, senior patients may simply decrease their activities to prevent symptoms, yet when asked, they report activity from a memory of months earlier. Because of inaccurate reporting of activity, HF in older adults is often difficult to recognize and, therefore, goes untreated. Thus, the nurse should routinely ask questions related to activity-limiting dyspnea. A key indicator in establishing a baseline for functional capacity is to ask the patient what his or her maximal asymptomatic activity is now, what it was 6 months ago, and what it was 1 year ago. Other important questions include “How far can you walk without getting short of breath?” The answer to a question, such as “How far is the bathroom from your bed?” can elicit information about symptoms in walking, sleep habits, and nocturia. “What is the activity that commonly produces shortness of breath?” Try to avoid questions that can be answered “yes” or “no” (e.g., “Do you experience shortness of breath when simply sitting?” “Do you wake at night feeling short of breath?”). Rather, say, “tell me about what you do during a typical day.” Repeating these questions in subsequent interviews will help monitor changes in activity associated with treatment or with suspected fluid gain. The goal is to identify whether the patient is physically capable of performing activities of daily living (ADL).

HFrEF is a pathophysiological process in which LV dysfunction occurs independent of symptom development (Brucks et al., 2005). Symptom expression is dependent on compensatory mechanisms and the length of time HF has been present. Patients with acute HF, as seen with MI, may be more symptomatic because their compensatory mechanisms have not fully developed. In comparison, the patient with long-standing HF may have severe dysfunction but may not become symptomatic until consuming a high-sodium meal or experiencing physical stress. Fluid overload can then occur rapidly, oftentimes overnight. In this case, compensatory mechanisms are now exhausted and, as a result, fail. The window of opportunity to successfully intervene is narrow, as is the margin of error. Treatment for fluid overload in this case must be swift and brisk but gentle enough to maintain BP (Grady et al., 2000). Nurses need to be aware of the importance of both early recognition and early intervention in the patient with fluid overload. A few hours delay in providing treatment can mean the difference between successful management at home or need for hospital admission with variable outcomes.

Knowledge of past medical history will help to anticipate problems related to other conditions because their presence may complicate assessment and management of HF. Cardiac risk factors; levels of physical activity; and control of lipids, HTN, obesity, DM, and smoking need to be determined. Additionally, it is important to consider that older adult responses to HF medications and treatment are variable. Other drugs commonly used in this age group, such as over-the-counter NSAIDs, can actually exacerbate fluid overload by increasing sodium retention. Previous questions related to cardiovascular functional capacity may have already provided some information, but additional information on musculoskeletal and neurological function can add needed insight.

Assessment for additional symptoms will assist in identifying the patient with HF. Orthopnea is the most sensitive and specific symptom of elevated filling pressures, and it tends to reliably parallel filling pressures in patients with this symptom (Anker et al., 2003; Stevenson & Perloff, 1989). Nocturnal or exertional cough is often a dyspnea equivalent and should not be confused with the cough from an angiotensin-converting enzyme (ACE) inhibitor, which is not associated with activity or position. Individual patients generally exhibit patterns of fluid overload that reoccur in subsequent exacerbations. These should be documented, be made available to all on the care team, and be used in patient education for self-monitoring and for early recognition by the health care team. Questions related to symptoms and function should be part not only of the initial assessment, but also of subsequent visits as a means of surveillance (Stevenson & Perloff, 1989).

The clinical presentation of HF may include a variety of symptoms reflective of pulmonary congestion and decreased cardiac output. The questions related to health history are important to include and/or observe during the health encounter. Although the presence of any one major symptom is sufficient to warrant consideration of HF, symptoms occurring with other physical findings of orthopnea, paroxysmal nocturnal dyspnea, and progressive dyspnea on exertion are virtually diagnostic of fluid overload. The Framingham criteria (Margolis et al., 1974) are validated and are most often used to identify congestive HF or HF exacerbation. If two major criteria or one major with two minor criteria are present, the professional can have reasonable certainty that the patient has HF. These criteria are listed as follows.

Major:

Minor:

The presence of other comorbidities, such as DM, renal dysfunction, and liver disease, along with systemic physiological changes associated with aging, further complicates the assessment and management of HF in the older adult. Comorbidities should also be carefully assessed by reviewing laboratory data. DM may necessitate monitoring of blood glucose because wide variations in glucose can affect the ischemic threshold. Renal dysfunction and liver disease may affect pharmacodynamics of drugs used to treat HF. Inclusion of the pharmacist on the health care team or at least a consultation with the pharmacist will assist in ensuring the efficacy and safety of medications in the aging population. Anemia, a common medical condition in older adults, affects oxygenation, activity tolerance, and subsequent fluid balance (Young et al., 2008). The presence of COPD, as well as other comorbidities, may necessitate special precautions when assessing and managing oxygen therapy and beta blockers.

