Heart Failure 101

1. The heart is a four chambered, 2-sided pump. Heart failure can happen as a result of damage or weakening of heart muscle or valves (Heart and Stroke Foundation of Canada, 2018)
   1. Abnormalitites in heart function can cause blood to back up in peripheral circulation causing edema. Failure or inadequate pumping can also cause congestion in lungs manifesting as pulmonary edema. Inadequate pumping of the heart also leads to perfusion and oxygenation difficulties (Heart and Stroke Foundation of Canada, 2018)
      1. New York Heart Association Functional Classification of People with Cardiac Disease (NYHA, 2018)
         1. Class I: No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, dyspnea, palpitations, or anginal pain.
         2. Class II: Slight limitations of physical activity. No symptoms at rest. Ordinary physical activity results in fatigue, palpitations, dyspnea, or anginal pain
         3. Class III: Marked limitation of physical activity. Usually comfortable at rest. Ordinary physical activity causes fatigue, dyspnea, palpitations, or anginal pain
         4. Class IV: Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken discomfort increases.

1. Hypertension

   Annotations:

   • Hypertension and ethnicity: In Canada people who are Black or of South Asian descent are three times more likely to develop HTN than White individuals or East Asian Canadians. Black Canadians have a higher mortality rate related to HTN than White individuals. Female Black Canadians have a disproportionately high prevalence of HTN.HTN is more prevalent among First Nations adults than the general population and HTN is more aggressive in Black and Aboriginal populations and results in more severe end-organ damage (Lewis, 2014, pg. 867).
   1. High pressures within vessels cause damage and scarring to vessels and valves
      1. Damaged vessels lose elasticity, scar and narrow forcing the heart muscle to pump harder through narrow openings
         1. The heart compensates by getting larger (cardiomegaly), to pump more blood, but efficiency begins to decline (American Heart Association, 2018).
2. Diabetes

   Annotations:

   • People diagnosed with Diabetes (Type I and Type II) are at very high risk of heart disease and stroke (Canadian Diabetes Association, 2018). People with Diabetes may develop heart disease 10 to 15 years earlier than individuals without diabetes (Canadian Diabetes Association, 2018). High blood glucose (sugar) is one risk factor for heart attack or stroke, but people with diabetes often have a number of other risk factors. These include being overweight (especially if they have excess fat around the waist), inactive lifestyles, high blood pressure and high cholesterol. People who smoke or have a family history of heart disease or stroke are at even higher risk (Canadian Diabetes Association, 2018). 
   1. Individuals who have been diagnosed with diabetes, tend to develop hypertension and atherosclerosis from elevated lipid levels, both of which are closely linked to heart disease (American Heart Association, 2018).
      1. Atherosclerosis and hypertension increase the risk for CVD, PVD, and stroke
         1. Causing damage or weakness to heart muscle
3. Coronary Artery Disease
   1. CAD is a disease process that involves the blood vessels of the heart itself. It affects the arteries supplying blood to the heart muscle and is associated with serious conditions including myocardial infarction, stable/unstable angina, and reduced oxygen and nutrient flow to tissues (Lewis, 2014).
      1. CAD is caused by atherosclerosis, which causes narrowing and blockages of coronary arteries and by cardiac disease processes. This condition is exacerbated by a poor diet, sedentary lifestyle, smoking, high cholesterol, long-standing hypertension, drug and alcohol abuse and increased body weight particularly of the abdominal girdle (Heart and Stroke Foundation of Canada, 2018).
4. Other Causes: (Heart and Stroke Foundation of Canada, 2018)
   1. Alcohol and Drug Abuse
      1. Heavy binge drinking is associated with increased risk for hypertension. It can also be problematic when interacting with medications (Heart & Stroke, 2018). Drugs such as amphetamines, cannabis (marihuana), cocaine, ecstasy, heroin, opiates, LSD and PCP all increase your risk of having a stroke or developing heart disease (Heart & Stroke, 2018).
   2. Unhealthy Body Weight
      1. Increased triglyceride (LDL) levels
      2. Increased risk of Type II Diabetes
      3. Hypertension
      4. Sleep Apnea
      5. Increased risk of MI
      6. Increased risk of CAD
      7. Body Mass Index (Canadian Diabetes Association, 2018; American Heart Association, 2018; Heart and Stroke Foundation of Canada, 2018)

