Practice Tip of the Week | Nurse Identification of Heart Failure: Early Recognition and Escalation

By Jenny Kelly, DNP, RN in collaboration with the Texas Nurses Association Nursing Practice Committee

Heart failure (HF) is a clinical syndrome associated with structural and/or functional cardiac abnormalities that impair ventricular filling or cardiac output (Fraser et al., 2024; Heidenreich et al., 2022). Nurses are uniquely positioned to identify
early decompensation by detecting changes in respiratory status, fluid balance, perfusion, and functional tolerance before severe deterioration occurs (Fraser et al., 2024; Harrington et al., 2023). This article provides a guideline-aligned framework
for nursing identification of HF, including focused assessment of congestion and hypoperfusion, escalation triggers, documentation strategies, and patient education priorities (Heidenreich et al., 2022; NursingCenter, 2024).

Introduction

Heart failure contributes substantially to morbidity, mortality, and healthcare utilization, with a large proportion of costs attributed to HF hospitalizations and readmissions (Fraser et al., 2024). Contemporary guidance emphasizes patient-centered prevention,
diagnosis, and management across the HF continuum, including early stages where symptoms may be mild or absent (Heidenreich et al., 2022; Harrington et al., 2023). Nurses, who perform continuous bedside assessment, are well positioned to recognize
early indicators of congestion, reduced perfusion, and clinical instability and to escalate concerns promptly (Fraser et al., 2024).

Definition and Classification of Heart Failure

Heart failure is defined as a clinical syndrome with symptoms and/or signs caused by a structural and/or functional cardiac abnormality and corroborated by elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic congestion
(Fraser et al., 2024). Current guidelines classify HF using both stages (A–D) describing disease progression and ejection fraction phenotypes (e.g., HFrEF, HFmrEF, HFpEF) describing ventricular function and filling pressures (Heidenreich et al., 2022;
NursingCenter, 2024). Understanding these classifications helps nurses interpret assessment findings and anticipate risk, particularly for patients in Stage A (at risk) or Stage B (pre-HF) who may not yet have classic symptoms (Heidenreich et al.,
2022; Harrington et al., 2023).

Nursing Assessment Framework for Identifying Heart Failure

Bedside identification of worsening HF is supported by a structured nursing approach that assesses two overlapping domains: (a) congestion/volume overload and (b) reduced cardiac output/hypoperfusion (Harrington et al., 2023; NursingCenter, 2024). Expert
nursing guidance emphasizes trending objective measures—such as weight, intake and output, oxygen requirements, lung sounds, and hemodynamics—rather than relying on isolated values (Fraser et al., 2024).

Congestion: Indicators of Fluid Overload

Congestion often presents with exertional dyspnea, orthopnea, and fatigue, reflecting increased filling pressures and pulmonary fluid accumulation (Harrington et al., 2023; NursingCenter, 2024). Physical assessment may reveal rales/crackles and diminished
breath sounds, and imaging may identify pleural effusions in more advanced congestion (Harrington et al., 2023). Systemic congestion may manifest as peripheral edema, abdominal distention/ascites, hepatomegaly, and jugular venous distention (JVD)
(Harrington et al., 2023). Daily weight monitoring and accurate intake and output measurement support detection of fluid retention and evaluation of response to therapy, including diuresis (Fraser et al., 2024; Wagner & Lukey, 2025).

Low Perfusion: Indicators of Reduced Cardiac Output

Reduced forward flow can produce fatigue, weakness, and decreased activity tolerance, which may be more apparent with exertion (NursingCenter, 2024). Declining renal perfusion can be reflected by decreased urine output, particularly when paired with hypotension
or worsening symptoms (Harrington et al., 2023). Telemetry trends are also clinically relevant; new or worsening tachyarrhythmias may accompany decompensation and can exacerbate symptoms (Wagner & Lukey, 2025).