As overuse of salt in the diet may precipitate fluid overload, a comprehensive dietary history is absolutely essential. The nurse should include specific questions about what the patient eats for meals and who prepares those meals realizing that it may be more important to discuss food preparation and sodium restriction with the patient’s primary caregiver. Additionally, does the patient use the saltshaker or salt substitutes at the table or in cooking? How often does the patient eat out at a restaurant or order in food? A review of foods high in sodium on a printed list often reveals foods the patient is eating but previously did not admit to. For instance, important dietary questions related to use of canned products or deli meats, which contain higher amounts of sodium, should be included. A list of the sodium and the potassium content of a variety of foods, including fruits and vegetables, can be helpful in providing the information necessary for the patient to make appropriate daily choices. Because assessment of nutritional status is critical to elicit accurate fluid and sodium intake, it is prudent in the acute care setting for the older adult to have a dietician consultation. Additionally, as cachexia is a harbinger of a downward spiral in patients with HF, questions need to be included on the health history related to appetite and weight loss (Evangelista et al., 2000; Lavie, Osman, Milani, & Mehra, 2003).

Current prescription and over-the-counter medication use should be assessed, along with any alternative or herbal therapies. Many older adults who are eligible for aspirin, beta blockers, and ACE inhibitors (ACEIs) do not receive these medications despite the important role that these agents have in reducing CHD-related morbidity and mortality (Anker et al., 2003; Colucci et al., 1996, 2007; Packer, 1998; Packer, Bristow, et al., 1996; Schocken et al., 2008).

Included in the health history should be questions related to medication adherence and the patient’s decision to either take or not to take medications (Grady et al., 2000; Riegel et al., 2009). Understanding a patient’s rationale to selectively not take certain medications at certain times will help reveal ways for the nurse to intervene. Patients may wish to adjust their diuretic dose so that they can function socially during the day. This is not an adherence issue but a sound decision based on the patient’s rationale as to how to fit the medication regimen into his or her lifestyle. The interview can reveal whether “nonadherence” has such a rationale. If a cause is not found, other issues need to be explored, such as cost, number of medications, and/or the frequency of the doses. Ways to simplify the drug regimen should be explored as the older adult can become overwhelmed because of cognitive impairment, lack of health literacy with poor understanding of medication importance, and when symptomatic, for example, simply unable to do more than breathe.

Psychosocial factors, personal beliefs and behaviors, along with cultural and environmental influences, all contribute to management of chronic disease. The importance of depression and social support has been well documented in the older adult; therefore, all of these factors need to be assessed (Davos et al., 2003; Faris et al., 2002). The nursing assessment in individuals with HF should identify the individual’s response to treatment, which can then be used to assist the individual in subsequent management of symptoms and the underlying condition, health-promotion and disease prevention activities, and chronic disease management. Awareness of the patient’s own perception of why he or she sought medical care and a detailed analysis of the symptoms will assist in assessing the individual’s or caregiver’s ability to identify symptoms, his or her knowledge regarding the condition, its prognosis, and general health beliefs, along with the prior ability to manage this or other medical conditions.

The Physical Assessment of the Older Adult With Fluid Overload

Physical assessment of the patient with suspected fluid overload includes inspection; palpation; and auscultation of the peripheral vasculature, heart, lungs, abdomen, and extremities. Orientation, functional limitations, and mental clarity are observed during examination of vital signs, which include height and weight and waist circumference.

A patient’s height and baseline weight are important indicators of both nutritional and fluid status. Patients may know their ideal weight or “dry weight.” Ascertain this when obtaining the health history to establish initial goals in diuretic treatment. Hospitalized patients with HF should have a weight measurement each day. The importance of daily weights should be emphasized with each weight in the hospital setting to reinforce the need to continue this practice at home. At home, weights should be taken daily, typically the first thing in the morning on arising, before breakfast, and with no clothes or wearing light clothing to avoid false fluctuations (Grady et al., 2000; Riegel et al., 2009; Riegel, Naylor, Stewart, McMurray, & Rich, 2004). This provides the best baseline for consistency. A 2-lb weight gain overnight or a 3-lb weight gain in a week is an indication that medical management must change. Measurement of a senior’s waist circumference is also important to determine at baseline, because many times, this is the location for fluid accumulation (Grady et al., 2000). Once height and weight are measured, a body mass index (BMI) should be calculated. Research has shown that higher BMIs (25–30 kg/m²) are associated with longer survival (Horwich et al., 2001; Lavie et al., 2003; Pickering et al., 2005, 2008).