         Annotations:

         • Printable BMI Chart. (n.d.). [JPEG] Retrieved from             https://www.vertex42.com/ExcelTemplates/bmi-chart.html
         1. Normal: 18.5 -24.5
         2. Overweight: 25-29.9
         3. Obese: 30 +
   3. Valvular disorders and cardiomyopathy
      1. Conditions of heart valves that involve stenosis (narrowing) of the great vessels or regurgitation of blood back ward into atria or peripheral circulation. Cardiomyopathy refers to a group of disease that directly affect the structural or functional ability of the myocardium. May be primary (idiopathic) or secondary (attributed to another disease process) (Lewis, 2014).
   4. High Cholesterol
      1. LDL (low density lipoprotein) and HDL (high density lipoprotein) levels can be checked with a simple blood test. Adults 20 years of age and older should have their cholesterol and other cardiac risk factors checked every four to six years (American Heart Association, 2018).
   5. Infections: Specifically, infections involving inflammation of the heart muscle or lining of the heart. Individuals with pre-existing heart valve abnormalities or heart conditions are at particularly increased risk.
      1. Oral Health and Periodontal Disease. Several studies by the Canadian Dental Health Association (Lavigne, 2004) and in The Journal of Dental Hygiene (Mosely et al., 2014; Jones, 2015) have shown a link between poor oral health and periodontal disease, and poor cardiovascular health. Some acute infections in individuals with heart conditions or weakened heart valves may develop more severe complications
         1. Myocarditis
            1. A condition of focal or diffuse inflammation of the myocardium. Most commonly caused by viral infections, parasites, fungi, radiation therapy, chemical or pharmacological interventions and autoimmune diseases. Myocarditis is frequently associated with acute pericarditis.
         2. Bacterial endocarditis
            1. Caused by bacteria circulating within the blood stream. Bacterial colonies reach heart muscle and valves and manifest inflammation and infection processes. Endocarditis is uncommon in healthy hearts.

               Annotations:

               • University of Cambridge. (2018). This Vibrant Bacteria Could Be Used to “Grow” Paint.  [JPEG] Accessed on 16 March 2018. Retrieved from            https://www.smithsonianmag.com/tag/bacteria/
   6. Hypervolemia
      1. An important reason that nurses must meticulously evaluate clients who are receiving IV therapy and fluid through peripherally or centrally inserted lines. Fluid overload can lead to pulmonary congestion, fluid and electrolyte imbalances, hypertension, edema, shortness of breath and death. Clients in heart failure can very easily be overloaded - exacerbating the condition significantly (Lewis, 2014).