Clinical Red Flags Requiring Escalation

Evidence-based guidance supports immediate escalation for signs of acute decompensation, including worsening hypoxemia, rapidly increasing oxygen needs, significant respiratory distress, or findings concerning for pulmonary edema (Harrington et al., 2023;
Heidenreich et al., 2022). Hemodynamic instability (e.g., symptomatic hypotension), markedly decreased urine output, and new clinically significant arrhythmias warrant urgent provider evaluation (Heidenreich et al., 2022; Fraser et al., 2024).

Documentation, Communication, and Trend Recognition

High-quality nursing documentation emphasizes trends in weight, fluid balance, oxygen requirements, respiratory assessment, and hemodynamics to support timely decision-making and evaluation of treatment response (Fraser et al., 2024). Clear communication
that links symptom changes with objective findings strengthens interprofessional response and supports guideline-directed care (Heidenreich et al., 2022).

Patient Education as a Component of Early Identification

Guidelines and nursing education resources emphasize self-monitoring and early reporting of symptoms to prevent progression and reduce avoidable hospitalization (Heidenreich et al., 2022; Harrington et al., 2023). Nurses should reinforce daily weights,
symptom recognition, medication adherence, and diet and fluid guidance as part of discharge readiness and transitions of care (Fraser et al., 2024; Harrington et al., 2023).

Conclusion

Nursing identification of HF relies on systematic assessment of congestion and perfusion, strong trend recognition, and timely escalation of red flags. Alignment with AAHFN and AHA/ACC guidance supports early intervention, improves safety, and strengthens
transitions across the HF continuum (Fraser et al., 2024; Heidenreich et al., 2022).

Nursing Practice Tips for Early Identification of Heart Failure

HF is a clinical syndrome caused by structural or functional cardiac abnormalities leading to congestion and/or low perfusion.

1. Key Assessment Focus Areas
   1. Assess congestion and perfusion every shift; compare to prior trends
2. Indicators of Congestion (Fluid Overload)
   1. Dyspnea on exertion, orthopnea, increased O2 needs.
   2. Crackles/rales, diminished breath sounds.
   3. Rapid weight gain (≥2 lbs/24 hr or ≥5 lbs/week).
   4. Peripheral edema, JVD, ascites.
3. Indicators of Low Perfusion
   1. Fatigue, weakness, reduced activity tolerance.
   2. Decreased urine output, cool/clammy skin.
   3. Confusion or altered mentation.
   4. Tachyarrhythmias or new rhythm changes.
4. Red Flags Requiring Immediate Escalation
   1. Worsening respiratory distress or SpO2 decline.
   2. Pink frothy sputum (pulmonary edema).
   3. SBP
      < 90 mmHg or symptomatic hypotension.
   4. New rapid arrhythmias or sharp drop in urine output.
5. Documentation & Communication
   1. Document trends: weights, I&O, lung sounds, O2 needs, telemetry.
   2. Report objective changes with symptom descriptions.
6. Patient Education
   1. Teach daily weights and symptom recognition.
   2. Reinforce medication adherence and sodium/fluid limits.
   3. Encourage early reporting of worsening symptoms.

References

Fraser, M., Barnes, S. G., Barsness, C., et al. (2024). Nursing care of the patient hospitalized with heart failure: A scientific statement from the American Association of Heart Failure Nurses. Heart & Lung, 64, e1–e16.

Harrington, D., Lenahan, C. M., & Beacom, R. (2023). Heart failure management: Updated guidelines. American Nurse.

Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., Milano, C. A., Nnacheta, L. C., Sandhu, A. T., Stevenson, L. W., Vardeny, O., Vest, A. R., & Yancy, C. W. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation.

NursingCenter. (2024). Assessment and diagnosis of heart failure (Pocket Card).

Wagner, M., & Lukey, A. (2025). Heart failure (CHF): Nursing diagnoses, care plans, assessment & interventions. NurseTogether.