Nursing the Acute Congestive Heart Failure Patient

Liz Farrow QVN

I believe it is very common as a nurse, when confronted with a congestive heart failure patient, to feel powerless and incompetent in the face of such a debilitating condition. But things don't have to be this way.

We tend to stand back and watch as these animals struggle to breathe, and hope that the medications the vet has given are fast-acting. Quite to the contrary, there are numerous things which can be done to actively help our patients become more comfortable whilst in our care. But firstly, here's some background so that we are all on the same page as far as what is happening with a patient in heart failure.

What is heart failure?

Heart failure is a syndrome resulting from cardiac disease, and occurs when the heart is unable to deliver oxygen to all the tissues of the body.

This sets in motion a series of compensatory events and various hormones are released by several organs in an attempt to correct the symptoms. These hormones increase fluid in a conservation effort to increase blood volume and therefore the output of blood and oxygen by the heart. Fluid conservation is all very well when the heart is functioning normally, but in heart failure patients the pump fails and fluid accumulates in the lungs or abdomen (in the case of right-sided congestive heart failure). Fluid in the lungs is called pulmonary oedema, and will cause laboured breathing, coughing, increased respiratory rate, hypoxia (diminished oxygen to body tissues) and in some cases, nasal discharge.

Keeping your patient in a low-stress environment is certain to be beneficial. Do your best to separate these animals from high-traffic areas, loud noises, and other animals. Ask your clients to monitor their pet's respiratory rate when at rest. This should be less than 30 breaths/min. Be sure to explain that one breath equals one inhalation and exhalation. Anything over can be a sign that fluid has backed up in the lungs. This is also a great method for differentiating between congestive heart failure and a non-specific cough.

Upon presentation of these cases, we need to ascertain the oxygen saturation of the patient. This can be done quickly in the waiting room by noting the animal's ability to breathe comfortably. When this is compromised, the animal will try its best to compensate. This may simply be to increase its respiratory rate, or more severely by extending its head and neck posture with abduction of the elbows, flaring of the nares and open-mouth breathing.

Dogs are more likely to show clinical disease earlier due to lifestyle whereas some cats may not be diagnosed until much later. In either species, postural changes can be suggestive of extreme respiratory distress and warrant immediate attention.

Immediate oxygen supplementation should be provided while assessing for a patent airway.

What are the best methods of oxygen supplementation?

The following table shows the commonly-available methods of oxygen supplementation found in most clinics and the pros and cons of their use.

Propping up a patient sternally during respiratory distress will help the animal to utilise both lungs.

Whilst we are treating the patient with oxygen supplementation, we are also doing our best to relieve some of the fluid from the lungs with the use of a diuretic.

Diuretics will cause the animal to urinate more, and therefore there is an increased need for regular changes of bedding. Using nappies or pads to line the bottom of the cage will absorb a lot of leaks and stop the animal itself from becoming soaked.

Be sure to get a baseline respiratory rate prior to administering your diuretics, and recheck the rate every 15 minutes for the first few hours of monitoring. This will give you a good indication of whether or not more medication is required.

Once the respiratory rate/effort has reduced after medication, we will attempt to wean the animal off oxygen supplementation by placing them in a cage to breathe room air. Regular SpO2 checks (& visual observations) will alert us if the patient is unable to maintain their own oxygen saturation levels.

Once the patient is stable and comfortable, further non-emergency diagnostics and treatment can be discussed. Owners may choose to proceed to cardiac ultrasound or elect to proceed straight to medical treatment with regular rechecks.

At this point many of our patients are discharged with detailed instructions for home monitoring and regular rechecks. Straightforward homecare and close monitoring are often sufficient to ensure the condition is well controlled.

So although congestive heart failure cannot be cured, there are numerous ways in which basic nursing can actively assist pets with the condition.

The final tool available for high quality care is the humble telephone. Regular proactive checks take only a few minutes and can be done by a nurse within the overall veterinary treatment plan. Not only does it result in earlier warning that medications may need to be altered, but clients and their pets definitely appreciate the simple act of keeping in touch for the benefit of their four legged loved one.

Helpful nursing tips

1. Keeping your patient in a low-stress environment is certain to be beneficial. Do your best to separate these animals from high-traffic areas, loud noises, and other animals.



2. Immediate oxygen supplementation should be provided while assessing for a patent airway.



3. Propping up a patient sternally during respiratory distress will help the animal to utilise both lungs.



4. Be sure to get a baseline respiratory rate prior to administering your diuretics, and recheck the rate every 15 minutes for the first few hours of monitoring. This will give you a good indication of whether or not more medication is required.



5. Have the owner make an appointment for one week later to have the pet’s urea, creatinine and electrolytes checked. We do not want the patient to become dehydrated or put any unnecessary pressure on the kidneys (frusemide increases potassium loss) whilst on medication.

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