1. Symptoms
   1. Right-Sided Symptoms
      1. Fatigue
      2. Dependent Edema
      3. Upper Right Quadrant Pain
      4. Anorexia and GI Bloating
      5. Nausea
   2. Left-Sided Symptoms
      1. Fatigue
      2. Dyspnea
      3. Orthopnea
      4. Dry Hacking Cough
      5. Pulmonary Edema
      6. Nocturia
      7. Paroxysmal Nocturnal Dyspnea
2. Signs
   1. Signs of Left-Sided Failure
      1. Left Ventricular Heaves
      2. Cheyne-Stokes Respiration
         1. Patients with respiratory pattern disturbances or altered respiratory function and impairment of gas exchange must be monitored for fluctuations in blood pH Normal: 7.35 - 7.45
            1. pCO2 = 34 - 45 mmHg (Lewis, 2014)
            2. pO2 = 80 - 100 mmHg (Lewis, 2014)
            3. HCO3 = 22 - 26 mEq/L (Lewis, 2014)
      3. Pulsus Alternans
      4. Increased Heart Rate
      5. Crackles (pulmonary edema)
      6. S3 S4 Auscultation
      7. The most common form of initial heart failure experienced is left-sided failure. Left-sided failure is caused by left-sided dysfunction (back-up of blood), increased pressure on the pump and great vessels causes increased pressure and extravasation of fluid in vessels - which manifests as pulmonary congestion and edema (Lewis, 2014).
   2. Signs of Right-Sided Failure
      1. Right Ventricular Heaves
      2. Murmurs
      3. Peripheral Edema (Lewis, 2014)
         1. 1+ Slight pitting, no visible change in shape of the extremity; depth of indentation <6mm; disappears rapidly
         2. 2+ No marked change in shape of the extremity; depth indentation 6-12mm; disappears 10-15 sec
         3. 3+ Noticeably deep pitting; swollen extremities; depth of pitting 1 -2.5cm; duration 1-2 minutes
         4. 4+ Very swollen; distorted extremity; depth of pitting >2.5 cm; duration 2-5 minutes
      4. Weight Gain
         1. Patients must be weighed daily, in conjunction with a closely monitored fluid intake restriction (1.5 - 2.0 L per day Lewis, 2014).
            1. Sudden weight gain of 2kg in 2 days is often indicative of exacerbated heart failure (Lewis, 2014)
      5. Increased Heart Rate
      6. Ascites
      7. Jugular Vein Distention
      8. Hepatomegaly
      9. Causes: Right-sided failure causes backup of blood into the right atrium and into venous circulation. This manifests as peripheral edema in dependent areas of the body (feet, ankles, wrists). The primary cause of right-sided failure is left-sided failure. In this case left-sided failure results in pulmonary congestion and increased pressure on blood vessels of the lung (pulmonary hypertension). Cor pulmonale results (right ventricular dilation and hypertrophy caused by pulmonary pathology) as a result of right-sided failure (Lewis, 2014).

