Heart failure is not a diagnosis that announces itself quietly. It is, in nearly every case, a culmination — the end point of years of haemodynamic strain, myocardial remodelling, and compensatory mechanisms that have finally exhausted themselves. As a nurse, your role is not simply to administer medications and monitor numbers. It is to understand the physiology well enough to anticipate deterioration, interpret subtle signs, and intervene with precision.
This chapter covers the nursing management of adult patients with heart failure — both heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF) — across the acute inpatient and chronic outpatient settings.
Understanding HFrEF vs. HFpEF
The distinction between HFrEF and HFpEF matters clinically because, despite sharing the same syndrome, the pathophysiology differs substantially — and so do the pharmacological targets. HFrEF is characterised by a dilated, weakened ventricle with impaired contractility (EF < 40%). HFpEF involves a stiff, poorly compliant ventricle that struggles to relax and fill, despite preserved systolic function (EF ≥ 50%).
| Feature | HFrEF (Systolic HF) | HFpEF (Diastolic HF) |
|---|---|---|
| Ejection Fraction | < 40% | ≥ 50% |
| Ventricle appearance | Dilated, thin-walled | Normal size or hypertrophied |
| Primary problem | Weak contraction (systolic) | Impaired relaxation (diastolic) |
| Common causes | CAD, MI, cardiomyopathy | HTN, diabetes, obesity, age |
| Pharmacological targets | ACEi/ARB, beta-blocker, MRA, SGLT2i | Symptom management; SGLT2i emerging |
Key Terms — Classification
- Ejection Fraction (EF)The percentage of blood pumped out of the left ventricle with each contraction. Normal EF is 55–70%.
- HFrEFHeart failure with reduced ejection fraction (EF <40%). Previously called systolic heart failure.
- HFpEFHeart failure with preserved ejection fraction (EF ≥50%). Previously called diastolic heart failure.
- Cardiac RemodellingStructural and functional changes to the heart — hypertrophy, dilation, fibrosis — in response to chronic haemodynamic stress.
- PreloadThe degree of ventricular stretch at the end of diastole, primarily determined by venous return and blood volume.
- AfterloadThe resistance the ventricle must overcome to eject blood — primarily determined by systemic vascular resistance.
Nursing Assessment Priorities
A structured and thorough assessment is the foundation of safe heart failure nursing. The classic presentation of acute decompensated heart failure — orthopnoea, paroxysmal nocturnal dyspnoea, bilateral ankle oedema, elevated JVP, and S3 gallop — is textbook, but your patients will rarely arrive with the textbook in hand.
Respiratory Status
Begin with respiratory assessment. The lungs are often the first organ to announce a decompensating heart. Auscultate carefully for bibasal crackles — fine crepitations that do not clear with coughing, reflecting fluid accumulation in the alveolar spaces. Document respiratory rate, oxygen saturation, and the work of breathing. Is the patient using accessory muscles? Able to speak in full sentences? Comfortable lying flat?
Clinical Warning · Respiratory Distress
Acute pulmonary oedema is a life-threatening emergency. If your patient is in severe respiratory distress (RR >30, SpO₂ <90% on oxygen, unable to speak), escalate immediately. Position upright, apply high-flow oxygen, prepare for IV furosemide and GTN infusion, and call for urgent medical review.
Escalation Protocol · ICU Liaison · Code Blue criteria
Fluid & Haemodynamic Status
Accurate fluid assessment requires more than glancing at the fluid balance chart. Weigh your patient daily at the same time, on the same scales, in the same clothing — weight gain of more than 2 kg in 24–48 hours is a reliable early indicator of fluid retention. Assess for pitting oedema systematically: ankles, shins, sacral area in bed-bound patients.
Clinical Tip · Fluid Assessment
When assessing pitting oedema, press firmly over the tibia for 5 seconds and grade the resulting pit: 1+ (2 mm, disappears rapidly) through 4+ (8 mm, pit remains for over 2 minutes). Document the grade, location, and distribution consistently.
Assessment Technique · Grading Scale Reference
Fluid Management
The art of fluid management in heart failure lies in achieving euvolaemia — neither overloaded nor depleted. This balance is more difficult than it sounds. Over-diuresis produces azotaemia, electrolyte disturbance, and hypotension that can paradoxically worsen cardiac output. Under-diuresis perpetuates congestion, impairs respiratory function, and leaves the patient symptomatic.
In heart failure nursing, the fluid balance chart is your ECG. Look at it with the same seriousness, the same attention to trend, the same clinical suspicion when the numbers don't add up.
IV furosemide remains the cornerstone of acute decongestion. Administer as prescribed, typically as a bolus or continuous infusion depending on acuity. Monitor urine output hourly in the acute phase — a target of 100–200 mL/hour is a common initial benchmark. Electrolyte monitoring is non-negotiable: hypokalaemia and hypomagnesaemia potentiate the risk of serious dysrhythmias.
Medications: What You Must Know
The pharmacological management of HFrEF has an evidence base that few other conditions can match. Four drug classes form the quadruple therapy cornerstone: ACE inhibitors or ARBs, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors. Your role is not merely to administer these drugs but to understand their mechanisms, anticipate their side effects, and educate patients about why each one matters.
Clinical Tip · ACE Inhibitors
Always check BP and renal function before administering ACE inhibitors. The first dose can cause a sharp drop in blood pressure — particularly in patients who are fluid-depleted or on concurrent diuretics.
Pharmacology · RAAS Inhibition · Adverse Effects
Clinical Warning · Electrolytes & Digoxin
If your patient is prescribed digoxin, maintain serum potassium above 3.5 mmol/L at all times. Hypokalaemia dramatically increases the risk of digoxin toxicity.
Pharmacology · Digoxin Toxicity · Cardiac Monitoring
Patient Education & Discharge Planning
Heart failure has a readmission rate that reflects, in part, a failure of education. Patients who understand their condition — who can recognise early warning signs, adhere to fluid and sodium restrictions, and weigh themselves daily — do measurably better. This is your opportunity to make a real difference that extends far beyond the ward stay.