A thorough evaluation of the BP should be performed. A variety of environmental factors can influence BP determination; therefore, the room should be a comfortable temperature, the patient as relaxed as possible, and a 5-minute rest allowed before taking the first reading. Clothing that covers the area where the cuff will be placed should be removed, and the individual should be seated comfortably, with legs uncrossed, with the back and arm supported; the middle of the cuff on the upper arm should be at a level of the right atrium (Sansevero, 1997). The initial BP reading should be taken in both arms. Proper cuff size is critical to obtaining an accurate measurement. Obese individuals with large arm circumference need to have the appropriate cuff size for accuracy. Conversely, thin, cachectic patients will also have inaccurate readings with a standard cuff. The bladder length should be 80% of the arm circumference and width at least 40%. The midline of the bladder should be placed above the brachial artery, 2 to 3 cm above the antecubital fossa, where the artery should have first been palpated. When using the auscultatory method, which remains the “gold standard” for BP measurement, palpating the radial pulse first while inflating the cuff will identify the point at which the pulse disappears. For the subsequent auscultatory measurement, the cuff should then be inflated to at least 30 mmHg above this point. The rate of deflation is also extremely important with a rate of 2 to 3 mmHg/sec recommended. The first and last audible sounds are the SBP and diastolic BP (DBP), respectively. Two readings, taken 5 minutes apart should be averaged and if there is greater than 5 mmHg difference, additional readings should be obtained (Pickering et al., 2005, 2008; Sansevero, 1997).

Pseudohypertension is a rare phenomenon resulting from noncompressibility of thickened arteries and will result in the recording of falsely high BP when indirect methods are used. A high BP over time without any indication of end-organ damage and treatment of the BP creating symptoms of hypotension, such as dizziness, confusion, and decreased urine output, point to a diagnosis of pseudohypertension. This tendency for peripheral arteries to become rigid with aging may result in a need to increase cuff pressure in order to compress the artery. If suspected, an intra-arterial reading has been suggested to avoid overmedication with antihypertensives; however, this is an extreme measure and is rarely done. Most providers, who treat HTN in older adults, consider 160/90 mmHg as a hypertensive BP and will treat gently with appropriate antihypertensives and pull back on treatment if symptoms of hypotension or orthostasis occur. Isolated systolic HTN is also common in the older adult and is defined by an SBP greater than 140 mmHg and a DBP less than 90 mmHg. Care must be taken not to overtreat in this population, especially if aortic stenosis or other valvular disease is present. Older adults are also more likely to exhibit white-coat HTN, in which the BP may be elevated more than 140/90 mmHg in the presence of a health care worker and an actual reading at home is usually 135/85 mmHg or less. Therefore, assessment of the BP not only requires careful attention to technique but also consideration of the physiological abnormalities associated with aging. Home BP monitoring has been suggested as a means for patients to partner with their providers to provide care. For those patients who are unable for whatever reason, 24-hour ambulatory BP monitoring is available to more accurately assess BP fluctuations during the day (Arzt et al., 2006).

In addition, the standing BP should be assessed because older adults have a tendency for postural hypotension. Orthostatic hypotension is diagnosed when the SBP falls by at least 20 mmHg or the DBP by 10 mmHg within 3 minutes. The presence of orthostatic hypotension may also reveal early dehydration in a patient who is usually otherwise stable (Arzt & Bradley, 2006). Because dehydration is the second most common admission for the older adult with HF, with falls following closely behind, standing BPs should be part of the routine assessment. In addition, patients should be assessed for dehydration during diuresis and whenever a condition exists in which fluid loss could occur. This includes not only with vomiting or diarrhea but also with diaphoresis caused by extremes in temperature and humidity.

Inspection is the first step of the physical assessment. General inspection of the periphery includes the following:

Palpation of the extremities occurs following inspection of the skin color for temperature and turgor as well as the color of the nail beds. Capillary refill of the nail should be assessed by compressing the nail for 2 to 3 seconds and then releasing. Note the time elapsed until the original color returns. Normally, the nail bed is pink; capillary refill occurs within 2 to 3 seconds. A pale or cyanotic nail with delayed capillary refill may indicate decreased peripheral perfusion. The peripheral pulses should be palpated bilaterally, including radial, femoral, pedal, and posterior tibial pulse. Note pulse rate, rhythm, and symmetry.

Respiratory rate and effort should be assessed before auscultation of the lungs. If possible, oxygen saturation during rest and activity should be recorded. Patients whose oxygen level desaturates during activity to 86% or lower may require oxygen support at home. In addition, surveillance of oxygen saturation during sleep may be required if the patient or family reports difficulty with sleep at night. Sleep apnea can be the etiology of HF in patients with HF and, if untreated or treated ineffectively, can be the cause of exacerbation and decompensation in HF (Bennett & Sauvé, 2003; Cormican & Williams, 2004; Kaneko, Hajek, Zivanovic, Raboud, & Bradley, 2003; Lanfranchi & Somers, 2003; Maisel, 2001a; Mansfield et al., 2003). Use the diaphragm of the stethoscope to assess the lungs. Listen in all the lobes for diminished sounds, crackles, wheezes, or rhonchi. Lung sounds are an important part of the assessment, particularly in patients with a history of HF.