1. Chest X-Ray
   1. A radiographic picture of the heart, lungs and bones of the chest
      1. Used to diagnose a large or unusually shaped heart. Used to diagnose the presence of valvular dysfunction and evaluate how serious the condition may be (Heart and Stroke Foundation, 2018). Can also be useful in the differential diagnosis of pericarditis and endocarditis
2. Echocardiogram
   1. An echocardiogram uses sound waves to create a picture of the heart. It is the most widely used test to determine a heart's ejection fraction. (Normal: 50-70%)
      1. This diagnostic test is used to observe the valvular movement and swell as the shape and texture of the heart changes as it beats. It also looks at the heart chambers and the degree of mechanical heart function. Useful for diagnosing heart murmurs, myocardial infarction and infection of the heart. Echoes can be used to evaluate ejection fraction of the ventricles (Heart and Stroke Foundation, 2018; Lewis, 2014; Jiayun et al, 2015).
         1. Heart Failure with Preserved Ejection Fraction (formerly called DIASTOLIC Heart Failure)
            1. Heart muscle contracts normally but the ventricles do not relax as they should during ventricular filling (American Heart Associaton, 2018)
         2. Heart Failure with Reduced Ejection Fraction (formerly called SYSTOLIC Heart Failure)
            1. The heart muscle does not contract effectively and less oxygen rich blood is pumped out to the rest of the body (American Heart Association, 2018)
3. Electrocardiogram (ECG 12 Lead)
   1. A tool to measure the electrical activity of the heart.
      1. Useful in detecting abnormal electrical conduction in the hearts conduction system. this includes past, recent or ongoing heart attacks. All of which can result in heart muscle damage, coronary artery blockage, enlarged heart muscle, and inflammation of the pericardial sac. Can detect electrical disturbances and pathology due to lung diseases (Heart and Stroke Foundation, 2018).
         1. STEMI
            1. ST-Elevation Myocardial Infarction. Identified when the ST segment of the cardiac cycle is elevated by 2 mm or more above the isoelectric line, in two or more anatomically contiguous leads
               1. STEMIs indicate necrosis of cardiac muscle. Reversal of necrosis is not likely, but some hypoxic tissue damage may still be salvaged and some ischemia reversed.
                  1. STEMIs cause damage to the heart muscle itself and can lead to future heart failure or dysfunction. Recognizing the signs and symptoms of MI and making the appropriate interventions are vital to preserve heart tissue during an attack
                  2. Serum cardiac markers are measured if a patient is suspected of having an MI. Cardiac-specific troponin T (cTnT) and cardiac specific troponin I (cTnI) are highly specific indicators of myocardial injury
         2. N-STEMI
            1. Non- ST Elevation Myocardial Infarction
               1. NSTEMIs indicate hypoxia of cardiac tissues (ischemia) that may be reversible. Necrosis is not readily apparent but a myocardial infarction is still occurring and may lead to necrosis if no interventions are made.
4. Brain Natriuretic Peptide Test
   1. A blood test measuring levels of Brain Natriuretic Peptide - a hormone produced by the myocytes of the heart when the ventricles of the heart stretch too far too often.
      1. This blood test is used to determine the levels of brain natriuretic peptide (BNP) and if abnormally high levels are present it indicate heart failure. Usually used to determine heart failure also used when patients are having trouble breathing or have edema in the arms or legs (Heart and Stroke Foundation, 2018; Lewis, 2014).
5. Coronary Angiogram
   1. A radiographic image of the coronary vessels feeding the heart muscle. Achieved with the use of radiolucent dye.
      1. Used to determine if coronary arteries feeding the heart muscle are partially or completely obstructed. Treatment may include angioplasty, coronary artery bypass surgery, medical therapy or lifestyle changes (Heart and Stroke Foundation, 2018).
         1. Angioplasty is a procedure wherein a catheter is inserted through the wrist or groin into the heart. The catheter is used to inflate a balloon, to relieve obstruction of the coronary arteries.
6. Exercise Cardiogram (Stress Test)
   1. An exercise ECG is used to record the heart response to electrical impulses. This is done by recording the heart's electrical impulses, blood pressure, and heart rate while the patient is exercising.
      1. Used for unexplained chest pain and or if coronary artery disease is suspected. It is also used to determine the seriousness of coronary artery disease if diagnosed. Used to determine how much exercise a person can endure after an MI or surgery. Also recommended for people with arrhythmias, tachycardia, and bradycardia, palpitations and dizziness or fatigue (Heart and Stroke Foundation, 2018).

1. Medications
   1. Beta Blockers
      1. Beta-blockers function to counteract the negative effects of the failing heart such as increased HR. Beta-blockers decrease myocardial contractility, and decrease the work of the heart an in effect can lower blood pressure.
         1. Always assess patient's blood pressure before providing a medication that affects pressure. Normal reading for healthy adults is 120/80 mmHg. Some patients may have readings outside of the norm, in which case use the baseline to determine whether a pressure reading is normal for a patient. Assess whether the patient is symptomatic if readings are outside of norms.
            1. Example: Metoprolol
   2. ACE Inhibitors
      1. Useful in the treatment of systolic and diastolic HF. Considered to be first-line therapy for HF. Inhibiting conversion of Angiotensin I to Angiotensin II prevents vasoconstrictive effects of the renin-angiotensin-aldosterone system. (Lewis, 2014).
         1. Evaluate baseline and current blood pressure before administering.
            1. Example: Enalapril
   3. Cardiac Glycosides
      1. Function as positive inotropes and decrease the conduction speed within the myocardium, slowing the heart rate and decreasing the work of the heart. These actions lead to improved contractility and ventricular emptying because of improved stroke volume (Lewis, 2014).
         1. Very narrow therapeutic range. >2ng/ml = toxic range. Blood work must be monitored closely. K+ levels must be within normal range, hypokalemia can result in digitalis toxicity. Patients APICAL pulse rate must be assessed before administration (must be >60 beats per minute unless otherwise ordered by a physician)
            1. Example: Lanoxin
               1. ANTIDOTE: DIGIBIND
   4. Angiotensin Receptor Blocker
      1. Prevent the conversion of Angiotensin II, produces vasodilation and increases salt and water excretion (Lewis, 2014), effectively lowering blood pressure and workload on the heart muscle.
         1. Example: Losartan
   5. Diuretics

