Ch. 29 Flashcards
heart failure (HF) is also called
pump failure
heart failure
general term for the inability of the heart to work effectively as a pump
major types of HF are:
- Left-sided heart failure (most common)
- Right-sided heart failure (second common)
- High-output failure (least common)
preload
volume of blood in the ventricles at the end of diastole (end of diastolic pressure)
preload is increased in
- hypovolemia
- regurgitation of cardiac valves
- heart failure
afterload
resistance left ventricle must overcome to circulate blood
afterload is increased in
- HTN
- vasoconstriction
increased afterload = increased ___
increased cardiac workload
ejection fraction (EF)
percentage of blood ejected from left ventricle during systole
- normal: 50-70%
- can be assessed with echocardiogram (ultrasound)
how is EF computed?
amount of blood pumped out of the ventricle divided by total amount of blood in ventricle
left-sided HF
formerly known as congestive heart failure
LV to LA to lung
two types:
- systolic: measured by EF (more common)
* 60% of cases are systolic HF
problem: left ventricle (muscle) is weak (thin) and blood backs up from the heart back into in the lungs *pump problem; fills but doesnt pump
- diastolic: normal EF
problem: left ventricle (muscle) is stiff (thick) and as a result does not fill up with blood *not a pump problem; pumps but does not fill and has a limited amount of space to fill anyway
typical causes of left-sided HF
- hypertension
- coronary artery disease
- valvular disease
classification of left-sided HF: ACC/AHA
A. Patients at high risk for developing heart failure; might have HTN, MI, coronary artery disease; but do not have symptoms
- teaching important!
B. Patients with cardiac structural abnormalities or remodeling who have not yet developed symptoms; chest x-ray or echo reveals valvular abnormality but do not have symptoms
- teaching important!
C. Patients with current or prior symptoms of heart failure.
D. Patients with refractory end-stage heart failure
NYHA staging: class 1
- No limitations of physical activity.
- Ordinary activity does not cause undue fatigue, palpitations or shortness of breath.
NYHA staging: class 2 (mild)
- slight limitations of physical activity.
- Comfortable at rest, but ordinary physical activity results in fatigue palpitations and SOB. (walking to the mailbox)
NYHA staging: class 3 (moderate)
- Marked limitations in physical activity.
- Comfortable at rest, but less than ordinary activity causes fatigue, palpitations and SOB. (walking to the bathroom)
NYHA staging: class 4 (severe)
- Unable to carry out physical activity without symptoms.
- Symptoms of cardiac insufficiency at rest. If any physical activity is taken, symptoms increase. (cutting up pancake while sitting in bed)
NYHA staging: changes
- Changes are bases on exacerbations and remissions
- Can change depending on symptoms and treatment
right-sided HF: causes
- Left ventricular failure (left sided HF progresses to right-sided HF)
- Right ventricular MI
- Pulmonary hypertension (constriction of pulmonary ventricles)
right-sided HF
- right ventricle cannot empty completely
- increased volume and pressure in venous system and peripheral edema
- backs up from RV to RA to SV to rest of body
high-output failure: cardiac ouput
cardiac output remains normal or above normal
high-output failure: causes
caused by increased metabolic needs of hyperkinetic conditions such as:
- septicemia
- anemia (hgb around 5-6; prob getting blood transfusions)
- hyperthyroidism (T3, T4, TSH numbers out of wack)
compensatory mechanisms for heart failure
- sympathetic nervous system stimulation
- renin-angiotensin system (RAS) activation
- other chemical responses: B-type natriuretic peptide (BNP) released from L ventricle and responds to fluid volume overload
- myocardial hypertrophy: muscular wall around heart thickens to cause more forceful contractions
HF is caused by _____ in 75% of cases
systemic HTN
about 1/3 of patients experiencing an MI also develop ___
HF
HF etiology
Structural heart changes, such as valvular dysfunction (usually aorta or mitral valve), cause pressure or volume overload on the heart.
