Holistic Nursing Assessment for Congestive Heart Failure

Background and Initial Presentation

Many factors, both physical and psychological, impact the development of congestive heart failure (CHF). The prevalence of CHF in developed countries is 1–2% of the adult population overall, and the sudden onset of life-threatening complications associated with CHF symptoms makes it especially dangerous (Blinderman et al., 2008). Given its immediate dangers, it is critical that a patient presenting with CHF receives a systematic and comprehensive assessment.

The initial stage of the holistic nursing assessment is the patient's story. The nurse should initiate the interview by allowing the patient to introduce himself, enabling him to provide unfiltered information that expresses his immediate concerns. The following patient background was acquired: a 50-year-old man of Indian descent; a 20-year Australian resident; owner of an Indian restaurant; husband and father of three children.

These few details, while not yet providing specific medical data about the extent of his CHF complications, allow the nurse to make a number of useful inferences. His age does not place him in the elderly category, suggesting that onset of his CHF symptoms may be relatively recent or rooted in genetic predispositions. Australia is a developed country, and tentative conclusions may be drawn regarding the lifestyle culture to which he has been exposed. Cardiovascular disease is the leading cause of death in developed countries, so special attention should be placed on his dietary intake and exercise regimen. His family situation suggests psychosocial stability, while ownership of a busy restaurant may be a source of stress. All these factors must be taken into account when proceeding with the assessment.

In the subjective assessment, the nurse must specifically characterize the cardiorespiratory symptoms according to severity, location, duration, and time of onset. The nurse must also identify factors that aggravate or trigger symptoms, factors that relieve them, and a history of when the symptoms first appeared (Jarvis, 2009).

Subjective Assessment

Shortness of breath (dyspnea) is the cardinal symptom of congestive heart failure. The Borg Scale may be used to assess the degree of dyspnea from 0 (none) to 10 (maximal) (Karapolat et al., 2008). Other evaluators include exercise tolerance — the nurse should ask the patient how many stairs he can climb or what distance he can walk before reaching exhaustion. Further considerations include any association with paroxysmal nocturnal dyspnea: the nurse should ask whether the patient wakes frequently from acute breathlessness. The relationship between dyspnea and posture is also important to explore.

A persistent cough may be a further indicator of CHF. The nurse should characterize the quality of the cough as dry, hacking, loose, or productive, and record its severity and timing. Does the cough develop at night, with exercise, in cold air, or in particular environments? A related symptom that can be simultaneously assessed is sputum production. The color, consistency, and purulence of the sputum can provide further detail about the patient's state of health (Anon., 2010).

Occlusion of the heart muscle in CHF frequently produces chronic chest pain, which is especially important for determining disease progression. The nurse should pay particular attention to the radiation, severity, timing, and specific location of the pain. CHF tends to be localized in the congested part of the heart, and the radiation pattern and location of chest pain can help identify the site of congestion. Chest pain may also be coupled with faintness, shortness of breath, and nausea.

Also related to cardiac congestion and the heart's reduced efficiency as a pump is the buildup of fluid throughout the body, which may produce areas of peripheral oedema. This symptom is especially indicative and may be associated with leg cramps, tingling in the legs, and the presence of varicose veins.

Other cardiorespiratory symptoms common in CHF patients that should be included in the subjective assessment include cyanosis, pallor, wheezing, syncope, general fatigue, night sweats, palpitations, gastroesophageal reflux, and weight loss (Anon., 2010).

Patient History

The patient history provides the most transparent representation of the patient's developing condition and offers the foundation for prescribing specific interventions. It must therefore be taken with particular care. According to a number of recent studies, patients with diabetes mellitus — especially in combination with comorbid hypertension, coronary artery disease, smoking, and left ventricular hypertrophy — are at high risk of CHF (Held et al., 2007). These conditions place chronic stress on the heart and contribute to congestion in the heart muscle.

Important information to collect includes previous hospital admissions and surgeries for cardiac illness. Has the patient experienced a previous myocardial infarction, angina, or coronary artery disease? Has he ever been diagnosed with cardiac murmurs or valvular heart disease? Family history is also important for identifying genetic predispositions toward cardiovascular disease. The nurse should ask whether any family member has had a heart attack, particularly at a young age, or suffered a sudden cardiac death.

In terms of personal history, the nurse should calculate a body mass index (BMI) to screen for obesity, combined with a nutritional assessment. Research suggests that excessive sodium intake can have detrimental effects on patients with CHF (Paterna et al., 2008), which is especially relevant given the patient's profession as a restaurant owner. The nurse might ask how often he dines at his own restaurant. A smoking history — including daily usage and overall duration — should be obtained. The nurse should also assess the patient's occupational environment and frequency of exposure to stressful situations and irritating stimulants.

The most telling aspect of the medical history is the list of medications currently prescribed to the patient, which provides insight into past complications that have required treatment. Beta-blockers, diuretics, steroids, antihistamines, and angiotensin-converting enzyme (ACE) inhibitors all suggest previous cardiovascular disease (Anon., 2010).