      Annotations:

      • IMPORTANT!! Check patient's K+ levels and monitor closely during diuretic therapy Normal K+ (3.5 - 5.0 mmol) Normal NA (135 - 145 mEq) Normal Cl (96 - 106 mEq)
      1. Loop (Non-Potassium sparing)
         1. Inhibits NaCl reabsorption in the Loop of Henle. Increases the excretion of Na+ and Cl-. More potent diuretic, but has a shorter duration. Excretes K+ ions. Potassium levels must be closely monitored (Lewis, 2014). K+ level norm:3.5.5.0
            1. Patients who are experiencing heart failure, and who also receive digitalis may be at risk for hypokalemia. Patients are at risk for digitalis toxicity. Always review blood work and evaluate heart rate and blood pressure before administering this drug.
               1. Example: Furosemide
      2. Potassium Sparing
         1. Inhibit the Na+ retaining and K+ excreting effects of aldosterone in distal collecting tubules of the kidneys (Lewis, 2014).
            1. Patient's blood work must be closely monitored for hyperkalemia. Hyperkalemia can result in nausea and vomiting, abdominal cramping, headaches, cardiac dysrhythmias and cardiac arrest. Potassium sparing diuretics do not allow for the elimination of potassium during the filtration process by the kidneys. Hyperkalemia >5.2 mmol (Lewis, 2014) can cause severe cardiac side effects.
               1. Example: Spironolactone
   6. Nitrates
      1. Work to dilate and expand coronary vessels and decrease preload primarily and afterload (Lewis, 2014).
         1. Example: Nitroglycerine
   7. Antidysrhythmics
      1. Several major classes. Function to alter conduction velocity, and decrease impulse conduction, reduce contractility, and automaticity of pace maker cells and/or the myocardium (Lewis, 2014).
         1. Inotropic
            1. Modifies the contraction of the heart muscle
               1. Positive: Strengthen the force of the heart's contraction
                  1. Example: Digitalis
               2. Negative: Lessen the strength of the hearts contraction
                  1. Example: Metoprolol
         2. Dromotropic
            1. Modifies conduction speed of the heart's conduction system
               1. Positive: Increases conduction speed
                  1. Example: Phenytoin
               2. Negative: Decreases conduction speed
                  1. Example: Verapamil
         3. Chronotropic
            1. Modifies the rate and rhythm of the hearts conduction system
               1. Positive: Increases heart rate
                  1. Example: Epinephrine
               2. Negative: Decreases heart rate
                  1. Example: Digitalis
   8. Anticoagulants
      1. Most frequently used for patients with EF <20% or those experiencing atrial fibrillation to prevent thrombus formation from turbulent or stagnant blood flow
         1. Example: Warfarin
            1. ANTIDOTE: VITAMIN K
   9. Selective Sinus Node Inhibitor
      1. A newer class of medication that targets the Sinoatrial Node. The desired effect is to lower the cardiac resting rate, decreasing myocardial oxygen demand and preventing angina, while avoiding the typical side effects of Beta-blocking agents (psychological depression, erectile dysfunction, hypotension, and worsening of Atrioventricular Node disease (Lewis, 2014; Nguyen et al, 2016).
         1. Assess patient's heart rate and blood pressure before administering any drug that affects resting heart rate and subsequently blood pressure.
            1. Example: Ivabradine
   10. Pain Medication
       1. Opioid
          1. PRN as ordered by physician to treat chest pain, or for palliative care. Carefully monitor respiratory rate and depth.
             1. Morphine
                1. ANTIDOTE: NALOXONE
2. Surgical Intervention