HF incidence and prevalence
- 6.5 million people in the U.S. have
- Common chronic health problem with acute episodes causing frequent hospitalizations
- *Most common reason for hospital admission for people > 65 years old
- More common in African American individuals under 50 yo; over age of 50 kind of evens out ethnically
- Major cause of disability and death after MI
L-sided HF manifestations
*think fluid is backing up into the lungs; not enough oxygenation to the brain
- Weakness
- Fatigue
- Dizziness
- Acute Confusion (low flow)
- Pulmonary congestion (crackles) **
- Breathlessness/SOB/tachypnea/orthopnea (cant breathe lying flat)
- Oliguria: decreased UO (d/t decreased perfusion to the kidneys)
- Arrhythmias
(daily weights**)
R-sided HF manifestations
- Distended neck veins, increased abdominal girth
- Hepatomegaly (liver engorgement)
- Hepatojugular reflux
- Ascites
- Dependent edema (legs, feet, pitting edema)
- Weight—the most reliable indicator of fluid gain or loss (daily weights**)
lab assessment for HF
Electrolytes
Hemoglobin and hematocrit (may be decreased)
B-type natriuretic peptide (BNP) *specific for HF (released from ventricles when there is FVO; normal level is <100)
Urinalysis (proteinuria- if kidneys affected/high specific gravity- oliguria: retaining fluid&concentrated urine)
ABGs (may or may not be done)
imaging for HF
- CXR
- *Echocardiography (best diagnostic tool)
- Radionucleotide studies
HF priority hypotheses (nursing problems)
- Decreased gas exchange due to ventilation/perfusion imbalance (kidneys, heart, brain)
- Potential for decreased perfusion due to inadequate cardiac output
- Potential for pulmonary edema due to left-sided HF
non-surgical treatments for HF
- drug therapy
- Drugs to reduce afterload and preload
- Drugs to enhance contractility
- nutrition therapy/diet
interventions to promote oxygenation and gas exchange
- Ventilation assistance (nasal cannula, face mask)
- Maintain oxygen saturation of 90%
- Monitor respiratory rate every 1-4 hr
- Auscultate breath sounds every 4-8 hr
- Position in high Fowler’s if patient dyspneic
interventions to increase perfusion
- Improved and increased cardiac pump effectiveness
- Hemodynamic regulation
- drugs to reduce afterload
drugs that reduce afterload
(decreases resistances)
- ACE inhibitors (lisinopril), ARB’s (valsartan)
- Angiotensin receptor neprilysin inhibitor (ARNI)-combination drug- sacubitril/Valsartan
- Arterial vasodilators that reduce resistance
- Angiotensin Receptor Blockers (ARB)
interventions that reduce preload
- nutrition therapy: limit salt (2g sodium restrictive), fluid restriction (2L/day) (magic number 2)
- drug therapy
drug therapy that reduces preload
(decreases volume)
- Morphine- like 1-2mg through IV (decreases preload and afterload)
- diuretics (furosemide*, lasix, HCTZ)
- venous vasodilators (nitroglycerin)- sublingual, IV, transdermal: patch, paste route (s/e: flushing, HA,
IV in acute exacerbation situations always
drugs that enhance contractility
Digoxin
- Increases contractility
- Reduces heart rate (HR) (always assess HR first- typically hold if HR is <60 bpm)
- Slows conduction through atrioventricular node
- Inhibits sympathetic activity
- very narrow therapeutic window: use cautiously with elderly d/t toxicity risk
- check blood levels
Inotropic drugs
- IV (Dobutamine) (output infusion, or admitted to ICU/tele)
- Beta-adrenergic blockers (metoprolol, carvedilol)
- Aldosterone Antagonists
treating acute HF/congestive HF aka L-sided HF (acronym)
UNLOAD FAST
treating acute HF/congestive HF
Upright position
Nitrates
Lasix
O2
ACEI
Digoxin
Fluids (decrease)
Afterload (decrease)
Sodium restriction (2g/day)
Test (Dig level, ABGs, electrolytes-K+ level)
nonsurgical treatment options for congestive HF
- drug therapy
- Continuous positive airway pressure (CPAP): high amounts of oxygen through triangular mask
- Cardiac resynchronization therapy: affects both ventricles to help the L and R pump
- CardioMEMS implantable monitoring system: device sits in pulmonary artery; continuous readings of pressure in the artery
- Gene therapy (not used frequently)
interventions to decrease fatigue and weakness:
- Balance activity and rest.
- Nap to restore energy as needed.
- Recognize energy limitations.
- Conserve energy.
- Adapt lifestyle to energy level.
- Report adequate endurance for activity.
surgical management of congestive HF
Heart transplantation
Ventricular assist devices: internal pump
Other surgical therapies:
- LV surgical reconstruction
(need to know: these options only surface if diet/lifestyle and medication therapy does not work)
pulmonary edema
LV fails to eject blood adequately, ↑pressure in lungs, fluid leaks from capillaries into airways/tissues
- life threatening event- call a rapid response
- happens acutely/ sudden onset
pulmonary edema symptoms
- Extremely anxious
- Tachycardia
- Struggling for air
- Frothy blood-tinged sputum
- Crackles can be heard without stethescope
interventions for pulmonary edema
- Assess for early signs, such as crackles in the lung bases, dyspnea at rest, disorientation, and confusion.
- High-Fowler’s (90°)
- Oxygen therapy (face mask for extra oxygen)
- Meds: nitroglycerine: IV drip, rapid-acting diuretics: IV lasix, IV morphine sulfate
- Continual assessment
indications for worsening or recurrent HF
- Rapid weight gain (gaining 5lb or more in 1 week or 2-3lb in 1 day- call HCP)
- Decrease in exercise tolerance (SOB going to mailbox again)
- Cold symptoms: cough or SOB
- Excessive awakening at night to urinate
- Development of dyspnea/angina at rest: SOB at rest
- Increased edema in feet, ankles, hands: difficulty getting socks and shoes on
community-based care for pulmonary edema
- Home care management
- Teaching for self-management: MAWDS
Meds: explain what it is, how many times to take/when, side effects, purpose of med
Activity: want them to be active and exercising
Weights: daily weights, ask if they have a scale
Diet: 2g sodium, 2L fluid (restrictive!)
Symptoms: when to call HCP: weight gain, cold like symptoms, edema - Health care resources: visiting nurse
*if pt is readmitted within 30 days of d/c with pulmonary edema, medicare will not pay/cover the costs- hospital is not getting reimbursed
HF/PE: evaluating outcomes- the patient will ____
- Have adequate pulmonary tissue perfusion
- Have increased cardiac pump effectiveness
- Be free of pulmonary edema
expected changes in VS as a result of giving IV morphine, IV nitroglycerine, IV furosemide
- decreased BP (make sure dont become hypotensive)
- decreased HR (make sure dont become bradycardic)
- decreased RR (make sure dont become resp depressed)
- increased O2
- improved lung sounds (decreased crackles)
