Assessment

HISTORY. Patients with HF typically have a history of a precipitating factor such as myocardial infarction, recent open heart surgery, dysrhythmias, or hypertension. Symptoms vary based on the type and severity of failure. Ask patients if they have experienced any of the following: anxiety, irritability, fatigue, weakness, lethargy, mild shortness of breath with exertion or at rest, orthopnea that requires two or more pillows to sleep, nocturnal dyspnea, cough with frothy sputum, nocturia, weight gain, anorexia, or nausea and vomiting. Take a complete medication history, and determine if the patient has been on any dietary restrictions. Determine if the patient regularly participates in a planned exercise program.

The New York Heart Association has developed a commonly used classification system that links the relationship between symptoms and the amount of effort required to provoke the symptoms:

Class I: No limitations. No symptoms (fatigue, dyspnea, or palpitations) with ordinary activity. Class II: Slight mild limitation of physical activity. Comfortable at rest or mild exertion but more than ordinary exertion leads to fatigue, palpitations, dyspnea, or angina. Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity leads to fatigue, dyspnea, palpitations, or angina. Class IV: Symptomatic at rest; discomfort increases with any physical activity; confined to bed or chair.

PHYSICAL EXAMINATION. Observe the patient for mental confusion, anxiety, or irritability caused by hypoxia. Pale or cyanotic, cool, clammy skin is a result of poor perfusion. In right-sided HF, the jugular veins may become engorged and distended. If the pulsations in the jugular veins are visible 4.5 cm or more above the sternal notch with the patient at a 45-degree angle, jugular venous distension is present. The liver may also become engorged, and pressure on the abdomen increases pressure in the jugular veins, causing a rise in the top of the blood column. This positive finding for HF is known as hepatojugular reflux (HJR). The patient may also have peripheral edema in the ankles and feet, in the sacral area, or throughout the body. Ascites may occur as a result of passive liver congestion.

With auscultation, inspiratory crackles or expiratory wheezes (a result of pulmonary edema in left-sided failure) are heard in the patient's lungs. The patient's vital signs may demonstrate tachypnea or tachycardia, which occur in an attempt to compensate for the hypoxia and decreased CO. Gallop rhythms such as an S3 or an S4, while considered a normal finding in children and young adults, are considered pathological in the presence of HF and occur as a result of early rapid ventricular filling and increased resistance to ventricular filling after atrial contraction, respectively. Murmurs may also be present if the origin of the failure is a stenotic or incompetent valve.

PSYCHOSOCIAL. Note that experts have found that the physiological measures of HF (such as ejection fraction) do not always predict how active, vigorous, or positive a patient feels about his or her health; rather, a person's view of health is based on many factors such as social support, level of activity, and outlook on life.

Diagnostic Highlights

Test

Normal Result

Abnormality with Condition

Explanation

Echocardiography

Normal heart size,

Depressed cardiac

Measures chamber size, valvular

(ECHO)

structure, and cardiac

output, evidence of

structure and function, ventricular

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