   1. Heart Valve Repair/ Replacement
      1. Surgery to repair or to replace a dysfunctional valve of the heart. Most commonly performed on the MITRAL (or bicuspid) valve between the left ventricle and left atria. This valve experiences the greatest amount of backward force during the ejection of blood volume from the left ventricle out to systemic circulation
   2. Mechanical Assist Device
      1. A man-made pump that helps the heart to beat more effectively
         1. Intra-Aortic Balloon Pump
            1. A balloon placed within the aorta that inflates and deflates at a specific rate to assist the heart's left ventricle after an acute cardiac event (myocardial infarction, etc). By inflating with each beat, the balloon relieves the workload of the heart by decreasing resistance through the aorta (Heart and Stroke Foundation, 2018).
         2. Total Artificial Heart
            1. Research is ongoing to build a functional totally artificial heart and only a few trials exist in a small number of research facilities (Heart and Stroke Foundation, 2018).
         3. Implantable Ventricular Assist Device
            1. Called a VAD or VAS, this mechanical device takes over the heart's ventricles by beating for/assisting the heart. Patients with VADs have severely weakened hearts or are in end-stage heart failure (Heart and Stroke Foundation, 2018)
   3. Implantable Pace Maker
      1. Surgeons implant a device designed to regulate an abnormal heart rhythm (particularly if it is unresponsive to medication)
         1. Sternotomy: Similar to a thoracotomy, wherein the patient's chest wall is opened and leads are advanced into the heart (Heart and Stroke Foundation, 2018)
         2. Thoracotomy: Open Chest surgery. Small oval shaped pads are sewn onto the epicardium and the chest is closed (Heart and Stroke Foundation, 2018).
         3. Transvenous Approach: Leads are manipulated onto the endocardium through a venous access port by a surgeon (Heart and Stroke Foundation, 2018)
         4. Subxiphoid Approach: Similar to a thoracotomy, except that the incision is made to the left of the breast bone (Heart and Stroke Foundation, 2018).
         5. Internal Cardioverter Defibrillator (ICD) may or may not be required in management of lethal dysrhythmias
   4. Coronary Bypass Surgery
      1. Surgical procedure designed to improve coronary bloodflow to the heart muscle itself. Also commonly referred to as CABG surgery. Required when coronary arteries are completely blocked (atherosclerosis) and a detour must be built around the blockage.
         1. A section of vein or artery is removed from one part of the body and grafted into the heart to create a new pathway for coronary blood supply to reach the heart muscle. Percutaneous coronary intervention may also be used in place of CABG.
            1. CABG surgery is not a curative intervention. Lifestyle changes must be part of the patient's treatment plan
   5. Cardioversion
      1. A process of restoring the heart's normal rhythm by using electric current - similar to defibrillation but at much lower energy settings. The application of energy interrupts dysrhythmias (ie. atrial fibrillation) and allows the heart to naturally reset (Heart and Stroke Foundation, 2018).
         1. Chemical cardioversion is performed for the same purposes but with the use of medications rather than electrical current to reset an abnormal heart rhythm
   6. Atherectomy
      1. This procedure is similar to angioplasty. A catheter is threaded through the femoral artery, the fatty plaque is scraped away from the inside of the arteries and collected in the catheter. This procedure restores coronary circulation. After the procedure, a surgeon may choose to place a stent additionally (Heart and Stroke Foundation, 2018).