The cardiovascular assessment begins by locating the apex and apical pulse by feeling for the point of maximal impulse (PMI). In systolic HF, the PMI is displaced laterally and indicates the heart is dilated. Assessment of apical pulse rate and regularity, with attention to fullness and amplitude, also are important. Heart sounds should be ascertained with both the diaphragm and the bell of the stethoscope. Note the presence of S1 and S2 and of extra sounds, S3 gallop, S4 murmurs, clicks, or rubs. If extra heart sounds are present, also examine the carotid arteries by listening on both sides of the neck with the bell. Bruits sound like murmurs, so it is important to differentiate between the two. Some aortic murmurs will radiate into the neck and may even be audible when auscultating the lungs posteriorly. Always listen to the heart before listening for extra sounds in the neck. Carotids should be palpated unilaterally, never simultaneous bilaterally, to avoid occlusion of blood flow to the brain.

Jugular veins are assessed best with the patient in semi-Fowler’s position but, if the patient is severely dyspneic, Fowler’s position may be necessary. With the patient’s head in straight alignment, observe the jugular neck veins for the presence of jugular venous distention (JVD). Turning the head slightly to the left and shining a penlight angularly on the vein allows for easier visualization of JVD and “a” and “v” waves, particularly in obese patients with thick necks. The jugular venous pulse waves will vary with respiration and decrease during inspiration. The jugular vein is compressible and varies with the angle of the neck. In the absence of pathology, venous distention is not present. JVD is the most sensitive sign of elevated filling pressures and is present with fluid overload, cor pulmonale, or high venous pressure (Stevenson et al., 1989).

The abdomen should then be examined. First, auscultate for bowel sounds in a distended abdomen to assess for other pathology-causing distention. Next, palpate to determine whether the abdomen is soft and nontender. A protuberant abdomen with bulging flanks suggests the possibility of ascites. Because ascitic fluid characteristically sinks with gravity, whereas gas-filled loops of bowel float to the top, percussion gives a dull note in dependent areas of the abdomen. Look for such a pattern by percussing outward in several directions from the central area of tympany. Map the area between tympany and dullness. To palpate the liver, place your hand behind the patient, parallel to and supporting the right 11th and 12th ribs and adjacent soft tissues below. Remind the patient to relax. By pressing your left hand forward, the patient’s liver may be felt more easily by the other hand. Patients who are sensitive to palpation can rest their hand on your palpating hand. Note any tenderness. If at all palpable, the edge of the liver is soft, sharp, and regular. The liver can be enlarged in HF because of congestion. To further assess for volume excess, place the patient in semi-Fowler’s position at the highest level at which the jugular neck pulsations remain visible. Firmly apply pressure with the palmar surface of the hand over the right upper quadrant of the patient’s abdomen for 1 minute. A 1-cm rise in the jugular distention called hepatojugular reflux confirms the presence of fluid overload. Hepatojugular reflux may be associated with or without tenderness. Patients may also complain of a feeling of fullness.

The presence of peripheral edema, a symptom that can be related to fluid overload from cardiac renal disease or PVD, should be evaluated. Edema can also occur in response to medications such as calcium channel blockers. Dependent parts of the body, such as the feet, the ankles, and the sacrum, are the most likely locations to find edema. The presence and location of edema, and whether it is pitting or nonpitting, should be assessed. Depress an edematous area over a bony prominence for 5 to 15 seconds, then release. Grading scale for edema is as follows:

The neurological assessment cannot be overlooked because changes in HR and rhythm, a decrease in cardiac output, and side effects of cardiac medications may cause significant changes in mental status. The nurse can observe and assess the patient’s mood, thought processes, thought content, abnormal perceptions, insight, judgment, memory, and retention throughout the examination from intake of history and throughout treatment. Because depression is common among both the older adult and the chronically ill, signs of depression should be assessed (Koenig, 1998; Maisel, 2001b). Examples of signs of depression include feelings of hopelessness and sadness (also see Chapter 15, “Late-Life Depression”). The time, the day, and the year, as well as orientation to place, should be included. Memory of hospitalization, teaching that occurred while hospitalized, and subsequent events postdischarge can be addressed depending on whether the patient is hospitalized or being seen as an outpatient (Grady et al., 2000; Wang, FitzGerald, Schulzer, Mak, & Ayas, 2005).

To summarize, the physical examination findings consistent with HF include the following:

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