Annotations:

• Patient education before discharge is very important. Nurses should discuss modifiable risk factors when the patient is ready to learn. Modifiable risk factors include: Smoking, diet, reducing salt intake, reducing fluid intake, increasing exercise within tolerance to strengthen the heart muscle, maintaining a healthy body weight, avoiding foods high in cholesterol, and carefully controlling any endocrine disorders like diabetes or thyroid disorders (Heart and Stroke Foundation of Canada, 2018).

1. Smoking cessation
   1. Smoking triples the risk of heart disease for middle aged men and women in Canada (Heart and Stroke Foundation, 2018)
      1. People diagnosed with heart failure can use nicotine patches, puffers, tablets or chewing gum as a nicotine substitutes while they decrease their tobacco use. Physicians will often add these nicotine supplements onto a patient's MAR as a method of ensuring the body is not under stress with drawl while it recovers. These interventions may be used in conjunction with counseling therapy.
2. Exercise
   1. Within tolerance, and under the direction of a physician (Canadian Society of Exercise Physiology, 2018).
      1. Mild
         1. Walking
         2. Gardening
         3. Stretching
      2. Moderate
         1. Brisk Walking
         2. Biking
         3. Dancing
         4. Swimming
      3. Vigourous
         1. Basketball
         2. Jogging
         3. Fast Swimming
         4. Hockey
         5. Aerobics
3. Heart Failure Zones:The heart failure zone chart is an excellent way for patients to visualize the importance of management of symptoms and early recognition of complications or exacerbation of heart failure. Ensuring that clients have the knowledge and control over the management of their health is integral to avoiding repeated and longer hospital stays.

   Annotations:

   • HEART FAILURE ZONES. (n.d.). [JPEG] Accessed on 16 March 2018. Retrieved from    http://www.heartandstroke.ca/get-healthy
   1. GREEN ZONE: All Clear. There is an absence of symptoms (No chest pain, No shortness of breath, No weight gain, No swelling in feet, ankles, legs or abdomen):
   2. YELLOW ZONE: Caution - This is a warning zone. Symptoms start to show again. Some shortness of breath, weight gain, vomiting/diarrhea that last more than 2 days, light headedness, dry hacking cough, difficulty sleeping and low energy
   3. RED ZONE: EMERGENCY ZONE! You need to act fast! Shortness of breath that does not subside with rest, chest pain that does not subside with rest, confusion, loss of consciousness, racing heart beat and you struggle to breathe
4. Diet
   1. Foods to Avoid
      1. Processed Food
         1. White pasta
         2. White Bread
         3. Hot Dogs
         4. Frozen Pizza
         5. Deli Meat
      2. Salty Food
         1. Potato Chips
         2. Canned Foods
      3. Sugary Foods
         1. Cookies
      4. Saturated and Trans Fats
         1. Fried Foods
      5. Foods High in Cholesterol
   2. Canada's Food Guide and Heart Healthy Foods (Heart and Stroke Foundation, 2018; Canada's Food Guide, 2018)
      1. 7-10 servings of vegetables and fruits
      2. Choose Whole grain foods
         1. Wild Rice
         2. Oats
         3. Quinoa
         4. Whole Grain Bread
         5. Hulled Barley
      3. Protein
         1. White Fish (aim for 2 servings per week)
         2. Tofu
         3. Dairy and Milk Products
         4. Beans
         5. Lentils
   3. Fluid Restrictions
      1. A good technique to teach patients who are new to monitoring their fluid intake, recommend filling a 2L cola bottle with water to be used throughout the day. Once the 2L bottle of water is empty, the patient has reached their daily limit of fluid intake
5. Reduce Stress
   1. Yoga
   2. Meditation
   3. Balanced Diet
   4. Cut down on stimulants (caffeine, energy drinks, chocolate, tea and soft drinks)
   5. Setting Boundaries
   6. Get Enough Sleep
6. Support Systems. Patients ideally should have a support system at home. Those individuals with advanced heart failure may require assistance from CCAC or home visit nurses. Having supportive family members also makes this transition safer and less stressful for the person managing heart failure.
   1. Spouse
   2. Family Members
   3. Home Visit Nursing Care
   4. Close Friends
   5. CCAC
7. Energy Conservation
   1. Recommend pre planning days when possible, rest when fatigued, and set rest times for the afternoon hours.
      1. Patients will benefit from planning out activities that require higher amounts of energy and conserving energy to optimize independence in completion of activities of daily living (Lewis, 2014)
8. Activity Therapy
   1. Collaborate with physical, occupational, psychological and social capabilities
      1. Help patient determine commitment and provide obtainable goals
9. Oxygen therapy